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UP-2.187: Long Follow-Up Study of Original Orthotopic Ileal Neobladder Reconstruction in 61 Patients with Bladder Cancer
UNMODERATED POSTER SESSIONS
which concentration and days of treatment is better to remove all cells. Materials and Methods: SIS was obtained and processed and cut in 2⫻2 cm. squares. Under continuous agitation they were treated with escalating concentration of Triton X-100 ⫹ 0.1% of sodic acid during seven days. Random samples were taken every day at any concentration of detergent for histological analysis. Results: After 24 hours of decellularization process almost no cells were found on SIS (p⬍0.05). No differences among escalating concentrations of Triton X-100 were found. After 3 days of treatment no cells were seen at any detergent concentration. Conclusions: After 3 days of process acellular SIS were obtained whatever concentration of Triton X-100 is used. UP-2.185 In Vivo Responses to Biomaterials Used in Urological Reconstruction Williams H1, Singla A1, Broadrick K2, Krishnamurthy B2, Van de Vord P2 1 Department of Urology, 2Department of Engineering, Wayne State University Detroit, MI, USA Introduction and Objectives: Biological tissues are widely used in urological surgeries to treat conditions like pelvic organ prolapse and stress urinary incontinence. In this study, we examine the in vivo responses of several urological tissue samples currently used in urological reconstruction. Materials and Methods: Four commercially available tissue samples were evaluated from three different companies: Small intestine submucosa (SIS) (Cookbiotech), Tutoplast Fascia lata (FL) (Mentor Corp), Tutoplast Fascia dermis (FD) (Mentor Corp) and Pelvicol (P) (C.R. Bard). The biomaterial was implanted intraperitoneally at the bladder neck of Balb/c mice. Animals were sacrificed at 2, 4, 8, or 12 weeks post-implantation. Tissue incorporation, fibrous capsule thickness, cell number, cell morphology and angiogenesis were all evaluated. Results: Histological responses to the biomaterials were quite different. Implants from the SIS group were the only group to show a significance decrease in capsule thickness from 2 to 12 weeks of implantation (p⫽0.01) and tissue incorporation. The aspect ratio which is a measure of inflammatory cells induced by each tissue sample as compared to fibroblastic type cells demonstrated more inflammatory cells deposition for SIS (p ⬍0.05). In terms of angiogenesis, among the four
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groups tested, SIS generated the greatest angiogenic response at 2 weeks. Conclusion: SIS induced a less pronounced inflammatory response over time since the capsule thickness decreased with time and more tissue incorporation occurred, both of which demonstrate signs of biocompatibility. UP-2.186 New Technique for Uretero-Ileal Anastomosis in Orthotopic Ileal Neobladder: Fast, Direct and no Reflux nor Stenosis on Long Term Follow-Up Wishahi M Theodor Bilharz Research Institute, Cairo, Egypt Introduction: Radical cystectomy is the method of choice in treatment of muscle invasive bladder carcinoma, and orthotopic ileal neobladder is best patient choice. Since the invention of the Camey-Le Duc technique of uretero-ileal anastomosis in 1979, many procedures have been introduced and there are arguments and controversies on the significance of anti reflux methods. Materials and Methods: We describe our novel technique for uretero-ileal anastomosis in orthotopic ileal neobladder after radical cystectomy for invasive bladder carcinoma. The retrospective study included 230 patients operated upon over the last ten years having medical record available and regular follow-up. Selection criteria for application of this technique is the presence of normal ureters and upper tract in imaging studies, normal kidney function and normal liver function. The technique (Wishahi procedure): After construction of the detubularised ileal pouch in the form of Camey II or Hautman pouch or our spherical pouch, the ureter is anchored on a long soft 6 Ch multiple holes ureteric drainage stent. Anchorage is done by 4/O polyglycolic acid suture 1 cm away from the ureteric end, 1 cm button hole incision is done in the most lower, posterior and lateral site of the pouch. The stent is fixed to a specially designed malleable metal probe that will pass from the button hole incision taking the ureter for 1 cm inside the pouch and passing the stent from the anterior wall of the pouch and crossing the anterior abdominal wall. The ureter is fixed to the ileal pouch by four sutures. The pouch is anastomosed to the uretheral stump by 8 sutures, and a 20 Ch silicone catheter is left. The ureteric stents are removed after 12 days. Follow-up included ascending pouchogram,Tc99 and DMSA renogram.
