Bladder Replacement Research Articles

147 DIFFERENTIATION OF HUMAN BONE MARROW STROMAL CELLS INTO AN UROEPITHELIAL LINEAGE

You have accessJournal of UrologyStem Cell Research1 Apr 2010147 DIFFERENTIATION OF HUMAN BONE MARROW STROMAL CELLS INTO AN UROEPITHELIAL LINEAGE Elena McNeill, Shantaram Bharadwaj, Anthony Atala, and Yuanyuan Zhang Elena McNeillElena McNeill More articles by this author , Shantaram BharadwajShantaram Bharadwaj More articles by this author , Anthony AtalaAnthony Atala More articles by this author , and Yuanyuan ZhangYuanyuan Zhang More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.200AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The current strategy for engineering bladder tissues for reconstruction of the urinary tract involves obtaining a biopsy from patients for use in in vitro cell expansion. However, this approach cannot be used in bladder cancer patients requiring a complete bladder replacement. Bone marrow stem cells (BMSC) are capable of differentiating into multiple cell types. The aim of this study was to determine whether co-culture with human urothelium or culture in urothelium-conditioned medium (CM) could induce human BMSC to differentiate into urothelial like cells. These differentiation techniques could provide a novel source of urothelial cells for bladder tissue engineering in patients with bladder cancer. METHODS Human BMSC were purchased from a commercial source (Lonza). Flow cytometry was used to confirm that BMSC expressed the mesenchymal stem cell markers. Urothelium were obtained from bladder or ureter biopsy samples and cultured in keratinocyte serum-free medium. For co-culture experiments, BMSC were cultured with urothelium in a transwell plate. Urothelium were seeded on top of the permeable membrane within each well of this plate, and BMSC were cultured on a glass cover-slip beneath the membrane. For studies using the CM, media was collected every 12 hours from urothelium cultures maintained at 70% confluence. BMSC were seeded on glass cover-slips and placed on the bottom of 12-well plates. Several growth factors (PDGF-BB, VEGF, EGF, TGF-beta, bFGF and HGF) in urothelim CM were measured with ELISA. BMSC were cultured in the CM for urothelial differentiation. Cells were processed on days 3, 7, and 14 after seeding for RT-PCR and immunefluorescence analysis of uroplakin Ia, a specific urothelial cell markers, and expression of a panel of cytokeratins (CytoPan). RESULTS Prior to any treatment, BMSC did not express urothelial markers. After being co-cultured with UC or cultured using UC-derived CM, human BMSC expressed UC-specific genes and proteins: uroplakin-Ia, cytokeratin-7 and cytokeratin-13. PDGF-BB and VEGF were detected in the co-cultured or conditioned media. Urothelial differentiation of BMSC displayed time-dependent manner. Uroepithelial differentiation efficiency of BMSC was about 50% using co-culture and CM for up to 14 days. CONCLUSIONS This study demonstrated that human BMSC are able to give rise to bladder epithelial like cells when exposed to UC-conditioned media. BMSC could be an alternative cell source for urothelial differentiation in urinary tract reconstruction for cancer patients who need bladder replacement. Winston-Salem, NC© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e60 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elena McNeill More articles by this author Shantaram Bharadwaj More articles by this author Anthony Atala More articles by this author Yuanyuan Zhang More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

752 EVALUATION OF RENAL MORPHOLOGY AND FUNCTION AFTER ORTHOTOPIC BLADDER REPLACEMENT USING Z-SHAPED ILEAL NEOBLADDER: A SERIES OF 321 PATIENTS

