To evaluate the incidence and significance of an enlarged prostatic utricle in hypospadiac patients without underlying intersex 44 patients with the meatus located in the perineum, penoscrotal junction or proximal two-thirds of the penis were evaluated with cystourethroscopy immediately before the operation. There was an abnormally enlarged utricle in 57 per cent of the perineal, 10 per cent of the penoscrotal and none of the penile hypospadias and intersex revealed a high incidence of enlarged utricle or the presence of a vagina masculinus. Utricular enlargement in itself doses not indicate intersexuality but careful cystoscopic examination of its vault needs to be undertaken, searching for a cervix. An enlarged utricle can be a manifestation of delayed mullerian duct regression or decreased androgenic stimulation of the urogenital sinus.
A positive saralasin test in patients with angiographic evidence of renovascular disease and other positive functional tests gives further assurance that these patients will achieve normal or substantially reduced blood pressure postoperatively. In our experience with proved renovascular hypertension there was a 19 per cent incidence of falsely negative saralasin tests. Therefore, saralasin should not be used as the sole screening test in hypertensive patients suspected of having surgically correctable lesions. There is a direct correlation between elevated renin activity and a positive saralasin test. In some patients saralasin may be more sensitive than any other currently used test to detect overactivity of the renin-angiotensin system. This would determine those patients with technical errors in renin sampling and assays. Of the 16 patients (all normotensive) who had 6-month followup tests 5 had elevated peripheral renin activity, probably owing to furosemide stimulation. Of these 5 patients 2 had a positive postoperative saralasin test, raising the question of potential falsely positive responses in cases of essential hypertension and coincidental non-functional renal artery stenosis. Patients with high renin essential hypertension may respond to saralasin, even in the absence of renal artery lesions. A saralasin test should be done in a hospital where all specific conditions can be met and potential complications handled promptly.
A simplified surgical technique for a male-to-female transsexual operation has been developed and applied satisfactorily in a series of carefully selected patients. The simplicity of the technique allows relatively brief hospitalization for 1-stage sex conversion, provides satisfactory cosmetic and functional results and has not been accompanied by any untoward complications.
The urine of normal persons, as well as that of stone formers, contains inhibitors to crystallization of calcium oxalate. To ascertain differences, if any, between these 2 groups we measured nucleation rate, growth rate and total mass produced in an analytic system with 5 per cent urine added to 95 per cent synthetic urine that did not contain large organic molecules. We also observed the effects of addition of uromucoid to the synthetic solution. Normal urine and stone-forming urine contained significant inhibitors to total mass of calcium oxalate dihydrate crystals precipitated but total crystal mass was not significantly different between the 2 groups. Growth rate was significantly less in experiments with the urine of stone formers. The other major difference found in stone-forming urine was significant enhancement of nucleation rate when compared to normal urine. Since addition of uromucoid produced these same growth inhibition and nucleation enhancement effects but did not affect total crystal mass, we hypothesize that uromucoid has an important part in producing the differences noted between normal and stone-forming urine.
Urinary supersaturation in respect to brushite or calcium oxalate represents the main pathogenic factor in stone formation. Of the patients with calcium oxalate stones 30 to 40% present with hypercalciuria. Herein we determine and compare the effects and side effects in the treatment of hypercalciuria with sodium cellulose phosphate or Campanyl, a potassium versus calcium ion exchanger, and thiazides alone or in combination with an ion exchanger.
Comparisons of the bone marrow and serum acid phosphatase values obtained by counter-immunoelectrophoresis and the Roy biochemical test were made in 72 patients with and in 13 patients without prostatic cancer. The counter-immunoelectrophoresis test, when positive at more than 1 international unit per liter, showed only 4.4 per cent falsely positive results. The Roy biochemical test, which uses sodium thymolphthalein monophosphate as the substrate, had 65 per cent falsely positive bone marrow acid phosphatase levels.
Cystolysis, a procedure for the selective supratrigonal denervation of the bladder, was used in 6 patients with intractable interstitial cystitis and in 4 patients with an uninhibited neurogenic bladder. Good results were obtained in both groups of patients.
The difficult problem of a vesicovaginal fistula originally was cured surgically by Sims in 1849. During the last 25 years at UCLA and affiliated hospitals 68 patients have been treated by urologic surgeons for fistulas between the vagina and the urinary tract: 21 ureterovaginal and 47 vesicovaginal and urethrovaginal fistulas.
The simple, rapid and satisfactory method of the transvesical Harris-Hryntschak open prostatectomy is described. When this technique is used bleeding is reduced to an average of 85 ml. and visibility is improved by the local injection of a synthetic vasoconstrictor, ornithine-8 vasopressin, before enucleation. Hermostasis is obtained by tamponade with fine sutures occluding the bladder neck. Bladder closure is with heavy watertight, purse-string sutures. A "time and motion" study has reduced the usual operating time to 15 to 20 minutes with an intraoperative transfusion rate of 2.3%.
A canine model of bilateral chronic partial ureteral obstruction with one side severely obstructed and the other side moderately obstructed was used to determine which kidney should be released initially to facilitate maximum recovery of renal function. The data show a significantly greater return of total renal function (20%) if the more severely injured kidney is released first.
