Extracorporeal shock wave lithrotripsy of intrahepatic stones. Case presentation and review of the literature.

Primary hepatolithiasis, although rare, is a difficult condition requiring the combined management of radiology and surgery. Use of extracorporeal shock wave lithotripsy and percutaneous stone extraction, along with improved biliary drainage by choledochojejunostomy, should provide a safe effective approach to this unusual problem.

Sonographic evaluation of renal stones treated by extracorporeal shock-wave lithotripsy.

Real-time sonography was performed on 94 patients the day before and at 24 and 48 hr after extracorporeal shock-wave lithotripsy (ESWL) therapy. The ability of sonography to detect renal stones before ESWL, changes in the calculi after ESWL, and the occurrence of pre- and post-ESWL hydronephrosis was evaluated. Abdominal radiographs and linear renal tomography were used as the standard of comparison. Six other patients had sonography only either before or after ESWL. One hundred patients had a total 105 kidneys treated; 18 kidneys with more than three stones were not included. The other 87 kidneys had 102 stones evaluated by sonography before having ESWL; 66 stones (65%) were identified and 36 were not. Of those calculi not seen, 10 were less than or equal to 5 mm in diameter. Nineteen of the other 26 stones were in the ureter or at the ureteropelvic junction. Comparison of sonograms of 80 kidneys obtained before and after ESWL revealed no change in 37 (46%), more stones or fragments detected in 23 (29%), fewer stones or a change in location in 12 (15%), and an apparent decrease in the size of the original stone in eight (10%). Hydronephrosis was detected by pre-ESWL sonography in 16 kidneys (20%) and was noted to develop after ESWL in 20 (31%) of the 64 other kidneys. These results indicate that the ability of sonography to detect renal calculi is related not only to stone size but also to location. The clinical significance of pre- and post-ESWL hydronephrosis found by sonography must be considered in conjunction with the patient's symptoms, laboratory data, and other radiographic studies. Therefore, the routine use of sonography in the post-ESWL patient does not seem warranted.

Kidney changes after extracorporeal shock wave lithotripsy: appearance on MR imaging.

The occurrence of changes in the kidneys after extracorporeal shock wave lithotripsy (ESWL) was evaluated with magnetic resonance (MR) imaging in 34 patients, utilizing T1-weighted spin-echo pulse sequences. Five of the 34 patients underwent bilateral ESWL therapy before MR imaging. Of the 39 kidneys studied, 29 (74%) showed one or more changes on MR imaging: subcapsular or perinephric fluid (n = 10), focal (n = 16) or diffuse (n = 8) loss of the corticomedullary junction (CMJ), and focal areas of increased (n = 7) or decreased (n = 3) signal intensity. The CMJ changes were more prominent with increasing numbers of shock waves administered during the procedure. These relatively subtle changes detected on MR imaging may not be apparent with other imaging techniques. The long-term clinical significance of these findings is not yet known, although no apparent serious renal pathologic condition was detected.

Preservation of distal splenorenal shunt in a patient requiring left nephrectomy.

We report a case in which a prior distal splenorenal shunt for bleeding esophageal varices was preserved during subsequent left nephrectomy for adenocarcinoma. At nephrectomy portal hypertension with numerous collateral varices to the splenic vein was not a major technical problem. Shunt integrity was documented by postoperative angiography.

Massive prostatic infarction following aortocoronary bypass surgery: a report of two cases.

We present two patients who had massive prostatic infarctions following coronary bypass surgery. Whereas small areas of prostatic infarction are commonly seen in urologic practice, massive infarction is rarely seen. Massive prostatic infarction has been observed under conditions similar to those occurring with bypass surgery, so no claim is made that the condition occurs uniquely in patients who have recently undergone bypass surgery. Since coronary bypass surgery is commonly performed and since the procedure is often done on men with prostatic hyperplasia, we can reasonably expect to see this condition more commonly that we have in the past. It is our hope that others will be alerted to this condition and look for it in patients with prostatism who undergo coronary bypass surgery, other types of cardiac surgery, and any condition where prostatism and hypotension are present and pressor agents are used in treatment.

Unilateral multicystic renal disease in adults.

Patients with multicystic kidneys that remained undetected for many years are currently our best source of information on the long-term fate of this type of renal dysplasia. We review 24 cases with adequate data reported in the literature and add 3 personal cases. Significant problems that were encountered and were related to these retained multicystic kidneys include abdominal pain, erroneous diagnosis of renal agenesis leading to repeated unrewarding medical studies for abdominal pain, abdominal mass and renal neoplasm arising in the dysplastic kidney.

