Renal transplantation in Mississippi.

The present article reviews the results of cadaveric renal transplantation and organ donation in Mississippi during the years 1984-88. Patient and graft survival in cadaveric renal transplantation have continued to improve since the introduction of cyclosporine as an immunosuppressive agent. In the Mississippi Transplant Program recipients of primary cadaveric renal transplants currently demonstrate 93% patient and 82.3% graft survival rates. Despite this improvement in outcome slightly more than 1% of ESRD patients in the state undergo transplantation annually compared to 7.5% nationally.

Leuprolide acetate in the management of ureteral obstruction caused by endometriosis.

Endometriotic ureteral obstruction is a serious event commonly diagnosed late and therefore associated with a major risk of hydronephrotic renal atrophy. The standard therapy is surgical. However, medical treatment has been reported using danazol, progestins, and estrogen-progestin combinations, although solid documentation of the effect of hormonal therapy against ureteral endometriosis is lacking. Gonadotropin-releasing hormone (GnRH) agonist treatment of endometriosis has yielded good results but has not been adequately reported in patients with ureteric involvement. We report three patients treated with a GnRH agonist, leuprolide acetate, for 6-9 months as a preoperative course. One patient had bilateral and two had unilateral obstruction. The preoperative course relieved the obstruction in the patient with bilateral disease and in one with unilateral changes. The failure occurred in a patient with intrinsic ureteric endometriosis. This early experience suggests a place for GnRH agonist therapy for patients with ureteric obstruction due to endometriosis, probably, but not necessarily, in conjunction with a planned surgical procedure. If medical therapy is attempted, close surveillance of renal function is mandatory.

CAPD patients as renal transplant patients.

Most authors state that the continuous ambulatory peritoneal dialysis (CAPD) patient is not at increased risk when transplanted. These patients are always exposed to the risk of peritonitis, which may increase if patients are peritoneally dialyzed while immunosuppressed. The postoperative course of patients transplanted from our CAPD program from 1979 through August 1985 was evaluated. The transplant survival of patients dialyzed by CAPD, home hemodialysis, and at a free-standing dialysis facility were compared. Pretransplant dialysis modality did not influence long-term transplant success. Three of seven patients who required dialysis postoperatively developed peritonitis. The dialysis catheter was removed in two patients and one was treated by lavaging the peritoneal cavity with antibiotics. There was one instance of dialysate leaking through a drain in the transplant bed. This patient was converted to hemodialysis for subsequent dialysis. The dialysis catheters were removed at the time of discharge from hospital. Literature review confirmed this experience. Peritoneal dialysis post-transplant exposes the patient to a 10-33% risk of peritonitis and a 10% risk of a wound complication. Peritoneal dialysis patients are subject to risks unique to peritoneal dialysis. These complications do not translate into excessive morbidity or graft loss.

Bladder disruption in the premature male neonate.

Bladder injury in children is an unusual event that usually is associated with trauma or a surgical mishap. We describe-2 premature male neonates who were treated by minimal stimulation therapy and systemic paralyzation. Despite normal urological anatomy, each patient had a bladder rupture that we attributed to atony of the bladder coupled with the Credé maneuver, which produced high intravesical pressures.

Danazol in the management of ureteral obstruction secondary to endometriosis.

Ureteral obstruction caused by endometriosis is uncommon. It is, however, an important complication that imposes a 25% chance for permanent loss of renal function on the affected side. The standard management is surgical; however, three cases have been reported in which regression of obstruction followed medical therapy. This case report concerns a patient with long-standing partial ureteric obstruction due to endometriosis who was treated for 2 months with danazol. Clinical response of the endometriosis was excellent, but the obstruction persisted, a retroperitoneal ureteroneocystotomy was therefore performed. The ureter was found to be obstructed by dense fibrous tissue that contained endometrial glands. It seems therefore that a trial of danazol may be attempted in selected cases, but that the drug is unlikely to relieve endometriotic ureteric obstruction once dense fibrosis has occurred.

Chronic granulocytic leukemia after renal transplantation.

