A novel GPR55-mediated satiety signal in the oval Bed Nucleus of the Stria Terminalis

Nestled within feeding circuits, the oval (ov) region of the Bed Nucleus of the Stria Terminalis (BNST) may be critical for monitoring energy balance through changes in synaptic strength. Here we report that bidirectional plasticity at ovBNST GABA synapses was tightly linked to the caloric state of male rats, seesawing between long-term potentiation (iLTP, fed) and depression (iLTD, food restricted). L-α-lysophosphatidylinositol (LPI) acting on GPR55 receptors and 2-arachidonoylglycerol (2-AG) through CB1R were respectively responsible for fed (iLTP) and food restricted (iLTD) states. Thus, we have characterized a potential gating mechanism within the ovBNST that may signal metabolic state within the rat brain feeding circuitry.

RU486 facilitates or disrupts the sensitization of sexual behaviors by estradiol in the ovariectomized Long-Evans rat: Effect of timecourse

An acute injection of estradiol benzoate (EB) to the ovariectomized (OVX) rat activates low levels of lordosis, and subsequent progesterone (P) administration augments lordosis and recruits a complete pattern of sexual behavior including appetitive behaviors (e.g., hops/darts and solicitations). However, repeated injections of 5μg or 10μg EB (but not 2μg EB), administered every 4days to sexually-experienced OVX rats results in a behavioral sensitization, such that lordosis quotients (LQs) and appetitive behaviors progressively increase. We have shown that adrenal P does not play a critical role because behavioral sensitization to EB is not prevented by adrenalectomy. Here we tested whether P receptors play a role by examining the effect of chronic administration of the P receptor antagonist RU486 at a dose that reliably inhibits sexual behavior in fully primed OVX rats. Females were treated with EB (5 or 10μg), and 5mg RU486 dissolved in 0.4mL vehicle (VEH; 80% sesame oil, 15% benzyl benzoate, 5% benzyl alcohol) 48h and 5h prior to each of 7 tests, respectively, occurring at 4-day intervals in unilevel 4-hole pacing chambers. Control animals were treated with 2, 5, or 10μg EB+VEH. As expected, sensitization did not occur in females treated with 2μg EB+VEH, and those females received fewer intromissions and ejaculations than all other groups. RU486 did not prevent the sensitization of LQ, moderate and high lordosis magnitudes (LM2 and LM3) or appetitive sexual behaviors on early tests, and in fact potentiated appetitive behaviors, LQ, LM2 and LM3, consistent with its facilitative actions in females treated with EB-alone, as we and others have reported previously. However, despite the initial facilitation, blocking P receptors by chronic administration of RU486 inhibited the maintenance of behavioral sensitization to EB.

Treatment of post-orchiectomy hot flashes with transdermal administration of clonidine

The occurrence of hot flashes in men after bilateral orchiectomy for prostatic carcinoma can be bothersome and difficult to treat. Transdermal clonidine was administered to 7 patients with such symptoms. In 3 patients the hot flashes were ablated and in the remaining 4 the number and frequency of attacks were considerably reduced. No significant side effects were encountered. We suggest that transdermal clonidine (0.1 mg.) administered weekly can safely control undesirable hot flashes in men after bilateral orchiectomy.

Transrectal ultrasound in stage A1 prostate carcinoma

Transrectal ultrasound of the prostate was employed on 6 patients found to have Stage A1 carcinoma of the prostate after transurethral resection in order to identify those patients with residual tumor. Two patients were found to have residual tumor by transrectal ultrasound; this was confirmed by ultrasonic guided biopsy of the prostate. Of the remaining patients, an additional 2 on whom the ultrasound did not detect the tumor had tumor less than 1 cm in size, and in 1 patient no residual disease was found in the pathologic specimen. We conclude that ultrasound of the prostate offers another dimension in the staging of patients with Stage A1 carcinoma of the prostate.

Surgical implantation of the artificial urinary sphincter

The surgery necessary for sphincter placement is much more difficult than that required during the placement of penile prostheses, and there is definitely an associated learning curve. The risks of complications are present, but for a patient with the severe social and psychological disability of urinary incontinence, these risks are generally acceptable.

Bladder perforation caused by cucumis sativus repaired per vagina

A case of bladder perforation secondary to simulated intercourse with a cucumber is presented. Treatment by primary vaginal repair was successful.

