Technique of parastomal hernia repair using synthetic mesh.

We describe a reliable and simple technique of parastomal hernia repair using primary fascial repair with synthetic mesh that minimizes the known complications of infection and stomal stenosis while eliminating the need for peritoneal exploration, lysis of adhesions, and relocation of the stoma. We applied this technique to 6 patients (aged 65 to 83 years) with symptomatic, first-time parastomal hernias. The results are discussed.

The treatment of prostate cancer: an overview of current options.

PURPOSE: The purpose of this report is to discuss the current treatment options available to the patient with prostate cancer in all stages of the disease. OVERVIEW: With the exception of skin cancer, prostate cancer is the most common cancer in men in the United States. Most patients in the current era will present with organ-confined disease, amenable to curative treatment. Treatment for organ-confined disease includes watchful waiting, radical prostatectomy, radiation therapy, and cryosurgery in selective cases. Hormone therapy is the cornerstone of treatment of patients with advanced prostate cancer. There is no curative treatment for hormone-refractory prostate cancer. CLINICAL IMPLICATIONS: The availability of several therapeutic options for localized prostate cancer warrants careful consideration when planning treatment with curative intent. Patients need to be active participants in decision making, and they must be aware of the benefits and possible complications of the different types of treatment. Patients with advanced prostate cancer need to be aware that hormone treatment will provide temporization and palliation in the majority of cases. Hormone-resistant prostate cancer is refractory to most forms of conventional and experimental therapy.

Preliminary results of percutaneous treatment of renal cysts with povidone-iodine sclerosis.

Symptomatic renal cysts can be treated with percutaneous sclerosis using ordinary povidone-iodine solution. We describe our methods and outcomes in 5 patients so treated.

Identification of nuclear matrix protein alterations associated with renal cell carcinoma.

PURPOSE: Neoplastic transformation, including renal cell carcinoma (RCC), is always accompanied by changes in nuclear morphology. Nuclear grading of RCC is based on characteristic alterations in nuclear shape, size, area and other morphologic parameters. The nuclear matrix, which forms the skeleton of the nucleus, determines nuclear morphology. Alterations in nuclear matrix protein (NMP) composition specific to tissue and cancer type have been described in a variety of human cancers. We conducted a study to analyze the nuclear matrix protein composition of renal cell carcinoma and compare it to that of normal renal tissue and renal cell carcinoma cells grown in culture. MATERIALS AND METHODS: We analyzed the nuclear matrix protein composition of RCC tumor tissue and that of normal kidney tissue obtained from seventeen patients undergoing radical nephrectomy for RCC. We also analyzed the NMP composition of two renal cancer cell lines (A-498 and 769-P). RESULTS: We were able to identify five different and unique NMPs which were present only in the human RCC tumor samples and were absent in all normal kidney tissue. One NMP was found specifically in the normal kidney tissue. All five RCC specific NMPs were also identified in the nuclear matrix of the two cell lines analyzed. CONCLUSIONS: Five nuclear matrix proteins specific and unique to RCC were identified. These NMPs are different from those previously identified in other tissues and neoplasms. The RCC specific NMPs identified in this study can potentially be used as diagnostic markers for renal cell carcinoma and for therapeutic tumor targeting.

The use of 2 ipsilateral ureteral stents for relief of ureteral obstruction from extrinsic compression.