Urine analysis, ultrasound and intravenous radiography were done in 4 months follow-up. Results: The operative time for anastomosis of one ureter to the ileal pouch is 4 minutes. No urinary leakage was encountered at the site of the anastomosis, regular follow-up did not show any incidence of stenosis and there was no reflux on imaging studies. The kidneys and upper tract showed no deterioration on renographic studies. Conclusion: In our study, the use of our innovative technique of uretero-ileal anastomosis was fast which reduced the operative time, no complications as renal deterioration as a result of stenosis on the site of the ureteric anastomosis nor development of reflux were encountered. Ourtechnique (Wishahi procedure) would be applied safely in the construction of orthotopic ileal neobladder in laparoscopic cystectomy. UP-2.187 Long Follow-Up Study of Original Orthotopic Ileal Neobladder Reconstruction in 61 Patients with Bladder Cancer Zheng J, Zhang H, Chao Y, Xu Y, Peng B, Yan Y, Gao Q Department of Urology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China Introduction: The purpose of this study was to evaluate the long-term functional outcome and complications of our original ileal neobladder after radical cystectomy. Materials and Methods: From January 1988 to December 2006, 61 patients underwent construction of an orthotopic ileal neobladder after cystectomy. In this retrospective study, data were analyzed who received ileal neobladder following radical cystectomy with respect to complications, urinary continence, radiographic evaluation of the upper urinary tract and urinary reservoir, renal function, and urodynamic examinations. Results: By December 2006, 13 patients (21.3%) died. Urethral tumor recurred in one patient. Complications occurred in 18 patients (29.5%), mainly including postoperative urinary infection and elsewhere, ureteroileal obstruction, hemorrhage, urine leak, and intestinal obstruction. A total of 40 patients underwent radiographic evaluation of the upper urinary tract, including 34 patients (85.0%) with a normal radiographic graph. Renal function was stable or improved in 46 patients (95.8%) of 48 live patients. In the 48 patients who remained alive by December
UROLOGY 74 (Supplment 4A), October 2009
UNMODERATED POSTER SESSIONS
2006, 44 patients (91.7%) reported good diurnal continence and 42 patients (87.5%) reported good nocturnal continence, and 40 patients (83.3%) completed void. The urodynamic examinations were performed 60 months after operations, showing that the volume of neobladder, the intravesical pressure in filling phase, the maximum flow rate and the post-void residual were similar to the normal bladder. Conclusion: The findings reveal that our original ileal neobladder after radical cystectomy is a satisfactory method to treat the invasive bladder cancer, with acceptable complications. UP-2.188 The Structure of the Urinary Sphincter Complex and Its Continence Mechanism in Females Du G1, Chen B1, Zhang H1, Zhang Q1, Xu H1, Hu W2, Ye Z1 1 Department of Urolgy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; 2Department of Urology, Wuhan Central Hospital, Wuhan, China Introduction and Objectives: To investigate the structure of the urinary sphincter complex (USC) and the continence mechanism. Materials and Methods: The structure of the urethral lumen and its closing course was observed with F7 ureteroscopy in 15 adult female healthy volunteers, their rest urethral pressure profile (RUPP) and stress urethral pressure profile (SUPP) recorded. Female urethra specimens from 7 fresh corpses were harvested and processed for histological section. Masson’s trichrome staining was carried out to observe the different structural components of urethra. The essential components that comprise the USC and their role in the sphincter closing mechanism were deduced. Results: Under ureteroscopy, a striking structure observed in female urethra was the cresta urethralis that begins 5 to 10 mm below the internal metus and ends before the external metus. About 60% to 80% length of the urethral lumen was occupied by this convex cresta, which make the urethral lumen a reversed U shape latent cavity. When coughing, this cresta becomes thicker and projects inward and wads the urethral lumen tightly. On RUPP and SUPP recording, the high pressure zone was noted correspond to the area of cresta urethralis. On histological sections, besides the typical description of tissue components of outside circular striated muscle, middle smooth muscle, and mu-
