Cecoappendicovesicostomy: conduit-lengthening technique for use in continent urinary reconstruction

OBJECTIVES

To describe a conduit-lengthening technique for use in continent cutaneous appendicovesicostomy (Mitrofanoff procedure).

METHODS

Fifteen consecutive patients (4 male, 11 female) with a mean age of 14.2 years underwent tubularized cecal augmentation as a means to lengthen the catheterizable conduit while performing continent cutaneous appendicovesicostomy.

RESULTS

All patients successfully underwent appendiceal lengthening by tubularizing the cecum, thus creating a continent cutaneous cecoappendicovesicostomy. With a mean follow-up of 18.7 months, all patients have a working catheterizable conduit. One case of stomal stenosis occurred, producing a 6.7% conduit-related complication rate.

CONCLUSIONS

Cecoappendicovesicostomy is a safe and useful means of conduit lengthening for patients undergoing continent cutaneous appendicovesicostomy (Mitrofanoff procedure).

Cushing's syndrome associated with a pheochromocytoma

A norepinephrine producing right adrenal pheochromocytoma was associated with bilateral adrenal hyperplasia and clinically and biochemically evident Cushing's syndrome. Ectopic adrenocorticotropin production was suspected, but the six criteria for proof of ectopic adrenocorticotropin production could not be demonstrated. The diagnosis of Cushing's syndrome from ectopic hormone production by a pheochromocytoma requires a high index of suspicion and extensive biochemical and radiographic testing to confirm Cushing's syndrome, identify the cause of Cushing's syndrome, and localize the pheochromocytoma.

Expression and function of the leucine zipper protein Par-4 in apoptosis

The prostate apoptosis response-4 (par-4) gene was identified by differential screening for genes that are upregulated when prostate cancer cells are induced to undergo apoptosis. The par-4 gene is induced by apoptotic signals but not by growth-arresting, necrotic, or growth-stimulatory signals. The deduced amino acid sequence of par-4 predicts a protein with a leucine zipper domain at its carboxy terminus. We have recently shown that the Par-4 protein binds, via its leucine zipper domain, to the zinc finger domain of Wilms' tumor protein WT1 (R. W. Johnstone et al., Mol. Cell. Biol. 16:6945-6956, 1996). In experiments aimed at determining the functional role of par-4 in apoptosis, an antisense par-4 oligomer abrogated par-4 expression and activator-driven apoptosis in rat prostate cancer cell line AT-3, suggesting that par-4 is required for apoptosis in these cells. Consistent with a functional role for par-4 in apoptosis, ectopic overexpression of par-4 in prostate cancer cell line PC-3 and melanoma cell line A375-C6 conferred supersensitivity to apoptotic stimuli. Transfection studies with deletion mutants of Par-4 revealed that full-length Par-4, but not mutants that lacked the leucine zipper domain of Par-4, conferred enhanced sensitivity to apoptotic stimuli. Most importantly, ectopic coexpression of the leucine zipper domain of Par-4 inhibited the ability of Par-4 to enhance apoptosis. Finally, ectopic expression of WT1 attenuated apoptosis, and coexpression of Par-4 but not a leucine zipperless mutant of Par-4 rescued the cells from the antiapoptotic effect of WT1. These findings suggest that the leucine zipper domain is required for the Par-4 protein to function in apoptosis.

Bilateral ureteral obstruction associated with Henoch-Schoenlein purpura

Renal involvement is common in Henoch-Schoenlein purpura (HSP) and, while ureteral obstruction has been described in patients with the disease, it is rare. We report a female with HSP who developed bilateral ureteral obstruction from peri-ureteral vasculitis and subsequent ureteral ischemia. Hydronephrosis and typical findings on contrast urography indicated the diagnosis.

