Female urethral diverticulum. Clinical aspects and a presentation of 15 cases.

OBJECTIVE: Fifteen patients with female urethral diverticulum (FUD) were referred during nine years. In order to point out the symptomatology and findings and to evaluate the treatment we have reviewed these patients. METHODS: A retrospective analysis of 15 women treated with transvaginal diverticulectomy. The technique is described. RESULTS: The median age was 54 years. All the patients had symptoms of lower urinary tract disorder. The time from the first appearance of symptoms to referral was median 2 years (range, 4 days 30 years). Seventy-five percent of the cases had a pronounced tenderness. In 14 patients a suburethral mass could be found. Purulent material could be expressed in twelve cases. Three patients with symptoms for more than 10 years were characterized by stress incontinence and frequency and recurrent cystitis. No single diagnostic test proved to be specific for FUD. In eight patients (53%) the indication for operation was based only on symptomatology and the presence of a suburethral mass. CONCLUSION: Diverticulum of the urethra is to be suspected in women with unexplained lower urinary tract symptoms. We recommend a collaboration of the two specialties: Gynaecology and Urology.

The upper arm arterio-venous fistula--an alternative for vascular access in haemodialysis.

Forty-eight consecutive arteriovenous fistulae of the upper arm constructed in 44 patients between 1983 and 1987 were reviewed. The median observation time was 8.5 months (range 1 day-65 months). The overall patency rate for fistulae used for haemodialysis (early failures excluded) was 50% after one year and 38% after two years. However, only six (18.7%) of the used fistulae stopped because of thrombosis. The total number of thromboses was nine (19.6%). The main cause of discontinuance of fistulae was a high number of deaths (n = 22), presumably a result of a high median age of 62 years. Early failure rate was seven of 46 (15.2%); in three cases (6.5%) this was caused by thrombosis. The results are compared to other alternatives for radiocephalic fistulae and the difficulties of comparisons are discussed. It is concluded that the upper arm arteriovenous fistula can serve as a second choice, when a radio-cephalic fistula fails.

[Vasovasostomy in previously sterilized men. The functional result]. / Vasovasostomi hos tidligere steriliserede maend. Det funktionelle resultat.

A simple method of vasovasostomy by a macroscopic technique using a stent placed in the ductus deferens lumen is evaluated. In the reported 88 cases the patency is 74% and the pregnancy-rate is 31%. This type of vasovasostomy can be performed by all surgeons. The results are acceptable and can be compared to more advanced microsurgical methods.

PIP: A simple method of vasovasostomy by a macroscopic technique using a stent placed in the ductus deferens lumen was evaluated retrospectively at the urological department of Hvidovre Hospital, Copenhagen, Denmark, during 1978-1990. 88 operations were performed on 86 sterilized men. The average age was 38 years and the average time that elapsed from the original sterilization was 5.5 years. All patients were invited to undergo postoperative sperm analysis, and 71 (80.7%) answered a questionnaire about postoperative pregnancies. In all, postoperative sperm analysis responses were obtained from 61 patients (69.3%), and the analysis was performed an average of 7 months after the operation. In 52 cases (59.1%) information was obtained both about the eventual postoperative pregnancies and the results of the sperm analysis. In the reported 88 cases the patency was 74%, and 22 (31%) of the partners among these 71 patients became pregnant. Among 30 patients with severely reduced or reduced sperm quality there were 13 pregnancies (43%), while among 8 patients with normal sperm quality there were 2 pregnancies (25%). This indicates that there is no association between pregnancy and sperm quality. The chance of pregnancy was not related to the time period from sterilization to refertilization. In 10 patients the sperm analysis was repeated at a later time point, and in 5 patients the quality improved spontaneously. In 2 cases when refertilization was attempted again because of azoospermia, sperm analysis still showed continued azoospermia after the reoperation. This type of vasovasostomy can be performed by all surgeons. The results are acceptable and can be compared to advanced microsurgical methods.

Treatment of cystine stones: combined approach using open pyelolithotomy, percutaneous pyelolithotripsy, extracorporeal shock wave lithotripsy and chemolysis.

Treatment of cystine stones in the urinary tract can be difficult because of a high frequency of recurrence, resistance to Extracorporeal Shock Wave Lithotripsy (ESWL), difficulty in localization and access to peripheral stones during Percutaneous Nephrolithotripsy (PCNL), and the insufficient effect of oral chemolysis. We present two cases of urinary cystine calculi treated with a combination of pyelolithotomy, PCNL, ESWL and percutaneous irrigation chemolysis, using N-acetylcysteine and Tromethamine-E.

Carotid artery disease and low cerebral perfusion pressure: symptomatology, operative risk and outcome.