cosa, the striking cresta urethralis also be noted filling in the 60% to 80% length of urethral lumen. And the range of striated muscle was noted also correspond to the high pressure zone of RUPP and SUPP. The morphometrics of USC is similar to that of a floodgate. From tridimensional view point, the contraction of striated and smooth muscle will narrow the urethral lumen, inward promontory of the cresta urethralis will block the flow, mucosa layer has seal effect. Conclusions: The essential compositions that comprised USC are muscular tissue, cresta urethralis and mucosa. The detail sphincter mechanism should include three factors: musculature tissue contracts to narrow urethral lumen, cresta urethralis projects inward to wad the urethral lumen and block the flow and, sealing effect from the mucosa. UP-2.189 Evaluation of Pre-Operative Urodynamic Role in Renal Transplantation El-Hefnawy A, Wadie B, El Refaie A, Ghoneim M Mansoura Urology and Nephrology Center, Mansoura, Egypt Introduction and Objective: To evaluate the indications and urodynamic (UD) outcome findings prior to renal transplantation and assess its impact on surgical decision and management plan. Materials and Methods: Forty-nine patients (47 males and 2 females) with endstage renal disease underwent urodynamic studies as a part of pre-transplant work-up evaluation. Indications of UD were: Defunctionalized bladder (DB) in 18 (36.7%) patients, history of PUV in 5 (10.2%) patients, LUTs in17 (34.7%) patients and abnormal cystoscopic or radiological findings (eg. trabeculated bladder wall or vesicoureteric reflux) in 9 (18.4%) patients.All patients underwent video UD. Management of patients with abnormal UD findings was tailored according to the diagnosis of each case. Nine patients had LUTs underwent post-operative UD studies, 6 months after transplantation. Results: Pre-transplant UD was abnormal in 34 (69.4%) patients. Detrusor over activity was found in 18 (36.7%) patients, reduced bladder capacity (⬍ 200 ml) was found in 17(34.7%) patients while 13(26.7%) patients showed evidence of bladder outlet obstruction. One patient (2%) had myogenic failure. Mean bladder capacity was 271.2⫾177 ml, it was significantly lower in patients with DB (mean 171.2⫾66ml) as compared with remaining
UROLOGY 74 (Supplment 4A), October 2009
(men337.8⫾196.3) (p⬎.001).After UD evaluation, kidney transplantation was precluded in 13(26.5%) patients because of multiplicity of causes, not including their bladder condition. Bladder neck incision was carried out in 6 (12.2%) patients and 4(8.1%) patients were maintained on alpha blocker. Eighteen patients with DB were subjected to bladder training protocol then re evaluated after 3 months for bladder capacity. One of them was in need for augmentation ileo-cystoplasty. Bladder training was sufficient in 14 (28.6%) patients while antimuscarinic was indicated in remaining 3 (6.1%) patients. Post-transplant UD showed bladder instability in 4 (44.4%) patients, one of them had no DO in pre-transpalnt UD. Bladder capacity in this subset of patients was comparable to their pre-transpalant values (p⫽ 0.68). Conclusions: In patients with defunctionalized bladder, urodynamic evaluation is an integral part of pre-transplant investigation work up. Urodynamic results could have an impact on future treatment strategy for selected group of pre-transplant patients. Post-transplant follow up for those patients is mandatory. UP-2.190 Augmentation Cystoplasty in Neurogenic Bladder: Long-Term Urodynamic Evaluations El-Leithy T1, Ghobashy S1, Mahmoud M2 1 Theodor Bilharz Research Institute; 2AlAzhar University, Cairo, Egypt Introduction: Augmentation enterocystoplasty is well tolerated by patients with neurogenic bladder in whom conservative therapy has failed. However, few studies exist on long-term urodynamic evaluation of these patients. We assessed the clinical and urodynamic outcomes of patients with neurogenic bladder treated with augmentation enterocystoplasty with at least 3 years of follow up. Materials and Methods: A total of 119 patients with neurogenic voiding dysfunction underwent augmentation enterocystoplasty alone or in conjunction with various continence or antireflux techniques. Clinical outcomes regarding incontinence, medications, catheterization schedule, subsequent interventions, bowel function and patient satisfaction were addressed. Urodynamic evaluation was performed to assess the long-term durability of bladder augmentation. Results: Mean follow up was 5.0 years (range 3 to 8) 92.4% of our patients had near or complete resolution of urinary incontinence. Mean total bladder capac-
