Giant hydronephrosis: report of 4 cases with review of the literature

Giant hydronephrosis is uncommon. In 1939, Stirling defined it as the presence of more than 1,000 ml of fluid in the collecting system [1]. We herein report 4 cases of giant hydronephrosis containing 1,900 ml, 3,400 ml, 2,100 ml and 3,200 ml, respectively. Only 6 cases with a malignant tumor have been reported in the literature. Our second case with multiple foci of transitional cell carcinoma with squamous metaplasia is presented. This is the first report of this kind of pathological morphology with giant hydronephrosis. An erroneous diagnosis is often made in cases of giant hydronephrosis. For example, 3 of our 4 patients were first diagnosed as ovarian cyst, retroperitoneal hamartoma and hepatic cyst, respectively. We have found 523 cases reported in the literature. It is seen more often in males than in females (2.4:1) and more often on the left side than on the right side (1.8:1). The amount of fluid in the hydronephrotic sac is often between 1 and 2 liters. It is usually secondary to ureteropelvic junction obstruction, stones or congenital abnormality. Nephrectomy is often performed due to severe impairment of renal function. Acute renal failure and cardiopulmonary distress developed in our second case after the operation. The reason may be the sudden decompression of the huge hydronephrotic sac, which resulted in a change in the hemodynamic balance. Therefore, a two-stage procedure with slow decompression by percutaneous nephrostomy before the nephrectomy is preferred in the compromised patient.

[Duplex Doppler ultrasound of internal jugular vein ectasia. Case report]

A seven-year-old boy, who complained of painless swelling mass over the right neck on exertion, was diagnosed as right internal jugular vein ectasis by the duplex Doppler ultrasound. The caliber of the right internal jugular vein was prominently dilated when Valsalva maneuver was done, the duplex Doppler ultrasound showed an essentially flat wave from that indicated the swelling mass to be a venous structure. The clinical manifestation, etiology, pathological findings and diagnostic methods of the internal jugular vein ectasia were reviewed with emphasis on the advantages of duplex Doppler ultrasound in confirming the diagnosis.

Cyclic AMP induces activity increase of kinase FA (a transmembrane signal of insulin) during NG108-15 hybrid cell differentiation

The ATP.Mg-dependent protein phosphatase activating factor (protein kinase FA) has been identified to exist in neuroblastoma x glioma hybrid 108-15 cells (NG108-15 cells). More importantly, when NG cells were induced to differentiate with N6, O2'-dibutyryl adenosine 3',5'-cyclic monophosphate (dibutyryl cAMP), the cellular activity of kinase FA was found to increase dramatically. Time course study further revealed that induction of differentiation in NG cells by dibutyryl cAMP treatment increased the FA activity to over 3 times the levels found in undifferentiated cells and in a linear day-dependent manner, indicating that the FA activity level is correlated with the state of differentiation of NG108-15 cells. This is the first report providing initial evidence that protein kinase FA (a transmembrane signal of insulin) is involved in the induction of neuronal cell differentiation.

Urachal anomalies: acquired patent urachus and giant urachal cyst--2 cases report

Two cases of rare urachal anomalies in the adult are described, including one acquired patent urachus and one giant urachal cyst. The presenting symptoms and signs included pyuria, fever, lower abdominal pain and palpable abdominal mass. The correct preoperative diagnosis was made after sonography. The clinical and radiographic features and magnetic resonance imaging are presented. Stone formation and the huge capacity of the urachal cyst are first reported. Excision of the urachal tract with resection of the bladder dome and cauterization of the cystic wall with stone removal were performed in that order. When a young adult presenting with a wet umbilicus, acute abdominal pain or a lower midline abdominal mass, the possibility of an infected urachal anomaly should be considered in the differential diagnosis.

[Treatment of Wilms' tumor in children]

During the last 13 years, the Kaohsiung Medical College Hospital has treated a total of nine patients with nephroblastoma (Wilms' tumor). Among them, six were male and three were female. The age of the patients ranged from 7 months to 11 years old with an average of 3.25 years. 88.9 percent of the patients complained of abdominal mass. However, the initial symptom was gross hematuria in 33.3% of the patients. Seven out of the nine patients underwent simple nephrectomy while the remaining two were treated with the more conservative open biopsy. All patients died within three years of initial treatment except two, who never came back for follow-up treatment and whom we were unable to trace to determine whether they had survived. Nevertheless, the combination of surgery and postoperative chemotherapy helped to prolong the life of patients with Wilms' tumors.

[Primary tumor of the female urethra--a report of two cases]

From 1972 through 1986, 173 female patients with urinary tract tumors were treated at Kaohsiung Medical College Hospital. Only 2 (1.2%) had primary transitional cell carcinoma of the anterior urethra. These patients were treated with local excision of the tumor, one patient remained alive for more than three years while the other one was lost during the post-operative follow-up. Primary female urethral tumors are mostly malignant tumors. Prompt diagnosis and aggressive treatment is the only way to prolong the patients' survival time.

