Biomedical subjects
Publications and source records attributed to B Lytton.
A 16-year-old rhesus monkey with perineal swelling and urinary obstruction was found to have a congenital urinary bladder diverticulum. Because the diverticulum was located at the trigone, its distention partially obstructed the urethra, resulting in incomplete voiding. The diverticulum was resected and did not redevelop.
The collective published experience with continent urinary diversions, together with our own, indicates that there are certain basic principles with regard to continence, which is dependent on: (1) the pressure generated by the reservoir; (2) the outflow resistance of the outlet; and (3) detubularization, which is crucial to diminish the uninhibited involuntary bowel contractions. Detubularized ileal pouches provide the lowest pressures (less than 20 cm H2O). Although the majority of patients (approximately 85%) who have a low-pressure ileal neobladder are completely continent, a few experience persistent nocturnal incontinence as a result of low resting urethral pressure. Numerous continence methods have been described, each with its own unique set of problems. The most physiologic continence mechanism is the external urethral sphincter in men. It is clear that total continence with this mechanism is not assured. Other factors such as reservoir contractions, overflow incontinence, decreased sphincter tone, and loss of the normal vesicourethral reflex play an important role in nocturnal incontinence. However, understanding these contributing elements will allow us to refine the construction of a continent physiologic bladder substitute.
A high incidence of nocturnal incontinence has been a problem in patients undergoing continent urinary diversion when intact bowel segments are used. Detubularization has been advocated to solve this problem. Fifteen patients underwent continent urinary diversions and 4 underwent bladder augmentation with a variety of intestinal segments. Detubularization of the right colon anastomosed to the urethra was used in the first 3 patients, all of whom experienced nocturnal incontinence. Urodynamic studies showed high pressure contractions of the intestinal pouch of 60 to 100 cm. water pressure after the pouch was filled with 50 to 150 cc fluid. Incorporation of an ileal patch into the detubularized segment of colon was effective in reducing these pressures to 15 to 60 cm. water. This method reduced but did not eliminate the incidence of nocturnal incontinence. It is suggested that other factors may account for this problem.
Continent urinary diversion is a major advance in the treatment of selected patients following cystectomy. Twenty-eight patients have undergone some form of continent urinary diversion at Yale New Haven Hospital during the past three years; thirteen have a continent reservoir with a continent stoma on the abdominal wall, and empty the urine by self-intermittent catheterization, and 15 have a reservoir anastomosed to the urethra, the majority of whom void spontaneously. All are continent by day and over 50% are continent at night. A recent modification in the construction of the urinary reservoir would appear to have resolved the problem of nocturnal incontinence. The results and urodynamic studies in this group of patients are discussed, and it is concluded that a detubularized intestinal reservoir provides a safe and effective method for continent urinary diversion in selected patients following cystectomy.
Intravesical lithotripsy using electrohydraulic probe appears to be a rapid and safe technique to treat ureteral stones that are too large for intact extraction and inaccessible to ESWL. Strict adherence to the guidelines that have been discussed must be maintained to assure its safety.
Percutaneous nephrolithotripsy is reported to have few complications. However, we have treated 6 cases of complete ureteropelvic junction obstruction that occurred at a number of centers after percutaneous nephrolithotripsy. In 2 patients stones were impacted at the ureteropelvic junction, 3 had pre-existing stenosis and 1 had had no previous structural abnormality. All stones were less than 2 cm. in size and 5 were removed by ultrasonic disintegration. A nephrostogram after percutaneous nephrolithotripsy showed complete ureteropelvic junction obstruction in 4 cases and partial obstruction that progressed to total obstruction in 6 days in 1. In 1 case the nephrostogram was normal but occlusion was noted 2 weeks later. Initial management consisted of nephrostomy drainage for an average of 3.2 months. One patient was treated successfully with a ureteral stent for 6 weeks after balloon dilation, 1 had unsuccessful balloon dilation and 1 had undergone an unsuccessful endoscopic pyelolysis. Pyeloplasty was successful in 3 cases. In 1 patient 2 attempts at pyeloplasty failed and nephrectomy was performed. In the remaining patient ureterocalycostomy failed and interposition of a small segment of ileum was done. Pre-existing stenosis of the ureteropelvic junction or a stone impacted at the junction probably contributed to the obstruction and stenosis in 5 patients. The passage of ureteral guide wires should be avoided in these patients and impacted stones should be dislodged before endoscopic removal. Extracorporeal shock wave lithotripsy is an option in these cases if the stone can be dislodged or bypassed with a stent. Patients with pre-existing ureteropelvic junction obstruction might be treated best by open nephrolithotomy and pyeloplasty or by percutaneous nephrolithotripsy and endoscopic pyelolysis for ureteropelvic junction narrowing.