Followup of ureterosigmoidostomy diversion for bladder exstrophy--behavioral biofeedback as an alternative treatment for fecal-urinary incontinence: a case report

A total of 6 children underwent primary ureterosigmoidostomy diversion between 1972 and 1979. Despite preoperative testing of rectal competence all 6 children now experience rectal leakage. Behavioral biofeedback has been used in a 7-year-old boy who had learned to isolate and to contract the perineal muscles appropriately by 12 months of followup. The incidence of incontinence has been reduced from 15 to 5 per cent of the total hours recorded. The amount of waking hours in which the patient is wet has decreased from 31 to 6 per cent. Satisfaction of the child and parents is high.

Scott's inflatable penile prosthesis: evaluation of mechanical survival in the series 700 model

The series 700 penile prosthesis was implanted in 131 patients. Actuarial analysis revealed survival of the cylinders to be 98 per cent at 1 year and 92 per cent at 36 months. The only additional failures were leaks in the reinforced tubing in 9 cases. No tubing leaks have occurred since revisions were made by the manufacturer in October 1983.

Penile prosthesis: review of current models, mechanical reliability, and product cost

A fifty-year experience with the modern penile implant has led urologists to conclusions as to the reliability, applicability, and cost of these devices. Product evolution has led to a more physiologic erection. However, with increased sophistication, further potential for failure must be considered. Each modification must undergo the test of clinical experience in addition to classic bench testing in order to predict reliability accurately.

Urinary incontinence in the elderly. Ways to relieve it without surgery

Few studies of incontinence have been done on the elderly as a specific population, although epidemiologic reports reveal that incontinence is a debilitating condition that affects 15% to 30% of the elderly population of the United States. In diagnosing the problem, we use the simplest procedure that can supply the required information. However, if the diagnosis is uncertain or the treatment being considered is risky, urodynamic testing is necessary. Several nonsurgical treatments are available and have varying degrees of success in reestablishing continence. Some, such as pharmacotherapy and intermittent self-catheterization, are effective for some patients and are replacing bladder drill and bladder distention in popularity. Less conventional techniques (electrotherapy, biofeedback, and periurethral injection) are useful only in select cases and have had fewer clinical trials. Clamps and external devices for men and pessaries for women are prone to complications and generally are avoided in our practice. Long-term use of indwelling catheters is a last resort, to be considered only when all other alternatives have been exhausted. Further clinical research that considers the particular problems of the elderly is needed so that practical, humane, and effective treatment becomes possible.

Failure of the Jonas prosthesis

A total of 27 patients received the standard Jonas silicone-silver penile prosthesis. The procedure was done at 3 separate hospitals by 2 surgical teams. Four patients who were reported on previously presented consecutively to our clinic with failed penile rigidity and complete multiple wire fractures were found at reoperation. Therefore, the remaining 23 patients were reviewed and 7 had positive findings suggesting fracture, including decreased penile rigidity, crackling that was audible or palpable and/or evidence of fracture on an x-ray. Seven patients had completely negative evaluations and 9 were lost to followup. Two patients with suspicious x-ray findings and 1 with negative x-ray findings but who reported less rigidity have since had the prostheses removed, and all had multiple wire fractures. Radiographs of fractured prostheses, both in the penis and explanted, attest to the limited reliability of x-ray in the diagnosis of wire fracture.

Torsion of the contralateral testis 5 years after orchiopexy

We report a case of spermatic cord torsion in the contralateral testicle 5 years after surgical fixation. Since diagnosis of such a lesion is difficult a high degree of suspicion is necessary. If torsion is suspected exploration is mandatory. We strongly recommend the use of a nonabsorbable reaction-producing suture (for example silk) when an orchiopexy is performed, with the point of fixation being between the visceral tunica vaginalis and the dartos muscle.

Multiple fractures of the silver wire strands as a complication of the silicone-silver wire prosthesis

A review of 5 consecutive cases in which removal of the silicone-silver wire prosthesis was necessary within 2 years of implantation has revealed multiple breaks in all strands of the silver wire core in both of the paired cylinders.

Intermittent catheterization: evaluation of complete dryness and independence in children with myelomeningocele

We studied 46 children in active followup who have been managed by nonsterile intermittent catheterization to achieve continence. All patients were given maximum therapeutic doses of supplemental medication to improve dryness. Of the patients 33 per cent were noncompliant and, therefore, wet, 30 per cent were wet despite full compliance with the program, and only 24 per cent were completely dry and wearing regular underclothing. Nine children experienced side effects from the supplemental medications that were severe enough to warrant discontinuation of the drug. Of the 46 patients 19 have been removed from the catheterization program and currently are being managed by other modalities. Only 11 of the remaining 27 patients currently managed by catheterization perform the procedure independently. Results suggest that intermittent catheterization does not provide independence or social continence in many patients.