The utility of video-assisted thoracic surgery in the diagnosis of pulmonary metastases from renal cell carcinoma

The definitive diagnosis of pulmonary metastases requires histologic confirmation. Traditional methods of obtaining tissue for histologic review include transbronchial approaches, percutaneous transthoracic needle biopsy, and open lung biopsy. The purpose of this study is to identify the most effective methods of obtaining histologic confirmation of pulmonary metastases. The utility of video-assisted thoracic surgery in diagnosing pulmonary metastases is demonstrated in 2 patients with metastatic renal cell carcinoma. The diagnostic yields and complication rates of transbronchial approaches, percutaneous needle biopsy, open lung biopsy, and video-assisted thoracic surgery are compared. Finally, an algorithm for the evaluation of pulmonary lesions is presented.

Increased levels of nm23 H1/nucleoside diphosphate kinase A mRNA associated with adenocarcinoma of the prostate

Overexpression of the nm23H1 gene has been associated with the suppression of metastasis in several solid tumors. However, in colorectal carcinoma and neuroblastoma, increased levels of nm23 H1 nucleoside diphosphate kinase A (NDPKA) mRNA are associated with tumorigenesis. To determine the role of nm23 H1/NDPKA in the prostate, normal and/or malignant tissue samples from 29 consecutive patients were studied. Levels of nm23 H1/NDPKA mRNA and nm23 H1/NDPKA mRNA protein were determined in tissue from 18 and 27 patients, respectively. In all, 16 of the 18 tumor samples expressed increased levels of nm23 H1/NDPKA mRNA as compared with those measured in normal tissue. The level of nm23 H1/NDPKA mRNA was > 10-fold higher in a metastatic lymph node than in normal prostate tissue. All cancer specimens and areas of prostatic intraepithelial neoplasia showed immunoreactivity with the nm23 H1/NDPKA antibody; however, normal prostatic tissue was unreactive. These findings suggest that overexpression of the nm23 H1/NDPKA gene occurs frequently in adeno-carcinomas of the prostate and may be an early event in prostate cancer tumorigenesis.

"Stand-up" urologic endoscopy

OBJECTIVES

To report the advantages of performing diagnostic and therapeutic urologic endoscopic procedures with the urologic surgeon in the standing-up position.

METHODS

Our 25-year institutional experience with more than 10,000 cases of transurethral ablation of the prostate and other urologic endoscopic procedures, performed by the urologist in the standing-up position, was examined. A questionnaire of all 55 of our former urology residents was carried out to determine current practice trends.

RESULTS

We have noted no drawbacks from performing transurethral surgery in the standing-up position. Ninety-two percent of the respondents believe that the standing-up position was more comfortable for endoscopic surgery than the sitting-down position.

CONCLUSIONS

the standing-up technique of transurethral surgery minimizes positional stresses on the urologist's cervical and thoracic spine while optimizing endoscopic visualization and maneuverability. We recommend it in preference to the conventional sitting-down technique.

A new renal tourniquet for open and laparoscopic partial nephrectomy

PURPOSE

We describe a novel double loop renal parenchymal tourniquet for obtaining hemostasis during open and laparoscopic partial nephrectomy.

METHODS

One loop is positioned around the upper and 1 around the lower renal poles, thus securely entrapping the kidney. During partial nephrectomy the corresponding loop is double looped and cinched, thus achieving a tourniquet effect. The renal artery is not occluded. Intraoperative renal hypothermia is not required.

RESULTS

The renal tourniquet was used clinically during 6 open and 1 laparoscopic partial nephrectomies. Furthermore, during laparoscopic nephrectomy (5 porcine and 1 clinical cases) the double loop apparatus allowed for improved maneuverability of the kidney.

CONCLUSIONS

The novel renal tourniquet affords adequate renal parenchymal hemostasis during open and laparoscopic partial nephrectomy.

Identification of bone marrow micrometastases in patients with prostate cancer

BACKGROUND

Thirty percent of patients with clinically localized prostate cancer and a negative bone scan will experience relapse with recurrent disease despite treatment of the primary tumor. This may be due to the presence of metastatic prostate cancer cells at the time of treatment undetected by conventional methods, radionucleotide bone scan, and serum prostatic specific antigen blood test.

