Antibiotic-coated medical devices: with an emphasis on inflatable penile prosthesis

One of the most serious complications associated with the use of the inflatable penile prosthesis is infection. This can lead to significant morbidity for the patient, as well as significant health care costs. A number of methods have been used in attempts at minimizing the infection risk, including applying an antibiotic coating to the medical devise. This review aims to evaluate the effectiveness of these products in preventing clinically significant infections.

Cylinder sizing: less is more

In penile prosthesis implantation traditional cylinder-sizing techniques frequently result in penile cylinders that are too long for the corpora cavernosa. This can result in premature cylinder wear leading to cylinder aneurysm or fluid loss. Additionally, in the case of the length expanding Ultrex penile prosthesis, cylinders that are too long can result in an S-shaped cylinder deformity. We describe a cylinder measurement technique that avoids the problem of oversizing.

Penile prosthesis infections

In this retrospective review we looked at infection rates and risk factors in penile prosthesis recipients. Computer registry records of patients implanted with three-piece inflatable prostheses from April 1986 to March 1999 were reviewed. Bacteriological culture report data were obtained from the medical records. There were 491 three-piece inflatable penile prosthesis recipients with follow-up ranging from 1 to 168 months (mean 83). All patients were implanted more than 1 y ago. There were 10 infections in 491 recipients (2.0%). In 285 primary prosthesis recipients there were seven infections (2.5%). In 206 secondary prosthesis recipients there were three infections (1.5%). Seven infections occurred in 354 non-diabetics (2.0%) and three infections occurred in 137 diabetics (2.2%). None of these differences were statistically significant. Explants for infection were performed in 8 weeks or less following implantation in eight patients. In two patients explants occurred at 17 and 26 months following implantation. Cultures from the periprosthetic space grew E. coli (four), Proteus mirabilis (two), Staph. aureus (two), and bacteroides (two). Infections occurred in 2.0% of three-piece inflatable penile prosthesis recipients. There were no statistically significant differences in infection rates between first time and repeat prosthesis recipients and between diabetic and non-diabetic recipients. Eight of the 10 infections occurred 8 weeks or less following implantation.

Artificial urinary sphincter troubleshooting

An approach to solving the problem of persistent or recurrent urinary incontinence after artificial urinary sphincter implantation is presented. This practical approach is designed to identify the known causes of this disorder, with treatment being directed to the cause.

Long-term continence and patient satisfaction after artificial sphincter implantation for urinary incontinence after prostatectomy

PURPOSE

We assess long-term continence and patient satisfaction after implantation of the AMS Sphincter 800 (American Medical Systems, Minnetonka, Minnesota) in men who were incontinent after total and subtotal prostatectomy.

MATERIALS AND METHODS

Patients who had an artificial urinary sphincter implanted for urinary incontinence after prostatectomy and a minimum of 20 months of followup were identified from a patient database. The medical records of these 209 patients were reviewed, and a questionnaire was mailed. Telephone contact was attempted with patients who did not respond to the questionnaire. Of the 209 patients 11 (5%) had undergone device removal, 34 (16%) were deceased and an additional 51 (24%) could not be contacted for followup. Our study group consisted of the 113 patients with artificial urinary sphincters who could be contacted for followup. Mean followup was 73 months (range 20 to 170).

RESULTS

There were 4 (4%) patients who were dry and continent and 68 (60%) were incontinent using 0 to 1 pad daily. An additional 35 (31%) patients required 2 to 3 pads daily and 5 (4%) used more than 3 daily. There were 14 (12%) patients who had undergone surgical revision of the device. Of the 113 patients 31 (28%) were very satisfied, 50 (45%) satisfied, 20 (18%) neutral, 7 (6%) dissatisfied and 4 (4%) very dissatisfied. One patient was not using his device to control continence.

CONCLUSIONS

Artificial urinary sphincter implantation offers men who are incontinent after prostatectomy a reasonable chance for obtaining long-term satisfactory urinary control, although complete continence is unusual.

