Biomedical subjects
Publications and source records attributed to G W Drach.
We report 4 cases of anastomotic stricture after radical retropubic prostatectomy caused by erosion of suture material used to ligate the dorsal vein complex. In 2 patients there was overlying stone formation. The clinical features of this complication, management options, and means of prevention are reviewed.
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Emphysematous cystitis is an uncommon condition in which pockets of gas are formed in and around the bladder wall by gas-forming organisms. Persons with diabetes, neurogenic bladder and chronic urinary infection are predisposed to the disease. Severity of illness ranges from an asymptomatic condition to life-threatening cystitis. We present 2 cases of emphysematous cystitis. One case was an incidental finding on evaluation of abdominal discomfort with resolution upon removal of predisposing factors. The other patient presented with an acute abdomen that progressed to severe necrotizing cystitis ultimately requiring cystectomy. The initial involvement of the urologist as a consultant is emphasized. A complete review of the literature describes the incidence, various presentations, associated diseases and organisms, pathogenesis, and available methods for diagnosis and treatment reported for this disease. Successful management depends on early diagnosis with correction of underlying causes, administration of appropriate antibiotics, establishment of adequate bladder drainage and surgical excision of involved tissue when required. Early detection and prompt treatment are encouraged.
The locations of extracorporeal shock wave treatment induced renal vascular injury and the sources of significant renal hemorrhage were determined in a rat model by means of two different vascular casting procedures. Silicone-rubber injected vascular preparations for light microscopy or corrosion casts for scanning electron microscopy were made following gross examination of the treated organs and their contralateral controls. After 1000 shock waves at 18 kV, five out of 20 treated kidneys appeared to be normal or minimally affected, while 15 showed gross evidence of marked vascular injury. Gross interstitial hemorrhage (15/20), subcapsular hematomas (7/20), and hemorrhages into the renal pelvis (5/20) were confirmed by extravasations of casting materials. These could be traced back to their vascular sources in several instances. Disruptions of interlobar and arcuate veins gave rise to most significant interstitial, subcapsular, and renal pelvic extravasations. On a microscopic scale cortical venules were among the most frequently injured vessels. The arterial vasculature was not spared. Arterial injury ranged from complete arcuate occlusion to small afferent arteriolar and glomerular capillary extravasations. The significance of shock wave induced vascular injury is discussed with respect to potential clinical side effects of ESWL.
We longitudinally followed serum prostate specific antigen (PSA) levels in 48 patients who were treated with either orchiectomy, monthly luteinizing hormone-releasing hormone injection or continuous diethylstilbestrol for stage D2 prostate adenocarcinoma and achieved an objective response. Of the patients 34 had clinical evidence of disease progression (median remission duration 19 months). Median length of followup for the 14 patients who remained in remission was 42 months. Pretreatment performance status, pretreatment extent of metastases as measured by a bone scan and post-treatment nadir PSA level were univariately correlated with remission duration. After adjustment for the 2 former pretreatment variables, a highly significant independent effect of the nadir PSA level on remission duration persisted. Patients whose post-treatment nadir PSA level decreased below 4 ng./ml. had a significantly longer remission duration than those whose nadir PSA remained elevated (median 42 versus 10 months, p less than 0.0001). No cases were observed to progress (as defined by our criteria independent of PSA level) while the serial post-treatment PSA levels continued to decrease or remained at a plateau after reaching the nadir. The time at which the PSA began to increase once the nadir was reached predated objective evidence of progression in all patients except 2 in whom the 2 events occurred simultaneously (mean lead time 7.3 +/- 5.0 months). We conclude that following serial PSA levels in patients treated with androgen ablation for metastatic prostate cancer can aid in distinguishing favorable from nonfavorable responders early in the course of therapy and greatly assist in monitoring for progression.
The acute scrotum generates a long list of differential diagnoses. An unusual etiology includes insect envenomation, which typically is an acute process with rapid onset of symptomatologies. Two patients with genital envenomation are reported. We review the reported cases at our institution with all types of bites and stings. Symptoms of pain and pruritus, and signs of ecchymosis and edema preceding exfoliating dermatitis were evident in both cases. Mild analgesics and antihistamines promoted resolution in each instance.