METHODS

The authors used polymerase chain reaction (PCR) amplification of the prostate-specific antigen (PSA) mRNA sequence reverse-transcriptase PCR (RTPCR) and immunohistochemistry using a PSA antibody to identify metastatic prostate cancer cells in the bone marrow of patients with prostate cancer.

RESULTS

Micrometastases were found in the bone marrow of 29 of the 55 patients (51%) with prostate cancer and in 0 of the 5 patients with benign prostatic hyperplasia. Samples from five of the seven patients with lymph node metastases and from all five patients with bony metastases contained micrometastases. Of the samples taken from 43 patients undergoing radical prostatectomy and with no evidence of metastatic disease, 19 (44%) had micrometastases. Four of the 20 samples (20%) from patients with pathologically localized disease and 15 of the 23 samples (65%) from patients with extraprostatic disease had micrometastases (P = 0.003). Bone marrow slides were available on 24 of the 29 patients who were positive for micrometastases by RTPCR: Immunohistochemistry using the PSA antibody identified metastatic cells in 19 of these 24 patients.

CONCLUSIONS

Reverse-transcriptase polymerase chain reaction of bone marrow samples from patients with clinically localized prostate cancer may improve the accuracy of prostate cancer staging and identify patients at high risk for metastatic disease.

Familial paraganglioma

Extra-adrenal pheochromocytomas and paragangliomas are rare tumors of neural crest origin, most commonly found in the retroperitoneum. Because these tumors are so uncommon, relatively little is known about their natural history. Comparisons between adrenal pheochromocytomas and extra-adrenal pheochromocytomas have appeared in the medical literature. Like pheochromocytomas, paragangliomas may occur as functional or nonfunctional tumors. Furthermore, although the hereditary occurrence of pheochromocytomas is well documented, the familial nature of paragangliomas is unclear. We present the first report of a mother and son with nonfunctional paragangliomas occurring in the same anatomic location and describe their care and treatment.

Laparoscopic live-donor nephrectomy

Laparoscopic nephrectomy with ablative intent has been performed clinically. The current study aimed to determine whether a physiologically and anatomically intact kidney suitable for transplantation could be harvested laparoscopically. Three weeks after an ablative laparoscopic right nephrectomy, 15 pigs were divided into two groups: the study group (n = 10) underwent a laparoscopic live-donor left nephrectomy of the solitary kidney and conventional autotransplantation; the control group (n = 5) underwent an open live-donor left nephrectomy of the solitary kidney and conventional autotransplantation. All study kidneys underwent laparoscopic in situ hypothermic perfusion. The mean length of the left renal artery and vein were similar in the study and control groups: 3.1 cm and 3.4 cm, respectively, in the study group compared with 2.5 cm and 3.8 cm, respectively, in the control group (P = 0.5). No intraoperative renal vascular injuries or postoperative ureteral complications were noted in either group. Renal histopathologic examination immediately after live-donor nephrectomy and at 1 month post-transplant showed similar findings in the two groups. The mean serum creatinine at 7 and 30 days postoperatively was not significantly different: 2.1 mg/dL and 1.6 mg/dL, respectively, in the study group and 1.7 mg/dL, and 1.4 mg/dL, respectively, in the control group (P = 0.4). We conclude that laparoscopic live-donor nephrectomy can be performed safely and reproducibly in the porcine model.

Laparoscopic retroperitoneal renal cystectomy

Laparoscopic manipulation of retroperitoneal organs is usually performed by the transperitoneal approach primarily because of the ease of access by way of the pneumoperitoneum. However, difficulty in adequately accessing structures that are surrounded by bowel, liver, spleen or postoperative adhesions makes this approach suboptimal in certain cases. We describe the use of the retroperitoneal laparoscopic approach to the upper pole of a kidney for marsupialization of a symptomatic, recurrent, complex renal cyst. An algorithm for current management of symptomatic renal cysts is discussed.

