Positional variation in the Whitaker test

PURPOSE

To describe positional variation in the outcome of the Whitaker test.

MATERIALS AND METHODS

The authors retrospectively reviewed the cases of six patients in whom the pressure gradient during Whitaker testing varied by at least 10 cm of water and changed from normal ( < or = 13 cm of water) to abnormal ( > 13 cm of water) when patients were placed in different positions.

RESULTS

Four patients had obstruction only in nonstandard positions. All had intermittent symptoms, and three had ureteral kinks at fluoroscopy. Two patients with ileal conduits had abnormal results in the standard position but normal results at repositioning related to compression of the conduits (seen as conduit distention at fluoroscopy). All six had undergone urinary tract surgery. Gradient differences with positional change ranged from 10 to > 38 cm of water.

CONCLUSIONS

Whitaker testing in different positions may help identify intermittent obstructions that might otherwise go undetected or prevent inappropriate diagnosis of obstruction. Intermittent or unexplained symptoms, tortuous ureters, malpositioned kidneys, or previous surgery are indications for provocative positional testing.

Applying critical pathways to neurosurgery patients at the University of Michigan Medical Center

Project Overview: In April 1990, The University of Michigan Hospitals began a major, multidisciplinary project to standardize care processes in order to increase efficiency and reduce costs while maintaining the quality of clinical care. A team of nurses began the project by developing critical pathways for two neurosurgery procedures--lumbar laminectomy and transphenoidal pituitary tumor resection. The pathways were reviewed by physicians and other staff from other disciplines and were implemented in January of 1991.

KEY FINDINGS

Data from the first 14 months show a decrease in patients' average lengths of stay in both the intensive care unit (ICU) and routine care unit. Costs and variance data are being analyzed and further improvements to the pathways are being made. Eleven critical paths are now being used for neurosurgery patients. In retrospect, participants learned that physicians should be involved at the earliest stages of critical pathway development and in the process of implementation.

Stryker frame gantry modification for extracorporeal shock wave lithotripsy to circumvent positioning problems

From July 1986 through December 1989, 45 patients with renal or biliary calculi were treated on a Dornier HM3* lithotriptor using a Stryker frame gantry modification. The modification was necessary due to inability to position the patients in the standard gantry. The situations that required nonstandard positioning techniques included stones in the distal or mid ureter, renal transplant, gallbladder or common bile duct, and unusual body habitus, such as myelomenigocele, bilateral lower extremity amputations and children with stones. Positioning with adequate focus of the shock wave was achieved in 87% of the patients and fragmentation was achieved in 89%. The Stryker frame gantry modification is an excellent method to circumvent positioning problems with the Dornier HM3 lithotriptor, extending lithotripsy capability to patients who might otherwise not be candidates.

Extracorporeal lithotripsy. An important adjunct in the nonoperative management of retained or recurrent bile duct stones

Retained or recurrent bile duct stones can be successfully removed in up to 80% to 85% of patients with the use of percutaneous or endoscopic techniques. However, problems related to difficult biliary access, large stones, and biliary strictures may decrease the success rate of this approach. We evaluated the safety and efficacy of extracorporeal shock-wave lithotripsy (ESWL) in 16 patients with complicated biliary stones treated prospectively over a 24-month period. Successful stone fragmentation was achieved in 15 patients (94%) using a Dornier HM3 lithotripter (average of 2290 shocks at 22 kV). Three patients (19%) required a second ESWL treatment. Biliary clearance of stone fragments was spontaneous in seven (43%) of the patients and required additional treatment in eight (57%) of the patients. Complications from ESWL were minor and included transient hematuria and ecchymoses at the skin entry site. Extracorporeal shock-wave lithotripsy failed in one patient (6%) with a biliary stricture and surgery was required. At hospital discharge, all patients were asymptomatic and stone free. Treatment with ESWL appears to be a safe and effective adjunct for selected patients with complex biliary stone disease.

