Decreased incidence of prostate cancer with selenium supplementation: results of a double-blind cancer prevention trial

OBJECTIVE

To test if supplemental dietary selenium is associated with changes in the incidence of prostate cancer.

PATIENTS AND METHOD

A total of 974 men with a history of either a basal cell or squamous cell carcinoma were randomized to either a daily supplement of 200 microg of selenium or a placebo. Patients were treated for a mean of 4.5 years and followed for a mean of 6.5 years.

RESULTS

Selenium treatment was associated with a significant (63%) reduction in the secondary endpoint of prostate cancer incidence during 1983-93. There were 13 prostate cancer cases in the selenium-treated group and 35 cases in the placebo group (relative risk, RR=0.37, P=0.002). Restricting the analysis to the 843 patients with initially normal levels of prostate-specific antigen (< or = 4 ng/mL), only four cases were diagnosed in the selenium-treated group and 16 cases were diagnosed in the placebo group after a 2 year treatment lag, (RR=0.26 P=0.009). There were significant health benefits also for the other secondary endpoints of total cancer mortality, and the incidence of total, lung and colorectal cancer. There was no significant change in incidence for the primary endpoints of basal and squamous cell carcinoma of the skin. In light of these results, the 'blinded' phase of this trial was stopped early.

CONCLUSIONS

Although selenium shows no protective effects against the primary endpoint of squamous and basal cell carcinomas of the skin, the selenium-treated group had substantial reductions in the incidence of prostate cancer, and total cancer incidence and mortality that demand further evaluation in well-controlled prevention trials.

External vacuum therapy for erectile dysfunction: use and results

This review assesses the continuing role of noninvasive vacuum therapy as treatment for erectile dysfunction and discusses the action of negative pressure in producing assisted erection. Through recent research in this area has centered on the development of pharmaceutical therapies, vacuum-therapy programs appear to be a consistent long-term option for patients experiencing either chronic or occasional impotence of any etiology. Very little testing is required before the initiation of vacuum treatment, and the overall; clinical success rate is approximately 90%. Significant success has been reported in more difficult patient populations, including those with veno-occlusive disorders and explanted penile prostheses. Vacuum therapy may also be used in conjunction with other therapies to enhance results. Contraindications to the use of vacuum therapy are few and primarily include patients with unexplained intermittent priapism and bleeding disorders. Side effects such as occasional numbness, pain, penile bruising, or petechiae have a low incidence. A recently reported survey of 5,847 vacuum users showed that 83.5% of patients continue to use the device for intercourse as desired. Patients should receive individual instruction in the use of these devices and should expect a learning or practice period to achieve optimal results. As newer treatments for erectile dysfunction gain increasing attention, it should be kept in mind that nearly every patient showing impotence of any degree or duration as well as patients who have failed other therapeutic choices are candidates for vacuum therapy.

Hypoplasia of urinary bladder

Three female patients with hypoplasia of the urinary bladder and associated congenital anomalies are described. All were first seen in early infancy with significant obstructive uropathy and were managed by early loop cutaneous ureterostomy. All have survived to adulthood and 2 patients have received a kidney transplant into an ileal conduit; 1 patient continues to do well with cutaneous ureterostomy only. Pathogenesis, management, and long-term outcome are discussed.

Application of smooth Teflon clip to inferior vena cava during radical cystectomy to prevent postoperative pulmonary embolism

Between 1976-1986, a smooth Teflon clip was applied to the inferior vena cava of 56 patients who underwent radical cystectomy for bladder cancer. The purpose of the clip is to narrow the lumen of the inferior vena cava so that large emboli will be trapped and thus prevented from reaching the lungs. These 56 patients were compared with a group of 26 historical controls who underwent radical cystectomy without application of such a clip between 1967-1976. One patient (1.8%) whose vena cava was clipped had a pulmonary embolus which was fatal. Four (15.4%) of the 26 control patients had postoperative pulmonary emboli, the embolic event being fatal in 3 (11.5%). Application of the smooth Teflon clip to the inferior vena cava significantly lessens the incidence of pulmonary embolism following radical cystectomy.

