תוצאת חיפוש

The Mitrofanoff Pouch in Lower Urinary Tract Reconstruction

J.H. Pinthus, Y. Mor, J. Ramon

Urology Dept., Chaim Sheba Medical Center, Tel Hashomer

The Mitrofanoff principle, first described in 1980, consists of implanting a tubular organ such as the appendix, ureter, or fallopian tube into the wall of the bladder (or urinary reservoir) to create a non-refluxing, catherizable urinary conduit. Between 1993-1996, 7 men and 1 woman (aged 48-64, average 59) underwent radical cystectomy and urethrectomy combined with the creation of a MAINZ I urinary reservoir (based on the Mitrofanoff principle). In men the indication for the procedure was the diagnosis of invasive transitional cell carcinoma of the bladder with involvement of the prostatic urethra. All patients had refused urinary diversion to an ileal conduit because of its deleterious effect on the quality of life.

In all patients the postoperative course was uneventful, apart from intraperitoneal urinary leakage from the reservoir in 1, successfully managed conservatively. The patients have gained full control of urinary drainage, performing intermittent self-catheterizations every 4-5 hours. In 3 patients there were difficulties with catheterization due to stenosis of the conduit, usually at the skin level. None have suffered leakage from the reservoir, during the day, even when it was full.

Our experience shows that creation of a continent urinary reservoir according to the MAINZ I technique is an excellent surgical solution for patients in whom the creation of an orthotopic reservoir is impractical. The use of the umbilicus as a stomal site preserves normal body image and thus does not interfere with quality of life as in those undergoing radical cystectomy.

Empirical Treatment of Urinary Tract Infections in the Delivery Room

Peter Jakobi, Orly Goldstick, Renato Finkelstein, Joseph Itzkovitz-Eldor

Obstetrics and Gynecology Dept. and Infectious Disease Unit, Rambam Medical Center, Haifa

Urinary tract infection (UTI) is the most common bacterial infection during pregnancy. In prenatal and delivery wards treatment is usually started at once in pregnant women with symptoms suggesting UTI, but there is no uniformity as to treatment. We surveyed such treatment in the delivery rooms throughout Israel, and whether the treatment differed in simple cystitis as opposed to pyelonephritis. Results of positive urine cultures from symptomatic parturients admitted here during 1995-1996 were examined.

There were 17 different empiric treatment protocols in 28 delivery rooms, whose daily cost ranged from 1-119 NIS. We present the antimicrobial sensitivity of 156 bacteria isolated from the urinary cultures from pregnant women in our prenatal ward. Based upon urinary flora, sensitivity and daily cost, we suggest a protocol for empiric treatment. We recommend first and second generation cephalosporins for treatment of simple lower (UTIs), while gentamicin is suggested for treatment of clinical pyelonephritis during pregnancy. There is no medical nor economic justification for the multiplicity of empiric treatment protocols currently used. Considering our results, our protocol is cost-effective for the empiric treatment of UTI in hospitalized parturients and in the community as well.

Transurethral Microwave Thermotherapy

Boaz Moskovitz, Shahar Madjar, Sarel Halachmi, Ofer Nativ

Dept. of Urology, Bnai Zion Medical Center, Haifa

The effectiveness of transurethral microwave thermotherapy (TUMT) for benign prostatic hypertrophy in poor surgical risk patients (ASA class IV) with indwelling catheters, was assessed. All had had an indwelling catheter for 1-12 months. Removal of the catheter was possible in 14 out of the 24 (58.3%). Urinary peak flow rates were 12.2±3.5 ml/sec at 3 months of follow-up and post-voiding residual urine volumes of less than 50 ml were recorded in 13 catheter-free patients. Our data suggest that TUMT is an effective procedure for management of high risk patients with indwelling catheters in whom surgery or anesthesia are contraindicated.

Screening for Transitional Cell Carcinoma of the Bladder with Trophoblastic Differentiation

M. Moldavsy, A. Sazbon, N. Kuchersky, H. Turani

Division of Cytology and Depts. of Urology and of Pathology, Rebecca Sieff Government Hospital, Safed

Urinary bladder carcinoma with trophoblastic differentiation (TD) is a variant of urothelial (transitional cell) carcinoma (TCC) which secretes placental proteins, predominantly beta-human chorionic gonadotropin (HCG). An aggressive clinical course and a poor prognosis are characteristic of this tumor. We evaluated the frequency and clinical and pathological appearance of TCC-TD in the Upper Galilee and Golan Heights between 1988 and 1995 inclusive. Beta HCG, human placental lactogen (HPL), pregnancy specific beta-1 glycoprotein (SP-1) and placental alkaline phosphatase were determined immunohistochemically in paraffin-embedded TCC of urinary bladder. Tumor grade, stage and patient survival were also determined. There was beta-HCG immunostaining in 13 of 62 cases (20.9%). TD was correlated with higher grades of TCC and with advanced stages of disease. No cases of TCC-TD were found in grade 1, stage 0. Co-expression of beta-HCG and HPL was displayed in 2 cases, beta-HCG and SP-1 in 9, and beta-HCG, HPL and SP-1 in 2. Disease-free survival and overall survival were shorter in TCC-TD.

Continuous Quality Improvement in Anesthesia

Luis Gaitini, Sonia Vaida, Shahar Madgar

Depts. of Anesthesia and of Urology, Bnai-Zion Medical Center, Haifa

Slow continuous quality improvement (SCQI) in anesthesia is a process that allows identification of problems and their causes. Implementing measures to correct them and continuous monitoring to ensure that the problems have been eliminated are necessary. The basic assumption of CQI is that the employees of an organization are competent and working to the best of their abilities. If problems occur they are the consequences of inadequacies in the process rather that in the individual. The CQI program is a dynamic but gradual system that invokes a slower rate of response in comparison with other quality methods, like quality assurance. Spectacular results following a system change are not to be expected an the ideal is slow and continuous improvement.

A SCQI program was adapted by our department in May 1994, according to the recommendations of the American Society of Anesthesiologists. Problem identification was based on 65 clinical indicators, reflecting negative events related to anesthesia. Data were collected using a specially designed computer database. 4 events were identified as crossing previously established thresholds (hypertension, hypotension, hypoxia and inadequate nerve block). Statistical process control was used to establish stability of the system and whether negative events were influenced only by the common causes. The causes responsible for these negative events were identified using specific SCQI tools, such as control-charts, cause-effect diagrams and Pareto diagrams. Hypertension and inadequate nerve block were successfully managed. The implementation of corrective measures for the other events that cross the threshold is still in evolution. This program requires considerable dedication on the part of the staff, and it is hoped that it will improve our clinical performance.

Fungus-Ball in a Preterm Infant Successfully Treated with Fluconazole

Mirit Hershman-Sarafov, Orora Tubi, Isaac Srugo, David Bader

Neonatal and Radiology Depts., and Microbiology Laboratory, Bnai-Zion Medical Center and Bruce Rappaport Faculty of Medicine, The Technion, Haifa

Very-low-birth-weight premature infants are at high risk for invasive candidiasis. The most commonly involved organ is the kidney. Renal candidiasis may present as fungus-ball obstructive uropathy. We describe unilateral renal obstruction secondary to fungus-ball in a premature infant. Noninvasive, systemic antibiotic treatment, including amphotericin B and fluconazole, resulted in disappearance of the finding.