Long-term continence and patient satisfaction after artificial sphincter implantation for urinary incontinence after prostatectomy

PURPOSE

We assess long-term continence and patient satisfaction after implantation of the AMS Sphincter 800 (American Medical Systems, Minnetonka, Minnesota) in men who were incontinent after total and subtotal prostatectomy.

MATERIALS AND METHODS

Patients who had an artificial urinary sphincter implanted for urinary incontinence after prostatectomy and a minimum of 20 months of followup were identified from a patient database. The medical records of these 209 patients were reviewed, and a questionnaire was mailed. Telephone contact was attempted with patients who did not respond to the questionnaire. Of the 209 patients 11 (5%) had undergone device removal, 34 (16%) were deceased and an additional 51 (24%) could not be contacted for followup. Our study group consisted of the 113 patients with artificial urinary sphincters who could be contacted for followup. Mean followup was 73 months (range 20 to 170).

RESULTS

There were 4 (4%) patients who were dry and continent and 68 (60%) were incontinent using 0 to 1 pad daily. An additional 35 (31%) patients required 2 to 3 pads daily and 5 (4%) used more than 3 daily. There were 14 (12%) patients who had undergone surgical revision of the device. Of the 113 patients 31 (28%) were very satisfied, 50 (45%) satisfied, 20 (18%) neutral, 7 (6%) dissatisfied and 4 (4%) very dissatisfied. One patient was not using his device to control continence.

CONCLUSIONS

Artificial urinary sphincter implantation offers men who are incontinent after prostatectomy a reasonable chance for obtaining long-term satisfactory urinary control, although complete continence is unusual.

Penile prosthesis implantation

The development of effective systemic therapy for the treatment of erectile dysfunction has resulted in a significant increase in the number of men presenting for treatment. Not all men with erectile dysfunction will respond to systemic therapy; those who fail may be candidates for penile prosthesis implantation if second and third lines of treatment also fail or are rejected by the patient and his partner. Penile prosthesis implantation continues to play a role in the treatment of erectile dysfunction. There is a potential for the number of penile prosthesis implantation procedures to actually increase. The ideal penile prosthesis is a three-piece inflatable device that permits good penile flaccidity and increases in size and becomes rigid with inflation.

Hemoglobin and methemoglobin concentrations after large-dose infusions of diaspirin cross-linked hemoglobin

Diaspirin cross-linked hemoglobin (DCLHb) solution is a purified human hemoglobin product chemically stabilized to deliver oxygen to tissues. We determined the peak plasma hemoglobin concentration and assessed changes in methemoglobin concentration after the infusion of 1 g/kg DCLHb in large blood loss surgical patients. This prospective, randomized study included 26 surgical patients who were either infused with up to three 250-mL units of 10% DCLHb or transfused with up to three units of packed red blood cells during the study infusion period. Serial plasma hemoglobin, plasma methemoglobin, and whole blood methemoglobin levels were measured before and at intervals up to 48 h after the study infusion period. Plasma hemoglobin and blood methemoglobin concentrations increased during the infusion of DCLHb. The plasma hemoglobin values in the DCLHb group continued to increase during each of the infusion periods to reach a peak plasma concentration of 1450 +/- 176 mg/dL. The fraction of whole blood methemoglobin increased from 0.84 +/- 0.77% at baseline to 4.08 +/- 1.36%. With a median DCLHb dose of 936 mg/kg (range 658-1500 mg/kg), the harmonic mean half-life was 10 h, and the increased whole blood methemoglobin reached a range not associated with complications.

IMPLICATIONS

The dose of diaspirin cross-linked hemoglobin (DCLHb) (936 +/- 276 mg/kg) used in this study was one of the largest reported in humans to date. The DCLHb mean half-life was 10 h. The half-life observed was 2-4 times that found at smaller doses in previous studies. Whole blood methemoglobin fraction increased during DCLHb infusion but did not reach a range associated with complications.