Chronic granulocytic leukemia (CGL) developed in a 31-year-old man after he underwent a third renal transplant. The leukemia was initially controlled with azathioprine sodium and prednisone therapy, but eventually it entered blast cell crisis. This was controlled with an adult acute lymphocytic leukemia protocol with an excellent response. Despite discontinuing treatment with azathioprine and with the use of busulfan to control the peripheral WBC count, the patient maintained stable renal function for one year following treatment of the blast cell crisis and subsequently died of sepsis. We suggest that CGL after renal transplantation is similar to that observed in the general population and can be treated with the usual chemotherapeutic agents for the disorder without sacrificing renal function.

Complications of posterior urethral valve surgery and their prevention.

The treatment of patients with posterior urethral valves has improved dramatically in recent times. Our personal experience with 207 patients with posterior urethral valves between 1957 and 1978 reveals a striking reduction in both mortality and morbidity during the latter decade. We have attempted to identify clearly the incidence, etiologic factors, preventive measures, and surgical treatment of complications arising in these patients. The overall improvement in management is certainly attributable to a growing experience and the constant advancements in the medical and surgical armamentarium. Our next goal at this time is to maximize long-term renal function and growth potential in these patients.

Megalourethra with posterior urethral valves.

A case of posterior urethral valves and scaphoid megalourethra is presented. We believe this is the first report to document the association of these two anomalies, although urethral valves have been reported in at least 2 patients with saccular anterior urethral diverticula. Although fusiform megalourethra is often associated with other genitourinary anomalies, the scaphoid type is thought to be an isolated defect. This report would suggest that patients with either type of megalourethra should have complete urologic investigation.

Cryptorchidism in boys with posterior urethral valves.

A review of 207 male children with poterior urethral valves revealed an over-all incidence of cryptorchidism of 12 per cent. This association of cryptorchidism in boys with posterior urethral valves has not been described previously.

Renal function in continent patients after surgical closure of bladder exstrophy.

We assessed the upper urinary tracts and renal function in 22 children who had achieved continence after staged correction of bladder exstrophy. All patients had been followed for an average of 8 years after completion of the reconstructive operation. In 15 patients the upper urinary tract was normal and only 1 of the remaining 7 required surgical correction (transureteroureterostomy) of the residual anomaly. Renal function was normal in all children. We attribute these satisfactory results to careful selection of patients, improved surgical techniques and good postoperative care.

Primary hydronephrosis. Assessment of diuretic renography, pelvis perfusion pressure, operative findings, and renal and ureteral histology.

Hydronephrosis generally implies ureteropelvic junction obstruction, but may be mimicked by a variety of other disorders. The authors have attempted to determine the relative diagnostic value of diuretic renography and the pelvis perfusion test in children with hydronephrosis by correlating the results with operative findings, renal and ureteral histology, and postoperative results.

Growth in boys and posterior urethral valves. Primary valve resection vs upper tract diversion.

Seventy-four patients with posterior urethral valves were evaluated for long-term growth potential and renal function. In those boy diagnosed and treated within the first year of life, initial treatment by temporary supravesical diversion (prior to valve resection) was associated with better growth potential and renal function than was treatment by primary valve resection alone.

Siblings with prune belly syndrome and associated pulmonic stenosis, mental retardation, and deafness.

This is the fifth family in the literature with siblings having the prune belly syndrome. It is the first with associated pulmonary stenosis, mental retardation, and hearing deficit. A genetic factor is suggested as the primary cause of the syndrome.

Mechanical genital maldevelopment presenting as pseudovaginal perineoscrotal hypospadias.

Pseudovaginal perineoscrotal hypospadias is the descriptive terminology of a phenotypic genital abnormality that may develop from multiple etiologic factors, such as defective virilization-masculinization owing to deficient androgenic synthesis, defective androgenic action or mechanical embryologic failure. The case presented herein typifies a mechanical abnormality that results in perineal hypospadias with the appearance of a vaginal introitus but with rectal mucosa incorporated in the urethral opening.