Biomedical subjects

R Bihrle

Publications and source records attributed to R Bihrle.

At least 37 records · Page 2Linked to original sources

PubMed1996

Amebiasis of the penis.

Penile amebiasis is rarely a recognized entity because the penis is not the usual site of presentation for amebiasis. Homosexual men have a higher risk of acquiring the lesion. Amebic ulcers resemble cutaneous lesions arising from squamous cell carcinoma, chancroid, primary syphilis, granuloma inguinale, and many other causes. An amebic ulcer should be suspected in a patient with balanoposthitis that resists antibiotic therapy. Biopsy is fundamental to isolate the trophozoites to confirm the diagnosis. Metronidazole and hydrochloric emetine are still the treatment of choice. This diagnosis should especially be considered in cases of lesions detected in patients who practice anogenital sex or who are immunocompromised.

Adolescent↗

PubMed1996

Genital Fournier's gangrene: experience with 38 patients.

OBJECTIVES: Fournier's gangrene (FG) is an extensive fulminant infection of the genitals, perineum, or the abdominal wall. We report our experience with the management of this difficult infectious disease. METHODS: Thirty-eight patients were admitted with the diagnosis of FG between May 1993 and May 1995. All patients were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and application of unprocessed honey dressings. Patients then underwent split-thickness skin grafts or delayed closure as needed. RESULTS: Patient ages ranged between 33 and 86 years (mean, 54) with a mean hospital stay of 17 days (range, 1 to 45). Sixty-six percent of the patients were diabetic, 16% had previous orchiepididymitis, and 5% had scrotal and urethral trauma. All the patients underwent surgical debridement and application of unprocessed honey to the wound. Cystostomy was performed in 60% of the patients and 21% underwent orchiectomy of the affected side. Free skin grafts were applied to 6 patients (16%) and the remaining wounds, once clean, were approximated. One patient died as a result of severe metabolic acidosis and sepsis. CONCLUSIONS: The management of this infectious entity should be aggressive. Patients with FG need extensive debridement and cystostomy or colostomy when necessary. Broad-spectrum triple antimicrobial regimen and aggressive debridement are mandatory. Topical application of unprocessed honey is beneficial to the healing process. A minority of patients require split-thickness skin grafts on denuded areas.

Adult↗

PubMed1996

Mohs' micrographic surgery and distal urethrectomy with immediate urethral reconstruction for glanular carcinoma in situ with significant urethral extension.

OBJECTIVES: To report the use of conservative extirpative surgical techniques to manage glanular carcinoma in situ with significant urethral extension. METHODS: Over a 5-year period, 2 patients with carcinoma in situ of the glans with significant distal urethral involvement, who refused penectomy, were managed with combined treatment modalities using Mohs' micrographic surgery and distal urethrectomy with immediate urethral reconstruction. RESULTS: At follow-up of 5 years and of 12 months, there has been no evidence of meatal or proximal urethral recurrence. CONCLUSIONS: Mohs' micrographic surgical excision and distal urethrectomy with immediate urethral reconstruction offers an acceptable alternative to partial penectomy in patients with perimeatal carcinoma in situ who fail conservative treatment or refuse penectomy.

Aged↗

PubMed1996

Delayed orchiectomy after chemotherapy for metastatic nonseminomatous germ cell tumors.

PURPOSE: We reviewed current experience at our university with delayed orchiectomy after chemotherapy in patients with metastatic nonseminomatous germ cell tumors. MATERIALS AND METHODS: We retrospectively analyzed the records of 160 patients with metastatic germ cell cancer who were given systemic chemotherapy, and subsequently underwent orchiectomy and retroperitoneal lymph node dissection. RESULTS: Analysis of 160 testicular specimens revealed necrosis or scar in 70 (43.7%), pure teratoma in 50 (31.2%) and persistent germ cell cancer in 40 (25%). Corresponding incidences of histopathological findings in the post-chemotherapy retroperitoneal lymph node dissection specimens were significantly different, correlating with less than half of the cases (chi-square, p = 0.002). CONCLUSIONS: Our study confirms the need for delayed orchiectomy after systemic chemotherapy even when there seems to be a partial or complete clinical response at other sites.

Adolescent↗

PubMed1996

Teratoma in the orchiectomy specimen and volume of metastasis are predictors of retroperitoneal teratoma in low stage nonseminomatous testis cancer.

