Delineating the genotypic and phenotypic spectrum of HECW2-related neurodevelopmental disorders

BACKGROUND

Variants in HECW2 have recently been reported to cause a neurodevelopmental disorder with hypotonia, seizures and impaired language; however, only six variants have been reported and the clinical characteristics have only broadly been defined.

METHODS

Molecular and clinical data were collected from clinical and research cohorts. Massive parallel sequencing was performed and identified individuals with a HECW2-related neurodevelopmental disorder.

RESULTS

We identified 13 novel missense variants in HECW2 in 22 unpublished cases, of which 18 were confirmed to have a de novo variant. In addition, we reviewed the genotypes and phenotypes of previously reported and new cases with HECW2 variants (n=35 cases). All variants identified are missense, and the majority of likely pathogenic and pathogenic variants are located in or near the C-terminal HECT domain (88.2%). We identified several clustered variants and four recurrent variants (p.(Arg1191Gln);p.(Asn1199Lys);p.(Phe1327Ser);p.(Arg1330Trp)). Two variants, (p.(Arg1191Gln);p.(Arg1330Trp)), accounted for 22.9% and 20% of cases, respectively. Clinical characterisation suggests complete penetrance for hypotonia with or without spasticity (100%), developmental delay/intellectual disability (100%) and developmental language disorder (100%). Other common features are behavioural problems (88.9%), vision problems (83.9%), motor coordination/movement (75%) and gastrointestinal issues (70%). Seizures were present in 61.3% of individuals. Genotype-phenotype analysis shows that HECT domain variants are more frequently associated with cortical visual impairment and gastrointestinal issues. Seizures were only observed in individuals with variants in or near the HECT domain.

CONCLUSION

We provide a comprehensive review and expansion of the genotypic and phenotypic spectrum of HECW2 disorders, aiding future molecular and clinical diagnosis and management.

AB0731 IMPACT OF FIBROMYALGIA ON DISEASE ACTIVITY INDICES, HEALTH RELATED QUALITY OF LIFE AND FATIGUE IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Psoriatic arthritis (PsA), causes inflammation in joints and enthesis, emotional instability and poor quality of life (QOL).1Fibromyalgia (FM) may coexist with PsA, complicating its diagnosis and management.2The effect of FM on the QOL and fatigue in PsA patients has not been vastly studied.3

Objectives:

Assess the effect of FM on PsA patients’ disease activity indices, QOL and fatigue.

Methods:

This study included Group I: 37 PsA only patients (61.7%), 48.38 ± 11.69 years and group II: 23 FM-PsA patients (38.3%), 50.78 ± 11.8 years, according to classification criteria for PsA and 2016 Revisions to 2010/2011 FM diagnostic criteria. Psoriasis area severity index (PASI), disease activity in PsA (DAPSA), composite PsA activity index (CPDAI), PsA QOL and multidimensional assessment of fatigue (MAF) were assess in both groups. The severity and impact of FM was assessed in group II.

Results:

Patients with FM-PsA had a statistically higher PsA disease activity in subjective measures only but not in objective measures. Table 1

Table 1.

Comparison between the studied groups according to disease activity

Group I(37)Group II(23)Test ofSignificancePMean ± SDtCPDAI8.68 ± 3.3311.26 ± 2.033.735*<0.001*Median (Minimum – Maximum)UPASI8.3 (0 – 45.7)14.4(0.9 – 49.6)292.5*0.043*DAPSA29 (14 – 89)45.5 (20.5 – 99)226.0*0.002*C-reactive protein (mg/dl)6.3 (0.3 – 72)6 (0.8 – 61.6)409.50.80268 Tender joint count7 (2 – 64)23 (8 – 68)112*<0.001*66 Swollen joint count2 (0 – 23)4 (0 – 10)300.50.055Leeds enthesitis index2 (0 – 6)6 (3 – 6)76.5*<0.001*Dactylitic count0 (0 – 8)0 (0 – 7)4210.924

U: Mann Whitney test

t: Student t-test

p: p value for comparing between the studied categories

*: Statistically significant at p ≤ 0.05

Patients in both groups had similar functional level by health assessment questionnaire (HAQ) (U=339, p=0.188) and QOL by PsAQOL (U=306, p=0.068). While, MAF was statistically higher in group II patients 34 ranging from 28 to 48.7 in group II vs 26.5 ranging from 0 to 49.5 in group I (U=172.5, p<0.001).

In group II patients: the mean tender point count was 16.50 ± 1.84, fibromyalgia severity scale (FSS) was 20.7 ± 3.99 and fibromyalgia impact questionnaire (FIQ) was 57.22 ± 7.30. There was a statistically significant correlation between FSS and DAPSA (rs=0.59, p=0.003), PsAQOL (rs=0.64, p=0.001) and HAQ (rs=0.613, p=0.002), and between FIQ and PASI (r=0.488, p=0.018), PsAQOL (r=0.576, p=0.004), HAQ (r=0.557, p=0.006) and MAF (r=0.619, p=0.002).

Conclusion:

These results might highlight the importance of considering FM as a contextual factor in disease activity assessment in patients with PsA, especially in those with discrepancies in TJC/patients reported outcomes versus SJC/inflammatory markers or persistently high disease activity indices.

References:

[1]Turkiewicz AM, Moreland LW. Psoriatic arthritis: Current concepts on pathogenesis-oriented therapeutic options. Arthritis Rheum 2007;56(4):1051-66. 2. Husted JA, Thavaneswaran A, Chandran V, Gladman DD. Incremental Effects of Comorbidity on Quality of Life in Patients with Psoriatic Arthritis. J Rheumatol 2013;40(8):1349-56. 3. Brikman S, Furer V, Wollman J, Borok S, Matz H, Polachek A, et al. The effect of the presence of fibromyalgia on common clinical disease activity indices in patients with psoriatic arthritis: a cross-sectional study. J Rheumatol 2016;43(9):1749-54.

Acknowledgments:

Our sincere gratification to our mentor the late Prof. Dr. Abdel Moneim Helal.

Disclosure of Interests:

None declared

AB0762 METABOLIC SYNDROME IN EGYPTIAN PSORIATIC ARTHRITIS PATIENTS

Background:

Psoriatic arthritis (PsA) is a chronic inflammatory arthritis affecting 20:30% of patients with skin Psoriasis (PsO). It is strongly associated with obesity, particularly excess visceral adiposity, which leads to insulin resistance, hyperglycemia, dyslipidemia, and hypertension (HTN).

All the previous findings are grouped in Metabolic Syndrome (MetS) which increase the risk of development of Type 2 diabetes mellitus (T2DM) by five folds and cardiovascular disease (CVD) by two folds.

Objectives:

The aim of this work was to define those who fulfill MetS criteria in PsA patients thus of greater risk to develop CVD and T2DM.

Methods:

Fifty PsA patients diagnosed according to the CASPAR criteria and 50 matched healthy controls were included in this study.

All patients were subjected to thorough clinical evaluation of the musculoskeletal system. The disease activity was assessed by DAPSA and BASDAI. Skin severity was assessed by the PASI. Disability assessment was done by the HAQ-DI. Laboratory investigations included: CRP, uric acid and diabetic profile (includingHOMA-IR) and lipid profile in patients and control subjects.