Ventriculo-peritoneal shunt pseudocyst causing ureteropelvic junction obstruction in a child with myelomeningocele and retrocaval ureter

We report on a boy with myelomeningocele and a ventriculo-peritoneal shunt, who presented with progressive ureteropelvic junction obstruction and an enlarging right upper quadrant mass. Exploration revealed a large pseudocyst around the distal portion of the shunt, causing obstruction of an unsuspected retrocaval ureter. To our knowledge this is the first reported case of an upper urinary tract complication due to a ventriculo-peritoneal shunt as well as the first case of a retrocaval ureter associated with myelomeningocele.

The inflatable penile prosthesis, reoperation and patient satisfaction: a comparison of statistics obtained from patient record review with statistics obtained from intensive followup search

Of 179 patients who received the inflatable penile prosthesis 43 per cent have required reoperation, 60 per cent of which were performed for mechanical failure. An attempt to evaluate the adequacy of chart review in assessing current function and patient satisfaction was made by comparing reports obtained by chart review to those obtained by direct patient interview. Results showed that if chart review alone was used malfunction would have been underestimated by 13 per cent and patient satisfaction overestimated by 21 per cent. The importance of direct followup in evaluating patients with the inflatable penile prosthesis is demonstrated.

The inflatable penile prosthesis: failure of the rear tip extender in reducing the incidence of cylinder leakage

Of 184 patients who have received an inflatable penile prosthesis at our institution since 1974, 43 per cent have undergone reoperation, the majority of which were owing to cylinder leakage. Comparison by life-table analysis of cylinders placed before and after introduction of the rear tip extender does not show an improvement in cylinder survival to date.

Impotence: the surgical approach

Techniques are now available to restore erectile potency. Several prosthetic devices have been developed that afford a high degree of reliability. The inflatable prosthesis is cosmetically superior, but it is associated with the highest mechanical complication rate. Penile revascularization is a technique with great potential, but the methodology at this point requires further development. Surgeons involved with the treatment of impotency must acquire both the surgical skills required by the operative techniques as well as a philosophical approach to the psychological aspects involved in such therapy. Restoration of penile rigidity can, for some men, mean a new lease on life, but in the improperly selected patient a surgical success may be associated with utter patient dissatisfaction.

The diagnosis and surgical management of vasculogenic impotence

Thirty-two patients have been treated for organic impotence at our institution during a 16-month period. Of these patients 5 were found to have penile vascular insufficiency and underwent a femorocavernosal bypass with an autogenous saphenous vein graft. Initial results were excellent but late failures occurred. At 28 months all shunts were occluded. Microscopic examination of the cavernous tissue revealed fibrous thickening of the septa and loss of cavernous spaces. These findings suggested that late failure in direct revascularization may be associated with fibrotic changes that occur under high pressure inflow to the corpora cavernosa.

Aggressive management of bilateral renal cell carcinoma

We review 4 cases of bilateral renal cell carcinoma. Treatment included extracorporeal surgery with subsequent autotransplantation in 2 patients and radical nephrectomy combined with contralateral partial nephrectomy in the remaining 2 patients. Absence of recurrence as well as length of patient survival supports this aggressive therapy.

The management of vesicoureteral reflux in the pediatric neurogenic bladder

An integrated method of management has been used in 29 children with neurogenic bladders and vesicoureteral reflux. Radiological followup reveals that resolution or improvement of reflux occurred in 48 per cent of the renal units managed by close observation only, 48 per cent managed by intermittent catheterization, 75 per cent managed by vesicostomies and 100 per cent in which the ureters were reimplanted. As in the non-neurogenic bladder successful management of reflux and prevention of upper tract deterioration can be achieved by conservative management as well as by ureteroneocystostomy. A protocol of management is outlined.

Correlation of antibody-coated bacteria with intravenous pyelogram in children with refluxing and nonrefluxing units

A fluorescent technique for detecting immune globulins on the surface of urinary bacteria has been used to differentiate upper from lower urinary tract infections. In an attempt to correlate positive fluorescence with deteriorative changes on the intravenous pyelogram, a total of 79 pediatric patients was studied. Twenty-three had ileal conduits with freely refluxing urine. The remaining 56 children had intact urinary tracts. Thirty of these had vesicoureteral reflux. Urine cultures were studied in conjunction with fluorescent antibody determinations. In patients with significant bacteriuria good correlation was seen with the presence of bacterial fluorescence and positive renal changes. This correlation was 88 per cent in patients with bowel conduits, 71 per cent in patients with vesicoureteral reflux, and 38 per cent in patients without reflux. Possible false positive and false negative results were relatively low, each occurred in 10 per cent of the specimens examined. It is concluded that the combindation of urinary tract infection and positive bacterial fluorescence is seen when upper tract deterioration has occurred and is seen most frequently in association with urinary reflux. In these instances aggressive therapy is often indicated.