PURPOSE: We determined whether teratomatous elements in the orchiectomy specimen predict for teratoma in the retroperitoneum in patients who have not received chemotherapy. MATERIALS AND METHODS: We retrospectively reviewed the records of patients with clinical stages A, B and B2 nonseminoma who underwent retroperitoneal lymph node dissection. RESULTS: Teratomatous elements in the orchiectomy specimen predict for retroperitoneal teratoma. CONCLUSIONS: When deciding on treatment for low stage nonseminoma, the presence or absence of teratoma in the orchiectomy specimen should be considered to minimize double therapy.

Humans↗

PubMed1996

Post-chemotherapy resection of nonseminomatous germ cell testicular tumors metastatic to the mediastinum.

PURPOSE: We determined if the behavior of germ cell tumors metastatic to the mediastinum is different from that of primary mediastinal germ cell tumors, a group known to have distinct clinical features. MATERIALS AND METHODS: A search of the computerized data base for germ cell tumors metastatic to the mediastinum at our university revealed 80 patients, 65 of whom underwent concomitant retroperitoneal lymph node dissection at mediastinal surgery. RESULTS: Of the patients 60 (75%) are free of disease, 14 (18%) died of cancer and 6 (8%) are living with disease. Mediastinal pathology included teratoma in 65% of the patients, cancer in 26% and fibrosis in 9%. Of the 65 patients who underwent retroperitoneal lymph node dissection 75% had teratoma, 15% had fibrosis and 10% had cancer. Mediastinal relapses after dissection were rare (4 of 80 patients). CONCLUSIONS: Germ cell tumors metastatic to the mediastinum appear to behave similarly to those metastatic to the retroperitoneum. Primary mediastinal germ cell tumors have an entirely different clinical course. Teratoma is the predominant pathological type of post-chemotherapy germ cell cancer metastatic to the mediastinum.

Adolescent↗

PubMed1996

Noninvasive ultrasonic subtotal ablation of the prostate in dogs.

OBJECTIVE: To determine whether high-intensity focused ultrasound (HIFU) can be used for subtotal ablation of the prostate gland in dogs without causing damage to surrounding tissues. DESIGN: Experimental trial. ANIMALS: Adult hounds > or = 5 years old and weighing between 20 and 30 kg. PROCEDURE: Prostatic ablation was performed in all dogs, using a transrectal HIFU probe. Acute effects of HIFU treatment were evaluated in 4 dogs. These dogs were euthanatized and necropsied 4 hours after the procedure. Chronic effects were evaluated in the other 3 dogs. Serial CBC, serum biochemical analyses, urinalyses, and transrectal ultrasonography were performed. Dogs were euthanatized and necropsied 3 months (1 dog) or 1 year (2 dogs) after HIFU treatment. RESULTS: Histologic examination of the prostate glands from the 4 dogs euthanatized 4 hours after treatment revealed that 80 to 90% of the gland had undergone hemorrhagic, liquefactive necrosis. Only slight discoloration of the prostatic capsule was detected, and there were not any gross or histologic lesions of the rectal mucosa or urinary bladder. All 3 dogs followed up after HIFU treatment developed cystic cavities within the prostate. Clinicopathologic testing did not indicate any long-term adverse effects. CONCLUSIONS AND CLINICAL RELEVANCE: This method was effective in causing subtotal ablation of prostatic tissue in dogs. Further study of morbidity is required before the technique can be used clinically.

Animals↗

PubMed1996

Nerve sparing post-chemotherapy retroperitoneal lymph node dissection for advanced testicular cancer.

PURPOSE: Nerve sparing techniques are used routinely during retroperitoneal lymph node dissection in patients with low stage testis cancer in an attempt to preserve postoperative ejaculation. Preservation of ejaculation without an increased retroperitoneal recurrence rate in such patients prompted us to reevaluate the role of nerve sparing techniques in select patients undergoing post-chemotherapy retroperitoneal lymph node dissection. MATERIALS AND METHODS: Of 472 patients who underwent post-chemotherapy retroperitoneal lymph node dissection between March 1988 and January 1995, 93 (19.7%) underwent a nerve sparing procedure. Two patients died of disseminated cancer within 6 months after post-chemotherapy retroperitoneal lymph node dissection. In 10 patients the ejaculatory status could not be established from the clinical notes and the patient was lost to followup. The remaining 81 patients form the basis of this report. Disease status, complications and ejaculatory status were evaluated. Mean followup was 35.5 months. RESULTS: Of the patients 76.5% reported normal ejaculation after post-chemotherapy retroperitoneal lymph node dissection. Testis cancer recurred after nerve sparing surgery in 6 patients but no tumor was retroperitoneal. Ten pregnancies have been reported to date with uneventful term deliveries in 7. CONCLUSIONS: Select patients are candidates for nerve sparing post-chemotherapy retroperitoneal lymph node dissection. Although indications for nerve sparing techniques in the post-chemotherapy population have expanded, the local recurrence rate has not increased. Nerve sparing post-chemotherapy retroperitoneal lymph node dissection can preserve the inherent fertility potential of the patient without increasing retroperitoneal relapse rates.