Use of the rigid ureterorenoscope has become widely accepted for the diagnosis of ureteral lesions, and for the removal and disintegration of ureteral calculi. Few complications have been reported. During the last 3 years 128 ureteroscopic procedures were performed for a variety of indications (98 for stone disease). There were 26 complications: 22 minor with no morbidity and 4 major that required surgical correction. Minor complications consisted of asymptomatic ureteral perforations in 6 patients, perforations with urinary extravasation, pain, ileus or fever in 4, migration of the stone into the kidney in 10 and migration of the stone outside the ureter with the calculus left in situ in 2. Major complications included ureteral perforation during basket extraction of an upper ureteral stone, urinoma following perforation and requiring drainage, stenosis of the intramural ureter that was corrected by marsupialization and aseptic necrosis of the ureter that was treated by ileal replacement.
Acute adrenal insufficiency postoperatively is an uncommon problem and, if unrecognized, it may cause serious morbidity and can be fatal. It can occur as the result of acute bilateral adrenal hemorrhage associated with anticoagulation, inadvertent injury to or removal of a solitary adrenal gland, or postoperative stress in an individual with incipient adrenal insufficiency. Its manifestations, such as fever, tachycardia, hypotension, lethargy, abdominal pain and gastrointestinal dysfunction, mimic the other more common postoperative complications and compound the difficulty in establishing the correct diagnosis. Once the diagnosis is made the condition is readily managed successfully. We report 3 cases of acute adrenal insufficiency occurring after salvage cystectomy, ileal replacement of the ureter and retropubic prostatectomy, which illustrate the salient clinical features, problems in diagnosis and predisposing risk factors. All 3 patients survived once the diagnosis of adrenal insufficiency was made. These cases emphasize the need to be aware of the possibility of this complication to make the correct diagnosis and to institute proper treatment.
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Endoscopic suspension of the vesical neck has been reported to be as effective as anterior urethropexy in the treatment of female stress urinary incontinence. We compared our first 29 patients treated with endoscopic suspension of the vesical neck between 1982 and 1985 to our last 21 patients treated with anterior urethropexy between 1979 and 1985. Both groups were comparable in regard to age, parity, duration of symptoms and previous surgery for stress urinary incontinence. All patients underwent thorough preoperative urodynamic testing. Endoscopic suspension of the vesical neck successfully cured stress urinary incontinence in 26 patients (90 per cent), while anterior urethropexy resolved the incontinence in 20 (95 per cent). Of the 3 failures of endoscopic suspension 2 probably were related to technique or material failure. Hospitalization was reduced for endoscopic suspension versus anterior urethropexy (mean 4.04 versus 6.00 days, respectively). The most common complication after endoscopic suspension of the vesical neck was transient urinary retention (34 per cent). We conclude that endoscopic suspension of the vesical neck is an effective method to treat stress urinary incontinence, and that it also reduces hospital stay and postoperative recovery.
Survival following the diagnosis of renal adenocarcinoma in a group of young adults, twenty to forty years of age, was distinctly better than that found in adults over age forty. This disparity could not be accounted for by a larger proportion of younger patients with early stage disease, nor by a greater percentage of non-cancer deaths in the older group. Perhaps a more favorable host-tumor immunologic balance is present in younger individuals.
