Dermoid cyst of the maxillary sinus.

Dermoid cysts are rare developmental teratomatous lesions composed of ectodermally derived stratified squamous epithelium and mesodermally derived skin adnexal structures. As part of the teratomatous lesion group, dermoid cysts are related to teratoid cysts, true teratomas, and epignathi. Although several theories have been postulated, the pathogenesis of dermoid cysts, and teratomatous lesions in general, is unclear. Most commonly affecting sites within the head and neck, dermoid cysts may be found in the frontotemporal/lateral brow area, central nasal area, oral cavity, lateral neck, and other sites. We present what is believed to be the first reported case arising within the maxillary sinus and briefly discuss the possible pathogenesis.

Ureterolithiasis: can clinical outcome be predicted with unenhanced helical CT?

PURPOSE: To evaluate the use of helical computed tomography (CT) without contrast material enhancement for prediction of a favorable outcome in ureterolithiasis. MATERIALS AND METHODS: CT studies were reviewed in 69 patients with a single ureteral stone not located at the ureteropelvic junction. CT findings (tissue rim sign, hydronephrosis, perinephric fat stranding, perinephric fluid collections, and thickening of renal fascia) were graded on a scale of 0-3. Stone diameter and renal parenchymal enlargement were also measured. RESULTS: Twenty-two patients had spontaneous passage, 12 did not respond to conservative treatment, and 35 were lost to follow-up. When the latter 35 patients were excluded, perinephric fat stranding (P = .044) and perinephric fluid collections (P = .021) were graded significantly higher in patients with spontaneous stone passage. Mean stone diameter was significantly larger (P < .001) in patients in whom conservative treatment failed (mean, 7.8 mm) than in patients with spontaneous stone passage (mean, 2.9 mm). The presence of a tissue rim sign and the grade of hydronephrosis, renal fascial thickening, and renal parenchymal enlargement were not significantly different between the two groups. CONCLUSION: In addition to stone size, the degree of perinephric fat stranding and the presence of perinephric fluid collections are useful ancillary signs for help in predicting the likelihood of stone passage.

Unenhanced helical CT of ureterolithiasis: value of the tissue rim sign.

OBJECTIVE: The tissue rim sign-a rim or halo of soft-tissue attenuation seen around the circumference of an intraureteral calculus on unenhanced axial CT-has been described as useful in differentiating ureteral calculi from extraurinary abdominal or pelvic calcifications. The purpose of this study was to determine the prevalence of the tissue rim sign in patients with ureterolithiasis and extraurinary calcifications and to determine the relationship between the tissue rim sign, the size of a calculus, and the degree of urinary obstruction. MATERIALS AND METHODS: Unenhanced helical CT studies followed by excretory urography were obtained in 59 patients with suspected acute ureterolithiasis. Each calcification along the expected course of the ureter seen on axial CT scans was categorized as a ureteral calculus or as an extraurinary calcification. Each categorization was based on CT, urographic, and clinical findings and the presence or absence of a tissue rim sign. When the outer wall of the ureter could not be seen because there was no clear fat plane at the level of the calcification on CT, the sign was categorized as "indeterminate." The size of the calculus was measured on CT, and the degree of urinary obstruction was estimated on the basis of the urograms. RESULTS: Thirty-two patients each had a single ureteral calculus. Of these patients, CT revealed a positive tissue rim sign in 16 patients (50%), was negative in five patients (16%), and was indeterminate in 11 patients (34%). In addition, we saw 57 extraurinary calcifications in 18 patients (11 patients with ureteral calculi and seven patients without ureteral calculi). None of the 57 extraurinary calcifications was associated with a positive tissue rim sign. The tissue rim sign was negative in 39 (68%) of the 57 extraurinary calcifications and indeterminate in the remaining 18 (32%). Ureteral calculi with a negative tissue rim sign were larger than ureteral calculi with a positive tissue rim sign (p < .01). A high degree of obstruction was present in four of five patients with ureteral calculi for which CT showed a negative tissue rim sign. Conversely, six of 16 patients in whom CT revealed a positive tissue rim sign also had a high degree of obstruction. Therefore, no clear relationship was found between the degree of obstruction and the presence of a positive tissue rim sign. CONCLUSION: A positive tissue rim sign is specific for the diagnosis of ureterolithiasis. However, a negative tissue rim sign does not preclude such a diagnosis. The presence or absence of this tissue rim sign correlates with the size of a calculus but not with the degree of urinary obstruction. When CT reveals an indeterminate tissue rim sign, careful inspection for other CT findings, such as ipsilateral ureteral dilatation, perinephric edema, dilatation of the intrarenal collecting system, and renal swelling, is necessary.