Adolescent↗

PubMed1995

Ultrasound and microbubbles: their generation, detection and potential utilization in tissue and organ therapy--experimental.

Ultrasound-induced cavitation in tissue and organs has been well recognized and documented. Generally, this phenomenon has been seen as something to be avoided except in cases such as lithotripsy, where its production is considered an essential part of the treatment process or as a desirable contrast media in some areas of visualization enhancement. This article covers three areas in which the phenomenon has been observed, and shows how the effect can or may be therapeutically beneficial. Studies in the pig show that implanted human gallstones and the gallbladder itself can be eliminated in a nonsurgical procedure using ultrasound-induced cavitation in the gallbladder. In the dog brain, relatively stable cavitation-induced microbubbles have been transported through the vascular system to regions outside a focal seeding site. These bubbles produce ablation of tissue volumes at a remote site when irradiated with appropriate ultrasound. The cavitation phenomenon has been observed in the dog and human prostate. In the human prostate, microbubbles transported from ultrasound-induced focal seeding sites can be readily visualized with ultrasound and may be potentially useful under controlled conditions in tissue debulking for the treatment of benign prostatic hyperplasia (BPH). A similar microbubble transport has not been seen in the dog prostate under similar ultrasound treatment parameters. The ability to detect cavitation-induced microbubbles, follow their transportation through the vascular system and excite them at the appropriate time and place provides interesting possibilities for therapy. Of course, the entire microbubble process can be avoided by working below the cavitation threshold, thereby using only the absorption of ultrasound in tissue to produce focal thermal lesions. The term microbubble is used here in the context of those bubbles which can be transported in the vascular system down to vessels diameters below the 100-microns range. This is the vessel size in the vascular field into which microbubbles are transported and can be both visualized as well as disrupted with ultrasound.

Absorption↗

PubMed1995

Clinical stage B non-seminomatous germ cell testis cancer: the Indiana University experience (1965-1989) using routine primary retroperitoneal lymph node dissection.

Between 1965 and 1989, 1180 patients at Indiana University, U.S.A., underwent retroperitoneal lymph node dissection (RPLND) for non-seminomatous germ cell (NSGC) testis cancer of whom 638 cases had primary RPLND. A subset of 174 cases were considered clinical stage B (or II) before surgery (retroperitoneal nodal metastases by clinical staging). Surgery revealed that 23% (n = 41) had pathological stage A disease (no cancerous nodes). This error rate in clinical staging has decreased somewhat with improved techniques, but remains approximately 20% over the last decade. The relapse rate in pathological stage A (n = 41) was 5% (n = 2), both of whom were cured by chemotherapy. The relapse rate in pathological stage B without postoperative adjuvant treatment (n = 54) was 35% (n = 19); 2 patients died. This indicates that 65% of pathological stage B cases were cured by RPLND alone. From 1979 to 1989, the 140 pathological stage B cases participated in a randomised prospective trial of post-RPLND adjuvant chemotherapy versus no postoperative treatment. Forty two per cent (n = 59) received postoperative platinum-based therapy (two cycles), and there has been no relapse after RPLND for stage B disease. While advances in chemotherapy for NSGC testis cancer have led to its application by several study groups to clinical stage B (or II) testis cancer (with surgery reserved only for those in partial remission), the equivalent cure rate with RPLND surgery with chemotherapy rescue reserved for those who relapse appears to have both cost and risk-benefit advantages.

Chemotherapy, Adjuvant↗

PubMed1995

Ectopic ureters and ureteroceles in adults.

Ectopic ureters and ureteroceles are typically diagnosed in childhood and rarely present in adults. Nevertheless, ureteral ectopia should be included in the differential diagnosis of older patients who present with urinary tract infections or urinary incontinence. Detection is often delayed because of inadequate evaluation and heightened awareness is necessary on the part of treating physicians. Earlier detection and proper diagnosis serves to minimize morbidity and, in some cases, may maximize the possibility of renal preservation. Case reports serve to highlight the spectrum of these uncommon but clinically important anomalies.