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which concentration and days of treatment is better to remove all cells. Materials and Methods: SIS was obtained and processed and cut in 2⫻2 cm. squares. Under continuous agitation they were treated with escalating concentration of Triton X-100 ⫹ 0.1% of sodic acid during seven days. Random samples were taken every day at any concentration of detergent for histological analysis. Results: After 24 hours of decellularization process almost no cells were found on SIS (p⬍0.05). No differences among escalating concentrations of Triton X-100 were found. After 3 days of treatment no cells were seen at any detergent concentration. Conclusions: After 3 days of process acellular SIS were obtained whatever concentration of Triton X-100 is used. UP-2.185 In Vivo Responses to Biomaterials Used in Urological Reconstruction Williams H1, Singla A1, Broadrick K2, Krishnamurthy B2, Van de Vord P2 1 Department of Urology, 2Department of Engineering, Wayne State University Detroit, MI, USA Introduction and Objectives: Biological tissues are widely used in urological surgeries to treat conditions like pelvic organ prolapse and stress urinary incontinence. In this study, we examine the in vivo responses of several urological tissue samples currently used in urological reconstruction. Materials and Methods: Four commercially available tissue samples were evaluated from three different companies: Small intestine submucosa (SIS) (Cookbiotech), Tutoplast Fascia lata (FL) (Mentor Corp), Tutoplast Fascia dermis (FD) (Mentor Corp) and Pelvicol (P) (C.R. Bard). The biomaterial was implanted intraperitoneally at the bladder neck of Balb/c mice. Animals were sacrificed at 2, 4, 8, or 12 weeks post-implantation. Tissue incorporation, fibrous capsule thickness, cell number, cell morphology and angiogenesis were all evaluated. Results: Histological responses to the biomaterials were quite different. Implants from the SIS group were the only group to show a significance decrease in capsule thickness from 2 to 12 weeks of implantation (p⫽0.01) and tissue incorporation. The aspect ratio which is a measure of inflammatory cells induced by each tissue sample as compared to fibroblastic type cells demonstrated more inflammatory cells deposition for SIS (p ⬍0.05). In terms of angiogenesis, among the four
S290
groups tested, SIS generated the greatest angiogenic response at 2 weeks. Conclusion: SIS induced a less pronounced inflammatory response over time since the capsule thickness decreased with time and more tissue incorporation occurred, both of which demonstrate signs of biocompatibility. UP-2.186 New Technique for Uretero-Ileal Anastomosis in Orthotopic Ileal Neobladder: Fast, Direct and no Reflux nor Stenosis on Long Term Follow-Up Wishahi M Theodor Bilharz Research Institute, Cairo, Egypt Introduction: Radical cystectomy is the method of choice in treatment of muscle invasive bladder carcinoma, and orthotopic ileal neobladder is best patient choice. Since the invention of the Camey-Le Duc technique of uretero-ileal anastomosis in 1979, many procedures have been introduced and there are arguments and controversies on the significance of anti reflux methods. Materials and Methods: We describe our novel technique for uretero-ileal anastomosis in orthotopic ileal neobladder after radical cystectomy for invasive bladder carcinoma. The retrospective study included 230 patients operated upon over the last ten years having medical record available and regular follow-up. Selection criteria for application of this technique is the presence of normal ureters and upper tract in imaging studies, normal kidney function and normal liver function. The technique (Wishahi procedure): After construction of the detubularised ileal pouch in the form of Camey II or Hautman pouch or our spherical pouch, the ureter is anchored on a long soft 6 Ch multiple holes ureteric drainage stent. Anchorage is done by 4/O polyglycolic acid suture 1 cm away from the ureteric end, 1 cm button hole incision is done in the most lower, posterior and lateral site of the pouch. The stent is fixed to a specially designed malleable metal probe that will pass from the button hole incision taking the ureter for 1 cm inside the pouch and passing the stent from the anterior wall of the pouch and crossing the anterior abdominal wall. The ureter is fixed to the ileal pouch by four sutures. The pouch is anastomosed to the uretheral stump by 8 sutures, and a 20 Ch silicone catheter is left. The ureteric stents are removed after 12 days. Follow-up included ascending pouchogram,Tc99 and DMSA renogram.