Ischemic colitis as a cause of massive lower gastrointestinal bleeding and peritonitis. Report of five cases

Vascular disorders of the colorectum are considered rare in Taiwan, however, recently the authors encountered five cases of ischemic colitis, all in men over 50 years of age. Cases one and five involved stricture, case two was secondary to obstructive colon cancer, and case three was of the gangrenous type presenting with peritonitis due to colonic perforation. Case four was of the transient type with acute massive lower gastrointestinal bleeding secondary to traumatic shock. All five patients were treated successfully by resection.

[Surgical treatment of ureteropelvic junction stricture]

Forty-five patients with hydronephrosis due to pelviureteric junction stricture were operated on at Kaohsiung Medical College Hospital between 1971 and 1986. In unilateral cases, the left kidney was affected more frequently than the right (24 to 13), while 8 (18%) had bilateral ureteropelvic stricture. Of the 45 cases, 24 cases (53%) underwent Anderson-Hynes pyeloplasty, 5 cases underwent Y-V plasty, 5 cases underwent ureterolysis and 11 cases underwent simple nephrectomy due to severe hydronephrosis. Except for the 11 nephrectomy cases, 11 of the remaining 34 cases had ureteral catheter placement and 9 cases had double-J ureteral catheter placement, postoperatively; another 14 cases received no ureteral stent for draining urine. The results were very encouraging with clinical improvement in 64% of the patients, and improvement in the pelviocaliceal system and early appearance of contrast medium in the ureter in 47% of the patients. The results of pyeloplasty with and without a nephrostomy or ureteral stent were compared. Patients with a nephrostomy or ureteral stent tended to have an increased incidence of urinary tract infections and longer hospital stays. In general, the results of treatment were poorer for patients with a nephrostomy or ureteral stent, than for patients without.

[Evaluation of impotence: intracorporeal injection of papaverine by color duplex sonography]

From February 1989 to June 1989, 49 patients consulted our OPD for the complaint of impotence. The average age was 46.9 +/- 11.2 y/0. We applied intracorporeal injection of papaverine (60 mg) by color duplex sonography (Acuson 128) for evaluation. The results of the papaverine test were: good response in 6 (12%), imperfect response in 21 (43%) and impaired response in 22 (45%). So the total positive response rate was 55%; and the total negative response rate was 45%; two patients (4%) experienced priapism. Spontaneous detumescence occurred after aspiration of the corpus cavernosum and no complications ensued. We utilized duplex sonography for evaluating penile blood flow before and after papaverine injection. Diameters of the deep artery was: right artery increased from 0.42 +/- 0.13 mm to 0.76 +/- 0.26 mm, while the left artery increased from 0.43 +/- 0.19 mm to 0.64 +/- 0.31 mm. Following injection, the peak velocity and the increased change of peak velocity were higher in patients in the positive response group than in the negative response group. There was no correlation for the percent of increase in diameter of the deep arteries. This technique provides a safe method with few complications for the objective assessment of response to intracorporeal papaverine injection and the anatomic structure of the penis. Use of this technique can also avoid unnecessary examinations and influence the strategy of treatment. After normal values and parameters are established, this method should be a useful diagnostic tool.

[Diagnosis and treatment of adult polycystic kidney disease]

A review of 20 polycystic kidney disease patients in admitted to Kaohsiung Medical College Hospital is herein reported. In this series 60% of the patients were in the fourth to sixth decades of life at the time of diagnosis. The average age was 50 years. The disease was generally more commonly found in the females than in male subjects. Flank pain and gross hematuria was the most common presenting symptom in these cases. In 70% of the patients hypertension were noted, besides 55% of patients have associated liver cysts and 9% of the patients have associated pancreatic cystic diseases. In a comparison of ultrasonography, CT scans, renal angiography, intravenous pyelography and retrograde pyelography in the evaluation of polycystic kidney disease, it was found that CT scans and ultrasonography had more than a 90 per cent diagnostic accuracy rate, while intravenous pyelography had only a 30 percent accuracy rate. Because of improved treatments such as antibiotic and hemodialysis techniques the five-year survival rate of patients, with polycystic kidney diseases, may be increased.

[Clinical experience of treatment of urethral stricture]

The records of 53 patients treated for urethral stricture at Kaohsiung Medical College Hospital over a 8-year period were reviewed. Young men those affected and trauma appeared to have been the most frequent etiological cause. Of the 53 patients 12 were treated by filiform dilatation , 33 were treated by metal sound dilatation , and 8 underwent a pull-through technique. Good results were noted in 29 cases (54.7%), fair in 10 (18.9%) and poor results in 14 (26.4%). When the results were analyzed according to the method of treatment, poor results were most common among those who had underwent the pull-through technique and the metal sound dilatation as compared to filiform dilation group.