Stones and infection in renal caliceal diverticula: treatment with percutaneous procedures

Percutaneous treatment of symptomatic caliceal diverticula has expanded the application of uroradiologic intervention. To assess the safety and efficacy of these procedures, we have reviewed our experience with percutaneous management of 12 symptomatic caliceal diverticula, 10 with stones and two infected. Nine stone-bearing diverticula were punctured directly with subsequent tract dilatation, nephroscopic stone extraction, and cavity obliteration (six with fulguration and drainage and three with drainage alone). One case was approached indirectly by puncturing a distant calix, dilating the diverticular neck, and flushing the stones into the collecting system for extraction. This cavity was not treated. Two infected diverticula were punctured directly for drainage and obliteration (one by fulguration and one by tetracycline sclerosis). Complete stone extractions were accomplished in all 10 cases. In eight with clinical follow-up ranging from 4 months to 6 years, one stone has recurred and seven patients are asymptomatic. Follow-up urograms were available in eight of 10 patients in whom cavity obliteration was attempted; in six (75%) of eight, nonvisualization of the diverticulum indicated successful obliteration. Only one major complication (urinoma requiring drainage) occurred. We conclude that percutaneous procedures are safe and effective in treating infected or stone-bearing caliceal diverticula. Direct diverticular puncture for access and diverticular fulguration for cavity obliteration is our preferred technique.

Treatment of renal transplant stones by extracorporeal shock-wave lithotripsy in the prone position

Two patients with renal transplant lithiasis were successfully treated with extracorporeal shock-wave lithotripsy (ESWL) in the prone position. Pathogenesis and treatment of transplant lithiasis are discussed. Performing ESWL on renal transplant patients in the prone position has advantages over standard positioning techniques.

Initial clinical trials with a tubless lithotriptor

The Medstone 1050 is a new tubeless lithotriptor developed in the United States. Under Food and Drug Administration guidelines a human treatment protocol has been developed. The first 50 patients treated at a single site and followed for a minimum of 3 months are presented. All stones treated were 3 cm. or less in longest dimension and located in the renal pelvis, calices or proximal ureter. An adequate fragmentation rate of 90% was achieved in this group. There were no significant complications in any patient. A larger multicenter study presently is underway.

Iatrogenic lithotripsy failure: penetration of shock waves through tape

Foam tape used to protect epidural catheters during immersion in a Dornier HM3 lithotriptor was identified retrospectively as the cause of poor stone fragmentation. Studies of shock wave penetration through various protective type materials indicate that a particular water repellant tape is least likely to impair shock wave penetration.

Distinguishing benign from malignant euadrenal masses

STUDY OBJECTIVE

To determine the efficacy of 131I-6-beta-iodomethylnorcholesterol (NP-59) adrenal scintigraphy in distinguishing benign from malignant euadrenal masses.

DESIGN

Case series of patients with incidentally discovered unilateral, euadrenal masses.

SETTING

Referral-based nuclear medicine clinics at university and affiliated Veterans Administration medical centers.

PATIENTS

Consecutive sample of 119 euadrenal patients with unilateral adrenal masses discovered on computed tomographic (CT) scans for reasons other than suspected adrenal disease.

INTERVENTIONS

Adrenal scintiscans done using 1 mCi of NP-59 intravenously, and gamma camera imaging 5 to 7 days later.

MEASUREMENTS AND MAIN RESULTS

Mean lesion diameter was 3.3 +/- 1.9 cm (SD) (95% CI: 2.9 to 3.6 cm). In 76 patients, NP-59 uptake lateralized to the abnormal adrenal seen on CT scans (concordant imaging), and in all of these patients, a diagnosis of adenoma was made by needle-aspiration biopsy, adrenalectomy, or extended follow-up with repeat CT scans that were unchanged at 6 months or later. Twenty-six patients had absent or markedly reduced NP-59 uptake in the glands identified as abnormal on CT scans (discordant imaging). These adrenal masses proved to be metastatic malignancies in 19 patients, primary adrenal neoplasms other than adenoma in 4, and adrenal cysts in 3. Bilateral, symmetric accumulation of NP-59 was seen in 17 patients, in whom the adrenal masses were shown to be metastatic malignancies in 2, and adenomas in 6 (the lesions in these cases being 2 cm or less in diameter), and lesions not truly involving the adrenal in the rest (periadrenal metastases in 4 and pseudoadrenal masses in 5). Sensitivity was 76% (26 of 34 patients; CI, 58% to 88%); specificity, 100% (85 of 85 patients; CI, 95% to 100%), and accuracy, 93% (111 of 119 patients: CI, 88% to 98%).