PURPOSE: We present our early experience with the novel approach of placing 2 parallel stents simultaneously in extrinsically obstructed ureters in which single stents had failed. The increased stiffness of 2 stents reduces kinking and luminal compression, and the potential space between the stents likely preserves flow around as well as through them. MATERIALS AND METHODS: Four patients recently presented with ureteral obstruction secondary to nonurinary tract malignancies. Previous stenting with a single 6F Double-J* stent had failed in all cases. Three patients experienced flank pain and 1 had persistent azotemia within 3 days of initial stent placement. All patients had significant residual sonographic hydronephrosis despite good stent position. In all cases cystoscopy/stent exchange was performed under local anesthesia with intravenous sedation. Parallel 4.7F Double-J stents were placed simultaneously over 2, 0.035 hydrophilic coated glide wires under fluoroscopic guidance after removal of the malfunctioning 6F stent. RESULTS: Stent placement was uneventful in all 4 patients with prompt drainage of contrast material seen after parallel ipsilateral stent placement. Patients tolerated the double 4.7F parallel stents with no discernible difference in irritative symptoms compared to single 6F stents. Flank pain and azotemia resolved in 3 patients, and hydronephrosis improved in all 4 after placement of parallel Double-J stents. All patients remain alive with a mean followup of 5.8 months (range 4 to 8). Except for 1 patient who later underwent ureterolysis, each has subsequently had the stent changed every 3 months. No patient has required proximal urinary diversion (that is percutaneous nephrostomy tube). CONCLUSIONS: Placement of 2 ipsilateral parallel ureteral stents simultaneously is an easy technique. It may obviate percutaneous nephrostomy tube placement in patients in whom drainage with a single stent failed, especially in cases of extrinsic ureteral compression.

Circumferential laser vaporization for severe meatal stenosis secondary to balanitis xerotica obliterans.

PURPOSE: A new technique for treating meatal stenosis due to balanitis xerotica obliterans was used. MATERIALS AND METHODS: Three patients with complete urinary retention and 1 with severe obstructive symptoms due to balanitis xerotica obliterans were treated with circumferential carbon dioxide laser vaporization of the urethral meatus. RESULTS: All 4 patients void spontaneously at 1 to 4.5 months of followup with peak flow rates of 1.25 to more than 3.0 standard deviations less than the mean normal peak flow rates at similar voided volumes. All patients are pleased with the postoperative results. CONCLUSIONS: Circumferential carbon dioxide laser vaporization monotherapy shows promise in treatment of meatal stenosis associated with balanitis xerotica obliterans.

Severe injury from neodymium: yttrium-aluminum-garnet laser therapy for penile condylomata acuminata.

Laser therapy is widely accepted as a safe and effective means of treating genital condylomata acuminata. In this report, single-session neodymium: yttrium-aluminum-garnet laser treatment of extensive condylomata of the penis resulted in deep coagulation necrosis and sloughing of penile shaft skin and urethra. Management of this unfortunate occurrence is also described.

Ureteral entrapment in the sacroiliac joint in pelvic trauma.

We describe a case of unilateral entrapment of the ureter in the sacroiliac joint of a patient who sustained blunt abdominal trauma resulting in fractures of the public rami and sacroiliac joint and multiple bladder perforations. The entrapment was discovered intraoperatively and released by external traction and reduction of the pelvic fractures. No ureteric damage was observed, and reimplantation was not necessary. The importance of evaluating the upper tracts for potential injury in patients with fractures of the bony pelvis and concomitant bladder rupture is emphasized.

The limited role of imaging techniques in managing children with undescended testes.

We studied the usefulness of radiography for localization of cryptorchid testes. A total of 23 radiographic studies ordered by referring physicians was done for testis localization in 18 boys. Two patients had retractile testes and were followed expectantly. Ultrasonography failed to detect palpable testes in both cases. A total of 16 boys (19 undescended testes) underwent operative exploration and the findings were compared. Ultrasonography correlated with the operative findings in 7 of 12 cryptorchid testes (58%), while computerized tomography and magnetic resonance imaging correlated in only 4 of 12 (33%) and 0 of 1 (0%), respectively. The overall accuracy of radiological testing was 44%. Physical examination was 53% accurate when performed by the referring physician and 84% accurate when done by the attending pediatric urologist. In no case did radiographic assessment influence the decision to operate, the surgical approach or the viability/salvageability of the involved testes. Preoperative radiography for undescended testes is neither necessary nor helpful.

Control of the deep dorsal venous complex in radical retropubic prostatectomy.

We describe a method to control the deep dorsal venous complex, which has allowed for a considerable decrease in blood loss during radical retropubic prostatectomy. We reviewed 28 consecutive patients treated with this technique with respect to blood loss (982 ml.), operating room time (197 minutes), complications, postoperative hospitalization and transfusion requirements. The results are favorable when compared to previous reports.