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2010752 EVALUATION OF RENAL MORPHOLOGY AND FUNCTION AFTER ORTHOTOPIC BLADDER REPLACEMENT USING Z-SHAPED ILEAL NEOBLADDER: A SERIES OF 321 PATIENTS Yann Neuzillet, Laurent Yonneau, Thierry Lebret, Jean-Marie Herve, Pierre-Marie Lugagne, and Henry Botto Yann NeuzilletYann Neuzillet More articles by this author , Laurent YonneauLaurent Yonneau More articles by this author , Thierry LebretThierry Lebret More articles by this author , Jean-Marie HerveJean-Marie Herve More articles by this author , Pierre-Marie LugagnePierre-Marie Lugagne More articles by this author , and Henry BottoHenry Botto More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1304AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To evaluate the results in terms of preservation of renal morphology and function with Z-shaped ileal neobladder performed at our center. METHODS 321 consecutive patients, 27 women (8%) and 294 men (92%) who had an orthotopic bladder replacement using Z-shaped ileal neobladder between May 1990 and January 2009. The techniques used for uretero-neobladder anastomosis were those of Camey-Leduc, a direct anastomosis or anastomosis “in trunk” respectively in 3, 252 and 66 cases. Renal function was assessed by creatinine clearance (MDRD) and renal morphology was assessed by IVP and/or by CT-scan. RESULTS The mean age of the patients was 63.4±11.8 years. The mean follow-up was 59.4 ± 55.5 months. The surgical indications were bladder tumors in 315 (98.2%) cases and non-oncological in 6 (1.8%) cases. Three (1%) patients had a creatinine clearance (MDRD) below 30 ml / min. before cystectomy, including one with a abnormal upper urinary tract (UUT) morphology. Ten (3.1%) patients required a surgical procedure for uretero-neobladder anastomosis stenosis. The preservation of the upper tract morphology, and necessity of a surgical procedure was independent of the techniques used for uretero-neobladder anastomosis. At the end of follow-up, renal function was reduced by 11 ml/min. on average. Creatinine clearance was 79±21 ml/min and 68±30 ml/min respectively before cystectomy and at the end of the follow-up (p <0.0001). After cystectomy, fourteen (4.3%) patients had creatinine clearance which is now below 30 ml/min. Forty five patients (14%) developed metabolic acidosis, easily controlled by oral treatment with bicarbonate. CONCLUSIONS In our series of 321 patients, Z-shaped ileal neobladder allowed the preservation of the morphology and function of the upper tract in more than 89% despite reduction of creatinine clearance. Figure 1. Modification of UUT morphology. Table. Change in creatinine clearance according to the morphology of the upper tract: Normal morphology AFTER cystectectomy (n= 287) Pathological morphology AFTER cystectectomy (n= 34) p= Normal morphology BEFORE cystectectomy (n= 277) -11,54 ± 36,19 (lost of 14% of initial value) -28,03 ± 32,98 (lost of 35% of initial value) 0,04 Pathological morphology BEFORE cystectectomy (n= 44) 0,16 ± 46,47 (lost of 0% of initial value) -13,54 ± 26,13 (lost of 18% of initial value) 0,46 p= 0,15 0,29 Suresnes, France© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e294 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Yann Neuzillet More articles by this author Laurent Yonneau More articles by this author Thierry Lebret More articles by this author Jean-Marie Herve More articles by this author Pierre-Marie Lugagne More articles by this author Henry Botto More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

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We are grateful for the helpful editorial comments agreeing on our views associated with urinary diversion surgery. Urinary reconstruction should match the needs and expectations of the individual patient, and most patients in turn adapt to whatever is expected of them. Patient participation with unbiased counseling before any treatment and the availability to choose between all available forms of treatment is the key to postoperative satisfaction. How Close Are We to Knowing Whether Orthotopic Bladder Replacement Surgery Is the New Gold Standard?—Evidence From a Systematic Review UpdateUrologyVol. 74Issue 6PreviewTo compare the clinical effectiveness and risk profile of the different types of surgeries using transposed intestinal segments in a systematic review update. Urinary diversion is designed to improve or replace the function of the diseased urinary bladder. Full-Text PDF Editorial CommentUrologyVol. 74Issue 6PreviewThe goal of any form of urinary diversion should be the control of urinary bladder disease and the preservation of a patient's quality of life (QoL). Safeguarding a patient's QoL is related both to the surgical urinary diversion form that is psychologically and socially acceptable and to the preservation of renal function.1 In fact, there are several reasons for deterioration of renal function that are generally diversion-related.2 In this sense, the incorporation of an antireflux system with urinary diversion or bladder replacement should protect the upper tract from regurgitation of the infected contents of the reservoir. Full-Text PDF

Incidence of New Onset Metabolic Acidosis Following Enteroplasty for Myelomeningocele