Direct internal carotid artery blood pressure measurements in patients undergoing carotid endarterectomy identified 49 patients, among 239 consecutive cases (21%), who had a reduction in perfusion pressure of 20% or more. The clinical history, objective findings and angiographic data were compared with those of a control group of a further 49 patients selected from the remaining patients operated on over the same period. The two groups were compared for short- and long-term outcome of surgery. We were unable to delineate a symptomatic neurological profile that identified patients with low perfusion pressures. Surgery in patients with low perfusion pressures seemed to be associated with an increased complication rate (12% versus 4%), although this was not statistically significant. Definite postoperative improvements in persisting neurological deficits were observed only in one patient. Long-term results were equal in the two groups with an annual stroke risk of 3%.

[Ergotism in migraine. Peripheral vascular complications in 14 patients with migraine]. / Ergotisme ved migraene. Perifere kredsløbskomplikationer hos 14 patienter med migraene.

The general occurrence of subclinical ergotism with reduced peripheral systolic blood pressures in patients taking ergotaminepreparations regularly for migraine and the frequent occurrence of milder symptoms indicates that severe ischaemia of the extremities is not as rare a complication as would appear from the few case reports published. The 14 cases reported here constitute the largest series published of migraine patients with acute ergotism. The patients, all women, were admitted to a vascular department over a period of 14 years. They suffered from severe ischaemia of one or more extremities after consumption of varying doses of ergotamine tartrate. Ten patients had previously exhibited symptoms of acute or chronic ergotism, but only eight were admitted with this diagnosis. Liver enzyme tests were abnormal in five out of six patients examined, while three patients had ECG signs of myocardial ischaemia, regressing during treatment. At the beginning of the period, hyperbaric oxygen at 3 ATAB was the standard treatment. Since 1980, the treatment of choice has been continous i.v. nitroglycerine infusion for 24 hours. Nine patients experienced prolonged postischaemic symptoms; one patient required a forefoot amputation and four patients had permanent ischaemic muscular damage. Increased bioavailability of ergotamine due to hepatic vasospasm is suggested as a cause of sudden reduced tolerance to ergotamine. Peripheral systolic pressures and liver function tests should be controlled in patients taking ergotamine regularly. Subclinical ergotism over a prolonged period may facilitate development of occlusive peripheral vascular disease.

[Femoro-crural in situ bypass]. / Der femoro-crurale in-situ-Bypass.

During a period of 21 months from April 1986, 108 in situ femoro-crural bypass procedures were performed. The indication for surgery was in all cases a limb threatening ischemia. Always the technique described by Leather et al. was used. All the patients had obstructive disease of the crural arteries, thus the distal anastomosis was performed in a single crural or pedal artery for 102, and for 40 at the level of the ankle or foot. 97 per cent of the patients were discharged from the hospital with a salved limb, the one year patency was 76 per cent and one year limb survival 90 per cent. In our hands the in situ technique has shown much better results than the reversed vein technique.

Effect of electrode temperature on orthostatic changes in forefoot transcutaneous oxygen tension (tc-PO2).

The influence of increasing the temperature of the transcutaneous oxygen tension (tc-PO2) electrode from 37 to 45 degrees C on the orthostatic changes in tc-PO2 was studied in six normal subjects. The tc-PO2 electrode was mounted on the forefoot. The blood pressure of the forefoot was changed by elevating and lowering the forefoot in relation to heart level. At all electrode temperatures tc-PO2 decreased about 35% when the forefoot was elevated. At electrode temperatures between 41 and 45 degrees C tc-PO2 increased about 20% when the electrode was lowered below heart level. This indicates a passive vascular bed in the heated tissue under the electrode. However, at 37 degrees C tc-PO2 decreased about 40% when the forefoot was lowered. This indicates that the local vasoconstrictor response to increased venous transmural pressure is preserved when the tissue under the electrode is heated to 37 degrees C only. The study suggest that tc-PO2 monitoring at 37 degrees C may be used for continuous, non-invasive monitoring of the local vasoconstrictor response, and thus of arteriolar contractility and intact sympathetic innervation.

Kinetics of cefuroxime in the groin wound after vascular prosthetic implantation.

The kinetics of cefuroxime in serum and wound fluid were investigated in the period after vascular prosthetic implantation. Cefuroxime was administered as intravenous bolus injections in doses of 0.75 gm (five patients) or 1.5 gm (five patients). The concentration of cefuroxime in wound fluid increased after the injection and reached a maximal level corresponding to serum concentration levels with 1.5 hours. The subsequent elimination of cefuroxime from the wound fluid closely paralleled the elimination from the serum. The wound fluid concentrations were found to be greater than the minimum inhibitory concentration for Staphylococcus aureus and Escherichia coli in 8 and 5 hours, respectively, after injection of 0.75 gm of cefuroxime, and in 11 and 7 hours, respectively, after injection of 1.5 gm of cefuroxime.