Subjects were defined as having MetS according to International Diabetes Federation (IDF) criteria:

Abdominal obesity was measured by Waist circumference (WC) for Egyptian cutoffs values (WC>100.5 cm in men and >96.25 cm in women).The subjects must have central obesity to identify MetS plus any two of the following four factors:

Results:

Metabolic syndrome was significantly higher among PsA patients than control group (42% Vs 16% respectively).

Regarding frequency of MetS components, obesity was the highest component among PsA patients (62%) as illustrated in Figure 1.

CRP mean level was significantly higher in PsA patients compared to control group with p <0.001*. CRP serum level showed a positive significant correlation with DAPSA score and HOMA-IR (P= 0.031, 0.002 respectively)

Correlations between MetS components and (disease activity, skin severity and physical function) are shown in Table 1.

Conclusion:

1-There is high frequency of MetS in PsA patients compared to control group.

2- Obesity and DMT2 were the most common components of MetS.

References:

[1]Eder L, Harvey P, Chandran V, Rosen CF, Dutz J, Elder JT, et al. Gaps in diagnosis and treatment of cardiovascular risk factors in patients with psoriatic disease: an international multicenter study. The Journal of rheumatology. 2018:jrheum. 170379.

[2]Alberti KGMM, Zimmet P, Shaw J. Metabolic syndrome—a new world-wide definition. A consensus statement from the international diabetes federation. Diabetic medicine. 2006;23(5):469-80.

Psoriatic ArthritisMetabolic syndromeWCBMITGHDLFBSHOMA-IRSystolic BPDiastolic BPDAPSArs-0.2330.0810.086-0.1160.2630.3870.136-0.170P0.3080.7280.7100.6160.2500.0830.5570.462BASDAIrs0.798*0.1520.060-0.110-0.424-0.2940.168-0.027P<0.001*0.5090.7980.6360.0550.1960.4670.906PASIrs0.435*0.2260.363-0.521*-0.276-0.253-0.054-0.060P0.049*0.3240.1060.015*0.2270.2680.8180.795HAQ-DIrs0.1890.1760.168-0.286-0.240-0.184-0.343-0.276P0.4130.4450.4660.2090.2950.4240.1280.225

Disclosure of Interests:

None declared

Radioimmunotherapy of methicillin-resistant Staphylococcus aureus in planktonic state and biofilms

Background

Implant associated infections such as periprosthetic joint infections are difficult to treat as the bacteria form a biofilm on the prosthetic material. This biofilm complicates surgical and antibiotic treatment. With rising antibiotic resistance, alternative treatment options are needed to treat these infections in the future. The aim of this article is to provide proof-of-principle data required for further development of radioimmunotherapy for non-invasive treatment of implant associated infections.

Methods

Planktonic cells and biofilms of Methicillin-resistant staphylococcus aureus are grown and treated with radioimmunotherapy. The monoclonal antibodies used, target wall teichoic acids that are cell and biofilm specific. Three different radionuclides in different doses were used. Viability and metabolic activity of the bacterial cells and biofilms were measured by CFU dilution and XTT reduction.

Results

Alpha-RIT with Bismuth-213 showed significant and dose dependent killing in both planktonic MRSA and biofilm. When planktonic bacteria were treated with 370 kBq of ²¹³Bi-RIT 99% of the bacteria were killed. Complete killing of the bacteria in the biofilm was seen at 185 kBq. Beta-RIT with Lutetium-177 and Actinium-225 showed little to no significant killing.

Conclusion

Our results demonstrate the ability of specific antibodies loaded with an alpha-emitter Bismuth-213 to selectively kill staphylococcus aureus cells in vitro in both planktonic and biofilm state. RIT could therefore be a potentially alternative treatment modality against planktonic and biofilm-related microbial infections.

Bi-allelic ADARB1 Variants Associated with Microcephaly, Intellectual Disability, and Seizures

The RNA editing enzyme ADAR2 is essential for the recoding of brain transcripts. Impaired ADAR2 editing leads to early-onset epilepsy and premature death in a mouse model. Here, we report bi-allelic variants in ADARB1, the gene encoding ADAR2, in four unrelated individuals with microcephaly, intellectual disability, and epilepsy. In one individual, a homozygous variant in one of the double-stranded RNA-binding domains (dsRBDs) was identified. In the others, variants were situated in or around the deaminase domain. To evaluate the effects of these variants on ADAR2 enzymatic activity, we performed in vitro assays with recombinant proteins in HEK293T cells and ex vivo assays with fibroblasts derived from one of the individuals. We demonstrate that these ADAR2 variants lead to reduced editing activity on a known ADAR2 substrate. We also demonstrate that one variant leads to changes in splicing of ADARB1 transcript isoforms. These findings reinforce the importance of RNA editing in brain development and introduce ADARB1 as a genetic etiology in individuals with intellectual disability, microcephaly, and epilepsy.

16q22.1 microdeletion and anticipatory guidance

The widespread availability of comparative genomic hybridization (CGH) array analysis has led to the discovery of several genomic microdeletion-associated syndromes and has identified possible genetic causes for patients with previously unexplained clinical features. We report the case of four unrelated patients who share common clinical characteristics, namely failure to thrive, developmental delay, dysmorphic features, and congenital anomalies. CGH array analysis revealed that all four patients had a de novo microdeletion at 16q22.1. In this case report, we describe the clinical features of these patients and offer possible explanations for how their 16q22.1 microdeletion may account for their symptoms. We also suggest guidelines for the management of 16q22.1 microdeletion based on the phenotypes seen in our patients and the function of the genes affected by this microdeletion.

Clinical presentation and natural history of infantile-onset ascending spastic paralysis from three families with an ALS2 founder variant

Biallelic mutations of the alsin Rho guanine nucleotide exchange factor (ALS2) gene cause a group of overlapping autosomal recessive neurodegenerative disorders including infantile-onset ascending hereditary spastic paralysis (IAHSP), juvenile primary lateral sclerosis (JPLS), and juvenile amyotrophic lateral sclerosis (JALS/ALS2), caused by retrograde degeneration of the upper motor neurons of the pyramidal tracts. Here, we describe 11 individuals with IAHSP, aged 2-48 years, with IAHSP from three unrelated consanguineous Iranian families carrying the homozygous c.1640+1G>A founder mutation in ALS2. Three affected siblings from one family exhibit generalized dystonia which has not been previously described in families with IAHSP and has only been reported in three unrelated consanguineous families with JALS/ALS2. We report the oldest individuals with IAHSP to date and provide evidence that these patients survive well into their late 40s with preserved cognition and normal eye movements. Our study delineates the phenotypic spectrum of IAHSP and ALS2-related disorders and provides valuable insights into the natural disease course.

