Biomedical subjects
Publications and source records attributed to P Jonas.
Fistulas of the ureter are uncommon and are usually secondary to trauma or iatrogenic in nature. Spontaneous rupture of the ureter is rare, usually ending in a periureteral abscess. Two cases of spontaneous rupture of the ureter secondary to calculous disease resulting in ureterocutaneous fistulas are described.
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Echinococcal involvement of the urinary tract is extremely rare. We present 11 such cases, 10 with renal and 1 with bladder involvement. Clinical and laboratory findings were nonspecific. Calcification was present in all but 1 case. The excretory urogram and retrograde pyelogram demonstrated parenchymal soft-tissue masses causing pressure on and dilatation of the collecting system. Angiography in 3 cases showed the masses to be avascular. The ultrasound findings of a multicystic lesion with mixed echogenicity were typical of echinococcal cysts, while a CT scan in 1 patient showed a cyst with densely calcified border. The combined findings of these different modalities aid greatly in establishing the correct diagnosis.
Leukoplakia of the bladder is widely accepted as a precancerous lesion. We describe a patient in whom squamous cell carcinoma presented as an enterourethral fistula 10 years after cystectomy for leukoplakia of the bladder. During cystectomy we left most of the prostate and posterior urethra intact to preserve potency. In view of this case we recommend that in patients with bladder leukoplakia in whom ablative surgery is being contemplated a complete cystoprostatectomy be performed and a urethrectomy be considered seriously.
Solcoderm, a new topical agent, was used in the treatment of genital and anal cutaneous condylomata in 11 patients. This is a relatively inexpensive form of treatment, which may be used in any office practice setting with no need for anesthesia and very few side effects. The success rate of 100% warrants its further use in the treatment of this disease entity.
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Acquired obstructions of the lower urinary tract in children are uncommon. They can be divided into intrinsic and extrinsic lesions, and have a very varied etiology. Several illustrative cases are reported, such as traumatic and infectious strictures, meatal stenosis, benign and malignant tumors, fused labia, and epidermolysis bullosa. Many of these lesions have distinct radiographical features, best demonstrated by micturating cystourethrograms.
Eighty-one patients with proved preoperative sterile urine and undergoing transurethral resection of the prostate were studied. The patients were divided into 3 groups: group A received sulfamethoxazole-trimethoprim (ST) preoperatively and postoperatively for ten days; group B received ST in 2 divided doses, one pre- and one postoperatively; group C received no prophylaxis. In groups A and B, we found urinary infection in 3.8 per cent of patients compared with 32 per cent in group C. Performing prostatic chip cultures, we found that most urinary infections were unrelated to a prostatic source. When the prostate was infected, 75 per cent had infected urine postoperatively. We believe that prophylactic antimicrobial treatment should be given to all patients undergoing transurethral prostatectomy. However, it seems that immediate perioperative treatment suffices.
The records of 105 patients who had undergone unilateral reimplantation for ipsilateral reflux were reviewed. Patient age, grade of preoperative reflux, completely duplicated collecting systems, preoperative findings of contralateral dilatation of the lower ureter or radiographic evidence of pyelonephritis had no predictive value in regard to the appearance of postoperative contralateral reflux. Of the 105 patients 16 had postoperative contralateral reflux: neurogenic problems were found later in 3, reflux resolved spontaneously within 18 months postoperatively in 9, 1 remains in followup and 3 have undergone repeat operations, for a rectified rate of treatment failure of 3 of 102 (2.9 per cent).
The incidence of urinary infection and its source after transurethral resection of bladder tumors were investigated. Patients undergoing transurethral prostatectomy constituted the control group. All patients had proved preoperative sterile urine and did not receive any antimicrobial treatment. The incidence of urinary infection following transurethral resection of bladder tumors was 19.4 per cent, with an incidence of positive tumor chip cultures of 3.2 per cent. The incidence of urinary infection after transurethral prostatectomy was 32 per cent, with an incidence of positive prostate chip cultures of 8 per cent. We concluded that the source of urinary infection following transurethral resection of bladder tumors and transurethral prostatectomy in most cases is not from within the tissue but rather from perioperative manipulations.
The major long-term morbidity following retroperitoneal lymph node dissection is sterility resulting from sacrifice of the thoracolumbar chain or the hypogastric plexus during dissection of the iliac vessels at the bifurcation. Seven males who were devoid of sperm emission and ejaculation as a result of this kind of operation for testicular cancer were treated with imipramine 25 mg t.i.d. In 2 of the patients, antegrade ejaculation appeared during treatment with this drug. We feel that this success rate of 2 out of 7 calls for further studies, as the problem of these young men was considered hopeless until recently.
We evaluated 16 children with ectopic ureterocele diagnosed and treated between 1970 and 1980. The clinical presentation, radiological findings and operative management are presented and discussed. Since ectopic ureterocele has a broad spectrum of presentation and pathophysiology, treatment must be individualized. Upper pole heminephrectomy with partial ureterectomy, thus avoiding ligation of the ureteral stump, is the preferred surgical treatment. Transurethral uncapping of the ureterocele is indicated only for extremely ill infants with severe septicemia that does not respond to conservative treatment. Unsuspected ectopic ureterocele discovered incidentally during surgery is best managed either by upper pole nephro-ureterectomy or reimplantation of both ureters in their common sheath.
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Hypospadias in a congenital anomaly which in most cases has to be corrected surgically. We include micturition cystourethrography (MCU) in the preoperative workup of all these children as well as three months postoperatively. Meatal stenosis and müllerian duct remnants are known to occur in this condition, but vesicoureteral reflux (VUR) was an unexpected finding in many boys who were asymptomatic and had no evidence of urinary tract infection. Fifty-eight of 305 hypospadiacs, examined by MCU, proved to have reflux, most of them grade II. In 37, VUR was found before surgery and in the remaining 21 after surgical correction, many of them with meatal stenosis. In 10 patients reflux appeared in the postoperative period where there had been none in the preoperative study; 8 of the 10 had a postoperative stricture of the distal urethra, and VUR subsided in 4 after adequate dilatation. We conclude that vesicoureteral reflux is not uncommonly found in patients with hypospadias, even in those who are completely asymptomatic. We believe this is an additional incentive to include an MCU in the pre- and postoperative evaluation of patients with this anomaly.
A total of 10 patients with factor XI deficiency underwent prostatectomy: 3 who underwent suprapubic prostatectomy and 3 who underwent transurethral resection received fresh frozen plasma preoperatively, while 4 received fresh frozen plasma only in response to bleeding. We conclude that all patients who present with partial or severe factor XI deficiency should receive fresh frozen plasma preoperatively and for at least 10 to 14 days postoperatively. We believe that all Ashkenazi Jews who are about to undergo a urological operation should be screened for factor XI deficiency even when a history of a bleeding tendency is not present.
We report 2 patients who were operated on for hypospadias in whom severe dysuria developed several weeks after the removal of a Foley catheter, which had been in place for two and eight days, respectively. Distal urethral narrowing was diagnosed by endoscopy and by micturating cystourethrography. Since we believe the urethral stricture was caused by the indwelling catheter, we now use cystotomy for urinary diversion in all patients operated on for hypospadias.
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