Mechanical devices for the treatment of erectile dysfunction

Almost all men with erectile dysfunction can be successfully treated. External erection devices are safe and effective for the management of partial impotence. If external devices fail to produce adequate penile engorgement or if they cannot be used, invasive treatments are available. Penile implants remain the gold standard for the management of erectile impotence, especially complete impotence. A satisfaction rate of 80 to 90 percent can be expected with all of the currently available implants. Attention to surgical detail and proper patient selection usually produce an excellent functional and anatomic result.

Cytologic detection of urothelial cancer and other abnormalities in a cohort of workers exposed to aromatic amines

A total of 541 members of a cohort at increased risk for occupational bladder cancer underwent a 33-month program of screening with urine cytology. Selected workers received further urologic study with cystoscopy and bladder biopsies. Eight workers had positive or suspicious cytologic findings. Only one of the eight had a prior history of bladder cancer. Biopsies showed invasive carcinoma and/or nonpapillary carcinoma in situ in five workers in this group, severe atypia in one, and no significant abnormality in two. Of 56 workers who had atypical cytologic findings, 16 had bladder biopsies, which showed atypia of flat urothelium in 11, nonpapillary carcinoma in situ in one, noninfiltrating papillary carcinoma in one, and no significant abnormality in three. The cytologic detection of urothelial abnormalities often required more than a single specimen. Since the cohort in this study may develop more bladder cancers with the passage of time, continued follow-up is indicated.

In situ dissection of cadaver kidneys

Major anatomic injuries occurred in 18 of 151 (12%) en bloc kidneys. No injuries occurred among the in situ kidneys. The rates of delayed graft function were equal. All the kidneys removed by the in situ method were removed by one surgeon (ALH). The results are good enough to recommend the technique even without a randomized study.

Torsion of the spermatic cord in adults

Intravaginal torsion of the spermatic cord is seen typically in the peripubertal period. At our hospital 33 patients with intravaginal torsion were seen between 1970 and 1986, and 13 (39%) were more than 20 years old. Because of delay in seeking treatment or error in initial diagnosis proper treatment often was late in these 13 adults. This delay in treatment allowed for a testicular salvage rate of only 38%. Increased awareness by physicians that torsion often occurs in adults plus an accurate history and evaluation may allow for a higher testicular salvage rate in this age group.

Vacuum constriction device for management of erectile impotence

A mechanical device for treatment of impotence based on the concept of entrapment of blood in the penis following vacuum-assisted tumescence is described and more than 15,000 units have been marketed. A total of 1,517 users who acquired the device between 1974 and 1987 completed a questionnaire concerning the system. Of these patients 92 per cent either achieved an erection or an erection-like state that was satisfactory for intercourse and 77 per cent had intercourse at least every 2 weeks. No serious ill effect from use of the device has been reported a and it is particularly effective in the management of partial impotence. In selected patients the device is an alternative to either surgical placement of a penile prosthesis, intracavernous injection of vasoactive drugs or sexual abstinence.

Ureteroneocystostomy in renal transplantation: a simple transvesical technique

A simple transvesical technique for transplant ureteroneocystostomy is described. The method has been used in 245 transplants during a 6-year period. Only 4 significant complications (1.6 per cent) were recognized and no kidney was lost owing to a complication of ureteroneocystostomy.

Suction device therapy in the management of erectile impotence

The ErecAid System is based on the simple concept of entrapment of blood in the penis following vacuum-assisted penile engorgement by proximally placed elastic constriction bands. The SYNERGIST Erection System is a semirigid external appliance shaped like a condom that is left on the penis after vacuum tumescence has been achieved. Both devices can be used safely by any man who feels that he has an impotence problem, and the outcome is fairly predictable. These devices seem to be especially effective in men with partial impotence, and they offer the impotent man an alternative to surgical placement of penile prosthesis, a surgical revascularization procedure, intracavernosal injection of vasoactive drugs, or sexual abstinence. These devices appear to be safe and relatively inexpensive ways for the impotent man to make his penis rigid enough to engage in sexual intercourse. An impotent man who selects suction-device therapy may still be able to use other forms of treatment should he need or choose it.