Differential-display reverse transcription-PCR (DDRT-PCR): a new technology for molecular detection and studying one of the antagonistic factors of Bacillus endophyticus strain SA against Staphylococcus aureus (MRSA)

Differential Display (DDRT-PCR) is a powerful technique for analyzing differences in gene expression. In-vivo expression technologies and differential display RT-PCR are providing new approaches to further examine a microbe's response to experimental conditions which more closely resemble natural microbial associations and habitats. In this study, Bacillus endophyticus strain SA isolated from the inner tissue of the stem of the cultivated plant (Salvadora persica, Asir, Kingdom of Saudi Arabia) produces an antagonistic factor. This factor has a broad spectrum of activity against Gram-positive and specifically against Staphylococcus aureus (MRSA). The antagonistic factor was isolated from the bacterial culture medium and purified by thin layer chromatography technique, then analyzed by GC-MS analysis. Identification of the producer strain was performed using the partial nucleotide sequence of 16S rRNA gene, which indicated that this strain is identical to B. endophyticus with 99 % similarity. The sequence of this strain was deposited at NCBI GenBank under accession number KF011545. Application of differential display RT-PCR revealed that the isolate was able to up-regulate a gene with serine protease like protein. The protein is well known as antimicrobial agent and was reported to be produced by plants, animals and insects. Serine protease is also known to be produced by bacteria for purposes oth er than bacterial-bacterial antagonistic effect, which has been confirmed by this study.

Whole Genome Sequencing Expands Diagnostic Utility and Improves Clinical Management in Pediatric Medicine

The standard of care for first-tier clinical investigation of the etiology of congenital malformations and neurodevelopmental disorders is chromosome microarray analysis (CMA) for copy number variations (CNVs), often followed by gene(s)-specific sequencing searching for smaller insertion-deletions (indels) and single nucleotide variant (SNV) mutations. Whole genome sequencing (WGS) has the potential to capture all classes of genetic variation in one experiment; however, the diagnostic yield for mutation detection of WGS compared to CMA, and other tests, needs to be established. In a prospective study we utilized WGS and comprehensive medical annotation to assess 100 patients referred to a paediatric genetics service and compared the diagnostic yield versus standard genetic testing. WGS identified genetic variants meeting clinical diagnostic criteria in 34% of cases, representing a 4-fold increase in diagnostic rate over CMA (8%) (p-value = 1.42e-05) alone and >2-fold increase in CMA plus targeted gene sequencing (13%) (p-value = 0.0009). WGS identified all rare clinically significant CNVs that were detected by CMA. In 26 patients, WGS revealed indel and missense mutations presenting in a dominant (63%) or a recessive (37%) manner. We found four subjects with mutations in at least two genes associated with distinct genetic disorders, including two cases harboring a pathogenic CNV and SNV. When considering medically actionable secondary findings in addition to primary WGS findings, 38% of patients would benefit from genetic counseling. Clinical implementation of WGS as a primary test will provide a higher diagnostic yield than conventional genetic testing and potentially reduce the time required to reach a genetic diagnosis.

The Egyptian National Breast Screening Program: Priorities, challenges, and results of the pilot phase

1523

Background: According to the World Health Organization,the number of breast cancercases in developing countries will increase dramatically by the year 2050. Egypt is likely to see an increase in this disease burden unless effective programs for early detection and control are implemented. Many women, especially those who are medically underserved, still do not understand the importance of regular mammograms, or how and where to get one. Methods: Four mobile mammography vans were launched in October 2007, to screen women over 45 years old in the underserved areas of Cairo. Each van was equipped with a full field digital mammography (FFDM) machine, dedicated computer system linked to the National Breast Screening Center via video SAT & ADSL, sphygmomanometer, blood glucose measuring kit, and spring scale and meter to measure weight and height. Based on positive findings, patients were directed to Cairo University Hospital to receive appropriate treatment. Mobile units continued to operate through October, 2008. Results: From October 2007 through October 2008, 11,414 women were screened for breast cancer, hypertension, diabetes, and obesity. Two hundred forty four (2.13%) women were radiologically positive for cancer; of these, only 112 (45.9%) women agreed to be recalled for assessment; of these, 49.1% were confirmed to be true positive with BI-RADS 4,5 (61% cases were mass, with 27.9 % 1–2 cm in size; 16.4% cases were microcalcifications alone; multicentricity in 6.6 %; bilaterality in 2.5% of cases). 36.6% were false positive, and 14.2% are under further investigation. Conclusions: Although Cairo is the most developed city in Egypt, there is lack of breast cancer awareness, especially in the underserved areas. Breast cancer is now a priority for the Ministry of Health, with four more vans and 10 fixed FFDM units to be implemented during the next year. A 5-year plan has been established to cover all 29 Egyptian Governorates.

No significant financial relationships to disclose.

Optimal target heart rate for exercise-induced T-wave alternans

OBJECTIVES

This study was conducted to determine the optimal target heart rate (HR) for the use of exercise-induced T-wave alternans (TWA) as an index for risk of malignant ventricular tachyarrhythmias.

BACKGROUND

Rate-dependent TWA is an index of vulnerability to ventricular tachyarrhythmias. However, false positive TWA was reported to occur in normal subjects at high HR.

METHODS

Two groups were evaluated: Group I: 50 patients with malignant ventricular tachyarrhythmias, who received an implantable cardioverter-defibrillator (ICD); and Group II: 55 age-matched normal subjects. In both Groups, TWA was evaluated during symptom-limited bicycle exercise test.

RESULTS

Peak HR during exercise test was 103 +/- 17 beats/min in Group I, versus 124 +/- 18 beats/min in Group II (P < 0.001). In Group I, 4 patients were excluded from analysis, due to high noise level or frequent ectopy during exercise. Out of the remaining 46 patients, TWA was present in 28 patients (61%), and absent in 18 (39%). In group II, TWA was present in four subjects (7%), and absent in 51 (93%). HR at the onset of TWA was 91 +/- 11/min in Group I, and 119 +/- 12/min in Group II (P < 0.001). Receiver operated characteristics curves demonstrated that a HR of 115 beats/min was the cutoff with the best sensitivity and specificity for TWA (100 and 96%, respectively). None of the patients in Group I developed TWA at HR > 115 beats/min, while two out of four in Group II had TWA at HR > 115/minutes. However, 13 patients in Group I who had no TWA were unable to exercise to a peak HR > 115 beats/min, compared to nine subjects in Group II.

CONCLUSIONS

A target HR of 115 beats/min was highly sensitive and specific for determination of exercise-induced TWA as an index of risk of malignant ventricular tachyarrhythmias. However, a significant number of patients may not be able to achieve this target HR, resulting in an indeterminate test. The value of pharmacologic testing in this group should be assessed.

Nonpenetrating deep sclerectomy versus trabeculectomy in bilateral primary open-angle glaucoma

OBJECTIVE

To establish the efficacy and safety of nonpenetrating deep sclerectomy versus trabeculectomy in primary open-angle glaucoma.

DESIGN

Prospective randomized trial.

PARTICIPANTS

Thirty-nine patients (78 eyes) with bilateral primary open angle glaucoma were included in the study.

INTERVENTION

Eyes were randomly assigned to receive deep sclerectomy in one eye and trabeculectomy in the other eye.

MAIN OUTCOME MEASURES

Mean intraocular pressure (IOP), postoperative medications, visual acuity, success rate, and complications.