Extant literature is mixed regarding risk of metabolic acidosis after enteroplasty for myelomeningocele. This study is the first known attempt to describe the pattern of developing metabolic acidosis in a group of children who underwent enteroplasty and served as their own controls. Multiple preoperative and postoperative laboratory measures for each child were obtained for comparison. This retrospective cohort study allowed participants to serve as their own controls for pre-intervention and post-intervention analysis. The setting was a tertiary, university affiliated, interdisciplinary spina bifida program. All patients followed in the spina bifida program who had undergone ileal or colonic enteroplasty were included for review (total 113). Strict exclusion criteria were preoperatively diagnosed renal insufficiency, preexisting metabolic acidosis consistent with renal tubular acidosis (pH less than 7.35, bicarbonate 20 mmol/l or less) and history of augmentation using gastric or ureteral tissue. Final analysis included 71 children who met inclusion criteria. Children in our spina bifida program periodically undergo routine laboratory evaluation of electrolytes, blood urea nitrogen, creatinine, blood count, and venous blood gases including pH, bicarbonate and partial pressure of carbon dioxide. Primary outcome measures were comparative shifts in blood gases and electrolytes that would confirm the new onset of metabolic acidosis after enteroplasty. Changes in electrolytes and serum creatinine were secondary outcome measures to identify potential markers for postoperative effects. With each child as his/her own control, analysis included paired t tests. No statistically significant differences (p <0.05) were found when comparing laboratory values before and after bladder augmentation, including pH, bicarbonate, partial pressure of carbon dioxide and electrolytes. No child had metabolic acidosis based on the aforementioned criteria. Followup ranged from 1 to 138 months after enteroplasty (mean 46.8). Respiratory compensation was considered in the analysis, and no difference in partial pressure of carbon dioxide following surgery was noted (p = 0.65). To our knowledge no previous study has examined the matched paired results of before and after development of metabolic acidosis among children (serving as their own controls) with myelomeningocele undergoing ileal or colonic enteroplasty. The negative statistical results in this controlled cohort are clinically significant. If a child with myelomeningocele has metabolic acidosis after enteroplasty, other clinical reasons beyond the effects of surgery warrant careful consideration.

Myogenic differentiation of human bone marrow mesenchymal stem cells on a 3D nano fibrous scaffold for bladder tissue engineering

Current strategies for engineering bladder tissues include a bladder biopsy for in vitro cell expansion for use in reconstructive procedures. However, this approach cannot be used in patients with bladder cancer who need a complete bladder replacement. Bone marrow mesenchymal stem cells (BMSC) might be an alternative cell source to better meet this need. We investigated the effects of soluble growth factors, bladder extracellular matrix (ECM), and 3D dynamic culture on cell proliferation and differentiation of human BMSC into smooth muscle cells (SMC). Myogenic growth factors (PDGF-BB and TGF-β1) alone, or combined either with bladder ECM or dynamic cultures, induced BMSC to express smooth muscle-specific genes and proteins. Either ECM or the dynamic culture alone promoted cell proliferation but did not induce myogenic differentiation of BMSC. A highly porous poly- l-lactic acid (PLLA) scaffold provided a 3D structure for maximizing the cell-matrix penetration, maintained myogenic differentiation of the induced BMSC, and promoted tissue remolding with rich capillary formation in vivo. Our results demonstrate that myogenic-differentiated BMSC seeded on a nano fibrous PLLA scaffold can be potentially used for cell-based tissue engineering for bladder cancer patients requiring cystoplasty.

How Close Are We to Knowing Whether Orthotopic Bladder Replacement Surgery Is the New Gold Standard?—Evidence From a Systematic Review Update

To compare the clinical effectiveness and risk profile of the different types of surgeries using transposed intestinal segments in a systematic review update. Urinary diversion is designed to improve or replace the function of the diseased urinary bladder. Studies reporting on surgery involving intestinal segments transposed into the urinary tract were identified between January 1990 and January 2007 using MEDLINE, PubMed, EMBASE, CINAHL, and the Cochrane Library. All articles published in English language reporting on at least 10 patients and follow-up of at least 1 year were included. This is a substantive update of our previously published systematic review that reported on the evidence between January and to January 2003 (Nabi G, Yong SM, Ong E, et al. J Urol. 2005;174:21-28). Between January 1990 and January 2007, a total of 5651 abstracts were reviewed. Of them, 557 studies met the inclusion criteria reporting on 46,921 participants (an additional 14,126 participants reported on between January 2003 and January 2007). Operative complications were lowest in ileal conduit diversion, whereas postoperative morbidity and mortality were lower for orthotopic bladder replacement surgery. Of the 35 quality-of-life studies, only 2 studies (Dutta SC, Chang SC, Coffey CS, et al. J Urol. 2002;168:164-167; Hobisch A, Tosun K, Kinzl J, et al. World J Urol. 2000;18:338-344) reported a better quality of life with orthotopic bladder replacement. This systematic review update fails to reveal a clear winner, with each intervention type having advantages and disadvantages. With > 46,000 patients included in transposed intestinal segment research over the past 16 years, it is surely a criticism of our speciality that we are no closer to answering the question of what is the best way to improve or replace the function of the diseased bladder.