CONCLUSIONS

Functional NP-59 scintigraphy can be used to accurately and noninvasively characterize many euadrenal masses; concordance of CT and NP-59 scans can be used to exclude the presence of a malignancy or other space-occupying adrenal lesion.

Evaluation of male external genital diseases in the emergency room setting

This article briefly discusses various diseases of the external genitalia as they pertain to the emergency physician. Conditions emphasized include penile and scrotal trauma, Fournier's gangrene, and the "acute" scrotum. Practical advice regarding diagnosis and treatment is offered.

Treatment of painful caliceal stones

Nonmobile caliceal stones cause pain more often than previously appreciated. The character and intensity of the pain differs from typical renal colic. Twenty-six patients with caliceal stones and pain underwent attempted treatment for pain control via stone removal or disintegration: 15 were treated with percutaneous stone extraction (PSE), 10 with extracorporeal shock-wave lithotripsy (ESWL), and 1 required open surgery after failing PSE. One patient had persistent pain after ESWL and subsequently underwent PSE; 25 of 26 patients had complete relief of pain. Morbidity was minimal. Patients with painful caliceal stones should be offered ESWL, followed by PSE if pain persists.

Experience with pubovaginal slings for urinary incontinence at the University of Michigan

In July 1983 pubovaginal slings were used first at our university to treat incontinence in female patients with poor urethral function. From then until July 1, 1986, 82 such procedures were performed on a diverse group of patients, including a male patient. Initial success occurred postoperatively in 67 patients, with 15 failures. Of these failures 7 were related to urethral dysfunction. Another sling procedure was done in 2 patients and they are continent, while 3 were treated with medication: 2 became dry and 1 remains wet. A total of 8 patients suffered detrusor-related incontinence postoperatively (2 required augmentation cystoplasty for poor bladder compliance). To date 78 patients (95 per cent) are continent. Of the patients 2 required periodic intermittent catheterization for more than a year postoperatively and 12 are managed by chronic intermittent self-catheterization on a planned basis for neurogenic vesical dysfunction.

Ureteral stone management: emerging concepts

A total of 206 procedures was performed on 193 patients with ureteral calculi. The success rate was 62 per cent for stones proximal to the pelvic brim and 94 per cent for stones distal to the pelvic brim (87 per cent success over-all). Of the procedures 61 were done for fragments lodged in the ureter following extracorporeal shock wave lithotripsy. Ureteroscopy was done in 147 cases. Our current management concepts (including extracorporeal shock wave lithotripsy) for proximal and distal ureteral calculi are presented.

Candida pyocalix: unusual complication of prolonged nephrostomy drainage

Long-term nephrostomy drainage rarely is used except in extreme circumstances. We report an unusual complication, that is Candida pyocalix in a solitary kidney. The obstruction developed following removal of the nephrostomy tube at the infundibular outlet to the calix where the tube had resided.

Carcinosarcoma of bladder. Evaluation by electron microscopy and immunohistochemistry

A case of carcinosarcoma of the urinary bladder characterized by electron microscopy and immunohistochemistry is described. The use of these studies in poorly differentiated bladder neoplasms and in suspected cases of carcinosarcoma is encouraged. Increased accuracy in characterizing these tumors will permit a better understanding of their natural history and response to therapy.

Long-term followup of the artificial urinary sphincter

The artificial urinary sphincter with a pressure regulating balloon was implanted in 30 patients. All implantations were done before September 1982, for a minimum followup of 1 year and an average followup of 3.7 years. Of the patients 21 (70 per cent) have a functioning sphincter: 17 are continent and 4 are slightly incontinent, requiring 1 pad per day. Failure was owing to erosion in 6 patients and infection of the device in 3. Critical factors for successful implantation include preoperative evaluation, cuff location and pressure, primary deactivation and postoperative care. Our experience supports the further use of this device in appropriate cases.

