Biomedical subjects
Publications and source records attributed to S D Boyd.
Emphysematous pyelonephritis is a life-threatening necrotizing renal infection characterized by the production of gas. Of 8,105 admissions to our diabetes service during the last 5 years we identified 13 cases. The patients were managed aggressively with fluids and antibiotics, followed by immediate nephrectomy. The mortality rate is 40 to 50 per cent, primarily owing to sudden septic complications.
From August 1982 through January 1984, 51 patients underwent urinary diversion that included creation of a continent reservoir from an ileal segment, according to the method described originally by Kock. An important modification included removal of a narrow strip of mesentery for 8 cm. along the afferent and efferent limbs of the pouch to allow adequate ileal intussusception, and fixation to prevent reflux and to ensure continence. Previous urinary diversion was by ureterosigmoidostomy in 3 patients, standard ileal conduit in 7 and suprapubic cystotomy in 1. A total of 39 patients underwent simultaneous anterior exenteration for pelvic malignancy. There was 1 postoperative death and early complications occurred in 10 patients. Of these 10 patients 4 required reoperation: 2 for drainage of a pelvic abscess, 1 for conversion to a standard ileal conduit and 1 for bleeding. Late complications occurred in only 8 patients: 5 required reoperation and revision of the continence valve mechanism, and 3 required hospitalization for brief episodes of pyelonephritis. The end result in 49 of 50 patients has been an overwhelming success. Patients perform self-catheterization every 4 to 6 hours during the day and once at night for volumes ranging up to 1,400 cc. Serum electrolytes have remained normal and hyperchloremic acidosis has been encountered in only 1 patient who had had compromised renal function preoperatively with hyperchloremic acidosis as a result of previous ureterosigmoidostomy. X-rays of the Kock pouch have shown evidence of reflux in only 1 patient, and all excretory urograms have demonstrated either normal upper tracts without obstruction or improvement in patients with preoperative hydronephrosis. Although preliminary, this clinical trial suggests that the quality of life for patients considered previously to be candidates for cutaneous diversion can be improved markedly by a modified Kock continent ileal reservoir.
A highly successful transvaginal bladder neck suspension for female stress urinary incontinence is described and illustrated. Precise lateral placement of sutures, maximum mobilization of the anterior vaginal wall and bladder neck, and ease of approach are keys to the technique. The procedure can be utilized in any setting with minimal complications and with neither obesity nor multiple previous surgeries as contraindications.
Kock and associates have made a major contribution to the urologic surgical armamentarium by developing a method to create a continent internal urinary reservoir out of ileum. This innovative procedure now offers patients requiring cystectomy for bladder cancer or cutaneous urinary diversion for any reason a real alternative to the standard ileal conduit, which requires wearing an external appliance. Operative technique, including some modifications developed by the authors, is presented.
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Two cases of diabetes insipidus (hypothalamic and nephrogenic) with massive nonobstructive trabeculation and dilation of the bladder and hydroureteronephrosis are reported. The cases are evaluated thoroughly--radiologically and urodynamically. Treatment options are discussed, including the use of an important new drug, dDAVP. The general subject of diabetes insipidus and its urologic implications is reviewed.
Limited chemical extraction of hydrophobic glycopeptides and subtotal autodigestion of the donor's cells and plasma membranes in undemineralized cortical bone in vitro reduces the putative quantity of haptenic substances absorbed by the recipient. Iodoacetic acid and sodium azide or other sulfhydryl group enzyme inhibitors added to the buffer solutions during in vitro autodigestion and estraction of intracellular alloantigens protects the bone matrix morphogenetic property against enzymatic degradation. The delayed hypersensitivity reaction induced by aseptically collected freeze-dried bone and the destruction of the bone morphogenetic property caused by radiation-sterilization is avoidable by sequential chemodigestion and chemosterilization of bone that preserves the maximum morphogenetic potential while transferring a minimum quantity of alloantigen.
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Insoluble bone gelatin with inclusions of insoluble noncollagenous protein produces new bone when implanted in muscle in allogeneic rats. The implanted residue provides the milieu for expression of bone morphogenetic potential of migratory mesenchymal cells. Neutral buffer solutions activate endogenous enzymes that degrade components essential for cell interactions and differentiation of bone. Chloroform-methanol either denatures or extracts constituents responsible for degradation. Insoluble bone gelatin produces new bone after extraction at 2 degrees with neutral salts, 0.5 M EDTA, 0.1 M Tris.HCl, 4 M urea, 0.5 M hydroxylamine, and 10 M KCNS, as well as after limited digestion with pepsin or collagenase, but not after extraction with 5 M guanidine, 7 M urea, water saturated with phenol, or after alkali hydrolysis with 0.1 N NaOH. The specific activity of cell populations interacting with insoluble bone gelatin suggests that a chemical bond between collagen and a noncollagenous protein or part of a protein, cleaved by a neutral proteinase, controls the bone morphogenetic reaction.
Transurethral resection of the prostate (TURP) is the only recognized treatment in patients with benign prostatic hyperplasia (BPH). Transurethral hyperthermia (TUHT) was used as an alternative treatment in patient who refused TURP. From 1987 to 1988, 21 BPH patients with moderate to severe symptoms and signs of prostatism were treated with TUHT in a phase I trial. Mean pre-treatment subjective and objective values were: total symptom score (TSS) 13.5, obstructive symptom score (OSS) 6.5, irritative symptom score (TSS) 7.0, peak flow rate (PFR) 11.6 cc/sec, post-voiding residual volume (PRV) 187 cc, and prostate volume (PV) 93 cc. TUHT was given for a total of 177 sessions (mean 8.4), each of 60 min duration at a steady state. Temperature was recorded continuously on the urethral surface, in all treatments. It ranged from Tmin 40.3 degrees C to Tmax = 49.2 degrees C and Tmean = 44.1 degrees C. The mean minimum temperature of > or = 42 degrees C was obtained in 98% of the TUHT sessions. Treatments were given on an outpatient basis without sedation or anaesthesia. Treatment tolerance was excellent with minor acute toxicity common (71% of patients), of no clinical importance and with no late complications. Of the 21 patients treated, 17 (81%) had an objective and 15 (71%) a subjective improvement recorded at 6 months post-treatment. This statistically highly significant improvement included: 61% decrease in TSS; 66% decrease in OSS; 55% decrease in ISS; 42% increase in PFR; 55% decrease in PRV; and 21% decrease in PV. Of the 17 patients with objective improvement, nine have maintained their response to TUHT for a minimum period of over six years, two relapsed at 11 and 40 months, respectively, and six patients died of cardiovascular causes maintaining their response to death. This study has demonstrated TUHT treatment efficacy with no major or clinically important toxicity in BPH patients. A relative weakness of this report is a lack of verification of objective study parameters in the patients at seven years post-treatment. Prospective randomized trials are needed to define the role of TUHT in the management of BPH patients.
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