Renal autotransplantation as an alternative to ileal interposition has been done successfully in patients with repetitive episodes of renal colic. Urinary tract continuity has been re-established by anastomosis of a Boari tube directly to the renal pelvis. This has resulted in easy egress of recurrent calculi without pain. Furthermore, the musculature of the Boari tube seems to be adequate for prevention of vesicorenal reflux. The procedure has been devoid of electrolyte and mucous urinary retention problems associated with ileal interposition and it is advocated as an alternative in the management of such patients when medical therapy fails.
The intersegmental nature of renal incisions is axiomatic. Deviation from the intersegmental plane is hazardous. If divided along intra-arterial planes papillae appear to heal with little structural or functional impairment.
Cis-platinum as single agent therapy was investigated in 8 patients with stage D transitional cell carcinoma of the bladder. Dramatic responses were obtained in some patients and the quality of life was improved for as long as 8 months but no cures were obtained. Also noted was an occasional marked loss of renal function as measured by creatinine clearance despite a carefully managed protocol to avert this known side effect of cis-platinum (nephrotoxicity). No auditory problems were noted in these 8 patients.
Six children have undergone reconstruction of the urinary tract 14 months to 14 years after supravesical diversion for neurogenic bladder dysfunction. Five are continent: 4 by intermittent catheterization and 1 by voiding to completion. One child is just beyond infancy and wets but is not yet on a systematic program. One boy was considered a technical failure despite incontinence because of progressive hydronephrosis from a non-compliant bladder but he subsequently had an augmentation cystoplasty. Urinary undiversion into a neurogenic bladder is an acceptable option as an alternative to ileal conduit revision or for reasons of patient preference, provided bladder storage capacity is adequate at acceptably low resting pressures, without incontinence.
Operative treatment of microphallus has been proscribed in recent reports. It is not indicated for the more common endocrine type because of deficient gonadotropin, primary testicular disorder or end-organ defect. However, an operation may be quite necessary for the other form owing to defective morphogenesis--the anomalous type. Representative cases provide evidence that the method of treatment depends on the type of microphallus.
Radioimmunoassay determinations of the biochemical tumor markers, alpha-fetoprotein or human chorionic gonadotropin, revealed elevated serum levels in 94 per cent of the patients with advanced disease. No falsely positive values have been observed. The markers are useful in monitoring the response to therapy and, when persistently elevated after therapy, indicate the presence of residual malignant tumor, usually embryonal carcinoma. However, they have a more limited role in the management and followup of the great majority of new patients with non-seminomatous germ cell tumors of the testis (stages A and B) owing to a falsely negative incidence of 38 per cent in patients found to have retroperitoneal metastases at lymphadenectomy. Furthermore, marker levels obtained during chemotherapy, even in the presence of residual tumor, frequently are normal. Thus, they have a limited role in the early detection of residual disease in patients treated systematically with prophylactic chemotherapy. A meticulous retroperitoneal lymphadenectomy remains the single most important factor in dictating the use of adjuvant chemotherapy, the specific agent and the combination and duration of therapy. The prophylactic use of actinomycin D in stage A and the early aggressive use of vinblastine sulfate and bleomycin in stage B2 have reduced the incidence of recurrence substantially. A prospective plan of management used in 95 consecutive patients since 1974 has resulted in survival free of tumor of 100 per cent for patients with stage A disease, 91 per cent for stage B and 61 per cent for stage C.
Of 63 patients with reflux and renal atrophy renal dysplasia was found in 9.5 per cent. Pyelonephritis was apparent in 81 per cent of the atrophic lesions. Urinary obstruction or ectasia was apparent in each case with dysplasia and only 2 were associated with histologic evidence of pyelonephritis. Pyelonephritis appears to be a major causal factor in atrophy occurring in renal units with reflux. Early urinary tract obstruction or distension may predispose to renal dysplasia.
Orchiopexy of high intra-abdominal testes with division of the internal spermatic artery and vein is associated with subsequent testicular atrophy in a significant percentage of cases. We herein describe 2 patients in whom arterial supply and venous drainage to the testis were maintained using microvascular anastomosis. The internal spermatic artery and vein were anastomosed to the deep inferior epigastric artery and vein. Patency of the vascular anastomosis was verified by subsequent radionuclide examinations and selective arteriography in 1 patient.
We studied calcium oxalate stone formation in rats after calculogenesis had been induced by a diet deficient in pyridoxine (vitamin B6). Urinary calculi had formed within 6 weeks in 86 per cent of 114 animals. The calcium handling properties of 17 tissues (including the renal sinus "gland") were compared in normal and pyridoxine deficient animals. A significant increase in calcium (85Sr) uptake was found in the renal sinus "gland" and the renal medulla after pyridoxine deprivation. The movement of calcium from the perihilar sinus tissues into the renal medulla was examined and the significance of our observations is discussed.
Experience with suprapubic closure of vesicovaginal fistulas in 42 patients considered candidates for this procedure is reviewed. Five patients required a second operation for cure and the reasons for failure are discussed. Wide exposure with tension-free closure of well vascularized flaps and the judicious interposition of pedicled omentum have produced the most encouraging results. The litigious nature of this distressing condition is lessened when primary closure is successful and supravesical diversion by ileal or colonic conduits can be avoided.
