Development of a carbon dioxide laser cystoscope

CO2 laser lesions were created at varying power densities on the exteriorized canine bladders. A 50-watt carbon dioxide continuous laser coupled to a Zeiss surgical microscope was used. A schematic power curve was developed indexing depth of bladder penetration by the laser against laser energy output. Once the optimal power settings for the carbon dioxide laser were established, vertical heat transmission, hemostasis, and healing were studied. A prototype carbon dioxide laser cystoscope was then constructed that allowed endoscopic delivery of the CO2 laser beam into the intact canine bladder. The beam was focussed by a germanium lens and directed out the end of the endoscope, using a movable mirror. Eight dogs were then endoscopically studied in vivo.

The flow rate nomogram: I. Development

In normal individuals the flow rate depends on the initial bladder volume in a non-linear fashion. A flow rate nomogram taking this relationship into account was developed as an aid in the interpretation of urinary flow rate data. With this approach excellent differentiation of normal from obstructed individuals was achieved. In addition, the variability in a single individual's flow rate over time was estimated to be relatively small and, thus, uroflowmetry may be used to identify changes in outflow resistance after medical or surgical therapy.

Topical induction of delayed hypersensitivity in the bladder

Delayed hypersensitivity reactions have been elicited by topical application of dinitrofluorobenzene to the bladder mucosa of sensitized dogs and rats. The resultant animal models may be of value in assessing the role of topically induced delayed hypersensitivity in the attempted immunotherapy of bladder cancer.

Retroperitoneal fibrosis with ureteral obstruction secondary to Actinomyces israeli

A case of Actinomycosis israeli causing retroperitoneal fibrosis and ureteral obstruction is presented. This rare occurrence followed direct extension of the infectious process from intra-abdominal abscesses to the retroperitoneum, resulting in dense fibrosis. Diagnosis is most commonly established by histologic identification of sulfur granules obtained at abdominal exploration. The pathogenesis and treatment of genitourinary as well as retroperitoneal actinomycosis is discussed.

The controversy of single versus multistaged urethroplasty

Experience with various 1 stage repairs for urethral strictures (patch graft, and excision and reanastomosis techniques) gained by ourselves and others is compared to reports on multistaged urethroplasties (Johanson, Leadbetter-Johanson and Turner-Warwick). Increased hospitalization, absence from employment and the morbidity of multiple anesthetics and operations are features of the multistaged approaches compared to the 1 stage operations. Furthermore, no advantage was seen when initial or final success rates were compared.

Hematuria in renal transplant recipients

This study is a retrospective analysis of microscopic and gross hematuria in 127 male renal transplant recipients. The incidence of hematuria was 12%. The causes of hematuria were similar to those in the general population with inflammatory conditions predominating. Urologic malignancy was not found. Hematuria heralded rejection episodes in three instances. Complete evaluation of hematuria revealed pathology of the urinary tract in every instance.

Development of a carbon dioxide laser cystoscope

A 50-watt carbon dioxide continuous laser coupled to a Zeiss surgical microscope was used to study the characteristics of laser-induced lesions on the exteriorized canine bladder. The relationship of energy to the depth of the lesion created by the laser was evaluated. Healing, vertical temperature transmission and hemostasis were studied. A prototype carbon dioxide laser cystoscope then was constructed and used endoscopically to create surgical lesions in the intact canine bladder.

The phentolamine test in neurogenic bladder dysfunction

In an attempt to improve the selection of patients with neurogenic bladder dysfunction likely to benefit from phenoxybenzamine therapy, the effect of intravenous phentolamine (Regitine) on the urinary flow rate was determined in normal and abnormal subjects. A nomogram relating mean flow rate to volume voided was constructed to aid in the interpretation of results. In 16 patients with neurogenic bladder dysfunction it was found that a response of more than 0.8 nomogram units indicates a likelihood of clinical improvement with phenoxybenzamine therapy. The clinical applications of this test are discussed.

An argument for epinephrine renal arteriography in the diagnosis of renal cell carcinoma

Two cases are presented where the diagnosis would have been missed or would have been very difficult with selective angiography only; the use of the epinephrine technique made these renal cell carcinomas obvious. The authors feel that epinephrine should be used in the presence of all renal masses to exclude or confirm the presence of renal cell carcinoma if this is not already obvious by selective arteriography alone.

Management of prostatic fistulas

Prostatic fistulas communicating with the rectum or perineal skin are unusual complications of a prostatic operation, pelvic trauma, prostatic abscess or other iatrogenic injury. A third of these fistulas may close spontaneously with proper urinary drainage and avoidance of fecal soilage. The many operative procedures described for the repair of these fistulas indicate that no ideal method of repair can be applied to every case. Operative management should be mandated by the size, location and duration of the fistula as well as by the surgeon's experience with the various anatomic approaches.