The 'acute' scrotum. Lesions that require immediate attention

An "acute" scrotum may result from an interesting and fairly predictable array of diseases. A good history and physical examination remain paramount in evaluation. Scrotal ultrasonography and testicular radionuclide scanning are important additions to our diagnostic armamentarium and should be used whenever possible. Unfortunately, the equipment and expertise needed to perform these useful examinations are not always readily available. If these tests cannot be done promptly and rapidly, treatment should be instituted without delay. Most lesions that cause an acute scrotum should be treated expeditiously, since careful treatment can greatly reduce patient discomfort, morbidity, and even mortality. Additionally, testicular salvage often depends on early and appropriate management.

Ulcer of the trigone: a late complication of cervical cerclage

Since the introduction of cervical cerclage for management of the incompetent cervix, few late complications of the procedure have been reported. We report a late complication of cervical cerclage manifested as a trigonal ulcer. Trigonal erosion by the knot of a mersilene ligature that had been placed around the cervix 22 years previously caused the ulcer. Endoscopic removal of the offending ligature allowed complete healing.

Risk factors for bladder cancer in a cohort exposed to aromatic amines

Occupational and nonoccupational risk factors for bladder cancer were analyzed in a cohort of 1385 workers with known exposure to a potent bladder carcinogen, beta-naphthylamine. Bladder cancer was approximately seven times (95% confidence interval [CI] = 3.9, 12.4) more likely in exposed rather than nonexposed individuals, yet, otherwise, the groups were generally similar in other exogenous or hereditary risk factors. A total of 13 cases of bladder cancer were identified. After the first year of a screening program involving 380 members of the cohort, 9 of the 13 cases of bladder cancer and 36 persons with atypical bladder cytology, histology, or pathology were compared with 335 noncases for distributions of different variables. Occupational variables were significant in a multivariate model that controlled for age, cigarette smoking history, and source of drinking water. The estimated odds ratio for the association for bladder cancer and the duration of employment, when controlling of these other variables, is 4.3 (95% CI = 1.8, 10.3). In addition to the occupational factors, age was significant in the multivariate analysis. Other potential risk factors, such as consumption of coffee or artificial sweeteners, use of phenacetin, or decreased use of vitamin A were not found to be significantly different in cases and noncases.

Risk assessment of a cohort exposed to aromatic amines. Initial results

A cohort of 1,385 workers potentially exposed to carcinogenic amines was evaluated to determine the extent of its risk for bladder cancer. The cumulative incidence of bladder cancer was determined from death certificates, from interviews with community urologists, and from a screening program. A total of 13 confirmed cases of bladder cancer were identified at the conclusion of the first year of study. The entire cohort has approximately a fourfold excess risk of bladder cancer; however, black workers with more than 10 years of employment had a risk ratio of 111 (based on three cases). The onset of disease occurred, on the average, 15 years earlier in these black workers than in the general U.S. population. The cumulative incidence of bladder cancer increased with the duration of employment, ranging from 0.4% for workers with five or fewer years of employment to 36% for those with greater than 20 years. No significant differences were found between cases and noncases for cigarette smoking, coffee drinking, use of artificial sweeteners, or prior employment in high-risk occupations. More cases of bladder cancer are expected in this cohort because many members have not yet achieved the average latency found for the confirmed cases.