Acute epididymitis in boys: a 5-year retrospective study

A retrospective study was undertaken of 25 children with epididymitis seen at our pediatric hospital during the last 5 years. The symptoms and signs in these patients were evaluated, as well as the results of urinalysis, urine culture, excretory urogram, scrotal scan, exploration and white blood count. The presence of underlying urological problems was particularly sought for and found to be rare prior to epididymitis. The treatment and results are reviewed.

The role of intraoperative angiography in salvaging bovine grafts for hemodialysis

Bovine grafts used in hemodialysis frequently need declotting. Success of the declotting procedure usually is dependent upon relieving outflow obstruction. Intraoperative angiography was done during 22 declotting procedures and outflow obstructions were detected in 14 grafts. Of these 5 grafts had clinically unsuspected clots, residual to the initial declotting attempt. Four grafts had stenotic areas at the site of the venous anastomosis, which were corrected subsequently by patch grafts. Two grafts had stenotic areas in the graft owing to an infolding of the intima covered with an organized blood clot. In 2 grafts the veins draining the grafts were stenotic for a considerable length and needed revision. In 1 graft there was stenotic change at the site of the arterial anastomosis, which required revision. Of the 14 grafts 11 have remained functioning for an additional 6 to 18 months after relief of obstruction.

Vascular-induced erectile impotence in renal transplant recipients

The incidence and pathogenesis of sexual dysfunction were studied in 16 male renal allograft recipients. In 9 patients with bilateral renal transplants in whom both internal iliac arteries were occluded nocturnal erections were absent and a penile arterial pulse could not be palpated. Of 7 patients with 1 renal allograft 4 demonstrated penile nocturnal tumescence and the penile pulse could be palpated in 5. Since interruption of pelvic arterial blood supply appears to contribute to impotence in renal transplant recipients consideration should be given to the use of the external iliac artery for arterial anastomosis. Two patients were treated successfully with an inflatable penile prosthesis.

Urolithiasis in children

A 10-year review of stones in children at the St. Louis University Hospitals is presented. Stones related to infection were seen most often and urinary diversion secondary to congenital abnormalities of the urinary tract was the most frequent predisposing cause. The morbidity of stones in children is high.

Scrotal scanning: present value and limits of interpretation

Forty-three testicular scans have been performed on 38 patients presenting with various scrotal symptoms. Scan diagnosis correlated correctly with the clinical findings in 86 per cent of cases. The most common cause of false positive testicular scan was found to be hydrocele. The mechanism responsible for this observation has been explored in a rat model. A false negative diagnosis was made in 2 cases owing to a small retracted scrotum in 1 patient and a markedly late discovered torsion in the second.

Osteomyelitis of the pubic symphysis after urologic surgery

Osteomyelitis represents a pyogenic infection of the bone and marrow. The diagnosis is based on specific criteria and often is difficult to make. Herein we present 2 cases initially thought to represent osteitis pubis but subsequently proved to be osteomyelitis and compare the 2 entities with emphasis on differential diagnosis and treatment. Despite certain differentiating characteristics the correct diagnosis is often uncertain without histologic examination. Since the treatment of these 2 entities is quite different equivocal cases should undergo surgical exploration and bone curettage. This procedure will enable definite diagnosis to be made and proper treatment to be instituted.

Comparison of intermittent catheterization and supravesical diversion in children with meningomyelocele

A comparison in terms of renal preservation as evidenced by urography is made between children with meningomyelocele on intermittent catheterization and children who had undergone diversion. Followup in the former group is only 2 1/2 years but at this time those patients on catheterization are doing as well and probably better than children who had undergone diversion and the quality of life for them is better.