RESULTS

At 12 months, mean IOP reduction was 12.3 +/- 4.2 (sclerectomy) versus 14.1 +/- 6.4 mmHg (trabeculectomy) (P = 0.15), and an IOP </= 21 mmHg was achieved in 36 (92.3%) and 37 eyes (94.9%) (P = 0.9), respectively. Complications included three (7.7%) flat/shallow anterior chambers and one (2.6%) hypotony (trabeculectomy), whereas internal iris incarceration was encountered in two eyes (5.1%) (sclerectomy).

CONCLUSIONS

Deep sclerectomy may provide comparable IOP reduction with fewer complications in management of primary open angle glaucoma.

Postradiation therapy adenosquamous cell carcinoma of the prostate

The objective of this study was to present two cases of adenosquamous cell carcinoma of the prostate following radiation therapy. Two patients with history of prostate cancer treated with radiation therapy presented with rectal bleeding and a large ulcerated rectal mass. The rectal biopsy revealed on both cases squamous cell carcinoma. The initial diagnosis was invasive squamous cell carcinoma from anal origin. Both patients underwent pelvic exenteration with continent urinary diversion. After extensive histological sampling and immuno-histochemisty, they were correctly diagnosed of adenosquamous cell carcinoma of the prostate with invasion of the rectum. The patients died 6 and 16 months after surgery with widespread metastases. A review of the literature is presented. Adenosquamous cell carcinoma of the prostate is an unusual histological variant of prostate cancer. To our knowledge, only three cases of adenosquamous cell carcinoma of the prostate following radiation therapy have been reported. The unusual clinical and histopathological features of the two cases reported here led to an initial mistaken diagnosis. Adenosquamous cell carcinoma of the prostate should be considered in the differential diagnosis when a patient with prostate cancer develops a rectal mass or rectal bleeding following radiation therapy and the rectal biopsy reveals squamous cell carcinoma. Prostate Cancer and Prostatic Diseases (2000) 3, 53-56

Sildenafil citrate (Viagra) for the treatment of erectile dysfunction in men with Parkinson's disease

Sildenafil citrate (Viagra) is a phosphodiesterase type V inhibitor used to treat erectile dysfunction. Ten men with idiopathic Parkinson's disease (PD) and erectile dysfunction were prescribed 50-100 mg sildenafil citrate to use in eight sexual encounters over a 2-month period. Patients underwent Unified Parkinson's Disease Rating Scale (UPDRS) evaluations and completed a Beck's Depression Inventory (BDI) and a Sexual Health Inventory-M version (SHI-M) at baseline and after 8 weeks. There was statistically significant improvement in total SHI-M scores (23.8 +/- 2.0 vs 16.6 +/- 2.8; p = 0.01), overall sexual satisfaction (p = 0.03), satisfaction with sexual desire (p = 0.04), ability to achieve erection (p = 0.02), ability to maintain erection (p = 0.03), and ability to reach orgasm (p = 0.04) with use of sildenafil citrate. UPDRS and BDI scores were not significantly changed. Side effects included headache in one patient during three sexual encounters. In this open-label study, sildenafil citrate significantly improved sexual function in men with PD and erectile dysfunction.

Simultaneous subconjunctival and subscleral mitomycin-C application in trabeculectomy

OBJECTIVE

To establish the efficacy and safety of simultaneous subconjunctival and subscleral application of mitomycin-C in trabeculectomy.

DESIGN

A prospective, randomized study.

PARTICIPANTS

Sixty-eight patients (68 eyes) with refractory glaucomas were included in the study.

INTERVENTION

Eyes were randomly assigned to receive intraoperative mitomycin-C (0.3 mg/ml) applied under the conjunctival flap (group 1), scleral flap (group 2), or under both flaps (group 3).

MAIN OUTCOME MEASURES

Mean intraocular pressure (IOP), postoperative medications, visual acuity, filtering bleb appearance, and complications.

RESULTS

There was a significant difference in IOP at 6, 9, and 12 months after surgery among the three groups (P = 0.021, 0.026, and 0.033, respectively ANOVA). At 12 months, the mean IOP in group 3 was 9.8+/-3.7 mm Hg compared with 13.4+/-5.5 mm Hg in group 2. (P = 0.015) and 12.4+/-4.4 mm Hg in group 1 (P = 0.039). Success rate (21 mm Hg or less), number of antiglaucoma medications, and complications showed no statistical significant difference between the three groups at each postoperative visit.

CONCLUSIONS

Mitomycin-C applied under the scleral flap may have an additional beneficial effect when combined with simultaneous subconjunctival exposure.

A feasibility study of gene gun mediated immunotherapy for renal cell carcinoma

PURPOSE

Gene modified autologous tumor cell vaccines have demonstrated a protective and therapeutic effect in murine tumor model systems. The majority of trials to date have used viral methods of gene transfer for vaccine construction. An alternative approach to transfer genes into tumor cells is to use the gene gun, which is a physical method of gene transfection that produces high levels of gene expression without viral agents. We establish the feasibility of generating cytokine secreting autologous renal tumor cell vaccines for use in gene therapy for metastatic renal cell carcinoma.

MATERIALS AND METHODS

We obtained 1 cm3 tumor tissue from 12 patients undergoing resection of primary or metastatic renal cell carcinoma. The tumor was disaggregated and placed in culture. The phenotype of the primary renal cell lines was established by microscopy and immunohistochemistry. The 1x10(7) lethally irradiated tumor cells were transfected with plasmid deoxyribonucleic acid containing the human (h) granulocyte-macrophage colony-stimulating factor (GM-CSF) gene under control of a cytomegalovirus promoter using the gene gun. The hGM-CSF production was assayed by enzyme-linked immunosorbent assay in the cell culture media 24 hours after transfection.

RESULTS

Of 12 tumor samples 8 grew rapidly to produce a mean of 1.8x10(8) cells after 4 to 5 passages in culture, which was sufficient to produce between 24 and 32 vaccines. Immunocytochemistry confirmed that all cultures were almost exclusively renal tumor cells. Gene gun mediated transfection of lethally irradiated tumor cells resulted in high levels of hGM-CSF production (mean 330 ng./10(6) cells per 24 hours).

CONCLUSIONS

We have demonstrated the feasibility of producing cytokine secreting tumor cell vaccines from primary and metastatic human renal tumors, and plan to use this approach in phase I clinical trials of gene therapy for metastatic renal cell carcinoma.

Fornix-based versus limbal-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil: four-year follow-up findings

PURPOSE

To evaluate the safety and efficacy of fornix-based conjunctival flap versus limbal-based flap in initial trabeculectomy with postoperative 5-fluorouracil.

METHODS

29 patients (58 eyes) with bilateral primary open-angle glaucoma (POAG) were included in the study. Patients were randomly assigned to have a fornix-based conjunctival flap in one eye and a limbal-based flap in the other, followed by subconjunctival injection of 5-fluorouracil.

RESULTS

Mean intraocular pressure (IOP) 2 years after treatment was 12.9 +/- 12.25 mmHg in eyes with fornix-based conjunctival flaps and 13.1 +/- 16.81 mmHg in eyes with limbal-based conjunctival flaps. At 4 years, mean IOP was 14.7 +/- 9.61 mmHg in eyes with fornix-based conjunctival flaps and 15.1 +/- 7.29 mmHg in eyes with limbal-based conjunctival flaps. Cumulative success at 4 years (IOP < 21 mmHg) was 89.6% in eyes with fornix-based conjunctival flaps versus 86.2% in eyes with limbal-based conjunctival flaps with medications. Cystic leaking blebs occurred in two cases, both with limbal-based flaps.