Malacoplakia associated with vesicoureteral reflux and selective immunoglobulin A deficiency

A case of malacoplakia involving the lower urinary tract of a young black boy, with associated bilateral vesicoureteral reflux, hydronephrosis and selective immunoglobulin A deficiency is reported. Reflux was caused by the malacoplakia. Reflux and hydronephrosis persisted despite elimination of bacterial infection and malacoplakia by drug therapy. These abnormalities were corrected by a conventional antireflux operation. Malacoplakia appears to be related to immunologic incompetence and diminished levels of intracellular cyclic 3',5' guanine monophosphate. Cholinergic agonists reverse or prevent the pathological changes of malacoplakia.

Cryptorchism and approaches to its surgical management

About 1 in 200 boys has cryptorchism, and orchiopexy remains the cornerstone of therapy. Inguinal orchiopexy is adequate for the palpable or low-lying testicle. The midline preperitoneal approach is particularly good for the high testicle, and it permits simultaneous orchiopexy in most instances of bilateral cryptorchism. For the very high testicle, microsurgical autotransplantation offers hope for functional and anatomic salvage.

An unusual case of anterior urethral injury

We report an unusual case of straddle injury manifested by complete transection of the urethra without disruption of Buck's fascia and concomitant intussusception of the detached distal urethral segment through the external urinary meatus.

The surgical management of acute bacterial epididymitis with emphasis on epididymotomy

During the course of acute bacterial epididymitis of nonvenereal origin, severe epididymal inflammation and edema can produce compression of adjacent branches of the spermatic vessels, which can compromise the testicular vascular system. Scrotal fixation over the involved testicle heralds this event and indicates actual or impending epididymal suppuration. At this crucial moment either surgical decompression of the epididymis or epididymectomy is indicated to prevent ischemia of the testis and subsequent development of gangrenous epididymo-orchitis with testicular slough. Between 1956 and 1980, 14 epididymotomies were done, which resulted in salvage of 12 testicles (86 per cent). During the same period 10 patients with acute epididymitis had progression of the disease to gangrenous epididymo-orchitis, which necessitated orchiectomy. Epididymotomy can prevent progression of acute epididymitis to gangrenous epididymo-orchitis in many instances and is believed to have a role in the management of this troublesome affliction.

Ureteral splints: results of a survey

The results of a survey concerning ureteral splints are reported. Of the respondents 70 per cent preferred the term splint to stent. There was general agreement that a splint should be used in any complicated pyeloplasty as well as in any patient undergoing an operation on the ureter or ureteropelvic junction draining a solitary kidney. Additionally, use of a splint after repair of ureteral injuries by a general urologist was believed advisable. Splints are not absolutely necessary in uncomplicated pyeloplasties and in most simple ureteroneocystostomies. Most urologists use ureteral splints, and believe that they do little or no harm and rather consistently terminate in a good postoperative result.

Penile lesions: a generalist's guide

Penile lesions are a discomfiting affliction demanding skillful diagnosis and management by the primary care physician. This article discusses and illustrates 14 common types, delineating characteristics, course, and treatment.

Ureteropyelocalycostomy in the management of lower calyceal stone

Side-to-side ureteropyelocalycostomy in 10 patients with lower calyceal calculi uniformly achieved good postoperative kidney drainage and has not been associated with stone recurrence during an average followup of 35.4 months. Five patients have maintained sterile urine postoperatively. Postoperative renal deterioration has been apparent in only 1 patient and it is unrelated to the operative procedure. This approach to the management of a lower calyceal stone has permitted excellent visualization of the collecting system for lithotomy and it has resulted in minimal renal tissue loss. The procedure is particularly appropriate for the management of lower calyceal calculi in kidneys in which there is medial parenchymal thinning over the calyx and preservation of all functioning renal tissue in deemed wise.

The midline preperitoneal approach to orchiopexy

The midline preperitoneal approach has been used to facilitate delivery of 42 high undescended testicles into a suitable scrotal position. The gonads were situated preoperatively either within the abdomen (59.5%) or in a high inguinal position (40.5%). The technique described here has allowed marked lengthening of the spermatic cord and visibly shortened the distance between the spermatic vessel-great vessel juncture and the most dependent portion of the scrotum. It has virtually eliminated the necessity for staged orchiopexy in patients with heretofore difficult to manage cryptorchism. In this series an overall satisfactory anatomic result was achieved in 76.9 per cent of patients.