High flow priapism associated with sickle cell disease.

Priapism associated with sickle cell disease is classically described as a low flow state. We report 2 cases of high flow priapism associated with sickle cell disease. High flow priapism has previously been reported almost exclusively in patients with traumatic rupture of the cavernous artery. Neither of our patients had historical or radiographic findings consistent with injury to the penile vasculature. One patient was treated unsuccessfully with intracorporeal injection of methylene blue and 1 underwent successfully bilateral pudendal artery embolization. The pathophysiological mechanism(s) responsible for the production of high flow priapism in patients with sickle cell disease is not known.

Renal cell carcinoma presenting as hemolytic anemia in pregnancy.

A patient presented at 29 weeks' gestation with severe hemolytic anemia. She was subsequently diagnosed as having renal cell carcinoma and had a radical nephrectomy at 31 weeks' gestation, which demonstrated stage I disease. This was followed by a normal vaginal delivery of a healthy infant at term and complete resolution of her anemia. This unusual presentation of renal cell carcinoma in pregnancy is discussed.

Voiding and erectile function after delayed one-stage repair of posterior urethral disruptions in 50 men with a fractured pelvis.

We evaluated 50 men who suffered a total disruption of the posterior urethra in conjunction with a fractured pelvis. The urethral disruption was treated with immediate placement of a suprapubic cystostomy and delayed one-stage urethroplasty. Subsequently, 15 required at least one visual urethrotomy and three underwent one urethral dilatation. All 50 now have a patent urethra and 38 (76%) void normally and are continent. Five have an areflexic bladder secondary to the injury and intermittently catheterize themselves but are continent. Three patients have mild urge incontinence and three mild stress incontinence, not requiring treatment or protection. One patient with an open bladder neck has moderate stress incontinence which has responded to imipramine therapy. Impotence was present both preoperatively and postoperatively in 24 (48%) of the patients but by one year only 16 (32%) of them were still not having erections. Eighteen patients (36%) claim to have erections equal to their pre-injury quality. However, 16 (32%) of the patients, although potent and able to have intercourse, have less than optimal erections.

The decline of urological education in United States medical schools.

In 1956, 99% of all medical schools required a clinical rotation through urology during year 3 or 4. By 1978 this percentage had decreased to 48% and currently it is only 38%. In addition, an estimated 10 to 15% of medical school graduates have never been exposed to urology (no lectures and no clinical rotation). Urological diseases continue to comprise a significant percentage of problems encountered by primary care physicians. The Education Council of the American Urological Association has adopted urological education objectives that should be incorporated into the curriculum of every medical school.

Intraoperative decision-making in renal trauma surgery.

Surgery for renal trauma requires three intraoperative decisions: Should the kidney be explored? Is pedicle control necessary? What procedure should be performed? In 85 explorations for penetrating (66) and blunt (19) trauma, we found that penetrating injuries, active hemorrhage, or major tissue destruction are reasons for mandatory renal exploration. This resulted in 26 nephrectomies, 9 partial nephrectomies, and 4 major renorrhaphies. Forty-six patients underwent minor renorrhaphy or needless exploration without complications. Formal pedicle control was carried out 33 times (39%), but it was never necessary to control parenchymal hemorrhage. Unless a wound overlies the great vessels, perirenal hematomas can be safely entered laterally without prior pedicle control using manual pedicle or parenchymal control if needed.

Bladder dysfunction in the elderly.

Bladder dysfunction in the elderly is an enormous public health problem. Laboratory research using animal models has to date not yielded clinically useful new information. Demographic and urodynamic studies in selected elderly patients indicate that neurological disease and bladder outlet obstruction are the primary causes for voiding dysfunction. The effect of aging per se on the urinary bladder is not known. Elderly patients who have bladder dysfunction should be evaluated with a careful history and physical examination combined with a practical urodynamic evaluation rather than simply being labeled as having "bladder dysfunction in the elderly."

Mixed density lesion of the anterior maxilla.

A case of COC which developed as a mixed lucent-opaque lesion in the anterior maxilla of a young person is discussed from the standpoint of clinical and radiographic differential diagnosis. Current concepts of the pathology of the COC and EOGCT are discussed.

Is phentolamine stable in solution with papaverine.