UP-2.183: Orthotopic Bladder Replacement (BR) or Ileal Conduit Diversion (IC): Are the Barriers to Randomisation Real?

With over 46,000 patients reported in transposed intestinal segment research over the past 16 years, we are no closer to answering the question of what is the best way to replace the function after radical cystectomy. We investigate what UK urologists feel about randomisation in this setting.

Nerve growth factor combined with vascular endothelial growth factor enhances regeneration of bladder acellular matrix graft in spinal cord injury‐induced neurogenic rat bladder

To determine the combined effects of nerve growth factor (NGF) and vascular endothelial growth factor (VEGF) on regeneration of the bladder acellular matrix graft (BAMG) in spinal cord injury (SCI)-mediated neurogenic bladder in rats. In all, 40 female Sprague-Dawley rats were used. At 8 weeks after spinalization surgery (neurogenic bladder), they were divided into five groups consisting of untreated controls and those whose bladders were injected with either no growth factor, NGF (2 microg/rat), VEGF (2 microg/rat) or both at partial BAMG replacement surgery. After 8 weeks, bladder function was assessed by urodynamic studies and the bladders were harvested for histological examination. Smooth muscle induction, collagen and nerve fibre regeneration were assessed immunohistochemically using antibodies to smooth muscle actin (alpha-actin), Masson's trichrome and protein gene product 9.5, respectively. Bladder capacity and compliance were significantly increased in all BAMG groups 8 weeks after surgery compared with that before bladder replacement surgery. Bladder capacity and compliance were much higher in the VEGF and NGF combined group than in the control, or NGF and VEGF alone groups. There was no significant difference in the residual volume ratio among all groups. This is the first report showing that NGF has a significant synergistic effect on the development, differentiation and functional restoration of the BAMG when administered with VEGF in neurogenic bladder. Our results indicate that NGF may be a useful cytokine for enhancing the regeneration of a functional bladder following acellular matrix grafting in a neurogenic rat model.

Temporal differentiation and maturation of regenerated rat urothelium

To determine if porcine small intestinal submucosa (SIS)-regenerated urothelium expresses markers of urothelial differentiation, uroplakin and zona occludens-1 (ZO-1), and whether their expression correlates with the histological appearance of the urothelium. In all, 15 rats underwent partial cystectomy and bladder replacement with SIS. Regenerated bladders were harvested at either 2, 7, 14, 28, or 56 days after SIS grafting. Histological examination with haematoxylin and eosin staining was conducted to assess tissue regeneration. Immunohistochemistry was performed with uroplakin and ZO-1 antibodies. By 14 days after SIS grafting, the urothelial layer was completely confluent over the SIS. Expression of uroplakin and ZO-1, evident at 2 days after SIS grafting, progressed from a cytoplasmic pattern of expression to a mature pattern of cytoplasmic and membrane expression by 56 days after SIS grafting. In vivo tissue regeneration produces histologically and phenotypically mature urothelium within 2 weeks of SIS implantation. Regeneration of functional urothelium is probably essential for the subsequent development of the remaining bladder.

Quality of Life in Elderly Bladder Cancer Patients Following Cystectomy and Urinary Diversion

This review aims to provide information about quality of life in elderly patients who have undergone radical cystectomy and bladder replacement for muscle-invasive bladder cancer, focusing on the best instruments for evaluation. Among patients over 75 years of age, bladder cancer is the fifth leading cause of death. Radical cystectomy is the standard treatment for muscle-invasive bladder cancer and it is also considered safe in the elderly population. Quality of life is an essential aspect following radical cystectomy and bladder replacement owing to its impact on patients’ satisfaction with body image and urinary, sexual and social functioning. Furthermore, the authors suggest that there are no significant differences between different methods of urinary diversion in the elderly.