Angiolymphoid hyperplasia with eosinophilia: report of a case with penile lesions

A case of angiolymphoid hyperplasia with eosinophilia of the penis is reported. In addition to the proliferation of swollen endothelial cells with features of histiocytes ("histiocytoid endothelial cells"), the lesions also showed a remarkable proliferation of pericytes both in relation to formed vascular channels and away from them. The authors consider that the inflammatory component is associated with even the earliest stages in the development of the lesions and that it not be dismissed as secondary.

Subcutaneous estradiol pellet implantation in management of advanced prostatic carcinoma

Thirty patients with previously untreated Stage C and D carcinoma of the prostate were treated with subcutaneously implanted estradiol pellets in an effort to determine the efficacy of this mode of therapy in the control of advanced prostatic carcinoma. Serum levels of gonadotropins, testosterone, and estradiol were obtained prior to institution of therapy and at monthly intervals thereafter. Twenty-eight patients were followed for at least one year. Sixteen patients were hormonally castrate at six months following 1-pellet implantation. In these 16 patients the means serum testosterone level was 43.6 ng./dl. with a serum luteinizing hormone (LH) of 13.3 mlU/ml. and a serum estradiol of 19.2 ng./dl. Twenty-two patients were hormonally castrate at twelve months following 1 or more pellet implantations. In this group the mean serum testosterone level was 51.5 ng./dl. with a serum LH of 16.2 mlU/ml. and a serum estradiol of 22 ng./dl. Fifteen patients who were taking narcotics for pain relief either became pain free or had a marked decrease in need for analgesics. Increased weight improvement in over-all well-being was noted in 86 per cent of patients. pellet implantation intervals ranged from four to ten months, with a mean interval of 5.85 months between implantations. Complications attributable to this mode of therapy were no more apparent than with oral estrogens. In addition to better compliance, subcutaneously implanted estrogen pellets appear to provide a safe, reliable, and effective method of tumor control and palliation in advanced carcinoma of the prostate.

Treatment of postoperative ureteral stricture by catheter dilation: a forgotten procedure

Some postoperative ureteral strictures can be managed successfully by simple catheter dilations as shown in the cases presented herein. It appears that only one or two dilations may be necessary for prolonged resolution of the obstructive process. Internal ureteral splints may be used with equally good results. Operating intervention should be reserved for those cases in which either ureteral catheterization cannot be accomplished or dense fibrosis renders adequate long-term management by catheter dilation impossible.

Improving the supracostal loin incisions

After routine supracostal loin incisions the incised edge of the diaphragm may be sutured to the lateral pericostal tissues adjacent to the superior rib. This embellishment hides the pleura from view and protects it from intraoperative injury. Additionally, the procedure results in fixation of the incised edge of the diaphragm when the wound is closed.

Bladder hernias

Six cases of bladder herniation are reported: 4 were associated with inguinal hernias, and 2 were situated in the lower midabdomen. In 1 patient a gangrenous intrascrotal ruptured bladder was found. In most instances simple fascial closure after reduction of the herniation sufficed for treatment. Bladder involvement in any low abdominal wall hernia should be suspected since failure to do so may lead to postoperative complications.

The Denis-Browne hypospadias repair revisited

Sixty-four cases of hypospadias repair by the Denis-Browne technique are reviewed. A urethrocutaneous fistula was the most common postoperative complication. Other less frequent complications were urethral stricture, residual chordee and improper location of the urethral meatus. These complications were corrected adequately and the results were satisfactory in all patients. This technique is simple, sound and trustworthy.