Current status of penile prosthesis implantation

Today most men with erectile dysfunction (ED) can be effectively treated with less invasive means than penile prosthesis implantation. Nevertheless, there remain men who do not respond to simple treatments such as systemic medication and who either do not respond to or reject intermediate treatment such as penile injection therapy. For these men, penile prosthesis implantation remains a reasonable option. This review discusses types of penile prostheses, how to choose among prosthesis types, key features of implant techniques, infection management, penile reconstruction related to prosthesis implantation, and patient and partner satisfaction.

Future considerations: advances in the surgical management of erectile dysfunction

As treatment options for erectile dysfunction (ED) continue to expand, and with more attractive alternatives such as effective systemic treatment becoming available, the number of men presenting for treatment of ED is increasing exponentially. Since a subset of these men continue to require surgical therapy, there is a potential for the number of operations for the treatment of ED and related disorders to actually increase. Areas in the surgical treatment of ED where improvements are needed are identified, including: measures to prevent penile prosthesis infections, better penile implants, improved penile augmentation procedures, better surgical procedures for the treatment of Peyronie's disease, improved penile revascularization procedures, and new motor and sensory penile nerve grafting procedures. International Journal of Impotence Research (2000) 12, Suppl 4, S140-S143.

Epithelioid sarcoma of the penis: report of an unusual case and review of the literature

Epithelioid sarcoma is a rare, slowly growing soft tissue tumor that uncommonly involves the penis, with only 11 previously reported cases. We present a case of penile epithelioid sarcoma in a 39-year-old man that mimicked Peyronie's disease, which was diagnosed 13 years following initial presentation. Preoperative magnetic resonance imaging showed multiple peripherally enhancing low signal intensity nodules involving the corpora cavernosa bilaterally. Following penectomy, histologic examination showed the typical features of epithelioid sarcoma, with a prominent pseudogranulomatous pattern. Immunohistochemically, the neoplastic cells demonstrated strong and diffuse staining for cytokeratins (AE1/AE3 and CAM 5.2), vimentin, epithelial membrane antigen, and CD34. Stains for S-100 protein, desmin, smooth muscle actin, and CD31 were negative. Electron microscopy demonstrated abundant intracytoplasmic intermediate filaments, scattered tonofilaments, and interdigitating filopodia. The present study is the first to describe magnetic resonance imaging and comprehensive immunohistochemical findings in penile epithelioid sarcoma. The majority of cases reported in the literature have demonstrated features similar to those typically found in epithelioid sarcoma involving the distal extremities. Consideration of epithelioid sarcoma in the differential diagnosis of a penile nodule or obstructive urinary symptoms may lead to early diagnosis and treatment.

Cost comparison of radical prostatectomy and transperineal brachytherapy for localized prostate cancer

OBJECTIVES

To compare perioperative costs associated with radical retropubic prostatectomy (RRP) to transperineal brachytherapy (BXRT) with iodine-125 (125I) seeds in the treatment of localized prostate cancer.

METHODS

Actual costs per case for the perioperative period were compiled prospectively for 583 consecutive patients undergoing RRP or BXRT between January 1, 1997 and October 30, 1998 using a hospital-wide cost accounting system. The total cost per case included both technical and professional components. The technical costs included those incurred for anesthesiology, laboratory medicine, medicine, pharmacy, nursing, radiology, 125I seeds, and BXRT technicians. Professional costs included fees from anesthesiology, laboratory, medicine, urology, radiation oncology, and physics. Cases were divided into three groups for analysis: group 1, RRP (n = 404); group 2, BXRT with planning ultrasound performed in the office setting before implantation (n = 107); and group 3, BXRT with planning ultrasound performed in the operating room at the time of implantation (n = 72). Results are reported as relative cost ratios, with RRP assigned a relative cost of 1.0.

RESULTS

The total relative perioperative cost for BXRT exceeded that for RRP by 85% to 105%. Technical cost, exclusive of 125I seeds, was substantially lower for BXRT (relative cost 0.36 to 0.42) but was more than offset by the cost of the seeds when comparing total cost with RRP. Performance of the planning ultrasound in the operating room (group 3) increased the total cost by 20%. The categorical technical costs for both BXRT groups were significantly lower for anesthesiology, laboratory medicine, medicine, pharmacy, and nursing but were significantly higher for radiology. The total professional costs were similar for all groups.