Étude comparative du drainage urétéral par sonde double J ou sonde urétérale après cystectomie-entéroplastie

The aim of the study was to compare ureteroileal anastomosis strictures rates in patients receiving either double J stent or open-ended ureteral stent, after bladder replacement for cancer. Medical charts from 75 patients who underwent cystectomy and Z pouch bladder substitution for bladder cancer, between 2001 and 2005, were retrospectively reviewed. Ureteroileal anastomosis was direct, spatulated end-to-side fashioned in all patients. Double J stents were used in 39 patients (group A) and open-ended ureteral stent were used in 36 patients (group B). Mean hospital stay, early and late complications were also observed. Seventeen anastomotic strictures have been documented during the follow-up: 5.2% in group A versus 18.3% in group B (p=0.012). Mean catheterization period was six weeks in group A and 12 days in group B. No significant differences were found in mean hospital stay, early and late complications. The use of internal double J ureteral stent is now a feasible option and can decrease the rate of anastomotic stricture. The fact that the double J stent is removed after the anastomosis healing period may be a possible explanation.

Clinical application of radical cystectomy with orthotopic ileal neobladder

Objective To evaluate the clinical efficacy of radical cystectomy with orthotopic ileal neobled-der. Methods 28 cases of bladder tumor treated with radical cystectomy with ileal orthotopic neobladder were studiedretrospectively. Results All patients achieved excellent continence,whereas possessory patients needed time-lapse e-mietion at nighttime. The mean bladder capacity for the entire group was 330 ml. Residual urine was less than 70 ml.All of these patients have been followed up for 4～58 months with a mean of 18 months. They were survival with no re-currences except 1 case. Good urinary stream was reported. A little operative complications occurred. ConclusionThe operation of radical cystectomy with orthotopic ileal neobladder might be an ideal way of bladder replacement,characterized by large capacity,low pressure, orthotopie continent urination. Key words: Bladder neoplasms; Radical cystectomy; Heal neobladder

Mortalité et morbidité des cystectomies totales pour cancer de la vessie chez les patients de plus de 75 ans

The objective of this study was to evaluate the mortality and morbidity of cystectomy and the functional results of the associated diversions in patients over the age of 75 operated for bladder cancer. From 1988 to 2002, 37 patients (29 men and 8 women) aged between 75 to 88 years (median: 79 years) underwent radical cystectomy for bladder cancer. All patients had at least one comorbidity factor, 17 patients were classified as ASA II (45.9%) and 20 were classified as ASA III and IV (54.1%). An external urinary diversion was performed in 35 patients and orthotopic bladder replacement was performed in two patients. The mean follow-up was 21.0 months (range: 0.3-88.6). The mortality, early and late morbidity, and functional results were analyzed. There was no intraoperative mortality and the early mortality rate was 5.4% (2/37). The early medical morbidity rate was 24.3%, essentially cardiovascular (pulmonary embolism, myocardial infarction, pulmonary edema), and the early surgical morbidity rate was 2.7%. The late morbidity rate was 27.0%, essentially corresponding to wound complications (peristomal or midline incisional hernias). In terms of functional results, a peristomal incisional hernia with stoma appliance difficulties was observed in 11.4% of patients with an external diversion. One of the two patients treated by bladder replacement performed intermittent self-catheterization and the other was continent during the day and required pads at night. This study shows that the acceptable mortality and early and late morbidity results allow radical cystectomy to be proposed in patients over the age of 75.

Regional biomechanical and histological characterisation of the passive porcine urinary bladder: Implications for augmentation and tissue engineering strategies

The aim of this study was to identify and quantify potential regional and directional variations in the quasistatic uniaxial mechanical properties of the passive urinary bladder wall. Overall, the lower body and trigone regions demonstrated the highest degree of directional anisotropy, whereas the ventral region demonstrated the least directional anisotropy. Significant regional anisotropy was found only along the apex-to-base direction. The dorsal and ventral regions demonstrated a significantly increased distensibility along the apex-to-base direction compared to the other bladder regions, whereas the trigone and lower body regions demonstrated the least distensibility. The trigone, lower body and lateral regions also demonstrated the highest tensile strength both at regional and directional levels. The study detected significant regional and directional anisotropy in the mechanical properties of the bladder and correlated this anisotropy to the distended and non-distended tissue histioarchitecture and whole organ mechanics. By elucidating the inhomogeneous nature of the bladder, the results from this study will aid the regional differentiation of bladder treatments in terms of partial bladder replacement with suitable natural or synthetic biomaterials, as well as the development of more realistic constitutive models of bladder wall biomechanics and improved computational simulations to predict deformations in the natural and augmented bladder.