A review of 117 partial nephrectomies

In this review of 117 consecutive partial nephrectomies calculi associated with infection was the most common indication for the operation. Other indications included congenital anomalies, trauma, arteriovenous malformations and tumor. Partial nephrectomy has been shown to be a relatively safe procedure, with a mortality rate of 1.7 per cent. However, considerable morbidity occurred when stone and/or infection persisted postoperatively. We herein emphasize that total intraoperative removal of calcareous debris, appropriate treatment of associated infection and avoidance of nephrostomy tubes are important to a successful postoperative result. Partial nephrectomy as a method to remove stones confined to or originating in a diseases calix appears unsurpassed.

Management of prolapsed ureterocele: past and present

A prolapsed ureterocele occurs more frequently in female subjects than in male subjects. At least 64 cases in female patients have been reported and an additional case in a 2-year-old girl is reported herein. Only 3 cases have been reported in male subjects. A method for management of a non-reducible ureterocele in female patients is outlined and discussed briefly.

Splinted vasovasostomy. Comparison of polyglycolic acid and polypropylene sutures

An experimental study was performed comparing 6-0 polypropylene and 6-0 polyglycolic acid sutures in vasovasostomy. An indwelling entirely intraluminal splint of PE-10 tubing was used which was surgically removed three weeks postoperatively. Three months after vasovasostomy patency was determined by vasography. Eighty-five per cent patency was achieved with polyglycolic acid compared with 58 per cent patency when polypropylene was used.

Pyrah technic for ileal conduit diversion: a 16-year experience

At our institution, 100 patients had ileal conduit diversion using the Pyrah technic between 1959 and 1975. The results of this technic compare favorably with those of other ileal conduit diversions, and it has the advantage of being somewhat shorter than the standard Bricker procedure. Sixty-seven were done because of benign lesions of the urinary tract and 33 were done as part of the planned treatment of various malignant conditions. We did 56 diversions in patients with neurogenic bladder dysfunction. There were 67 early and 69 late complications, and the complication rate was much higher in patients having preoperative irradiation. The most common complications were wound infections, pyelonephritis, ureteroileal anastomotic leaks or stricture, and stomal stenosis. The upper urinary tracts showed signs of progressive deterioration after diversion in 19% of patients. The operative mortality was 6%. The mortality was four times greater in the group with malignant conditions.

Vasovasostomy. Experimental comparative study of polyglycolic acid and polypropylene sutures in the dog

Experimental vasovasostomy in dogs using polyethylene tubing for splints and comparing polyglycolic acid to polypropylene sutures demonstrates the following: Polyglycolic acid sutures result in a higher vasovasostomy patency rate. Grossly and microscopically, polyglycolic acid sutures are associated with less vasal and perivasal fibrosis. Postoperative use of very small polyethylene tubing for splints appears feasible. Leaving splints entirely intraluminally at the time of surgery may be advantageous. It would necessitate vasotomy for removal of the splint postoperatively, but this is easily accomplished and not associated with increased morbidity. A transscrotal approach is associated with a much higher vasal patency rate than is an inguinal approach.

Semen cryopreservation: an update

Cryopreservation of semen has a place in reproductive medicine. It is done best using liquid nitrogen as the refrigerant and the pre-freeze semen should be of good quality. High quality spermatozoa survive the freezing-thawing process and ordinarily result in good babies. Abnormal sperm generally do not survive the freezing-thawing process, which, consequently, results in a more viable union and outcome from the germ cells. Cryopreservation of semen can be used to preserve semen before medical or surgical sterilization, to augment the sperm count in patients with certain types of oligospermia and to manage the childless couple by donor semen artificial insemination in those instances in which the husband is infertile. Cryopreserved semen produces babies and perhaps thousands of humans have been the result of conception that resulted from cryopreserved spermatozoa.