Incidental adenocarcinoma of the prostate: the role of repeat transurethral resection in staging

Accurate staging of patients with incidental prostatic adenocarcinoma (A1 vs A2) is crucial to the selection of appropriate treatment. To evaluate the potential sampling error in specimens obtained by transurethral resection, repeat resection was performed on 31 patients pathologically staged as A1 (five or less chips with tumor). Second specimens showed no tumor in 22 (71%), stage A1 in six (20%), and stage A2 in three (9%). The weight of tissue removed at reresection was greater in patients found to have more extensive involvement (P less than 0.005). No patient with initial Gleason score 2, 3, or 4 had stage A2 at reresection. Repeat resection is not routinely necessary, but may be helpful when the tumor is high grade but of minimal extent, in an anxious younger patient who may wish therapy if disease persists, or where some suspicion of an incomplete resection exists.

Bladder calculi complicating intermittent clean catheterization

Eight male patients on clean intermittent catheterization programs for neurogenic bladder dysfunction developed vesical calculi around pubic hairs inadvertently introduced into the bladder, acting as a nidus for incrustation. In three patients, the radiographic appearance of serpentine calcifications in the pelvis was highly consistent with calcareous deposits on strands of hair. Familiarity with this radiologic appearance should suggest the diagnosis in the appropriate clinical setting and help avoid misinterpretation of these calcifications, atypical of usual bladder stones.

Fate of patients started on clean intermittent self-catheterization therapy 10 years ago

We evaluated 60 patients placed on a clean intermittent catheterization program more than 10 years ago to determine their outcome. To date 27 patients still are performing self-catheterization, 18 have discontinued the procedure and 15 have been lost to followup. No patient has had deterioration in renal function. Prior incontinence was alleviated completely in 10 of the 27 patients still on the program and 10 of the 18 patients no longer on catheterization have returned to normal voiding. Clean intermittent catheterization is an effective treatment modality in properly selected patients, with few complications and excellent long-term results.

Neurologic disease masquerading as genitourinary abnormality--the role of urodynamics in diagnosis

While the great majority of patients with neurogenic bladder and sphincter dysfunction have identifiable neurologic disease a small group will present with obvious genitourinary problems caused by not so obvious neurologic conditions. Thirteen such patients are presented, with a discussion of the ability of various urodynamic tests to predict the presence of significant neurologic disease.

Simultaneous presentation of untreated hyperparathyroidism and obstructing ureteral calculi: surgical considerations

Simultaneous presentation of obstructing ureteral calculi and untreated primary hyperparathyroidism offers an interesting therapeutic dilemma. We herein review 8 cases, with 6 occurring in the last 3 years. When both conditions require surgical intervention the parathyroid adenoma should be excised first. The adenoma and offending stone can be removed at the same operation, with resultant prompt relief of pain and decrease in hospitalization.

The effect of single dose N-methyl-N-nitrosourea on bladder carcinogenesis by N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide in rats

The effect of a single intravesical dose of N-Methyl-N-Nitrosourea (MNU) on bladder carcinogenesis in Fischer rats by a suprathreshold dose of N-[4-(5-nitro-2-furyl)-2-thiazolyl] formamide (FANFT) was studied. Animals were sacrificed periodically during the course of the study and the experiment was terminated 50 weeks. Carcinomas were first noted in the MNU + FANFT group at 35 weeks versus 37 weeks for the group receiving FANFT alone. At 50 weeks, carcinomas were seen in 40 of 49 animals in the MNU + FANFT group and in 40 of 48 animals in the FANFT group. Of the animals developing bladder carcinomas 50 per cent receiving MNU + FANFT and 32 per cent receiving FANFT had high grade tumors. Six per cent of the animals receiving MNU alone developed bladder carcinomas whereas none was seen in a control group. In this system, the addition of an inducing dose of MNU did not alter the induction rate or results of carcinogenesis by FANFT. There was a tendency for higher grade tumors in those animals receiving the inducing dose of MNU.