CONCLUSIONS

Perioperative costs of BXRT with 125I seeds are substantially higher than RRP in the treatment of localized prostate cancer, primarily because of the cost of the seeds.

A technique of transrectal ultrasound guided transperineal random prostate biopsy in patients with ulcerative colitis and an ileal pouch

PURPOSE

Prostate biopsy in patients with rectal disease may present a difficult urological problem. We describe a useful technique for the accurate guidance of transperineal random prostate biopsy in patients with colorectal disease.

MATERIALS AND METHODS

Biopsy was required in a patient with ulcerative colitis and an ileal pouch who had chronic pouchitis. Biopsy through the pouch was avoided by performing random transperineal prostate biopsies using the ultrasound grid and stabilizing platform used for prostate brachytherapy.

RESULTS

Accurate random sampling of the prostate was accomplished. Multiple cores of prostatic tissue were successfully obtained.

CONCLUSIONS

Random transperineal biopsy of the prostate was accurately performed under transrectal ultrasound guidance. With the increasing availability of brachytherapy equipment we believe that this method may be used for prostate biopsy in patients with rectal disease.

Modified corporoplasty for penile curvature: long-term results and patient satisfaction

PURPOSE

In 1994 we began performing the modified corporoplasty technique in patients undergoing surgery to correct penile curvature. The procedure consists of transverse closure of the longitudinal tunical incisions. This technique allows minimal mobilization of the neurovascular bundles or corpus spongiosum and potentially decreases the risk of injury to underlying erectile tissue. We report long-term results of and patient satisfaction with this procedure.

MATERIALS AND METHODS

From June 1994 to June 1997, 28 consecutive patients 16 to 65 years old (mean age 45) selected for corporoplasty underwent a total of 29 operative procedures for disabling penile curvature. The etiology of curvature was Peyronie's disease in 19 patients (68%) and congenital curvature in 9 (32%). Results were obtained by retrospective chart review and telephone interview. Long-term followup available for 19 patients ranged from 11 to 46 months (mean 24.1).

RESULTS

Penile straightening was excellent in 25 patients (89%) and good with less than 20 degrees of residual curvature in 2 (7%). In 1 patient in whom the procedure failed excellent straightening was achieved after a repeat procedure. A total of 27 patients (96%) reported no change in erectile rigidity or maintenance postoperatively, while 1 described early detumescence. We contacted 19 patients at long-term followup, of whom 17 and 2 reported excellent and good penile straightening results, respectively. In 18 cases there was no change in erectile rigidity, while in 1 there was early detumescence. Some element of erectile shortening without functional problems was noticed by 11 patients, of whom 1 was bothered by shortening but achieves successful intercourse. Eight patients denied shortening. In regard to the overall result 9 patients were very satisfied, 6 satisfied, 2 neutral and 2 unsatisfied.

CONCLUSIONS

In select patients modified corporoplasty as described is an effective and durable procedure with a high rate of patient satisfaction. Patients should be counseled preoperatively concerning postoperative erectile shortening.

Review of Cleveland Clinic experience with penile fracture

OBJECTIVES

Fracture of the penis is an uncommon injury that results from trauma to the erect penis, usually during sexual intercourse. In some cases, the urethra is injured as well. To determine the outcome of immediate surgical management, we reviewed the cases of 8 patients with fracture of the penis who presented to the Cleveland Clinic from 1992 to 1998.

METHODS

Trauma was encountered during intercourse in all our patients. A concomitant urethral injury was found in 3 cases (38%); 1 was a complete disruption, and the other 2 were partial injuries. Patients were treated with immediate surgical exploration and repair, with preoperative urethrography in patients suspected of having a urethral injury.

RESULTS

All patients had a successful outcome, with preservation of sexual function and without significant penile curvature. Patients with urethral injuries reported normal voiding without the need for additional procedures.