CONCLUSION

The efficacy of limbal- and fornix-based conjunctival flaps in initial trabeculectomy with postoperative 5-fluorouracil was not significantly different; however, in this study cystic leaking blebs were encountered only in eyes with limbal-based conjunctival flaps.

One-site versus 2-site phacotrabeculectomy: a randomized study

PURPOSE

To compare 1-site and 2-site combined phacoemulsification with foldable intraocular lens (IOL) implantation and trabeculectomy.

SETTING

El-Maghraby Eye Hospital, Jeddah, Saudi Arabia.

METHODS

Seventy-six eyes with coexisting cataract and glaucoma were randomly assigned to have a mitomycin-C trabeculectomy in a superior quadrant combined with phacoemulsification and foldable IOL implantation through the same incision (1-site group) or a separate, temporal, clear corneal incision (2-site group). Postoperative evaluation included visual acuity, intraocular pressure (IOP), bleb assessment, and number of antiglaucoma medications. Follow-up ranged from 12 to 18 months.

RESULTS

Mean preoperative IOP was 28.1 mm Hg +/- 7.1 (SD) in the 2-site group and 26.2 +/- 6.5 mm Hg in the 1-site group. At 6 months postoperatively, mean IOP was 16.9 +/- 4.3 and 16.8 +/- 3.8 mm Hg, respectively (P = .9) and at 12 months, 17.6 +/- 3.3 and 19.1 +/- 3.1 mm Hg, respectively (P = .044). Twenty-three of 39 eyes (59%) in the 2-site group and 14 of 37 (38%) in the 1-site group had clinically apparent filtering blebs at 12 months (P = .065). Postoperative astigmatic change and complications were comparable.

CONCLUSION

Mitomycin-C trabeculectomy superiorly combined with separate temporal clear corneal phacoemulsification provided 1 year IOP control comparable to that with single-incision (1-site) combined cataract and glaucoma surgery.

Laparoscopic nephrectomy using the harmonic scalpel

Laparoscopic nephrectomy is gaining popularity. Improved instrumentation is making surgery easier with fewer complications. Our first three laparoscopic nephrectomies using the Harmonic Scalpel were performed on two women and one man. The surgical indications were nonfunctioning kidneys (two left, one right) with hypertension in one patient and stone disease in two. The three patients had a mean age of 46.3 years. The average hospital stay was 4 days, the average operative time 3.7 hours, and the average blood loss 160 mL. No complications occurred. Patients resumed oral intake within 8 hours postoperatively. We found the Harmonic Scalpel easy and safe to use. It saved time, was cost effective, and was capable of easily controlling small-vessel bleeding. In conclusion, the Harmonic Scalpel could be used effectively for both dissection and bleeding control without suction or other instrumentation.

The Hickman peel-away sheath: alternative for pediatric percutaneous nephrolithotomy

Percutaneous nephrolithotomy presents a therapeutic challenge in children because of the disproportion between the sizes of the instruments and the kidneys. A technique for pediatric nephrolithotomy used on a 2-year-old female child is presented. The patient was born prematurely and developed kidney stones as a complication of furosemide therapy. She failed medical management with hydrochlorothiazide, and the stone did not disintegrate following extracorporeal shockwave lithotripsy (ESWL). A Chiba needle was used to access the renal collecting system percutaneously. Using a guidewire, sequential dilatation was performed to 16F. A 15F Hickman catheter introduction kit was then used, and the sheath was partially peeled away. A 10F pediatric cystoscope and grasper were inserted through the sheath to remove the stones. A 12F catheter was then placed through the sheath; the sheath was peeled away, and the catheter was left indwelling for 48 hours. No complications ensued. A postoperative nephrostogram showed free drainage and absence of residual stones. Utilization of the Hickman peel-away sheath constitutes an excellent alternative nephrolithotomy technique for children with stones unresponsive to more conservative treatment.

Evaluation and management of parastomal hernia in association with continent urinary diversion

PURPOSE

We discuss the incidence and diagnosis of parastomal hernias in association with continent urinary reservoirs. We also present a surgical technique appropriate for correction of this complication.

MATERIALS AND METHODS

We evaluated 21 patients with parastomal hernia after construction of a continent urinary reservoir. The hernia developed secondary to diversion with an ileocecal segment in 19 patients and a Kock procedure in 2. Subsequent to development of the parastomal hernia 13 patients (61.9%) had simultaneous urinary incontinence, 2 (9.5%) had difficulty catheterizing the reservoir and 4 (19.047%) had associated pain over the stomal area. Evaluation was primarily by physical examination. However, 2 patients (9.5%) required abdominal computerized tomography to confirm the diagnosis of parastomal hernia. Surgical repair was recommended for all patients, and 19 underwent repair with or without revision of the anti-incontinence segment. Reconstruction included transabdominal takedown of the anti-incontinence segment from the abdominal wall with parastomal hernia closure through a midline incision, external reinforcement of the hernia opening with Marlex mesh when the diameter exceeded 6 cm., revision of the anti-incontinence mechanism when simultaneous urinary incontinence existed preoperatively and repositioning of the stoma site through a new selected area in the abdominal wall.

RESULTS

The success rate (mean followup 23.4 months) with this surgical approach was 89.5%. Incontinence due to failure of the anti-incontinence mechanism was successfully corrected in 13 patients (100%).

CONCLUSIONS

Long-term followup of continent urinary reservoirs is often associated with development of parastomal hernia. This complication can be associated with urinary incontinence, peristomal pain and difficult catheterization. Evaluation is primarily by physical examination but selected clinical situations require abdominal computerized tomography to confirm the diagnosis. The surgical technique following the steps described has been associated with minimal morbidity and has provided excellent surgical results (89.5% success rate).

Bladder Replacement and Urinary Diversion After Radical Cystectomy

BACKGROUND: The optimal mode of urinary tract reconstruction following cystectomy continues to challenge the urologic surgeon. Disadvantages with bowel conduits have prompted the search for better techniques to improve patient outcomes. METHODS: The development of urinary tract reconstruction is reviewed, and results from several forms of continent urinary diversion and bladder replacement construction are presented. The authors report on their experience in creating continent reservoirs or neobladders in over 400 patients. RESULTS: Several surgical approaches are now available for continent urinary diversion. Metabolic and nutritional abnormalities, stone formation, infection, and cancer formation are potential complications. CONCLUSIONS: Advances in surgical techniques, an understanding of the physiology of isolated bowel segments, and improvements in pre- and post-operative care have altered the field of urinary reconstruction after cystectomy for bladder cancer. Most patients can expect minimal morbidity and mortality.

Intraoperative mitomycin-C versus postoperative topical mitomycin-C drops for the treatment of pterygium

BACKGROUND AND OBJECTIVE

To evaluate the safety and efficacy of two different regimens of mitomycin-C (MMC) application as adjunctive chemotherapy in the treatment of pterygia.