One-stage total penile reconstruction with a free sensate osteocutaneous fibula flap

This is the first series of total penile reconstructions with the free sensate osteocutaneous fibula flap. The main advantages of this flap lie in its intrinsic rigidity, its superior donor-site location, and its long vascular pedicle. The fibula flap provides better bone volume than does the radial forearm flap, which commonly results in a floppy phallus in the absence of bone. Penile prostheses in other flaps have enjoyed limited success. Forearm donor-site complications can be avoided. The donor site in the lower extremity can be readily covered with a sock. The vascular pedicle of the fibula flap is of sufficient length to allow end-to-side anastomosis of the flap to the femoral artery. Interpositional vein grafts are unnecessary, and dissection of the inferior epigastric artery system to serve as a donor artery may be avoided. The appearance of the neophallus is excellent. We present only the first four continuous cases of the six we have performed because sufficient follow-up data are available only for these four. The advantages and disadvantages of fibula and forearm donor sites, the long-term fate of the bony component, the importance of sensation, and the vascularized urethral reconstruction are discussed. High patient satisfaction and the advantages of the technique convince us that the fibula osteocutaneous flap is superior for total penile reconstruction.

Experimental rectus abdominis myocutaneous and rectus abdominis myoperitoneal flaps as urinary bladder wall substitutes in miniature swine

An experiment was performed in Yucatan miniature swine to determine the feasibility and characteristics of musculocutaneous or musculoperitoneal flaps as urinary bladder wall substitutes. In five swine, a single-pedicle skin island flap (rectus abdominis myocutaneous, RAM/C) was sutured into the bladder. In five other swine the flap was a peritoneum island (rectus abdominis myoperitoneal, RAM/P). Three swine were sham-operated controls. The patches were in place for 20 weeks, remaining viable and elastic. Inflammation, maceration, and infection were absent. Skin patch histology was unchanged. The peritoneal patches became resurfaced with uroepithelium. The sham bladder volume (ml/kg body weight) did not differ significantly from RAM/P bladder volume (p = 0.54). RAM/C bladders were slightly smaller than shams (p = 0.11) and significantly smaller than RAM/P bladders (p = 0.03). Substitution of the bladder wall with RAM patch flaps is feasible. This is an important preliminary step toward our goal of nonenteral urinary bladder wall substitution.

Adenovirus-associated hemorrhagic cystitis treated with intravenous ribavirin

Adenovirus hemorrhagic cystitis following bone marrow transplantation occurs in 2 to 16% of the patients. While usually self-limiting, this disease can cause significant morbidity and even mortality in the immunocompromised patient. Risk factors include graft versus host disease and pre-transplant seropositivity to adenovirus. Standard treatment of this disorder consists of hydration, diuresis and analgesics. Failure of these measures leads to multiple blood transfusions, severe patient morbidity and possible death. When conservative therapy is unsuccessful, there is no proved standard of care. We recently used ribavirin, a broad-spectrum antiviral agent against adenovirus infection in vitro, to treat refractory adenovirus hemorrhagic cystitis after bone marrow transplantation. The hematuria and urinary symptomatology resolved without demonstrable side effects. We present ribavirin as a therapeutic alternative when conservative treatment for adenovirus hemorrhagic cystitis fails.

Analysis of iodine-125 interstitial therapy in the treatment of localized carcinoma of the prostate

Definitive treatment of localized carcinoma of the prostate has included radical surgery, external beam radiation therapy, and interstitial radiation therapy. The interstitial agent most commonly used is Iodine-125. Forty-eight patients were treated with interstitial radiation therapy using Iodine-125 implants with a median follow-up of 55 months. Forty-three percent of the evaluable patients had progressive disease with approximately 50% progressing at 5 years by Kaplan-Meier analysis. Overall actuarial survival in the group was 80% at 5 years. This and several other studies suggest that control of prostate cancer with Iodine-125 seeds may be suboptimal as compared with other treatment modalities, especially the radical retropubic prostatectomy. Analysis of treatment parameters is presented along with a discussion of the current status and future prospects for treatment of localized carcinoma of the prostate with interstitial radiation therapy.

Renal vein thrombosis presenting as renal mass

The excretory urogram of patients with acute renal vein thrombosis typically demonstrates symmetric enlargement of the involved kidney. We report a case of renal vein thrombosis that presented as a discrete renal mass on excretory urography and abdominal computerized tomography. The entity of renal vein thrombosis is briefly reviewed along with the computerized tomography findings seen in this setting.