CONCLUSIONS

Immediate surgical repair offers complete recovery for patients with penile fracture in most cases, even in the presence of urethral injury. We present our recommendations for treatment of this condition.

Management of severe corporeal fibrosis with implantation of prosthesis via a transverse scrotal approach

PURPOSE

We reviewed our experience in the management of severe corporeal fibrosis with placement of the AMS 700 CXM* prosthesis to determine the efficacy of this approach.

MATERIALS AND METHODS

The records of 26 men with severe corporeal fibrosis who underwent placement of the AMS 700 CXM prosthesis via a transverse scrotal approach between August 1991 and July 1996 were reviewed.

RESULTS

In all cases the AMS 700 CXM prosthesis was successfully implanted with primary closure of the tunica albuginea, although 2 patients required extended corporotomies. Followup data were available on all 26 men. At a mean followup of 22.5 months (range 3 to 63) 24 of the 26 men had a functional device (92%). One patient required explantation for infection and 1 underwent explantation for cylinder cross-over.

CONCLUSIONS

Implantation of the AMS 700 CXM prosthesis in patients with severe corporeal fibrosis produced good results at approximately 2 years of followup.

Long-term mechanical reliability of AMS 700 series inflatable penile prostheses: comparison of CX/CXM and Ultrex cylinders

PURPOSE

Recently, we have noted an increasing incidence of revisions being performed in patients implanted with the length and girth expanding AMS 700 Ultrex* inflatable penile prosthesis. This observation prompted us to compare the long-term mechanical reliability of the AMS Ultrex inflatable penile prosthesis versus the girth-expanding AMS 700 CX* or CXM* inflatable penile prosthesis in men with organic erectile dysfunction.

MATERIALS AND METHODS

Using chart review, mailed questionnaires and telephone interviews, we obtained accurate followup on 111 of 142 (78.2%) patients with CX/CXM implanted between June 1986 and September 1995, and on 152 of 179 (84.9%) patients implanted with Ultrex between October 1989 and September 1995. The CX/CXM and Ultrex groups were compared with regard to 3 end points: 1) mechanical failure caused by any malfunctioning component, 2) device failure caused by any cylinder complication and 3) cylinder aneurysms/leaks.

RESULTS

Followup ranged from 1.0 to 112.0 months for the CX/CXM group (mean 47.2 months), and 0.7 to 71.5 months for the Ultrex group (mean 34.4 months). CX/CXM versus Ultrex group comparison demonstrated 10 CX/CXM mechanical failures (9.0%) versus 26 Ultrex failures (17.1%), p = 0.001; 5 CX/CXM cylinder complications (4.5%) versus 13 Ultrex cylinder complications (8.6%), p = 0.0292; and 3 CX/CXM cylinder aneurysms/leaks (2.7%) versus 9 in the Ultrex group (5.9%), p = 0.0162. Kaplan-Meier estimates demonstrated significantly decreased mechanical survival in all 3 categories for Ultrex inflatable penile prosthesis versus CX/CXM inflatable penile prosthesis.

CONCLUSIONS

Although Ultrex cylinders provide length and girth expansion, Ultrex cylinders exhibit an increased mechanical failure rate at shorter followup compared with CX/CXM cylinders. This increased propensity for Ultrex cylinder problems should be closely monitored.

AMS 3-piece inflatable penile prosthesis implantation in men with Peyronie's disease: comparison of CX and Ultrex cylinders

PURPOSE

We compared the ability of the CX and Ultrex cylinders to straighten the penis in men who received a 3-piece AMS 700 series inflatable penile prosthesis for erectile dysfunction and erectile deformity due to Peyronie's disease.

MATERIALS AND METHODS

The records of 34 and 38 patients receiving devices CX and Ultrex cylinders, respectively, were reviewed.

RESULTS

All 34 patients receiving the CX cylinders achieved complete penile straightening with cylinder inflation and bending alone. In 10 of 38 patients receiving the Ultrex cylinders complete straightening with cylinder inflation and bending could not be achieved, and simultaneous corporoplasty was necessary.