Carcinoma of prostate metastatic to parotid gland.

A rare case of prostate cancer with metastasis to the parotid salivary gland is reported. The prostatic origin of the mass was proven by incisional biopsy and immunohistochemical staining for prostate-specific antigen. Additional studies of the tumor included ultrastructural and quantitative deoxyribonucleic acid (DNA) analysis.

Therapeutic use of ganciclovir for invasive cytomegalovirus infection in cadaveric renal allograft recipients.

Between November 1987 and September 1989, 419 cadaveric renal transplants were performed at our university. Of the patients 36 (8.6%) had invasive cytomegalovirus infection documented by gastric or duodenal mucosal biopsy in 23 (64%), bronchoalveolar lavage in 12 (33%), allograft biopsy or nephrectomy specimen in 5 (14%) and/or liver biopsy in 1 (3%). Cytomegalovirus severity was defined as mild in 27 patients, moderate in 6 and severe in 3. Ganciclovir [9-(1,3-dihydroxy-2-propoxymethyl)-guanine] was begun once the diagnosis was confirmed by histology or culture at a median of 56 days from transplantation (range 28 to 133 days). Duration of ganciclovir therapy was a minimum of 7 days or until fever was absent for 5 consecutive days (mean 12.2 +/- 3.5 days, range 4 to 21). Ganciclovir was well tolerated and side effects were limited to de novo neutropenia (7 patients), thrombocytopenia (2) and rash (1). Initial clinical improvement was observed in all patients. Two patients had recurrent cytomegalovirus infections that responded to a second course of ganciclovir. The 1-year actuarial patient survival was 100%. At a mean followup of 12.7 +/- 6.2 months 19 patients retained allograft function with a mean serum creatinine of 2.5 mg./dl. (range 1.2 to 4.6). Ganciclovir appears to be a safe and effective drug for the treatment of tissue invasive cytomegalovirus infection in cadaver renal transplant recipients. Prompt institution of this drug at diagnosis of invasive cytomegalovirus may lower the mortality rate formerly associated with this disease.

Highly sensitized patients with delayed graft function: a management protocol.

The postoperative management of the highly sensitized renal transplant recipient with delayed graft function on cyclosporine is complicated. Allografts with delayed graft function are reported to have a 20 to 30% poorer 1-year survival than allografts without delayed graft function. Several factors may be implicated in this poorer 1-year survival. A decrease in or cessation of cyclosporine dosage frequently is used in an attempt to minimize nephrotoxicity. Such under-immunosuppression can result in irreversible rejection. Occasionally, a pessimistic view of the prognosis for the transplant may result in early abandonment of the allograft with discontinuation of immunosuppression and allograft nephrectomy. We report on 3 highly sensitized patients whose kidneys had delayed graft function and were deliberately maintained on high doses of cyclosporine throughout the period of delayed graft function. Each graft achieved function (2, 4 and 5 months) after transplantation. The serum creatinine levels 20, 28 and 38 months after transplantation were 2.7, 2.0 and 1.0 mg./dl., respectively. We suggest that the maintenance of high cyclosporine levels throughout the delayed graft function period is useful in highly sensitized recipients and was an important factor in their successful outcome. A management protocol for such patients is proposed.

Early experience with the DuraPhase penile prosthesis.

A retrospective review of the medical records of 26 consecutive patients who underwent surgical implantation of the DuraPhase penile prosthesis for erectile impotence was performed. In addition, telephone interviews were used to evaluate patient and partner satisfaction with the device. Average patient age was 61 years. The presumed etiology of erectile dysfunction was vascular in 19 patients, postoperative in 4 and neurogenic in 3. Followup averaged 5 months (range 1 to 15 months). Sixteen patients and partners with a minimum of 3 months of followup were evaluated for satisfaction with the device. On a scale of 1 to 10 the average patient score was 8.6 and the average partner score was 9. Our early experience with the DuraPhase penile prosthesis has been favorable. Surgical insertion is simple, and patient and partner satisfaction has been superior. The device functions easily, can be well concealed and has excellent axial rigidity for intercourse.