Hematuria--harbinger of cancer

The complaint of blood in the urine or the finding of unexpected microscopic hematuria continues to be an important diagnostic clue to the presence of carcinoma of the urinary tract. Inadequate evaluation of this complaint or finding may lead to a delay in diagnosis and progression of disease. A thorough evaluation of the urinary tract with intravenous pyelography, urinary cytology, and cytoscopy is necessary.

The new era of hypospadias surgery

The authors review four current techniques in hypospadias surgery that yield superior functional and aesthetic results to those obtained in the older, multi-stage repairs. If the repair is performed before the age of memory recall, there will be less psychological trauma to both the patient and his parents.

The influence of uremia and immunosuppression on an animal model for ischemic colitis

Up to 1 percent of renal transplant recipients have been reported to develop ischemic colitis. Immunosuppressive agents and uremia have been implicated in the development of this complication, but their exact relationship remains unclear. A rat model was developed to determine the effects of uremia alone and in combination with immunosuppression on the development of ischemic colitis. Seventy-six animals were included in the study. Uremia and ischemic colitis were induced surgically. The immunosuppressive agents azathioprine and methylprednisolone were administered for 72 hours after a colonic segment was devascularized in chronically uremic rats. One-way analysis of variance (ANOVA) showed that uremia potentiates colonic ischemia significantly (4.09 cm2 vs 1.25 cm2, P less than 0.03). The addition of parenteral steroids (methylprednisolone) or azathioprine alone and in combination did not potentiate or reduce this ischemic process in uremic animals. Each of these factors alone is commonly present in the renal transplant population and can contribute to the development of potentially fatal ischemic colitis.

A trial of prophylactic thiotepa or mitomycin C intravesical therapy in patients with recurrent or multiple superficial bladder cancers

There were 40 consecutive patients with recurrent or multiple superficial stage Ta or T1 transitional cell cancer assigned randomly to receive prophylactic thiotepa or mitomycin C intravesical chemotherapy. Patients received 8 weekly instillations followed by 22 monthly treatments of either 60 mg. thiotepa or 40 mg. mitomycin C. Of 25 patients randomized to receive mitomycin C 4 had recurrence in a total of 337 patient-months (1.19 per 100 patient-months), while disease recurred in 1 of 15 patients randomized to receive thiotepa who were followed for a total of 220 patient-months (0.45 per 100 patient-months). No significant difference in recurrence rate was noted for either drug group (p equals 0.18). Toxicity requiring cessation of therapy was observed in 7 patients (28 per cent) on mitomycin C and none on thiotepa.

Adrenal insufficiency following unilateral adrenalectomy: a case report

We report a case of resection of a unilateral adrenal pseudocyst that precipitated life-threatening adrenal insufficiency. The patient had extremis unresponsive to pressor agents in the immediate postoperative period. Hydrocortisone administration produced temporary resolution and a cosyntropin-stimulation test confirmed adrenal insufficiency. Because of the presence of an adrenal mass, the preoperative evaluation included a formal endocrinological evaluation. Thus, we were able to document the occurrence of acute postoperative primary adrenal insufficiency.

Cholecystokinin and pain: a review

The recent discovery that cholecystokinin (CCK) is present in the nervous system has prompted studies that have nearly proven its neurotransmitter status. Pain modulation appears to be a major effect of CCK and proglumide, its antagonist. CCK's inhibitory effect and proglumide's potentiating effect on opiate analgesia may have clinical application; proglumide's inhibitory effect on opiate tolerance may help in management of chronic pain. More research is required before the CCK/opiate interaction can be exploited on a large scale to relieve pain.

The evaluation of postoperative function of the adrenal gland

The cosyntropin (Cortrosyn) stimulation test has been adapted for use in the postoperative period. The normal adrenal gland response to 200 micrograms of cosyntropin given intravenously has been quantified at six, 12, 24, 48 and 72 hours after extensive general surgical procedures. The value of the test in quickly and accurately diagnosing postoperative acute insufficiency of the adrenal gland remains to be established.