Oxalate stone disease after intestinal resection

There have been 543 jejuno-ileal bypass patients screened for the presence of urinary calculi 1 to 6 years postoperatively. Of these patients 9 per cent have had 1 to 2 calculi during the followup and 3 per cent have had multiple calculi. Ninety-four per cent of the recovered calculi consisted entirely of calcium oxalate. Seven patients had a history of stones before the bypass, 6 of whom have had additional stones postoperatively. To define the conditions associated with stone formation in these patients measurements of serum and urinary oxalate concentration, urinary calcium oxalate saturation, urinary crystal size distribution, and the rates of intestinal oxalate absorption and urinary crystallization have been performed on patients who did and did not have stones postoperatively. On the basis of these studies it appears that the patients in whom stones formed differ from those in whom they did not form only in the rate of urinary crystallization and in the number of large crystal particles present in the urine. Evaluation of current therapeutic modalities in terms of the capability to correct these stone-forming characteristics and to reduce actual calculus formation reveals that the only successful regimen is that which includes an extreme reduction of oxalate ingestion.

Jejunal intussusception following small bowel bypass for morbid obesity

In 600 patients who have undergone small bowel bypass for the treatment of morbid obesity, we have encountered three patients who developed intussusception in the bypassed intestine. Diagnosis in these cases has been difficult but in two patients with surgical marker clips applied to the transected fixed jejunum as well as to the adjacent mesocolon, diagnosis was made easier by the radiographic finding of separation of these clips. Clinical symptoms are difficult to evaluate and valuable time may be wasted before a diagnosis is arrived at. Once a diagnosis is made, operation with either reduction or resection of the area of intussusception should be carried out with refixation of the bowel to the mesocolon and reapplication of surgical marker clips. These marker clips are of great value in the diagnosis of intussusception occurring in the bypassed loop.

Changing attitudes toward urinary dysfunction in myelodysplasia

Alternative methods to supravesical urinary diversion in myelodysplastic children, which protect the upper urinary tracts and provide urinary continence, are now available in the form of prosthetic devices and intermittent clean catheterization with or without ancillary pharmacologic agents. We believe that these alternatives deserve a trial before proceeding to supravesical urinary diversion. Short-term evaluation indicated improvements and stability in most urinary tracts treated by these methods but we recognized that, just as with the ileal conduit diversion, a longer period of followup is required before definite statements can be made about the long-term results. However, if the criteria of sterile urine and bladder emptying at physiological pressure ranges are strictly met we would suspect a favorable outcome.

Posterior urethral valves

Twenty cases of posterior urethral valves are reviewed with the presentation of several illustrative cases. Review of the current literature regarding managment of patients is discussed.

Anterior bladder tube in radical retropubic prostatectomy

Six patients with a minimum of ten months' follow-up have undergone reconstruction of the urethra by anterior bladder tube after radical retropubic prostatectomy; 4 void well and are continent, 1 is incontinent, and 1 has severe stricture.

Aggressive management of genitourinary complications of renal transplantation

In the course of 184 renal transplantations performed in St. Louis since 1963, twenty-six minor and twenty-three major complications have occurred. As a result of these complications four kidneys have been lost and 1 patient has died. Aggressive therapy has been utilized in the management of all but two of the major complications and is associated with one death and the loss of two kidneys. On the basis of these results intensive therapy for genitourinary complications is encouraged, and the principles of therapy are discussed.

Serum lactic dehydrogenase and irreversible renal allograft rejection

The relationship between serum lactic dehydrogenase (SLDH) values and renal allograft rejection was examined in the dog and in man. Nine dogs with renal allografts and four with autografts had similar maximal elevations of SLDH during the first five postoperative days (mean, 420 +/- 213 and 433 +/- 80 I.U. per liter, respectively). During rejection of the allografts between days 7 and 14 the maximum SLDH was 810 +/- 285 I.U. per liter, and in autografts the peak SLDH was 233 +/- 22 I.U. per liter (p less than 0.01). The isoenzyme pattern of maximum SLDH during rejection was prominent in LDH5 and corresponded with renal tissue LDH isoenzyme composition. In 93 episodes of initial acute human renal allograft rejection reactions, the SLDH peaked above 500 I.U. per liter in 23 cases and remained below 500 I.U. per liter in 70 cases. SLDH levels above 500 I.U. per liter were associated with complete rejection of the kidney in 91 percent of patients and SLDH levels persistently below 500 I.U. per liter corresponded with reversal of rejection reaction in 99 percent of patients (p less than 0.01). Marked SLDH elevation is associated with severe, usually complete renal allograft rejection and may be useful in identifying patients with irreversible rejection reactions.

Anterior bladder tube for continence in neurogenic bladder. Experimental study

Experimental studies designed to evaluate the anterior bladder tube as a method of maintaining continence in the neurologically deprived bladded achieved a 50 to 60 per cent success rate. This success rate is not sufficient to warrant its clinical use.