CONCLUSIONS

Girth expanding CX cylinders have better penile straightening properties than girth and length expanding Ultrex cylinders. We recommend use of CX cylinders for 3-piece AMS 700 series inflatable penile prosthesis implantation in men with Peyronie's disease.

Cultures from genitourinary prostheses at reoperation: questioning the role of Staphylococcus epidermidis in periprosthetic infection

PURPOSE

We determine the colony counts of organisms present on culture of clinically uninfected genitourinary prostheses at reoperation for reasons other than infection. These results served as control data for comparison with cultures from infected devices to determine the relative incidence of organisms involved.

MATERIALS AND METHODS

Cultures were prospectively obtained from 65 penile prostheses and 22 artificial urinary sphincters. Patients were followed for a minimum of 12 months after reoperation or until development of infection (mean 27 months) at which time cultures were again obtained.

RESULTS

Low colony counts of Staphylococcus epidermidis were isolated from 40% of uninfected penile prostheses and 36% of artificial urinary sphincters. Only 3 of these devices later became infected (9%) and in all cases a higher colony count of another organism was found at explanation.

CONCLUSIONS

While Staph. epidermidis can cause prosthesis infection, low colony counts of the organism may not be associated with clinical infection. Therefore, the high incidence of infection attributed to this organism may be overestimated.

Primary erectile dysfunction in a man with congenital isolation of the corpora cavernosa

We report on a 33-year-old man with primary erectile dysfunction, isolated cavernous bodies, corporeal veno-occlusive dysfunction, and hypoplastic cavernous arteries. To our knowledge, this is only the second reported case of absence of communication between the corpora cavernosa.

Renal cell carcinoma arising in a regressed multicystic dysplastic kidney

Controversy surrounds the management of multicystic dysplastic kidney. Recent advances in radiological imaging have resulted in a higher incidence of its detection, and they provide an accurate noninvasive means of diagnosis and followup. Consequently, the need for surgical removal of these lesions is being reevaluated. We report a case of renal cell carcinoma arising from solid renal dysplasia associated with a regressed multicystic dysplastic kidney. We emphasize the potential risk of nonoperative management of these lesions and further define the spectrum of malignant degeneration associated with renal dysplasia.

Complex urethral reconstruction

Modern tissue transfer techniques, often incorporating penile or scrotal skin islands based on a dartos fascia pedicle, have revolutionized urethral reconstruction. There are certain situations, however, that require a more creative and complex approach. The majority of these cases involve patients with panurethral stricture disease or those who have undergone multiple previous procedures for urethral stricture disease or hypospadias and their subsequent complications. In this article, the authors discuss the various aspects of these two conditions and outline several techniques for urethral reconstruction in these challenging patients.

Complications of the exaggerated lithotomy position: a review of 177 cases

To examine the incidence and nature of complications associated with placing patients in the exaggerated lithotomy position, a retrospective review of 177 procedures requiring the use of that position was done. Factors analyzed were patient age, height, weight and time in position. Height-to-weight ratio was calculated in an effort to establish a relationship between body habitus and common peroneal nerve neurapraxia, the most common complication (15.8%) noted in the study. Statistical analysis failed to show any relationship between these factors and the incidence of neurapraxic complications. The study demonstrates the safety of this highly useful surgical position for perineal operations. The technical points relative to positioning are emphasized.

Preoperative evaluation of erectile function with dynamic infusion cavernosometry/cavernosography in patients undergoing surgery for Peyronie's disease: correlation with postoperative results

Most reports of surgical therapy for Peyronie's disease to date have not included detailed preoperative assessment of erectile function. To evaluate the relationship between preoperative erectile function and postoperative success, we reviewed 25 consecutive patients with Peyronie's disease who underwent surgery and evaluation with dynamic infusion cavernosometry and cavernosography preoperatively. Overall results of dynamic infusion cavernosometry and cavernosography revealed corporeal veno-occlusive dysfunction in 76% of the patients and inadequate arterial inflow parameters in 44%. Among 20 patients treated with plaque excision and dermal graft inlay, adequate postoperative erectile function for satisfactory intercourse occurred in 4 of 4 (100%) with an equilibrium accumulated intracorporeal pressure of greater than or equal to 70 mm. Hg, 9 of 12 (75%) with an equilibrium accumulated intracorporeal pressure of 40 to 65 mm. Hg and 1 of 4 (25%) with an equilibrium accumulated intracorporeal pressure of less than 35 mm. Hg. These data may be helpful to counsel patients before surgical therapy, and may explain some of the disparate results previously reported after plaque excision and dermal graft inlay on the basis of patient selection.