The serum and urinary cortisol response to operative trauma

Serum and urinary cortisol levels were monitored throughout the perioperative period in eight patients who underwent elective extensive general surgical procedures. Significant elevations of serum cortisol levels occurred four and eight hours after anesthetic induction and were reflected by elevated urinary cortisol production on the day of operation. Cortisol serum levels and urinary production rapidly returned toward normal as all subsequent measurements were insignificantly different from preoperative values. Adrenal gland stimulation resulting from general surgical procedures is intense but short-lived.

Comparison of epsilon aminocaproic acid and normal saline for postoperative bladder irrigation following transurethral resection of prostate

A prospective, randomized, double-blind trial of bladder irrigation with a 0.5% solution of epsilon aminocaproic acid (EACA) versus normal saline plus placebo was undertaken in 75 patients undergoing transurethral resection of the prostate for benign or malignant disease. Systemic absorption after irrigation with EACA was not detectable. No significant advantage, however, was demonstrated for the EACA solution over normal saline irrigation in measured postoperative blood loss, irrigant volume, hours of catheterization, or length of hospital stay.

Preoperative lymph node evaluation in prostatic cancer patients who are surgical candidates: the role of lymphangiography and computerized tomography scanning with directed fine needle aspiration

A total of 53 consecutive patients who were candidates for surgical treatment of prostatic cancer underwent preoperative evaluation of the lymph node status by computerized tomography scanning and/or lymphangiography combined with skinny needle aspiration biopsy of any abnormal lymph nodes. In 7 of 14 patients (50 per cent) ultimately found to have stage D1 disease lymphatic metastases were confirmed histologically with needle biopsy alone, thus, obviating the need for pelvic lymph node dissection. Over-all sensitivity, specificity and accuracy rates were 50, 100 and 91.4 per cent, respectively, for computerized tomography scanning with biopsy and 53.8, 100 and 84.1 per cent, respectively, for lymphangiography with biopsy. Computerized tomography scanning and lymphangiography with aspiration biopsy are cost-effective means to identify approximately 50 per cent of the patients who ultimately have lymphatic metastases.

Prospective DR matching for first cadaver donor renal allografts and retransplantation

From January 1981 through 1983 80 cadaver donor renal allografts were transplanted at a single center utilizing prospective HLA-DR matching. All patients received at least two blood transfusions prior to transplantation. One year actual allograft survival of 77% for initial grafts and 57% for retransplantation was observed. When there was no DR mismatch the results were 84% and 80% respectively. Only 6% of no-DR-mismatch initial grafts were lost to rejection or patient death. These significantly better results were associated with decreased incidence of acute rejection episodes with transplants well matched for DR. Matching for A and B locus antigens conveyed no benefits in this series. Use of prospective DR matching for donor/recipient selection also resulted in efficient transplantation. Patients receiving initial grafts waited an average of 3.9 months while retransplanted patients waited an average of 13.5 months after being entered on the waiting list. The data suggest that if all transplant centers would preferentially share kidneys regionally on the basis of DR matching, nearly all patients could receive timely allografts with no DR mismatch and good results at one year with conventional immunosuppressive therapy.

Nutritional assessment and therapy in advanced urothelial cancer

Patients with advanced urothelial cancers often have cachexia and anorexia resulting in severe malnutrition and depressed immunologic function. Careful nutritional assessment early in their evaluation and early use of parenteral and enteral nutritional supplements play an important role in allowing these patients to withstand their therapies safely as well as in improving their prognosis.

The efficacy of patient-controlled analgesia in patients recovering from flank incisions

We report on 13 patients undergoing flank incisions in whom the postoperative pain was managed with a patient-controlled analgesia device. An initial group of 7 patients was used to determine the optimal injection dose for each patient and to examine variability in narcotic requirement during the postoperative course. A progressive decrease in narcotic need was noted during the postoperative course with patient-controlled analgesia, resulting in excellent patient acceptance, no postoperative complications and no drug-seeking behavior. A second group of 10 patients was randomized prospectively to receive either patient-controlled analgesia or a standard regimen of intramuscular morphine sulfate. Based on nursing observations, an analgesia and sedation scale was developed that compared the 2 groups. Analysis of a questionnaire evaluating subjective perception of postoperative pain revealed significantly less pain, less sedation and greater activity among patients randomized to patient-controlled analgesia (95 per cent confidence limit).