PATIENTS AND METHODS

One hundred fifty-six patients underwent pterygium excision using the bare sclera technique. They were randomly assigned to have either 0.1 mg/ml of MMC applied to the bare sclera for 3 minutes intraoperatively, or 0.05-mg/ml drops applied topically for 2 weeks postoperatively. The mean follow-up period was 11 months (range 7 to 17).

RESULTS

Complications with the intraoperative MMC included 5 cases of recurrence (5.75%), 2 cases of superficial punctate keratitis (SPK), and 3 cases of delayed conjunctival wound healing. Topical MMC led to 6 cases of recurrence (6.9%), 5 cases of SPK, 4 cases of delayed conjunctival wound healing, and 2 cases of mild iritis.

CONCLUSION

A single, intraoperative application of MMC is a simple, effective alternative adjunctive treatment for pterygium.

Urethral obstruction after anti-incontinence surgery in women: evaluation, methodology, and surgical results

OBJECTIVES

To evaluate a group of women with voiding dysfunction and a low maximum flow rate (MFR) (less than or equal to 12 mL/s) after surgery for stress urinary incontinence (SUI); to establish diagnostic parameters indicating obstruction in an attempt to determine treatment selection; and to evaluate preliminary surgical results.

METHODS

Eighteen women who underwent anti-incontinence surgery for SUI were diagnosed as having infravesical obstruction (IO). Thirteen women (group A [72%]) presented with clinically predominant symptoms of urgency, frequency, intermittency, and a variable vesical residual volume (RV), and five (group B [28%]) had as their most significant symptoms a high vesical RV and urinary tract infection that had been managed with intermittent catheterization (IC). The diagnosis of IO, suspected after clinical history, was established after physical examination and cystoscopic, cystographic and urodynamic investigations.

RESULTS

Bladder instability was demonstrated in 6 group A patients (46%) and 1 group B patient (20%) (P = NS). Mean MFRs were 8.07 and 7.2 mL/s, respectively, in both groups (P = NS). Mean maximal voiding pressures (MVPs) were 20.23 and 5 cm H20, and mean RVs were 57.46 and 174 mL, respectively; both differences were statistically very significant (P <0.01 and P <0.001, respectively). High to normal MVPs occurred in 2 patients overall (11%). Bladder neck overcorrection, midurethral distortion, and postsurgical cystocele were demonstrated in both groups in 11 (85%), 0, and 2 (15%) patients in group A and 3 (60%), 2 (40%), and 3 (60%) patients in group B, respectively (P = NS). Patients in group A were treated surgically with cystourethrolysis and a repeated, less obstructive anti-incontinence operation. In group B 2 women (40%) had a similar surgical procedure; 1 (20%) underwent isolated urethrolysis; and 2 (40%) are currently maintained with IC.

CONCLUSIONS

Among these 18 patients with voiding dysfunction after anti-incontinence surgery, a primary diagnosis of IO was established clinically. Only patients with a low MFR were selected for this study. Cytographic and endoscopic investigation as well as the presence of postsurgical cystocele assisted in establishing the diagnosis. The success rate with urethrolysis and resuspension was 60% for the 13 women with predominantly urgency, frequency, and the highest MVPs (20.23 +/- 9.67 cm H20 [group A) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 +/- 7.07 cm H20 [group A]) and 33% for the 5 women with urinary retention presenting the lowest MVPs (5.00 +/- 7.07 cm H20 [group B]). An added resuspension procedure is probably unnecessary in the latter group of patients and requires careful individual selection in the former group.

Transscleral fixation of posterior chamber intraocular lenses in the absence of capsular support

PURPOSE

To evaluate the safety and efficacy of a modified technique of transscleral fixation of posterior chamber intraocular lenses (IOLs) in the management of unilateral aphakia and in cases of IOL exchange.

SETTING

El-Maghraby Eye Hospital, Jeddah, Saudi Arabia.

METHODS

This prospective study comprised 41 eyes of 41 patients who had transscleral fixation of a posterior chamber IOL using a modified technique. Of these patients, 36 had unilateral aphakia and 5 had pseudophakia requiring lens exchange. Patient age ranged from 40 to 80 years. Follow-up was 12 months.

RESULTS

Uncorrected visual acuity improved in all patients. Best corrected visual acuity was unchanged in 87.8% of patients, improved by two to four Snellen lines in 9.8%, and decreased by one or two Snellen lines in 2.4%. Most complications were minor and managed medically; only two patients required further surgical intervention.

CONCLUSION

Our modified technique is safe and effective. We recommend evaluation of longer term results.

Absence of neuropathic pelvic pain and favorable psychological profile in the surgical selection of patients with disabling interstitial cystitis

PURPOSE

We evaluated the results among patients with disabling interstitial cystitis treated by cystectomy, urethrectomy and creation of a continent colonic urinary reservoir (the Florida pouch). The value of psychological evaluation and pain localization techniques, as well as the use of a team approach in the evaluation of these patients were assessed.

MATERIALS AND METHODS

The 20 women and 2 men who underwent surgery for disabling interstitial cystitis ranged from 31 to 75 years old (mean age 48). The duration of symptoms ranged from 2 to 14 years (mean 7). All patients had undergone multiple prior therapies, including vesical hydrodistension, instillations, laser treatments, and use of tranquilizers and a variety of pain medications. Patients underwent a clinical, cystoscopic (with bladder biopsies) and urodynamic evaluation as well as examination by a gynecologist with expertise in vaginal ultrasonography. The last 5 patients underwent psychological evaluation and pain localization techniques.

RESULTS

Among the clinical parameters, the presence of a small capacity bladder with the patient under anesthesia (less than 400 cc) was associated with the best surgical results. Among 11 patients evaluated only clinically success was achieved in 64%, while all 5 (100%) who also underwent pain localization techniques and psychological evaluation had a successful outcome postoperatively. The overall surgical success rate in the 22 patients was 73%. Two patients undergoing psychological evaluation and pain localization techniques were not considered to be surgical candidates. Among 7 surgical failures 4 patients underwent postoperative psychological evaluation and pain localization techniques, and they would not have been considered candidates for surgery with the new parameters.

CONCLUSIONS

A team approach is essential in the evaluation of these patients. Following the initial selection of patients who had a small bladder capacity while under anesthesia, psychological evaluation and pain localizing techniques may assist surgeons in selecting those who would benefit from a radical operation.

Molteno implant versus trabeculectomy with adjunctive intreoperative mitomycin-C in high-risk glaucoma patients

PURPOSE

The Molteno implant is one of the most widely used drainage devices for the management of complicated glaucoma. Antiproliferative agents such as mitomycin-C (MMC) have markedly improved the outcome of glaucoma filtering surgery. This case control study compares the results of these two techniques in the management of high-risk glaucoma patients.

METHODS

Forty-three consecutive patients with complicated glaucoma who underwent glaucoma filtration surgery with intraoperative application of 0.3 mg/ml of MMC were matched with a control group of 43 glaucoma patients who previously had tube surgery using a single-plate Molteno drainage implant in most of the cases. Control patients were matched based on diagnostic group of glaucoma, the number of prior filtration surgeries, and patient age. All patients had a minimum follow-up time of 12 months.