Voiding Symptoms and Urodynamic Findings in Patients with Modified Ileal Neobladde

The aim of our study was to find the cause of urinary incontinence and voiding dysfunction in patients undergoing radical cystectomy and orthotopic bladder replacement with modified ileal neobladder (Reddy). Twenty-eight incontinent patients (operated on between 1988 and 2004) were involved in our examination. Based on the complaints of the patients, continence status was evaluated and divided into two groups: group I: partially incontinent (only night-time incontinence) n = 11 (39.3%) and group II: totally incontinent (night-time and daytime incontinence) n = 17 (60.7%). Detailed urodynamic examination (enterocystometry and urethral pressure profile) in addition to involuntary neobladder contractions and capacity detection were carried out on all patients. Furthermore resting pressure and maximal voluntary contraction ability of the sphincter were determined and statistically analyzed in both groups. Significant difference was noticed in resting pressure and maximal voluntary contraction ability of the sphincter among the partially incontinent and totally incontinent patients. Frequency, intensity and duration of involuntary neobladder contractions also showed significant differences between the two groups. Incontinence of neobladder depends not only on the destruction of resting and contraction capability of the urethral sphincter, but also on the presence or absence of involuntary contractions in the wall of the neobladder and decreased capacity of the neobladder.

Primary pelvic exenteration in cervical cancer patients

Despite the reports of a number of leading institutions concerning the use of primary exenteration, there are differences in regard to definition, indications, and interpretation of results of this treatment approach to cervical cancer. In this paper we present our own experience with 41 cervical cancer patients treated with primary exenteration at St. Stephen Hospital Budapest. We explore some important unsettled aspects (definition, indications, and quality of life consequences) of this treatment modality in view of our own experience and the literature. Between January 1993 and June 2006, 2540 invasive cervical cancer patients were seen at the gynecologic oncology service of the St. Stephens Hospital Budapest. Two hundred twelve (8%) of these patients were surgically explored with the plan of an exenterative surgery. Exenteration was the primary treatment in 41 (25%) of 166 completed exenterations; these 41 cases included 2 cases of supralevator total exenteration, 9 cases of supralevator anterior exenteration, and 30 cases of partial supralevator anterior exenteration. In the 2 total exenteration patients, anal function was restored with a low rectal anastomosis, with a temporary defunctioning colostomy in 1 patient. Urethral function was restored in 9 out of 11 supralevator exenteration cases with the Budapest pouch bladder replacement technique. In the remaining 2 cases, a Bricker conduit was used for urinary diversion. There was no operation-related mortality in this cohort of patients. An external fecal or urinary stoma was avoided in 38 (93%) out of the 41 primary exenteration patients; in 1 patient a temporary defunctioning colostomy was used; and in 2 patients a permanent ileal conduit was created. In 9 patients (22%), complications (ileus and peritonitis, occlusion of the femoral artery, stricture of the implanted ureter, and postoperative ureterovaginal fistula) necessitated surgical intervention. A quality of life study revealed the need for prolonged self-catheterization, partial (mainly night time) incontinence, and lymphedema in 7 patients. We consider and suggest that an en bloc resection of part(s) of the urinary bladder and/or the rectum with the uterine cervix should be considered an exenteration (partial exenteration). A 50% survival rate of a select group of stage IVA cervical cancer patients treated with primary exenteration can be considered significant, but cannot be considered superior to that of chemoradiation therapy. The same applies when considering treatment-related mortality and complications that require operative interventions. Low rectal anastomosis and orthotopic bladder replacement with a relative low risk of fistula formation in non-irradiated patients constitute a strong quality of life argument in favor of primary exenteration in a select group of stage IVA cervical cancer patients.