Embryologic considerations of diphallus and associated anomalies

Two patients, 1 adult and 1 infant, with complete duplication of the penis are described. The adult had a single bladder, a bifid scrotum, a low abdominal wall hernia, separation of the symphysis pubis, bilateral inguinal hernias, rectal prolapse, bilateral vesicoureteral reflux and bilateral staghorn calculi. The infant had duplication of the bladder, hypoplasia of the left kidney, lumbosacral anomalies, a hypoplastic left lower extremity, an imperforate anus, a infraumbilical wall hernia and separation of the symphysis pubis. A survey of the anomalies accompanying the 2 main types of diphallus (shaft and glans, and glans alone)showed that there was a preponderance of anomalies of posterior structures such as colon, bladder and spine in the shaft and glans diphallus, and a higher incidence of isolated exstrophy of the bladder in diphallus of the glans alone. The embryogenic implications of these findings are discussed.

Transvesical prostatic adenomectomy: a modification of Lower, Harris, and Hryntschak techniques

A review of 226 transvesical prostatic adenomectomies performed by a modification of Hryntschak's technique over a 13-year span is presented. The technique incorporates closure of the vesical neck with transverse sutures of 2-0 plain catgut around a plastic Foley catheter and primary closure of the cystotomy following routine adenoma enucleation. Hemostatic suturing of the posterior vesical neck before placement of the transverse vesical neck sutures is routinely omitted. The results have been uniformly good with low incidence of mortality and morbidity. The average operative blood loss was 761 ml and postoperative bleeding was minimal. This technique is safe, simple and requires an acceptable operating time.

The Pyrah technique for ileal loop diversion: experience with 100 cases

One hundred patients underwent ileal loop diversion using the Pyrah technique between 1959 and 1975. Sixty-seven were performed because of benign urinary tract lesions and 33 were performed as part of planned treatment of various malignant conditions. Neurogenic bladder dysfunction accounted for 56 of these diversions. There were 67 early and 69 late complications. Patients having preoperative irradiation therapy had a much higher incidence of complications. An alarming 19 per cent demonstrated progressive deterioration of the upper tracts following diversion. It is noteworthy that this rate of upper tract deterioration compares favorably with that reported in several other series. Early mortality was 6 per cent, and death occurred four times more often in patients with malignant conditions.

Neoplasia at the site of ureterosigmoidostomy

An increased incidence of neoplasia at the site of ureterosigmoidostomy must be considered in patients being evaluated for or who have undergone this procedure. A case of mucinous adenocarcinoma 24 years following bilateral ureterosigmoidostomy is reported. This patient had bilateral hydroureteronephrosis, which led to left nephroureterectomy and right cutaneous ureterostomy. Mucinous adenocarcinoma was diagnosed only after the edematous, protruding and inflamed cutaneous ureterostomy stoma was biopsied. To our knowledge this is the first reported case of transfer of such a malignancy to the skin at the time of cutaneous ureterostomy. We recommend that ureterosigmoidostomy be performed only in patients with a limited life expectancy who agree to long-term followup. This followup should be frequent, complete and continue for the remainder of the patient's life. We consider the tendency for development of neoplasia at the ureterosigmoid anastomosis to be a relative contraindication to ureterosigmoidostomy. However, with proper patient selection and followup, ureterosigmoidostomy is still a remarkably satisfactory method of urinary diversion.

Comparison of polypropylene and polyglycolic acid suture in experimental vasovasostomy

A preliminary study upon seven dogs comparing vasovasostomy using polypropylene suture to vasovasostomy using polyglycolic acid suture was carried out. Five of the seven vasa anastomosed with polyglycolic acid sutures were patent wherease none of the seven vasa anastomosed with polypropylene sutures were patent. There appeared to be less vasal inflammatory reaction where vasovasostomy had been accomplished with polyglycolic acid. This study indicates that further investigation comparing these and other suture materials in vasovasostomy is justified. It also suggests that improved results in vasovasostomy might be obtained by the use of polyglycolic acid suture.

Retroperitoneal fibrosis with intrinsic ureteral involvement

Two cases of idiopathic retroperitoneal fibrosis are discribed. In both cases intrinsic involvement of the ureteral muscularis was found, which is in contradistinction to the classical description of ureteral encasement or compression by the process without actual invasion. Surgical procedures, in addition to ureterolysis, may be required.