Digital fluorographic video-urodynamics in the long-term morphofunctional evaluation of Alcini's Ileocecourethrostomy and ileal reservoir

INTRODUCTION

The authors present the functional long-term follow-up by means of digital fluorographic video-urodynamics (DFVUDM) of two different surgical urinary diversions.

MATERIALS AND METHODS

64 of 101 patients submitted to radical cystectomy from 1983 to 1999 for infiltrating bladder cancer, were diverted by means of an Alcini's ileocecourethrostomy (ICUS+T), and the remaining 37 patients by means of an ileal reservoir (IR). All of those orthotopically diverted patients were submitted to an accurate follow-up which included DFVUDM 1, 3, 6, and 9 years after the surgical procedure (mean follow-up 51 +/- 42 months).

RESULTS

All the evaluated patients showed a neobladder with good function during both the filling and the voiding phases. In 88.8% of the DFVUDM examinations, it was possible to find a residual peristaltic activity of the neobladder walls. Such a residual peristaltic activity caused urinary leakage during the examination in 11.1% of cases, while vesico-ureteral reflux was detected in 12.5%. The patients voided by relaxing the perineal floor and/or by contracting the abdominal muscles: the emptying of the reservoir was often excellent with average residual urine of 28.5 ml. None of the patients needed clean intermittent catheterization. EMG evaluation of the pelvic floor in some of patients showed a peculiar EMG pattern characterized by an insufficient voluntary control of the perineal musculature with a slight increase of EMG activity during bladder filling. Moreover, an insufficient relaxation of the pelvic floor muscles in the beginning of and during the micturition has been seen. This particular EMG pattern was present in 22.22% of all patients included in this study while it was particularly high (81.81%) in patients with leakage.

CONCLUSION

DFVUDM evaluation represents a highly sophisticated tool which allows an accurate long-term morphofunctional evaluation of the urinary diverted patients. In this study, it is shown that the functional results of the two studied surgical procedures, namely Alcini's ICUS+T and IR, are quite similar, demonstrating that the taeniotomies on the cecal tract may have almost the same functional effects of detubularization. Although DFVUDM revealed imperfect functional performances in some patients, the quality of life of diverted patients in our series seems to be satisfactory.

Long-term behavior of secretory immunity in ileocecal and ileal orthotopic neobladders

OBJECTIVE

To compare secretory immunity in cecal and ileal orthotopic neobladders, and to detect its permanence over time.

PATIENTS AND METHODS

IgA was studied in the urine of 33 patients with ileocecourethrostomy (ICUS) and 13 patients with ileal reservoir (IR). The mean follow-up was 55 months. Results were compared in terms of the type of operation, a healthy control group, and the time since surgery.

RESULTS

Urinary IgA levels were significantly higher in ICUS and IR patients than in normal controls. No significant differences in IgA concentrations were detected in patients with different reservoirs and with regard to time.

CONCLUSION

Both the reservoirs maintain the function of producing IgA. In particular no differences were detected over time and urine could be a permanent antigenic stimulus. IgA could be considered an adjunctive factor for upper urinary tract protection. For this reason we prefer to use a simple, indirect antireflux mechanism, thus avoiding direct manipulation of the uretero-intestinal anastomosis.

[DRG charge and real cost of a radical prostatectomy: preliminary considerations before a study of cost reduction]

Aim of the work was to evaluate the real cost of a radical prostactemy in comparison with the DRG's tariff rates. This work has been conduct before a next study whose objective is the reduction of the costs. The unitary estimated cost of the radical prostatectomies performed from 1997 to April 1998 in the Urological Division of the Università Cattolica S. Cuore has been extrapolated from the entire clinical activity of the same period. The real cost of an uncomplicated radical prostatectomy was also detected. The estimated cost was Lit. 8,225,872 in comparison to the DRG's tariff rate of Lit. 8,842,000; instead the real cost was Lit. 9,085,407. Forty-seven percent of this sum was for routine care in the Division, while 30% for operating room, 5% for pharmacy, 4% for laboratory and 14% for other items. In our institution an operation of high specialization like radical prostatectomy already performed without any complication is little remunerative. Routine care was the major cost: we think its improvement is the first step in order to contain the expense. In this way we can expect secondarily also a reduction in the days of stay.