Phosphorylation and disassembly of intermediate filaments in mitotic cells

As baby hamster kidney (BHK-21) cells enter mitosis, networks of intermediate filaments (IFs) are transformed into cytoplasmic aggregates of protofilaments. Coincident with this morphological change, the phosphate content of vimentin increases from 0.3 mol of Pi per mol of protein in interphase to 1.9 mol of Pi per mol of protein in mitosis. A similar increase in phosphate content is observed with desmin, from 0.5 mol of Pi per mol of protein to 1.5 mol of Pi per mol of protein. Fractionation of mitotic cell lysates by hydroxylapatite column chromatography reveals the presence of two IF protein kinase activities, designated as IF protein kinase I and IF protein kinase II. Comparison of two-dimensional 32P-labeled phosphopeptide maps of vimentin and desmin phosphorylated in vivo in mitosis, and in vitro using partially purified kinase fractions, reveals extensive similarity in the two sets of phosphorylation sites. Phosphorylation of in vitro polymerized IFs by IF protein kinase II induces complete disassembly as determined by negative-stain electron microscopy. The results support the idea that the disassembly of IFs in mitosis is regulated by the phosphorylation of its subunit proteins.

A clinical evaluation of ultrasonography in the diagnosis of acute appendicitis

Recently ultrasonography (US) has proven effective in the diagnosis of acute appendicitis. However, the impact of US on surgical decision-making in clinical practice remains unclear. From August 1986 to July 1987, 62 patients with clinical signs of acute appendicitis received US examinations after initial clinical evaluations. According to clinical pictures, they were classified into two groups: group I, clinically typical (Alvarado's score greater than or equal to 7) and group II, clinically dubious (Alvarado's score less than or equal to 6) cases. All group I patients (n = 34) had surgery. Group II patients (n = 28) received close in-hospital observation on an every 4-hour basis for less than 24 hours. However, surgery was performed if Alvarado's score increased up to or above 7 or surgical indications became evident during observation. The pathologic reports and operative findings were retrospectively correlated with the US diagnosis. For group I patients, clinical examination without knowledge of US findings was correct in 30 (88.9%) cases, 26 (86.7%) of which were detected by US. Four (50%) of eight patients with negative US findings had acute appendicitis. In group II, 12 of 15 patients who had surgery had acute appendicitis, and 10 (83.3%) were detected by US. Two (11%) of 18 patients with negative US findings were finally proved to have acute appendicitis. The average duration from initial clinical examination to surgical decision fpr patients with acute appendicitis was 6.8 hours. There were no false-positives in either group. For patients with typical clinical presentation, US is not superior to clinical examination, and surgery is recommended even if US findings are negative.(ABSTRACT TRUNCATED AT 250 WORDS)

[Urethral injuries: analysis of 24 cases]

Cases analysis of 24 operations for the anterior urethral injuries is presented. 7 patients were treated one-stage transperineal end-to-end anastomosis and 17 underwent an immediate urethral realignment over a fenestrated catheter. Hospital stays were generally short and the rate of complication was low as well as the number of blood transfusions needed in both groups. The operating time however was longer in patients in the anastomosis group. Postoperatively, urethral strictures occurred in 71% of the patients who underwent one-stage transperineal end-to-end anastomosis and in 65% of those treated by realignment over a fenestrated catheter. The high incidence of postoperative stricture formation caused both techniques indicated neither procedure as a valuable modality for the primary and early treatment of anterior urethral injuries. According to the authors the suprapubic cystostomy and delayed urethroplasty offer a better choice of therapy.

Coincidental angiomyolipoma and renal cell carcinoma--report of 1 case and review of literature

A patient underwent simple enucleation for a suspected angiomyolipoma in the right kidney and histopathology revealed a mixture of renal cell carcinoma with angiomyolipoma. To our knowledge only 1 other case of a combination of a renomedullary tumor has been reported previously.

Clinical significance of ultrasonography, computed tomography, and biochemical tests in the rapid diagnosis of gallstone-related pancreatitis: a prospective study

Real-time ultrasonography (US), computed tomography (CT), and biochemical tests were prospectively performed to detect gallstones in 88 consecutive patients immediately after the onset of an attack of acute pancreatitis. The sensitivity of biochemical tests was 84.6% when the patients had three or more positives of five parameters [including serum bilirubin, alkaline phosphatase (AP), gamma-glutamyl transpeptidase (GGT), alanine transaminase (ALT), and alanine transaminase-aspartate transaminase (ALT-AST) ratio]. The sensitivity, specificity, and accuracy were 71.8, 98.0, and 86.4% for US, and 52.9%, 100%, and 79.5% for CT. The sensitivity, specificity, and accuracy were improved to 82.1, 100, and 93.2% by the combination of US and CT, and 94.9, 100, and 97.7% by the combination of US and biochemical tests. Adding CT to the combination of US and biochemical tests resulted in only a slight improvement in sensitivity and accuracy. In conclusion, a combination of US and biochemical tests can provide the best noninvasive method in rapidly detecting gallstones as an etiological factor in acute pancreatitis. Computed tomography is not cost-effective. A positive result of biochemical tests despite a negative finding in US calls for an intensive search for gallstones by further investigation with endoscopic retrograde cholangiography or repeated US examinations.