Adolescent↗

PubMed1995

Cystography after radical retropubic prostatectomy: clinical implications of abnormal findings.

OBJECTIVES: In many institutions, cystography is obtained routinely after radical retropubic prostatectomy to assess the integrity of the vesicourethral anastomosis before the removal of the catheter. This study presents the Indiana experience with cystograms performed following radical retropubic prostatectomy. METHODS: The experience with 260 cystograms performed in 245 consecutive patients following radical retropubic prostatectomy was reviewed retrospectively, with a special reference to the clinical implications of abnormal findings. RESULTS: After a standard catheterization period of 14 to 21 days (mean, 19.2), 94.3% of the catheters were removed safely without adverse clinical consequences. The presence of a minimal contained contrast extravasation did not affect outcome after the removal of the catheter. The overall incidence of clinically significant extravasation was found to be 5.7% and was further reduced to 2.4% if extravasation was not suggested clinically in the postoperative course. CONCLUSIONS: Based on the current literature, significant extravasation is a common finding during the first 5 to 8 postoperative days. Therefore, management strategies advocating early urethral catheter removal should include routine cystographic studies. Otherwise, cystographic confirmation of anastomotic integrity before the removal of the catheter following 14 to 21 days of catheterization is not indicated in the routine postradical prostatectomy patient.

Anastomosis, Surgical↗

PubMed1995

Early urethral catheter removal following radical prostatectomy: a pilot study.

OBJECTIVES: Postoperative urethral catheter drainage after radical prostatectomy is bothersome to patients. A pilot study was initiated to determine if urethral catheter removal prior to hospital discharge is feasible. METHODS: Thirty-three consecutive men undergoing radical retropubic prostatectomy were prospectively studied and followed for a minimum of 6 months (mean, 8.5). Postoperative cystography was utilized to direct early catheter removal. RESULTS: Of 33 patients, 27 (82%) underwent successful catheter removal at a mean of 4.2 postoperative days. No patient experienced urinary retention, urinoma development, pelvic abscess, or anastomotic stricture. Urinary continence is excellent (no pads required) in 70% and good (stress incontinence requiring 1 to 2 pads/24 hours) in 18% of patients at last follow-up. CONCLUSIONS: Following radical prostatectomy, early catheter removal prior to hospital discharge is feasible. Early results suggest no deleterious consequences. Prospective monitoring of more patients is needed to determine if this practice is widely applicable.

Adult↗

PubMed1995

An alternative surgical technique for the management of afferent limb structure in Kock pouch continent urinary diversion.

Stenosis of the afferent limb has recently been recognized as a rare cause of upper urinary tract obstruction in patients with a Kock pouch continent urinary diversion. Usually, it can be managed by endoscopic balloon dilation but occasionally open surgical reconstruction is required. We describe an alternative simpler surgical technique that was used in a patient who presented with anuria due to afferent limb stenosis 13 years after the construction of a Kock pouch continent urinary diversion.

Adult↗

PubMed1995

The role of retroperitoneal lymphadenectomy in clinical stage B testis cancer: the Indiana University experience (1965 to 1989).

Between 1965 and 1989, 1,180 patients underwent retroperitoneal lymph node dissection for nonseminomatous germ cell testis cancer (638 underwent primary dissection). Of these patients, 174 were considered to have clinical stage B disease preoperatively (suspected retroperitoneal node metastases by clinical staging). Surgery revealed that 41 patients (23%) actually had pathological stage A disease (no cancerous nodes). This nonspecificity in clinical staging remains consistent despite advance in clinical staging methods during this 25-year period. Of the pathological stage B cancer patients 65% were cured by retroperitoneal lymph node dissection alone. These long-term data indicate that primary retroperitoneal lymph node dissection for low stage metastatic nonseminomatous germ cell testis cancer (pathological stage B) not only had diagnostic but also therapeutic impact. Furthermore, this cure rate with long-term followup is equivalent to that of current series of primary chemotherapy alone for stage B disease, which are still relatively early reports. This cure rate with single modality therapy (retroperitoneal lymph node dissection alone) was accomplished within an average of 4 hours and, therefore, should be more time and cost-effective than prior reports of 3 and 4 courses of primary chemotherapy. In the post-cisplatin era (1979 to 1989), 140 patients with clinical stage B disease were treated with primary retroperitoneal lymph node dissection: 32 (23%) had pathological stage A cancer and 2 of them (6%) had relapse. Both patients are currently disease-free with subsequent chemotherapy. Of the remaining 108 patients with pathological stage B disease 49 received no adjuvant chemotherapy and 59 received cisplatin-based adjuvant chemotherapy. Among the former 49 patients 18 (37%) had relapse and 2 died. No patient receiving postoperative cisplatin-based adjuvant chemotherapy had relapse. The overall survival rate in these 140 clinical stage B cancer patients was 98%. There were 3 deaths, only 1 from cancer. The addition of cisplatin-based adjuvant chemotherapy postoperatively has rendered pathological stage B nonseminomatous germ cell testis cancer entirely free of subsequent relapse. Therefore, retroperitoneal lymph node dissection as monotherapy is curative in two-thirds of the patients with stage II disease, while the remaining one-third with progression to clinical relapse can be reliably saved by chemotherapy. Future considerations in selecting therapy for clinical stage II nonseminomatous germ cell testis cancer will be risk-benefit, cost-benefit and quality of life issues. Several cooperative studies will examine these issues, involving European and United States groups.