Compatibility of genitourinary prostheses and intermittent self-catheterization

The compatibility of genitourinary prostheses and intermittent self-catheterization was established in 13 prosthetic recipients who were concomitantly on intermittent self-catheterization for bladder emptying dysfunction. All patients were able to catheterize themselves successfully after implantation of the prosthesis. No prosthetic infection was encountered in our series. Two penile prosthetic recipients suffered unilateral epididymitis that was treated successfully. Although mechanical complications were encountered they were repaired readily and were not considered related to self-catheterization.

Parastomal ileal conduit hemorrhage and portal hypertension

An analysis of six cases of parastomal ileal conduit hemorrhage in patients with portal hypertension is presented. The presence of coexisting esophageal varices, documented in only one of six cases (17%), suggest preferential retrograde portal flow through mesenteric venous (as opposed to coronary-azygos) collateral channels. Venous phase mesenteric angiography offers the best diagnostic specificity and provides inferential evidence regarding overall liver blood flow. Operative therapy should be based on assessment and understanding of the splanchnic circulatory derangements which accompany intrahepatic portal obstruction.

Twenty-year outcome of cutaneous vesicostomy

Forty cutaneous vesicostomy urinary diversions were done at our hospital from 1958 to 1961. Of these cases 30 patients have been followed every 6 months or until death. The vesicostomy-related failure rate was 8.6 per cent, with new stones forming in 3 additional kidneys. Cutaneous vesicostomy provides long-term preservation of renal function in patients requiring urinary diversion. However, close followup is mandatory to ensure a good result.

Fixed eruption and fever after urography

We have described a patient with fixed bullous eruption, usually associated with severe fever, occurring on five occasions after a series of seven intravenous urograms between 1974 and 1979. Diagnosis was initially obscured because the onset of fever and dermatitis was delayed as long as 72 hours. This is only the second report of true ioderma ascribed to urographic contrast media.

Use of cryoprecipitate coagulum in extracting renal calculi

Human cryoprecipitated plasma can form an extractable coagulum which will effectively remove renal calculi in selected cases. We successfully used this blood product and a simplified injection technique in 30 patients undergoing surgery for upper tract calculi. Coagulum pyelolithotomy was performed in 24 cases with removal of all stones in 23 (96 per cent). In 6 patients incomplete stone removal by conventional operative methods was successfully completed by using the coagulum as an adjunctive procedure. In 10 of the 30 cases (33 per cent) radiographically "silent" calculi were recovered within the cryoprecipitate clot. The advantages of cryoprecipitate over previously reported blood products, certain technical simplifications, and the appropriate clinical indications for the coagulum procedure are discussed.

Further observations on the cystometric and uroflowmetric effects of bethanechol chloride on the human bladder

We evaluated the cystometric and uroflowmetric effects of bethanechol chloride on non-neurogenic, non-decompensated human bladders. Statistically significant changes were measured using cystometric and uroflowmetric parameters. We discuss the indications and methods for therapy with bethanechol chloride.

Usefulness of adrenal venography and iodocholesterol scan in adrenal surgery

Adrenal scintiscanning and venography with sampling of adrenal venous blood are valuable methods to localize adrenal cortical lesions of Cushing's syndrome and primary aldosteronism. Adrenal scintiscanning with dexamethasone suppression is most useful in differentiating adenoma from hyperplasia of primary aldosteronism.

Cryoprecipitate: its use and effects in canine coagulum pyelolithotomy

A fibrin clot forming an extractable cast or "coagulum" of the pyelocalyceal system was developed and characterized using a blood product not previously described--single donor type specific cryoprecipitate. The physical properties of the cryoprecipitate coagulum were investigated and compared with other described formulations. Simulated coagulum pyelolithotomy was performed in vivo in 11 canine kidneys with no adverse effect upon creatinine clearance or anatomic integrity. The advantages of the cryoprecipitate are detailed and a new, simplified operative technique is described.