A rupture of a large, tense hydrocele is presented. The patient was chronically treated with steroids for asthma control. Scrotal ultrasound was used to document hydrocele presence, rupture and recurrence.
We report 2 cases of nephrolithiasis owing to hematin stones. One patient had no apparent explanation for this finding, while the other was receiving warfarin anticoagulation for a prosthetic aortic valve. The chemical nature, etiology and clinical features of hematin calculi are discussed.
Most publications citing the effectiveness of renal extracorporeal shock wave lithotripsy have used plain abdominal radiography to assess residual calculi after treatment. We compared radiologist sensitivity and specificity in the detection of calculi on plain abdominal radiographs versus conventional film-screen and digital renal tomograms in extracorporeal shock wave lithotripsy patients. Of the patients 50 were imaged before and within 24 hours after lithotripsy. Six radiologists evaluated the resultant 300 studies for the presence and location of calculi. The mean sensitivity for digital tomograms was 83% for pre-lithotripsy and post-lithotripsy studies, which was significantly higher than for plain abdominal radiography and conventional tomography after lithotripsy. However, there were significantly more false positive stone diagnoses associated with digital tomogram interpretation. Signal detection analysis verified the over-all superiority of digital tomography for post-extracorporeal shock wave lithotripsy imaging. Calculus detection by conventional and digital tomography is superior to detection by plain abdominal radiography. However, because we did not perform delayed imaging, it is not possible to say what impact digital tomography might have on the management of extracorporeal shock wave lithotripsy patients.
Patients with cardiac pacemakers currently are treated by extracorporeal shock wave lithotripsy only by agreement between individual physicians and patients. We present the results of a survey of patterns of extracorporeal shock wave lithotripsy treatment (or nontreatment) of patients with pacemakers in the United States and Europe. Letters of inquiry regarding treatment of pacemaker patients were sent to 141 United States extracorporeal shock wave lithotripsy sites and 55 sites in Europe. Responses were received from 81 (57%) and 17 (31%) sites, respectively. A total of 131 patients received 142 treatments and pacemaker-related complications occurred in 4 (none was lethal, 3 were minor and all were corrected immediately). No patient required replacement of the pacemaker. No correlation existed between complications and pacemaker type or manufacturer. Urologists who treat patients with a pacemaker required previous clearance of the patients by the cardiologist, a cardiologist in or near the extracorporeal shock wave lithotripsy suite and standby of corrective equipment or temporary pacemakers.
Concerns about the safety of extracorporeal shock wave lithotripsy include the risk of vascular damage and the genesis of hypertension. We evaluated gross specimens and barium microangiograms of the right kidneys of 14 rabbits exposed to shock waves; the untreated left kidneys served as controls. Six rabbits were assessed immediately after shock wave treatment, whereas the other eight rabbits had the same procedure 3 months later. All six acute phase animals showed microangiographic changes indicative of shock wave trauma, including cortical, subcapsular, and medullary extravasation of barium and patchy loss of efferent vessels. No significant vascular abnormalities were seen in the control kidneys. All kidneys treated from the animals that had delayed microangiography showed macroscopic evidence of fibrotic capsular thickening and parenchymal scarring. Microscopically, there was crowding of glomeruli and areas of avascularity. In this model, shock waves damaged the cortical circulation and resulted in persistent alterations of the microvasculature that potentially could be responsible for the abnormal secretion of renin.