Urine analysis, ultrasound and intravenous radiography were done in 4 months follow-up. Results: The operative time for anastomosis of one ureter to the ileal pouch is 4 minutes. No urinary leakage was encountered at the site of the anastomosis, regular follow-up did not show any incidence of stenosis and there was no reflux on imaging studies. The kidneys and upper tract showed no deterioration on renographic studies. Conclusion: In our study, the use of our innovative technique of uretero-ileal anastomosis was fast which reduced the operative time, no complications as renal deterioration as a result of stenosis on the site of the ureteric anastomosis nor development of reflux were encountered. Ourtechnique (Wishahi procedure) would be applied safely in the construction of orthotopic ileal neobladder in laparoscopic cystectomy. UP-2.187 Long Follow-Up Study of Original Orthotopic Ileal Neobladder Reconstruction in 61 Patients with Bladder Cancer Zheng J, Zhang H, Chao Y, Xu Y, Peng B, Yan Y, Gao Q Department of Urology, Shanghai Tenth People’s Hospital, Tongji University, Shanghai, China Introduction: The purpose of this study was to evaluate the long-term functional outcome and complications of our original ileal neobladder after radical cystectomy. Materials and Methods: From January 1988 to December 2006, 61 patients underwent construction of an orthotopic ileal neobladder after cystectomy. In this retrospective study, data were analyzed who received ileal neobladder following radical cystectomy with respect to complications, urinary continence, radiographic evaluation of the upper urinary tract and urinary reservoir, renal function, and urodynamic examinations. Results: By December 2006, 13 patients (21.3%) died. Urethral tumor recurred in one patient. Complications occurred in 18 patients (29.5%), mainly including postoperative urinary infection and elsewhere, ureteroileal obstruction, hemorrhage, urine leak, and intestinal obstruction. A total of 40 patients underwent radiographic evaluation of the upper urinary tract, including 34 patients (85.0%) with a normal radiographic graph. Renal function was stable or improved in 46 patients (95.8%) of 48 live patients. In the 48 patients who remained alive by December
UROLOGY 74 (Supplment 4A), October 2009
UNMODERATED POSTER SESSIONS
2006, 44 patients (91.7%) reported good diurnal continence and 42 patients (87.5%) reported good nocturnal continence, and 40 patients (83.3%) completed void. The urodynamic examinations were performed 60 months after operations, showing that the volume of neobladder, the intravesical pressure in filling phase, the maximum flow rate and the post-void residual were similar to the normal bladder. Conclusion: The findings reveal that our original ileal neobladder after radical cystectomy is a satisfactory method to treat the invasive bladder cancer, with acceptable complications. UP-2.188 The Structure of the Urinary Sphincter Complex and Its Continence Mechanism in Females Du G1, Chen B1, Zhang H1, Zhang Q1, Xu H1, Hu W2, Ye Z1 1 Department of Urolgy, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; 2Department of Urology, Wuhan Central Hospital, Wuhan, China Introduction and Objectives: To investigate the structure of the urinary sphincter complex (USC) and the continence mechanism. Materials and Methods: The structure of the urethral lumen and its closing course was observed with F7 ureteroscopy in 15 adult female healthy volunteers, their rest urethral pressure profile (RUPP) and stress urethral pressure profile (SUPP) recorded. Female urethra specimens from 7 fresh corpses were harvested and processed for histological section. Masson’s trichrome staining was carried out to observe the different structural components of urethra. The essential components that comprise the USC and their role in the sphincter closing mechanism were deduced. Results: Under ureteroscopy, a striking structure observed in female urethra was the cresta urethralis that begins 5 to 10 mm below the internal metus and ends before the external metus. About 60% to 80% length of the urethral lumen was occupied by this convex cresta, which make the urethral lumen a reversed U shape latent cavity. When coughing, this cresta becomes thicker and projects inward and wads the urethral lumen tightly. On RUPP and SUPP recording, the high pressure zone was noted correspond to the area of cresta urethralis. On histological sections, besides the typical description of tissue components of outside circular striated muscle, middle smooth muscle, and mu-