Cloacal exstrophy

Although each patient with cloacal exstrophy must be considered as a unique individual and much controversy still remains about the treatment of this complex syndrome, our review of the literature suggests that the previously detailed series of stages in the approach to this patient represents a conservative, individualized, yet successful approach.

A comparison of clinical course with blood group antigen testing by specific red cell adherence and immunoperoxidase in ureteral and renal pelvic tumors

Specimens of transitional cell carcinoma of the ureter and renal pelvis from 20 patients were tested for blood group antigenicity using immunoperoxidase and specific red cell adherence methods. The results of antigen testing were correlated with tumor stage and grade as well as the subsequent clinical course of the patients. The specific red cell adherence test was negative in 80 per cent and the immunoperoxidase test was negative in 40 per cent of all tumors. Of the 4 patients with positive specific red cell adherence tests 3 had high grade (II to III), invasive tumors as did 7 of 12 with tumors that were positive by immunoperoxidase testing. Blood group antigen testing did not prove helpful in predicting the clinical course of our patients. In addition, a careful review of previously published data does not support the conclusion that blood group antigen testing is a valuable predictor of upper tract tumor aggressiveness.

Undiversion using ileocecocystoplasty in a case of retroperitoneal hemorrhage after cardiac catheterization

We performed urinary undiversion using ileocecocystoplasty in a patient who sustained bladder and ureteral necrosis secondary to transfemoral cardiac catheterization.

Radioimmunodetection of prostatic cancer. In vivo use of radioactive antibodies against prostatic acid phosphatase for diagnosis and detection of prostatic cancer by nuclear imaging

Radioimmunodetection (RAID) of prostatic cancer is done by injecting 131I-labeled rabbit antibody IgG against prostatic acid phosphatase (PAP) and performing total-body photoscans with a gamma scintillation camera. Of two patients tested, the PAP RAID scintiscans located the primary or recurrent prostatic cancers in both and showed no disease in the lungs of the patient shown subsequently to have lung cancer. The lung tumor nodules showing anti-PAP IgG accretion were assumed to be of prostatic cancer origin, since one of the original tumors removed from this patient's other lung a year earlier stained for PAP by immunohistochemistry. This study showed that PAP RAID can locate primary and metastatic tumors of prostatic origin.

Complications associated with preoperative radiation therapy and Iodine-125 brachytherapy for localized prostatic carcinoma

Twenty-five consecutive patients with localized adenocarcinoma of the prostate treated with 1,050 rad preoperative radiation therapy and Iodine-125 seed brachytherapy arreviewed. Significant long-term postoperative complications included radiation cystitis (12%), radiation proctitis (4%), genital and leg edema (12%), stress incontinence (8%), total incontinence (4%), and impotence (26%). Complications occurred in 75 per cent of patients who received additional postoperative radiation. Improved staging with CT scan, lymphangiography, and Chiba needle biopsy of any possibly abnormal lymph nodes provided excellent preoperative staging with only 1 patient (6%) upstaged at surgery to Stage D1.

Cutaneous stimulation of the bladder in multiple sclerosis: a case report

We report on the use of transcutaneous electrical nerve stimulation to improve bladder emptying in a multiple sclerosis patient with a hypotonic bladder. Urodynamic testing demonstrated decreased bladder capacity, earlier first sensation and increased bladder pressure during trials of stimulation.