Transcoccygeal 125iodine prostatic implantation for adenocarcinoma.

The transcoccygeal approach to the posterior surface of the prostate gland has been used for delivery of therapeutic levels of irradiation with 125iodine in 18 patients with clinical stages B1 and B2 adenocarcinoma without staging pelvic node dissection. The rationale for this approach, the surgical and radiological technique, and the early postoperative results and complications of this versus the retropubic approach with pelvic node dissection are described.

Observations on the small kidney associated with vesicoureteral reflux.

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.

Observations on the small kidney associated with vesicoureteral reflux.

Of 63 patients with reflux and renal atrophy renal dysplasia was found in 9.5%. Pyelonephritis was apparent in 81% 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.

Unsuspected renal tumors associated with renal cysts.

A series of renal tumors associated with renal cysts is presented. Prior to surgical exploration appropriate diagnostic studies failed to indicate evidence of the presence of neoplastic lesions. The importance of surgical exploration of avascular "benign" renal masses is emphasized.

Hypophysectomy in the treatment of disseminated carcinoma of the breast and prostate gland.

Transsphenoidal hypophysectomy offers gratifying palliative relief of pain to patients with metastatic cancer of the breast and prostate. This report represents the results of two years' experience with this procedure at Emory University School of Medicine. The physiologic rationale and clinical indications for hypophysectomy are described, as is the operative technic using the open transsphenoidal microsurgical approach. The series of cases reported here includes 20 men with disseminated prostatic carcinoma and 23 women and one man with metastatic carcinoma of the breast. All 44 procedures were done by the transsphenoidal microsurgical approach. Pain was the preoperative indication for surgery in 41, while three patients were operated on for extensive disease without pain. Satisfactory relief of pain was obtained in 76% of the patients with prostatic cancer and in 83% of the breast cancer patients. While the results are gratifying with regard to relief of pain, the duration of follow-up is not sufficient to comment on the value of the procedure in significantly prolonging life.

PIP: The indications for and the results of hypophysectomy for advanced cancer of the breast or prostate gland are reviewed. The technic of open microsurgical transsphenoidal hypophysectomy is described. Since the metabolism of some breast cancers is influenced by estrogenic hormones, the major effect of hypophysectomy seems to be the complete suppression of estrogen production by the gonads and adrenal glands by removal of gonadotropin and ACTH, respectively. Other specific substances, such as growth hormone or prolactin, may also be factors. In cases of prostate cancer which relapse after castration, the adrenals seem to elaborate a significant amount of extradgonadal androgen. Hypophysectomy removes the source of ATCH and thus stops androgen production by the adrenal glands. Other hormones may also be important. In premenopausal patients with advancing cancer of the breast, oophorectomy should be the initial procedure. Most patients after a previous favorable response to oophorectomy get a subsequent objective improvement from hypophysectomy. In postmenopausal patients the effects of hormone therapy should 1st be tried. Many patients responding favorably to hormone therapy will also be benefited later by hypophysectomy. Remission rates are higher in older women. However, hypophysectomy should be carried out relatively early to obtain a useful remission. About 25% of those not responding to other methods will obtain a remission following hypophysectomy. Along interval after the mastectomy before metastases occurs is a favorable prognostic sign. While bony metastases respond best, other sites of metastases do not contraindicate the operation. Most patients with prostatic metastases obtain relief after hypophysectomy, even some of those who have not been benefited by other methods. Advanced age alone is not a contraindication. A preoperative evaluation should be done including a series of endocrine studies. Open microsurgical transsphenoidal hypophysectomy is considered the operation of choice. Complete removal of the gland is accomplished with less disturbance to the patient than an intracranial operation. General anesthesia is used. After the operation tests for pituitary reserve are repeated and a maintenance regimen of hydrocortisone prescribed. Thyroid replacement therapy is often needed. Subjective remissions are more common than objective ones, particularly relief of pain. This operation was done on 20 men with metastatic cancer of the prostate and 23 women and 1 man with metastatic cancer of the breast. Of the prostate cases, 3 patients died during the early postoperative period. Of the other 17, there have been 7 deaths from the cancers after 1-7 months. Of the 23 breast cases, severe body pain was the indication for the operation. Relief occurred in 19 (83%). There have been 7 deaths from the cancers. Hypophysectomy does not predispose to or lead to alterations in emotional state or mental function. Others with larger series of cases have reported that those responding favorably have lived an average of 25.8 months while average survival of those not so responding has been only 5.6 months.