cosa, the striking cresta urethralis also be noted filling in the 60% to 80% length of urethral lumen. And the range of striated muscle was noted also correspond to the high pressure zone of RUPP and SUPP. The morphometrics of USC is similar to that of a floodgate. From tridimensional view point, the contraction of striated and smooth muscle will narrow the urethral lumen, inward promontory of the cresta urethralis will block the flow, mucosa layer has seal effect. Conclusions: The essential compositions that comprised USC are muscular tissue, cresta urethralis and mucosa. The detail sphincter mechanism should include three factors: musculature tissue contracts to narrow urethral lumen, cresta urethralis projects inward to wad the urethral lumen and block the flow and, sealing effect from the mucosa. UP-2.189 Evaluation of Pre-Operative Urodynamic Role in Renal Transplantation El-Hefnawy A, Wadie B, El Refaie A, Ghoneim M Mansoura Urology and Nephrology Center, Mansoura, Egypt Introduction and Objective: To evaluate the indications and urodynamic (UD) outcome findings prior to renal transplantation and assess its impact on surgical decision and management plan. Materials and Methods: Forty-nine patients (47 males and 2 females) with endstage renal disease underwent urodynamic studies as a part of pre-transplant work-up evaluation. Indications of UD were: Defunctionalized bladder (DB) in 18 (36.7%) patients, history of PUV in 5 (10.2%) patients, LUTs in17 (34.7%) patients and abnormal cystoscopic or radiological findings (eg. trabeculated bladder wall or vesicoureteric reflux) in 9 (18.4%) patients.All patients underwent video UD. Management of patients with abnormal UD findings was tailored according to the diagnosis of each case. Nine patients had LUTs underwent post-operative UD studies, 6 months after transplantation. Results: Pre-transplant UD was abnormal in 34 (69.4%) patients. Detrusor over activity was found in 18 (36.7%) patients, reduced bladder capacity (⬍ 200 ml) was found in 17(34.7%) patients while 13(26.7%) patients showed evidence of bladder outlet obstruction. One patient (2%) had myogenic failure. Mean bladder capacity was 271.2⫾177 ml, it was significantly lower in patients with DB (mean 171.2⫾66ml) as compared with remaining
UROLOGY 74 (Supplment 4A), October 2009
(men337.8⫾196.3) (p⬎.001).After UD evaluation, kidney transplantation was precluded in 13(26.5%) patients because of multiplicity of causes, not including their bladder condition. Bladder neck incision was carried out in 6 (12.2%) patients and 4(8.1%) patients were maintained on alpha blocker. Eighteen patients with DB were subjected to bladder training protocol then re evaluated after 3 months for bladder capacity. One of them was in need for augmentation ileo-cystoplasty. Bladder training was sufficient in 14 (28.6%) patients while antimuscarinic was indicated in remaining 3 (6.1%) patients. Post-transplant UD showed bladder instability in 4 (44.4%) patients, one of them had no DO in pre-transpalnt UD. Bladder capacity in this subset of patients was comparable to their pre-transpalant values (p⫽ 0.68). Conclusions: In patients with defunctionalized bladder, urodynamic evaluation is an integral part of pre-transplant investigation work up. Urodynamic results could have an impact on future treatment strategy for selected group of pre-transplant patients. Post-transplant follow up for those patients is mandatory. UP-2.190 Augmentation Cystoplasty in Neurogenic Bladder: Long-Term Urodynamic Evaluations El-Leithy T1, Ghobashy S1, Mahmoud M2 1 Theodor Bilharz Research Institute; 2AlAzhar University, Cairo, Egypt Introduction: Augmentation enterocystoplasty is well tolerated by patients with neurogenic bladder in whom conservative therapy has failed. However, few studies exist on long-term urodynamic evaluation of these patients. We assessed the clinical and urodynamic outcomes of patients with neurogenic bladder treated with augmentation enterocystoplasty with at least 3 years of follow up. Materials and Methods: A total of 119 patients with neurogenic voiding dysfunction underwent augmentation enterocystoplasty alone or in conjunction with various continence or antireflux techniques. Clinical outcomes regarding incontinence, medications, catheterization schedule, subsequent interventions, bowel function and patient satisfaction were addressed. Urodynamic evaluation was performed to assess the long-term durability of bladder augmentation. Results: Mean follow up was 5.0 years (range 3 to 8) 92.4% of our patients had near or complete resolution of urinary incontinence. Mean total bladder capac-
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