Qualité de vie après cystectomie : enquête nationale de l’Association française d’urologie (AFU), la Fédération des stomisés de France (FSF) et de l’Association française des entérostomathérapeutes (AFET) chez des patients ayant eu une dérivation urinaire cutanée non continente ou un remplacement vésical orthotopique

National multicentre study based on specific self-administered quality of life questionnaires in patients with Bricker ileal conduit urinary diversion or orthotopic neobladder. Questionnaires were distributed by three associations (FSF, AFU, AFET) and comprised general questions and questions specific to the type of diversion. A disability score was also included. Between September 2003 and March 2004, out of a total of 5739 questionnaires, 909 were returned and 877 were analysed: 738 patients with Bricker ileal conduit and 139 with orthotopic neobladder. The two populations differed at the time of the study (Bricker: 69% of men with a mean age of 70 years, orthotopic neobladder: 95.7% of men with a mean age of 64 years). The mean interval since the operation was seven years. Ninety-four percent of patients with Bricker ileal conduit and 93% of patients with orthotopic neobladder were satisfied or very satisfied with the diversion, despite mean disability scores of 5.2+/-3.7 and 3.1+/-3.6, respectively. A correlation between this score and patient satisfaction (Wilcoxon: p<0.0001) was only observed for patients with a Bricker ileal conduit. This score was significantly related to the presence of urinary incontinence with the two types of diversion. Incontinence was frequent (16.1% with Bricker ileal conduit) and 78% of patients feared episodes of incontinence, mainly due to the appliance. Daytime incontinence was frequent for 18.1% of patients with orthotopic neobladder and 40% of patients used at least one protection per day. Out of the patients with neobladder, 82.6% experienced nocturnal incontinence, interfering with sleep in 31.9% of cases. Sexual disorders and altered bowel habit (40%) were very frequent. Stoma-therapy management was insufficient for Bricker ileal conduit and exceptional after bladder replacement. Cystectomy with either ileal conduit urinary diversion or orthotopic neobladder alters many aspects of the patient's life, but patients finally accept and adapt to their new way of life.

Tissue Engineering and Regenerative Science in Pediatrics

Tissue engineering is a discipline that focuses on the regeneration of living tissues from a combination of cells, biomaterials, and signaling cues (1). The nature of this regenerative science is multidisciplinary, drawing knowledge from cellular and developmental biology, material science and engineering, drug delivery, and wound healing. There has been a tremendous growth in the number of scientific publications that relates to tissue engineering. A simple search in the PubMed database using the term “tissue engineering” shows that the number of publication has grown from less than one per year in the 1980s to 2087 in 2007. This tremendous growth is partly due to the increased interests in stem cells and their therapeutic potential, leading to a new era in regenerative science. Tissue engineering technology has been applied to many organ systems over the last two decades. Several tissue-engineered products are either in clinical use or in clinical trials. For example, skin substitutes made from human cells and collagen matrices have been used to treat patients with burn injury (2). Urinary bladder replacements made from autologous cells and biodegradable polymers to augment bladders of patients with myelomeningocele are in phase 2 clinical trials (3). These tissue-engineering based treatments bring new options and hope to a wide range of patients with tissue deficits. The potential applications of tissue engineering to the pediatric population are diverse. Congenital anomalies that require surgical reconstruction of the tissue deficits occur in every organ system. For example, children with a cleft palate may require bone grafts for reconstruction, and bone regeneration using stem cells, biomaterials, and molecular signals can avoid the donor site morbidity (4,5). In the cardiovascular system, children with congenital heart disease may require shunts, patches, and valves for their repair, and the use of cells and biomaterials to produce cardiovascular tissue substitutes are being actively pursued (6,7). In the genitourinary systems, children with hypospadias, dysfunctional bladders, and dysplastic kidneys will often require multiple procedures for urologic reconstruction. Tissue deficits in these settings are being addressed with emerging tissue-engineered products (8‐10). The application of tissue engineering is well suited to the pediatric population because children heal better and adapt faster than adults. It is also more

Clinical advance of orthotopic bladder replacement after radical cystectomy

The surgical technique of total bladder replacement orthotopic intestinal neobladder has already been a well accepted method for urinary tract reconstruction after cystectomy in woad wide medical center in past 20 yeas.In this review,the update advance and viewpoint in some critical aspects of patients selection,reflux prevention,upper tract safety,continence,oncology safety,specific complications and quality of life were evaluated in the orthotopic bladder replacement.It is possible that the orthotopic bladder replacement become a new gold standard in urinary diversion after radical cystectomy. Key words: Urinary bladder neoplasms; Cystectomy; Urinary diversion