Chemotherapy, Adjuvant↗

PubMed1995

Hyperamylasemia after post-chemotherapy retroperitoneal lymph node dissection for testis cancer.

PURPOSE: Postoperative hyperamylasemia was evaluated in patients undergoing post-chemotherapy retroperitoneal lymph node dissection for testis cancer. MATERIALS AND METHODS: Serum levels of amylase, lipase and bilirubin were evaluated prospectively in the immediate postoperative period in 39 consecutive patients who underwent post-chemotherapy retroperitoneal lymph node dissection. RESULTS: Hyperamylasemia was found in 16 patients (41%), hyperlipasemia in 17 (43%) and hyperbilirubinemia in 9 (23%). Peak elevations were observed at 24 hours postoperatively and most returned to normal at 1 week. Elevation of these parameters was significantly associated with length and difficulty of the procedure. No patient demonstrated clinical acute pancreatitis. CONCLUSIONS: Extended retraction of the pancreas during post-chemotherapy retroperitoneal lymph node dissection may cause a minor reversible injury to the pancreas expressed as hyperamylasemia, hyperlipasemia and, rarely, jaundice. These findings are important to consider in the differential diagnosis of hyperamylasemia following post-chemotherapy retroperitoneal lymph node dissection.

Adolescent↗

PubMed1995

Color Doppler flow imaging for deep venous thrombosis screening in patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostatic carcinoma.

Patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy are traditionally considered to be at high risk for postoperative venous thromboembolic complications. A prospective deep venous thrombosis screening regimen was initiated at our medical center in 1990 following 2 cases of fatal pulmonary embolism that occurred after hospital discharge. During a 3-year period 245 consecutive patients undergoing radical retropubic prostatectomy for prostate cancer were screened postoperatively for lower extremity deep venous thrombosis using ultrasound duplex scanning with color Doppler flow imaging. The results were correlated only with the development of clinical deep venous thrombosis. No additional diagnostic modalities were used to confirm a normal venous system in asymptomatic patients. Venous thromboembolic complications were encountered in 9 of the 245 patients (3.6%). In 2 patients deep venous thrombosis was associated with nonfatal pulmonary embolism. Only 2 of the 9 cases of deep venous thrombosis were detected by color Doppler flow imaging screening. The striking decrease in the incidence of deep venous thrombosis following radical prostatectomy in the last decade and the low yield of screening at a single point in time may warrant reconsideration of the need for deep venous thrombosis screening among patients undergoing pelvic lymphadenectomy and radical retropubic prostatectomy for prostate cancer.

Adult↗

PubMed1995

Complications of post-chemotherapy retroperitoneal lymph node dissection.

The surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy there was a higher occurrence of postoperative chylous ascites. Most of the other complications (gastrointestinal, lymphatic, neurological and renal) were temporary and treated conservatively. Perioperative management of the post-chemotherapy testis cancer patient is different from that of the patient undergoing primary retroperitoneal lymphadenectomy. The latter operation is usually performed in physically fit patients and the surgical template of dissection is of a smaller scale. Thus, the complications in this group are minor and without mortality. Specific technical considerations and difficulties are common to post-chemotherapy patients. Factors, such as large volume of disease, post-chemotherapy desmoplastic reaction and extensive retroperitoneal dissection, make these patients more prone to have complications. Decreased pulmonary, renal and nutritional reserves add to the surgical morbidity. Knowledge of possible pitfalls and their causes can avoid unnecessary operative complications.

Combined Modality Therapy↗