A case of endodermal sinus tumor of the infant vagina is reported with long-term survival after successful therapy by surgery, chemotherapy, and radiation. The previous 26 reported cases are reviewed and the problems of therapy and long-term management are discussed. Therapy of these tumors should be monitored by alpha-fetoprotein radioimmunoassay.
Rigid ureteroscopy is now an established technique for the management of ureteral stones. Manipulation of calculi can be done under direct vision using flexible forceps or stone baskets with increased safety and efficacy. We also have used a 5F electrohydraulic lithotripsy electrode to disintegrate stones that were too large to be removed by manipulation. Between October 1982 and January 1984, 36 ureteroscopies were performed for the removal of ureteral stones. In 26 cases (72 per cent) the stone was removed successfully. Electrohydraulic lithotripsy was used successfully to remove the stone in 9 cases (24 per cent) and there were no immediate complications. Followup with excretory urography in 7 of these patients 2 to 18 months after lithotripsy failed to reveal any evidence of long-term complications. We conclude that electrohydraulic lithotripsy under direct vision can be done safely if certain guidelines are adhered to strictly.
Records of 132 patients undergoing ileal or colonic conduit urinary diversion were reviewed. Drains were placed retroperitoneally in all cases. Urinary leakage occurred most frequently in patients with malignancies and was associated with previous pelvic irradiation or simultaneous cystectomy. Most leaks closed spontaneously with non-operative management.
We have treated 77 patients for clinically early stage carcinoma of the prostate, 9 stage A2, 63 stage B and 5 stage C, with direct implantation of 125I seeds into the prostate and pelvic lymphadenectomy. It is estimated that a minimum dose of 15,000 rad but a maximum dose of 35,000 rad is delivered to the prostate over several months. Of the 77 patients 14 (18 per cent) had metastatic disease in the pelvic lymph nodes. In 22 cases perineal needle biopsy was done 12 to 18 months after treatment and in 3 cases a second biopsy was performed after 2 to 3 years. Persistent tumor was present in 11 biopsies. Cytological changes were observed in 8 of these, primarily cytoplasmic vacuolation and nuclear pyknosis. There seemed to be no relationship between grade and stage of disease and histological evidence of persistence of tumor after radiation. One patient with persistent tumor in the postoperative biopsy has shown progression of disease after 2 years and another with a negative biopsy has a bony metastasis. The remaining 10 patients with persistent tumor have shown no sign of progression of disease during a 2 to 4-year interval.
Recent experience with 7 patients, as well as a review of the literature, indicates that partial nephrectomy provides satisfactory treatment of solitary and bilateral renal adenocarcinomas. Patient survival seems to be dependent on the adequacy of tumor resection and not on the fate of the contralateral kidney. Total nephrectomy, dialysis and subsequent transplantation are viable alternatives when it is technically not possible to preserve adequate renal parenchyma.
Selective gonadal venography was used on 28 patients with a total of 34 non-palpable undescended testes. The data obtained in this study suggest that 1) an internal spermatic vein with a pampiniform-like plexus indicates the presence of a testis, 2) a blind-ending vein on venography suggests the absence of a testis, 3) an internal spermatic vein or vas deferens may be present without a testis, 4) a testis probably cannot be present without a gonadal vein, 5) a testis may be present without a vas, 6) a blind-ending vas deferens does not necessarily indicate the absence of a testis and 7) a blind-ending vas deferens in a patient in whom a blind-ending gonadal vein is localized to the same region probably indicates the absence of a testis. Gonadal venography may localize a non-palpable undescended testis or suggest testicular agenesis. In addition, gonadal venography has aided in the selection of the operative approach and, in the future, may provide criteria under specific circumstances for determining whether an operation is necessary and, if so, the extent of surgical exploration.