Previous investigators reported that accurate estimation of average or maximum urinary flow rates required correlation with total bladder volume (voided plus residual volumes). To test this requirement we performed uroflowmetry studies on 124 patients before and 77 patients after prostatectomy. Of the patients 20 were tested on multiple preoperative and postoperative occasions to comprise paired observations. Observations were made on age, voided and residual volumes, voiding duration, and average, maximum and adjusted maximum flow rates. Prostatectomy resulted in significant increases in all flow rates and significant decreases in voiding duration. The procedure had significant effects on reducing residual volume but voided volumes increased and total volume decreased only slightly postoperatively. Preoperative average, maximum and adjusted peak urinary flow rates correlated negatively with residual volume (increasing residual volume correlates with decreasing flow rate). Maximum flow rates correlated positively with voided volume. Whether measured preoperatively or postoperatively no significant correlation was found among average, peak or adjusted flow rates and total bladder volume. The only consistent significant correlation found among voided, residual and total volumes, and other measurements was voiding duration, which increased as any of the aforementioned volumes increased. Comparison of the random total and paired populations revealed no significant difference. Use of voided rather than total volume seems preferred in correlations with maximum urinary flow rates. Determination of residual urine remains necessary as an estimation of emptying failure but it is not required information for determination of flow rates.
Bacterial isolates from expressed prostatic secretions were tested in vitro for susceptibility to five antimicrobial agents used in the treatment of prostatitis. Comparisons of susceptibility and resistance were made between minocycline and each of the other four agents: tetracycline, cephalexin, ampicillin, and trimethoprim-sulfamethoxazole. A high percentage of the isolates from patients with prostatitis which were resistant to tetracycline and trimethoprimsulfamethoxazole were susceptible to minocycline.
We performed 126 studies of replicate voiding in 7 individuals and 552 observations in normal, abnormal or treated male populations with a disposable device that measures peak flow and volume voided. These observations have led us to suggest that a voided volume of 150 ml. be used as the minimum acceptable volume for studies of male subjects in which peak flow is used to define normal versus abnormal voiding. At volumes greater than 150 ml. a straight line describes the relationship between volume voided and peak flow as accurately as the previously suggested hyperbolic curve. Increasing age of men again reveals progressive decrease in peak flow rate no matter what volume is voided. Comparison of peak flow rate, volume voided and age by 3-dimensional graphing was attempted but was found unsuccessful for clinical use. However, 3 biaxial linear graphs may be used to chart effectively the 3 parameters (age, volume and peak flow) and thereby judge normality or abnormality of peak flow rate for any age and volume voided.
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Of 265 patients with gynecologic carcinoma undergoing initial evaluation during a 5-year period 238 were staged prospectively with procedures that included cystoscopy. Endometrial carcinoma was noted in 98 patients, none of whom had evidence of bladder extension nor did the clinical stage of disease change after cystoscopy. Of 120 patients with carcinoma of the cervix 7 were found to have extension of tumor to the bladder. The clinical stage was elevated in 3 of these cases but remained unchanged in 4 because of the cytoscopic findings. Of all 238 patients with gynecologic carcinoma 3 (1 per cent) also were found to have unsuspected low grade transitional cell carcinoma of the bladder.
Eighty patients with proved calcium urolithiasis participated in an outpatient study designed to define the most likely metabolic problem related to the cause of the stone disease. Diagnostic categories included absorptive hypercalciuria (33 patients), renal leak hypercalciuria (20 patients), hypomagnesiumuria (27 patients), hyperuricemia and hyperuricuria (16 patients), hyperoxaluria (15 patients), normal stone-former (4 patients), renal tubular acidosis (2 patients) and suspicion of hyperparathyroidism (7 patients). Of the 80 patients 40 had more than 1 defect. Patients with a high suspicion of hyperparathyroidism were excluded from the study. Based on these criteria treatment plans incorporating medications, diet or both were instituted. Of 21 patients observed for greater than 2 years 90 per cent have shown no new stone disease.
In a series of 162 cases of surgically resected hyperplastic prostates the incidence of inflammation is 98.1%. Six morphologic patterns of inflammation are described: 1) segregated glandular inflammation, 2) periglandular inflammation, 3) diffuse stromal inflammation, 4) isolated stromal lymphoid nodules, 5) acute necrotizing inflammation and 6) focal granulomatous inflammation. The most common pattern, segregated glandular inflammation, is characterized by intraluminal neutrophils and foamy macrophages and by chronic inflammatory cells in the surrounding stroma. No significant morphological differences are found among groups of cases with positive and negative evidence by culture of bacterial prostatic infection. Quantitative but not qualitative morphologic differences are found between cases of gram-negative infections and infection by gram-positive organisms that often are considered non-pathogens.