Biomedical subjects
Publications and source records attributed to L Giuliani.
Acute hyperparathyroidism occurs infrequently and sometimes represents a diagnostic problem in urological patients. We report a case of acute hyperparathyroidism successfully treated by total parathyroidectomy and parathyroid autotransplantation.
Priapism can be successfully treated by unilateral or bilateral percutaneous transcatheter occlusion of the internal pudendal arteries. Occlusion should be reversible in order to avoid impotence. Embolization with autologous clot satisfies this requirement because of the clot lysis and consequent vessel recanalization. Three cases are extensively described which demonstrate the feasibility of the method and the ability to preserve sexual potency. The rationale for using interventional angiography in priapism is also discussed.
Radical nephrectomy with extensive lymphadenectomy was performed by the same surgeon on 104 consecutive patients with renal cell carcinoma. No significant differences in over-all survival owing to age, sex and preoperative embolization were noted. Only extension of the disease proved to be important as a prognostic factor. In the light of the statistical analysis of this variable the prognosis for patients with renal cell carcinoma has been classified as 1) good--patients with tumors confined to the kidney, 2) intermediate--patients with perirenal fat involvement, lymph node metastases and venous extension, and 3) poor--patients with distant metastases.
Abdominal testes represent 15 to 25% of all cases of cryptorchidism. In 5% the testis is so high in the abdomen that it is impossible to perform a conventional orchidopexy. The authors report an experience of 5 cases of testicular autotransplantation achieved by temporarily severing the testicular vessels and then reanastomosing them to the inferior epigastric vessels using a microsurgical technique with an operating microscope at 25 times magnification. Compared to traditional methods, autotransplantation permits an easy replacement of an ectopic testis into the scrotum and a more physiological blood supply to the testis. The authors discuss surgical and microsurgical techniques, testicular ischemia time and follow-up of patients who have undergone autotransplantation.
Six cases of renal bleeding which were successfully treated by transcatheter embolization with autologous clot are described and illustrated. The problems of clot lysis and consequent vessel recanalization are discussed both from an experimental and clinical point of view. It is concluded that clot embolization is suitable treatment for renal bleeding and, in selected cases, is preferable to open surgery.
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Cytogenetic analysis of resected bladder tumors was performed in 32 patients. None of these patients had previous irradiation or chemotherapy. Direct chromosome preparations were made. Of the 32 preparations, 22 had chromosome abnormalities. We have observed a good correlation between the chromosome abnormalities and the Stage/Grade of the tumors. Patients were followed from 6 to 33 months. During this period, 82% of the patients with noninvasive or submucosal invasive bladder tumors and chromosome abnormalities have had recurrences. The existence of a good correlation between chromosomal abnormalities and the capacity of the neoplasm to recur was confirmed.
The author reports a homogeneous personal series of 76 cervical operations for hyperparathyroidism: 66 primary in patients with lithiasis and 10 tertiary in patients with chronic renal failure. There were 56 single adenomas, one double adenoma and 19 cases of diffuse hyperplasia treated in the majority of cases by total parathyroidectomy followed by microsurgical auto-transplant of parathyroid to the forearm. No damage to the recurrent laryngeal nerve. The author saw no secondary hypoparathyroidism and only one case of persistent hyperparathyroidism in a patient with chronic renal failure and on dialysis, and one recurrence of lithiasis. In general, removal of the parathyroids preceded surgery for lithiasis except where there was obstruction of the urinary tract. In 6 cases, treatment of hyperparathyroidism and of lithiasis was simultaneous at the same operation without complications. It is of interest to note the rarity of staghorn calculi in patients with hyperparathyroidism which makes simultaneous operation possible. From a technical standpoint, routine identification of the recurrent laryngeal nerves ensures that they will remain undamaged. The author recommends routine dissection of all 4 parathyroids, and removal of the one or possibly two large glands when the others perfectly identified are normal. The discovery of 3 or, even more so, 4 enlarged parathyroids implies a diagnosis of hyperplasia. Management should then consist of total parathyroidectomy of the 4 glands followed by auto-transplant of small fragments of one half-gland to the forearm. Surveillance of parathormone levels in the arm veins will provide subsequent information as to the function of the transplant.(ABSTRACT TRUNCATED AT 250 WORDS)
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Clot embolization through percutaneous transcatheter technique has proved to be a highly effective and reliable method for stopping bleeding from renal or pelvic areas. The recanalization of the embolized vessels is constant and the recovery of the renal function quite satisfactory. In case of priapism temporary embolization may be very useful in selected cases.
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PTH radioimmunoassay today represents an unreplaceable tool in the diagnosis of primary hyperparathyroidism. However, the diagnostic importance of its dosage on selective venous samples is still discussed. Herein, we report our experience of 47 patients operated on for primary hyperparathyroidism. The catheterization of neck veins was performed according to Doppman and co-workers. The PTH assay was carried out with COOH- and NH2-specific antisera. (In 5 cases an inhibition test with CaCl2 infusion was practiced during selective catheterization to preoperatively discriminate between adenoma and hyperplasia.) In 8 cases loading tests with EDTA and in 6 cases with CaCl2 were also performed in association with peripheral venous sampling, in an attempt to improve its sensibility. The 47 cases operated upon showed the following results: the peripheral PTH values were significantly raised in 60% of the cases; the selective PTH dosage with COOH-specific antiserum showed a parathyroid hyperfunction in 100% of the surgically confirmed cases, whereas with the NH2-specific antiserum an increased PTH rate was found only in 84%. A right preoperative localization was obtained in 73%. The value of loading tests is more difficult to evaluate and is discussed in detail.
The precision of PTH measurement and the location of the implant allow the functioning of the transplanted tissue to be easily checked by separately measuring the PTH concentration in the arm bearing the transplant in comparison with the other side. In 10 of the 13 patients operated on by us it was observed that the transplant had grown and was functioning satisfactorily. In 2 further patients, in whom the PTH concentration alone gave no clear information on the functioning of the transplanted tissue, the tolerance test was for this purpose decisive. In fact the transplanted parathyroid tissue showed a rapid and clear response to pharmacodynamic stimulus, which demonstrated the viability of the transplant. We therefore venture to say that pharmacodynamic investigation is of a certain use in postoperative examinations of these patients, especially in doubtful cases. Unfortunately we have had no opportunity to perform a histological investigation of the implanted endocrine tissue, but this has already been reported on in print.
Personal experience in the surgical management of 15 cases of renal adenocarcinoma with neoplastic thrombosis of the vena cava inferior is described, and an account is given of the procedures adopted in accordance with the degree of endocavitary extension of the tumour. Emphasis is also placed on the need to ensure, as in all cases of nephrectomy for tumours, "neoplastic asepsis" by means of a preliminary vascular stage with the compartment intact. For this purpose, it is felt that sufficient preoperative angiographic evaluation of the intracavitary tumour is essential, coupled with absolute intraoperative control of the vena cava and/or right atrium proximally to the thrombus, to prevent the intraoperative mobilisation of neoplastic embolisms.
In recent years preoperative transcatheter embolization has been used widely in the management of kidney tumors. However, the effective clinical usefulness of this method has not yet been proved. Forty cases of kidney tumors treated by preoperative embolization and radical nephrectomy are reviewed and compared with a homogeneous group of patients who did not undergo preoperative embolization. Intraoperative blood loss, postoperative complication, and survival rate were statistically evaluated according to tumor stage. Advantages and disadvantages of preoperative transcatheter embolization of kidney tumors are reviewed.
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