RESULTS

Intraocular pressure (IOP) +/- 21 mm Hg was achieved 6 months postoperatively in 34 patients (79.1%) with Molteno implant and in 38 (88.4%) treated with MMC (p < 0.2), and 12 months postoperatively in 26 (60.5%) and 35 (81.4%) patients, respectively (p < 0.03). Complications after Molteno implant included hypotony (20.9%), flat anterior chamber (11.6%). tube-cornea touch (6.9%), and tube exposure (4.7%); after MMC, hypotony occurred in 6.9% and flat anterior chamber in 2.3%

CONCLUSIONS

A significantly greater reduction in IOP was noticed in MMC-treated eyes 12 months postoperatively. Complications occurred more frequently in the Molteno-treated eyes. Filtration surgery with adjunctive MMC therapy seems to have a higher benefit/risk ratio in the management of highrisk glaucoma.

Prostate cancer imaging with a new monoclonal antibody: a preliminary report

BACKGROUND

Optimal treatment of prostate cancer depends on accurate staging. Computed tomography (CT) and magnetic resonance imaging have severe limitations, and standard bone scanning can show only destructive osseous metastases. A radiolabeled antibody specific to prostatic adenocarcinoma could theoretically find evidence of soft-tissue metastases and lymph node involvement.

METHODS

An immunoconjugate (CYT-356) consisting of a murine monoclonal antibody against human prostatic adenocarcinoma bound to a linker-chelator and radiolabeled with indium 111 was administered intravenously to seven patients with documented Stage D adenocarcinoma of the prostate. Planar imaging was done on days 1, 2, and 3 after injection. The CYT-356 scans were compared with standard technetium Tc99m sulfur colloid bone scans and CT scans.

RESULTS

Optimal imaging results were obtained on the 72-h scans. All patients had lesions on both the 99mTc-sulfur colloid bone scan and the CYT-356 scan. The location of the lesions correlated to a great extent. Two patients had positive lesions biopsied, and both biopsies showed the presence of metastatic prostatic carcinoma. There were no side effects from administration of the antibody.

CONCLUSION

In this preliminary study, CYT-356 scanning appears to be a promising agent to accomplish specific staging of prostatic carcinoma.

The tapered and reimplanted small bowel as a variation of the Mitrofanoff procedure: preliminary results

Ten patients with a urethra that could not be catheterized and with absent appendixes underwent neobladder construction using an ileal segment fashioned to serve as the anti-incontinence mechanism. The latter was tapered and reimplanted following the guidelines of the Mitrofanoff procedure. Urinary reservoirs were constructed from detubularized segments of right colon, sigmoid colon and composite gastro-ileal combinations. Followup ranged from 9 to 21 months (mean 14.5). All patients presently catheterize the reservoir satisfactorily and are free of urinary leakage. Three patients (30%) experienced initial catheterization difficulties: 2 required endoscopic procedures and insertion of a stent, and 1 with stomal stenosis was successfully treated with a Y-V stoma plasty. One patient (10%) required a repeat ileal segment reimplantation due to urinary incontinence. The higher reoperation rate and the increased surgical complexity of this procedure compared with reconstructions using the ileocecal valve as part of the anti-incontinence mechanism make this operation a less attractive alternative in the creation of a continent urinary reservoir. However, with comprehension of the need for careful and detailed surgical technique in its creation, the tapered and reimplanted ileal segment is a successful choice as an alternative for the creation of an abdominal wall stoma when the appendix is unavailable.

Direct (nontunneled) ureterocolonic reimplantation in association with continent reservoirs

A total of 190 patients underwent continent urinary diversion using the Florida pouch. Direct mucosa-to-mucosa ureterocolonic reimplantation was used in 165 patients (326 ureters). Of the first 30 ureters in patients who underwent antireflux tunneled reimplantation obstruction occurred in 4 (13.3%). Obstruction developed directly in 16 of the ureters reimplanted (4.9%), and 3 of the 6 plicated and reimplanted megaureters (50%). Among the obstructed units 3 (13%) were treated unexpectedly by autonephrectomy, while the other 20 units (87%) were treated with percutaneous balloon dilation and internal stenting for 6 to 8 weeks. In the latter group 12 units (60%) recovered function, 3 (15%) had pyelonephritis requiring nephrectomy and 5 (25%) stabilized following a new reimplantation. Reflux was demonstrated in 23 units (7%). All units with reflux are being followed conservatively and renal deterioration has not been demonstrated. The incidence of ureteral obstruction with direct reimplantation is lower compared to a tunneled technique. This reimplantation procedure is technically simpler than others and is safe in adults when performed in association with a large volume, continent colonic reservoir.

The gastroileoileal pouch: an alternative continent urinary reservoir for patients with short bowel, acidosis and/or extensive pelvic radiation

We report on 6 patients who underwent a new type of continent urinary diversion: the gastroileoileal reservoir. These are a select group of patients who presented with the short bowel syndrome, acidosis, borderline diarrhea and/or severe pelvic radiation, which precluded the use of terminal ileum and the ileocecal segment. Considering these factors, and based on the different functional properties of the stomach as well as the need for a large reservoir, a segment of stomach and proximal ileum was used to construct the reservoir. Four patients have been followed for at least 6 months, with the longest followup being 12 months. Temporary dysphagia requiring hydrogen blockers developed in 1 patient. Results indicate excellent function of the continent urinary system, lack of metabolic complications, absent diarrhea and excellent patient tolerance. This procedure could be a useful alternative in some difficult clinical situations when continent urinary diversion is desirable.

Periurethral polytetrafluoroethylene paste injection in incontinent female subjects: surgical indications and improved surgical technique

We present the results with 2 techniques for periurethral polytetrafluoroethylene (Polytef) injection in 21 female subjects with type III stress urinary incontinence. The standard technique included the use of a stainless steel needle for injection, paste "sopping" and a Wolff, Storz or Lewy syringe as an injecting element. Postoperatively, no catheters were left indwelling and all patients were encouraged to urinate following recovery from the anesthesia. The modified technique included the use of a 14F angio-catheter for injection of the paste, paste heating and a Lewy syringe or Mentor gun as injector. Postoperatively, all patients were left with an indwelling suprapubic catheter for 3 to 5 days. A total of 27 injections was performed, including 9 with the standard technique and the last consecutive 18 with the modified technique. Average followup has been 11.4 months. Cure, improvement and no change rates from the preoperative condition were 11%, 22% and 67% with the standard technique and 39%, 17% and 44% with the modified technique, respectively. In the latter group 3 patients had received pelvic radiotherapy as definitive treatment for pelvic malignancies. The overall failure rate in patients with a stable detrusor was 42% compared to 75% in the group with bladder instability and low compliance. Advantages of the modified technique include avoidance in the formation of intraoperative and postoperative fistulas, and easier handling and injection of the heated paste to achieve urethral compression. Improved short-term results with the modified technique indicate that a larger group of patients and long-term followup are essential requirements to determine the true efficacy of this technical modification. Based on these preliminary results, we now prefer the modified technique to the standard technique in the management of type III stress urinary incontinence.