Clinical management of non-testicular intrascrotal tumors

Our 10-year experience with non-testicular intrascrotal tumors has been combined with an extensive survey of the literature. The over-all incidence of malignancy affecting intrascrotal structures is high: 1) 25 per cent of epididymal neoplasms are malignant, 2) excluding cord lipomas, 56 per cent of cord tumors are malignant and 3) 59 per cent of scrotal tunic neoplasms are of malignant origin. Because of the high incidence of malignancy and because tumors of these structures are often misdiagnosed, a clinical approach to the diagnosis and management of non-testicular intrascrotal masses is presented.

Metastatic infection secondary to genitourinary tract sepsis

Metastatic infections arising from sepsis in the genitourinary tract are reviewed in 175 cases, including five in which we treated the patients. The skeleton was the most common site of metastasis (59 per cent). The endocardium was next most frequently involved (28 per cent). Gram-negative organisms were implicated in less than two-thirds of the cases (59 per cent). Impaired host defense mechanisms were noted in 25 per cent of the patients experiencing metastatic infections. The lower urinary tract was the source of metastasis in 75 per cent of the patients, particularly after urologic manipulation in men. Women were more likely to experience metastatic infection from the upper urinary tract. Anatomic and pathologic considerations explaining these sex differences are presented.

Comparative effects of anticalculus management in the rat

Utilizing a low pyridoxine, ethylene glycol-fed rat model, various modes of anticalculus therapy were compared. Prophylactic papillary and parenchymal oxalate stone therapy is most effective with magnesium oxide. Hydrochlorothiazide is next in order as the therapy of choice in this group. A high calcium diet seems to negate the effect of magnesium oxide. Methylene blue, magnesium oxide, and even sodium phosphate, are not as effective as hydrochlorothiazide in the combined prevention and treatment of preformed parencymal calcium oxalate stones. No agent seems to have a profound effect on preformed apical papillary calculi.

Effect of tetracycline on calcium oxalate calculi: in vivo and in vitro studies

Inadvertent use of tetracycline hydrochloride while producing calcium oxalate stones in the rat resulted in a reduction of papillary concretions by one-half. Parenchymal calcifications in the continuing long term, preformed stone group were reduced to levels comparable to that of other useful agents. In vitro studies corroborated these findings at physiologic urinary pH ranges. The rationale and comparisons to other anticalculus drugs are discussed.

Treatment of posttransplant lymphoceles: internal versus external drainage

Six lymphoceles developed in 93 renal transplant recipients. Four were drained externally and two were drained internally. All patients with external drainage of lymphoceles experienced prolonged wound drainage with eventual contamination of the wound with pathogenic organisms. A technique of internal lymphocele drainage and its advantages was discussed.

The renal compression syndrome

A clinical example of perirenal compression producing documented renin-mediated hypertension is presented. The pathophysiology of this disorder is discussed as it relates to renin release mechanisms. In the future, recognition of the renal compression syndrome may obviate needless nephrectomies since simple removal of the source of compression should result in the cure of hypertension.

Regional program for kidney preservation and transplantation in New England

From July 1972 to March 1975, 431 cadaver kidneys were harvested and preserved by continuous pulsatile perfusion with cryoprecipitated human plasma. Forty-eight per cent of the transplanted kidneys were considered to have immediate function, another 48 per cent demonstrated acute tubular necrosis, and 4 per cent were classified as nonfunctioning. There was no difference in the incidence of acute tubular necrosis in relation to the total preservation time. There was a significant difference in the survival of primary cadaver grafts at six months and one year between the kidneys that demonstrated immediate function and those with acute tubular necrosis.

New look at pelvic exenteration

Our experience with 18 patients undergoing pelvic exenteration for advanced primary or recurrent pelvic malignancies is presented. Only one postoperative death was noted, and morbidity was minimal despite the advanced age and high incidence of radiotherapy failures seen in our patients. Although no improvement in cure of malignancy has been seen in this small series, appreciable periods of symptom-free life have been achieved in patients who were previously incapacitated by extensive pelvic pain, fistulas, sepsis, hemorrhage and urinary-fecal incontinence. Because of the symptomatic palliation obtained in our experience, with minimal morbidity and mortality, we have developed a liberal attitude toward the use of pelvic exenteration in the management of selected patients with extensive pelvic malignancy, even when cure is not anticipated.

Mechanical circulatory assistance with intra-aortic balloon counterpulsation for major abdominal surgery

Intra-aortic balloon counterpulsation (IABC) provides effective mechanical circulatory assistance (MCA) in many patients with cardiac disease characterized by low cardiac output and/or myocardial ischemia. The intra-aortic balloon pump (IABP) has been used almost exclusively in the care of patients with cardiac disease as their primary medical disorder. This report presents use of the IABP in three cases where cardiac disease was present, but abdominal pathology necessitating urgent surgical intervention was the primary medical concern. Experience with these three cases suggest that operative and early postoperative use of IABC in patients with documented heart disease undergoing major non-cardiac surgical procedures may reduce the high incidence of cardiac complications.

Effects of levodopa on the bladder outlet

Lower urinary tract function was studied in patients with Parkinson's disease. A significant proportion of patients receiving levodopa manifested clinical and radiological evidence of bladder outlet obstruction. We believe that neuropharmacologic bladder neck obstruction may be caused by the alpha-adrenergic properties of the metabolites of levodopa.