Survival in bilateral metachronous (asynchronous) Wilms tumors

The survival of patients with Wilms tumors has improved dramatically during the last few decades. In contrast, the bilateral form of the disease, especially when the tumors are not concurrent, is still considered by many to hold a much worse prognosis. A review of 50 cases reported during the last 20 years reveals that the survival of patients with metachronous Wilms tumors has improved in parallel with survival of patients with unilateral disease and, when matched for extent of tumor spread, survivals for the last decade are almost identical to those of bilateral synchronous disease and unilateral Wilms tumors.

Antimicrobial prophylaxis in children with urinary tract infection and vesicoureteral reflux

Thirty children with urinary tract infection and nonobstructive vesicoureteral reflux have been followed prospectively for a mean of 17 months. After classification according to age and grade of reflux, 10 patients were assigned at random to treatment with antimicrobial prophylaxis alone or antimicrobial prophylaxis plus corrective surgery. Twenty other patients were also treated with antimicrobial prophylaxis alone. All were assigned at random to treatment with a single daily dose of trimethoprim-sulfamethoxazole or nitrofurantoin. Cultures of urine, complete blood cell counts, and determination of levels of aspartate aminotransferase in serum were performed regularly during follow-up. Both drugs proved effective in prevention of recurrent infection, and no significant hematologic or hepatic abnormalities were noted. Current results suggest that either prophylaxis or surgery may effectively prevent chronic pyelonephritis or reflux nephropathy, but only continuing evaluation of this group of patients will confirm these results.

Does vesicoureteric reflux result in renal allograft failure?

Vesicoureteric reflux (VUR) into transplanted kidneys has been cited as an often disregarded but frequent complication of transplantation which is associated with a glomerular lesion that resembles membranoproliferative glomerulonephritis, marked proteinuria, and graft failure. To determine the prevalence of this complication in our transplant population, all of our 23 patients with marked proteinuria and 27 controls without proteinuria had voiding cystourethrograms performed approximately two years after transplantation. In our population, VUR was infrequent (8%). Moreover, in the three of the four cases detected renal function has not deteriorated and three of the four do not have marked proteinuria. We cannot confirm the suggestion that VUR is a frequent cause of late renal allograft failure.

The health and cost implications of routine excretory urography before transurethral prostatectomy

After critically reviewing 601 patients who had undergone transurethral resection of the prostate we conclude that the routine use of excretory urography is not indicated. In the vast majority of patients with only obstructive symptoms or acute urinary retention excretory urography is an expensive test, with an extremely low incidence of useful information. However, its selective use is indicated in cases in which hematuria or a history of renal disease coexists with obstructive symptoms. The time has arrived for physicians to re-evaluate the practices of the past. We all need to participate actively and to make specific recommendations, not generalities. We believe that if the guide lines suggested herein are considered the annual health costs would be decreased by an estimated $75,000,000 and the quality of urologic care would not be jeopardized.

Evaluation and treatment of urinary candidiasis

The incidence of genitourinary fungal infections is increasing, and because of their lethal potential, early diagnosis and treatment is mandatory. Candida is the most common urinary fungus and is manifest as renal involvement from systemic candidiasis, primary renal candidiasis, bezoar formation, cystitis, and as asymptomatic candiduria. The clinical status of the patient, serial urine cultures, excretory urogram, and serum candidal titers help to differentiate between the various disease states. Treatment is specific and is based on the clinical manifestation of the disease. Systemic candidiasis is treated with intravenous amphotericin. Fungal bezoars are best treated with oral flucytosine, ureteral and renal irrigation with amphotericin and, occasionally, operation. Cystitis is treated with oral flucytosine or amphoteric bladder irrigations. Asymptomatic candiduria is left untreated. A systematized evaluation and treatment regimen is presented.

Umbilical anomalies

During intrauterine development the primordia of the developing gastrointestinal and urinary tract come into close proximity in the umbilicus where the communication of these structures with the external environment is usually obliterated. In a small percentage of patients the omphalomesenteric duct and/or urachus may remain completely or partially patent. When complete patency is present, drainage of mucus, stool, or urine may occur. Partial patency may be manifest by an abdominal mass or by no symptoms at all. Definitive treatment includes total excision of the omphalomesenteric duct and/or urachus, lest recanalization of remnant tissue or carcinoma in later life occur.