Conversion from external appliance wearing or internal urinary diversion to a continent urinary reservoir (Florida pouch I and II): surgical technique, indications and complications

A total of 20 patients with diversion requiring an external appliance or internal urinary diversion underwent conversion to a continent urinary reservoir (Florida pouch I or II). All patients subsequently reported an improvement in the quality of life and expressed satisfaction with the new urinary diversion procedure. Of the patients 15 (75%) previously had an ileal conduit, while 1 (5%) had undergone ureterosigmoidostomy, 1 (5%) had cutaneous ureterostomy, 1 (5%) had a suprapubic tube, 1 (5%) had a sigmoid conduit and 1 (5%) had a cecal conduit. After the original diversion 3 patients (15%) had recurrent urinary infections, 3 had complications related to the stoma and external appliance (stenosis and skin dermatitis) and 5 (25%) had ureteral obstruction in 7 ureters. A total of 17 patients with conduits (85%) underwent conversion via different surgical technical aspects depending on the status of the intestinal segment from the conduit and the function of the ureteral reimplantation: in 14 the conduit was discarded or was used only to patch the newly created Florida I colonic pouch, while in 6 the conduit was preserved and 9 ureterointestinal reimplantations were left undisturbed (Florida pouch II). Among 7 ureters preoperatively obstructed (original diversion), reimplanting them into the pouch failed to prevent further renal damage in 5 (71%). Three renal units required nephrectomy, 2 kidneys deteriorated and 2 recovered renal function after percutaneous balloon dilation and stenting. Among 31 preoperatively nonobstructed renoureteral units (original diversion), 22 were reimplanted into the colonic reservoir. One of these units (4.2%) became obstructed postoperatively and 3 (13.5%) presently have reflux. The 10 reimplantations left undisturbed in the detubularized conduit drain satisfactorily without postoperative obstruction and in 6 reflux has not been demonstrated. Renal function (serum creatinine) is preserved in all patients but 15 (75%) have hyperchloremia of mild degree. Two patients (10%) have acidosis and 1 (5%) of these had low red blood cell folic acid. Conversion of an external or internal diversion to a continent colonic urinary reservoir (Florida pouch I or II) can be successful and improve the quality of life of the patient. The functioning renal units that were preoperatively obstructed were associated with a high failure rate (71%) after reimplantation. Metabolic alterations will require long-term followup, and are particularly worrisome in children and young adults.

Results, complications and surgical indications of the Florida pouch

One hundred and seven patients underwent continent urinary diversion using an extended, detubularized right colonic segment as the urinary reservoir and the distal part of the ileum as a continent catheterized efferent system. This reservoir allows the accommodation of a large volume of urine; urodynamics in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 milliliters (an average of 747 milliliters). The reservoir maximal volume and pressure remains unchanged in six patients studied urodynamically three to four years postoperatively. Maximal reservoir pressures ranged between 10 and 58 centimeters of H2O (an average of 35 centimeters). Of 201 ureterocolonic reimplantations, four ureters were initially reimplanted using a modified Le Duc procedure, 26 ureters were subsequently managed using the Goodwin transcolonic approach and 165 reimplantations were done with a direct (nontunneled) mucosa to mucosal anastomosis. The over-all success rates with each of the three techniques (absence of reflux and obstruction) have been 75.0, 84.7 and 87.4 per cent, respectively. However, the incidence of obstruction was 13.3 per cent for the tunneled and 4.2 per cent for the non-tunneled reimplantations. Six megaureters underwent imbrication and direct reimplantation, and three of these became obstructed. One patient died of pulmonary embolism. Medical and surgical complications markedly predominated in the group who underwent simultaneous cystectomies, and in this group, the over-all complication rate was comparable with that for previously reported series with ileal conduits. The double row plication of the distal part of the ileum and ileocecal valve allows easy catheterization every four to six hours and 105 patients (97.2 per cent) remained continent between catheterizations. The stoma is covered using a small gauze, cap or sterile adhesive strip. This protects clothing from mucus production by the stoma and an occasional episode of urinary dribbling. Seven patients required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.

The use of releasable sutures in Molteno glaucoma implant procedures to reduce postoperative hypotony

We used releasable sutures to minimize immediate postoperative hypotony and flat anterior chamber in 19 cases of refractory glaucoma requiring insertion of a single-plate Molteno implant in a one-stage procedure. A slip knot using 7-0 nylon suture was fashioned around the Molteno tube under a lamellar scleral flap. In 18 of the 19 eyes, anterior chamber depth was normal immediately after surgery.

The overlooked, retained Double J stent

A series of 4 patients with long overlooked, retained ureteral stents is presented to illustrate the variable, unpredictable, and at times, hazardous course of such patients. These cases are cited to re-emphasize the need for careful documentation, observation, and follow-up of patients in whom stents are placed.

A continent colonic urinary reservoir: the Florida pouch

A total of 92 patients underwent continent urinary diversion with an extended, detubularized right colonic segment as the urinary reservoir and the distal ileum as a continent catheterizable efferent system. In this series 65 patients were followed for 6 to 46 months (average 17 months). Our reservoir allows the accommodation of a large volume of urine; urodynamic studies in 28 patients demonstrated a maximum reservoir capacity varying between 550 and 1,200 cc (average 747 cc). Maximal reservoir pressures ranged from 10 to 58 cm. water (average 35 cm. water). Of the 127 ureterocolonic reimplantations 4 ureters were initially reimplanted with a modified Le Duc procedure, 26 ureters were managed subsequently with the Goodwin transcolonic approach and 91 reimplantations were done with a direct (nontunneled) mucosa-to-mucosa anastomosis. The overall success rates with each of the 3 techniques (absence of reflux and obstruction) were 75, 88.6 and 90.1%, respectively. Six megaureters underwent imbrication and direct reimplantation, and 3 of these (50%) became obstructed. Two converted ileal conduits were opened at the antimesenteric edge and were patched to the reservoir while the ureteroileal anastomosis was left undisturbed. One patient (1.5%) died of pulmonary embolism. Medical and surgical complications occurred only in the group who underwent simultaneous cystectomy and the over-all rate of complication was comparable to previous series with ileal conduits. The double row plication of the distal ileum and ileocecal valve allows for easy catheterization every 4 to 6 hours and 63 patients (97%) remain continent between catheterization. Four patients (6%) required reoperation for correction of incontinence or other complications. Our satisfactory experience with these patients makes this technique an excellent approach to achieving continent urinary diversion.

Combined cystourethropexy for the treatment of type 3 and complicated female urinary incontinence

We treated 37 women with type 3 stress urinary incontinence or with an associated complicating factor, such as morbid obesity, a large or proximal diverticulum or a urethrovaginal fistula, via combined transvaginal cystourethropexy. All women with type 3 stress incontinence had failed a previous anti-incontinence operation. Patients in both groups underwent suprapubic needle suspension and an additional bladder neck support procedure. Among 33 patients who underwent preoperative urodynamic studies 30 had stable bladders (90%), while 3 had low pressure detrusor instability (10%). The success rate in achieving continence, including cured and improved patients, was 94.6% with a followup of 3 to 72 months. Four patients (10%) required temporary intermittent catheterization for 3 to 4 weeks but none presented with long-term voiding dysfunction. The added bladder neck support improved our results in these complicated female incontinence cases compared to the standard suprapubic needle suspension procedures alone. The combined procedure currently is our method of choice for treatment of type 3 and other complicated cases of female urinary incontinence.