Penile venous ligation in 18 patients with 1 to 3 years of followup

We report the results of penile venous ligation in 18 consecutive patients with erectile insufficiency due to corporeal venous occlusive dysfunction. Patient age ranged from 25 to 65 years (mean 47). Duration of erectile dysfunction ranged from 9 to 468 months (mean 95) and followup ranged from 12 to 37 months (mean 24). Of 18 patients 11 (61%) have sufficient persistent improvement in erections to permit unaided coitus. Of 7 failures 6 had temporary improvement in erections after the procedure: in 5 the improvement lasted 6 months or less, while only 1 had lasting improvement (24 months) before relapse. Reports of results of penile venous ligation should not include patients who have been followed for less than 12 months. Longer followup is needed before results of penile venous ligation beyond 2 years are known.

Hypertension as a complication of multicystic dysplastic kidney

The detection of multicystic dysplastic kidney in utero using prenatal ultrasound is becoming a more frequent occurrence. An accurate diagnosis of multicystic dysplastic kidney usually can be made radiographically, and therefore the main indication for surgery in the asymptomatic patient may be the potential risk of complications developing later in life. We report hypertension as a complication of multicystic dysplastic kidney and review the literature.

Nephron-sparing surgery for renal cell carcinoma with venous involvement

A nephron-sparing operation recently has been shown to provide extended survival free of disease in selected patients with localized renal cell carcinoma, particularly for tumors of lower stage. To define better the role of conservative surgical treatment in more locally advanced renal cell carcinoma we reviewed 9 patients with venous tumor involvement in solitary functioning kidneys who underwent a nephron-sparing operation. Complete tumor resection with adequate preservation of renal function was accomplished in all cases. Of the 9 patients 5 had no evidence of disease 7 to 93 months (mean 33.2 months) postoperatively. The remaining 4 patients died of metastatic renal cell carcinoma 17 to 47 months (mean 35.5 months) postoperatively, 2 of whom had concomitant local recurrences in the renal remnant. Based on previously reported results of total nephrectomy for renal cell carcinoma with venous involvement and the morbidity associated with renal replacement therapy, we believe that a nephron-sparing operation is a viable option in the management of these patients.

Resection of nonrenal retroperitoneal tumors with large vena caval thrombi using cardiopulmonary bypass and hypothermic circulatory arrest

Cardiopulmonary bypass with deep hypothermic circulatory arrest is a useful adjunct in the operative management of renal cell carcinoma associated with large vena caval thrombi. We present 2 patients with nonrenal retroperitoneal tumors and extensive vena caval thrombi who underwent successful surgical treatment with this method. The primary tumor was a leiomyosarcoma of the vena cava in 1 patient and a pheochromocytoma with hepatic invasion in 1. Cardiopulmonary bypass with deep hypothermic circulatory arrest is effective in decreasing the operative risk and improving the feasibility of resection in complex surgical cases. Consideration should be given to its use in a wider range of indicated procedures.

Perioperative complications of adrenal surgery

Complications of adrenal surgery may be medical or surgical. The latter are related to the operative approach as well as to the type and extent of the adrenal lesion and are in general similar to those seen in other open procedures. The medical complications include adrenal insufficiency as a result of bilateral adrenalectomy or continuing contralateral suppression, as well as more specific problems resulting from the physiological derangements of Cushing's syndrome, pheochromocytoma, and primary aldosteronism. Nevertheless, with meticulous preoperative management and postoperative care, adrenal surgery can be performed with low morbidity and mortality rates.