Although the intracorporeal injection of mixtures of phentolamine and papaverine is used commonly in the diagnosis and treatment of erectile dysfunction, pharmacological data relating to the stability of such drug mixtures are lacking. The stability of phentolamine mesylate in aqueous solution and in solution with papaverine (0.83 mg. per cc phentolamine and 25 mg. per cc papaverine) was ascertained by high performance liquid chromatography and gas chromatography with mass spectrometry. No degradation of phentolamine occurred during 40 days whether the drug or drug combination was refrigerated or stored at room temperature. Phentolamine is stable for at least 40 days when mixed with papaverine.

Development of fibrotic penile lesions secondary to the intracorporeal injection of vasoactive agents.

Fibrotic penile lesions developed in 4 patients who had undergone intracorporeal injection of vasoactive agents. These lesions persisted for at least 3 months, and in some instances they caused pain and curvature of the penis during erection.

Interstitial gold and external beam irradiation for prostate cancer.

We treated 65 patients with prostatic cancer confined clinically to the prostate or periprostatic area during an 8-year period. Seven patients had stage A2, 38 stage B and 20 stage C disease. All 65 patients underwent staging pelvic lymphadenectomy and implantation of gold grains into the prostate (mean dose 3,167 rad). A total of 64 patients then completed a course of external beam irradiation to a mean total tumor dose of 6,965 rad. Complications of therapy were mild and limited (less than 3 months in duration) in most patients, and they included radiation cystitis (32 per cent), diarrhea (31 per cent), extremity lymphedema (7.7 per cent) and wound infection (3 per cent). Two patients suffered urinary incontinence after therapy and 2 (3 per cent) had diarrhea more than 3 months in duration. The actuarial 5-year survival rate for all patients was 87 per cent and the 5-year survival free of disease was 72 per cent.

The use of indwelling ureteral stents in managing ureteral injuries due to external violence.

Eighteen consecutive cases of ureteral injury due to external violence occurring over a 6-year period were reviewed. The diagnosis of ureteral injury was made either preoperatively on an intravenous urogram, or intraoperatively using indigo carmine. No patient had an isolated ureteral injury. Four patients with ureteral contusions were managed expectantly and needed no further therapy. Eleven patients with ureteral lacerations underwent spatulated, interrupted anastomoses of absorbable suture and placement of Silastic double-J ureteral catheters and had prompt resolution of urinary drainage and normal urograms post stent removal. Two initially nonstented patients with lacerations required delayed ureteral stent placement for massive retroperitoneal urine leakage while one patient did well with simple ureteroureterostomy without stenting. The only important complication from the use of ureteral stents was limited to a single patient, who failed to return for followup and developed a staghorn calculus on the stent. The use of Silastic double-J ureteral catheters resulted in little morbidity and allowed: relatively maintenance-free care; an extra measure of safety in multiply injured patients; and early hospital discharge.

Anatomical localization and some pharmacological effects of vasoactive intestinal polypeptide in human and monkey corpus cavernosum.

Vasoactive intestinal polypeptide is hypothesized to be a nonadrenergic, noncholinergic neurotransmitter important in the physiology of penile erection. To further explore this concept, anatomical localization of vasoactive intestinal polypeptide, in vitro muscle bath studies and in vivo injection experiments were undertaken in the monkey and man. Using immunohistochemical techniques vasoactive intestinal polypeptide was localized at the light microscopic level to nerves within the monkey and human penis. Ultrastructurally, a modified peroxidase-antiperoxidase technique was used to identify large vasoactive intestinal polypeptide-positive vesicles within peptidergic and cholinergic varicosities. In the in vitro muscle bath, the addition of 10(-7) M vasoactive intestinal polypeptide did not alter the baseline tension of strips of monkey and human corpus cavernosum. During contraction produced by norepinephrine stimulation, however, vasoactive intestinal polypeptide (10(-7) M) caused relaxation of the monkey (41 +/- 18 per cent, no. = 8) and human (23 +/- 8 per cent, no. = 5) corpus cavernosum. Intracorporal injection of vasoactive intestinal polypeptide (0.75 X 10(-9) to 3.75 X 10(-9) moles/kg.) had no effect on the monkey penis. Administration of vasoactive intestinal polypeptide (1.25 X 10(-9) to 2.5 X 10(-9) moles/kg.) into the internal iliac artery of the monkey, while having no effect on the flaccid penis, caused detumescence of the erect penis obtained by cavernous nerve stimulation (2-5 V, 40 Hz, 2 msec.). Although vasoactive intestinal polypeptide can be found within the nerves of the penis, its apparent in vitro and in vivo effects raise further questions concerning the role of this peptide in penile erection.