Transureteroureterostomy with cutaneous ureterostomy: a 25-year experience.

We reviewed 67 patients who underwent transureteroureterostomy with cutaneous ureterostomy for benign (32) and malignant (35) disease in regard to the indications for and complications of the procedure. The most common complications included urine leakage at the ureteroureterostomy, stomal stenosis and calculus formation. Renal function improved or remained stable in 75% of the patients. Transureteroureterostomy with cutaneous ureterostomy is a viable alternative diversion technique in a select group of patients.

Untreated rupture of the tunica albuginea.

A patient with untreated rupture of the tunica albuginea underwent surgical exploration 6 weeks after acute scrotal trauma. A layer of epithelium had grown across the bulging seminiferous tubules, and no further surgical repair was necessary. This spontaneous repair phenomenon has not previously been reported pictorially in the human testis. The recommended treatment of testicular rupture is surgical exploration and repair.

Males exposed in utero to diethylstilbestrol.

An increased frequency of various genitourinary anomalies, infertility, and testicular cancer among males has been reported to follow intrauterine exposure to diethylstilbestrol, but not all studies have confirmed an association. This study was designed to determine whether a cohort of males exposed in utero to diethylstilbestrol had a higher frequency of urogenital abnormalities than an unexposed cohort. Biases in selection of exposed and control participants were minimized. Of 828 exposed and 676 control men studied by medical-record review, 265 exposed men and 274 controls also underwent a special clinical examination. Overall, the data suggest that diethylstilbestrol exposure of males in utero did not increase their risk of genitourinary abnormalities, infertility, or testicular cancer. Previously reported increased frequencies of these abnormalities in diethylstilbestrol-exposed men may have resulted from selection biases or differences in diethylstilbestrol use, or both.

Influence of thiotepa and doxorubicin instillation at time of transurethral surgical treatment of bladder cancer on tumor recurrence: a prospective, randomized, double-blind, controlled trial.

The influence of the instillation of thiotepa or doxorubicin hydrochloride into the bladder at the end of transurethral surgical treatment on the recurrence of bladder cancer was evaluated. We studied in a randomized, double-blind, controlled fashion 89 patients with transitional cell epithelioma (carcinoma in situ or papillary carcinoma) whose tumors were considered to have been completely removed. Of these patients 28 (the control group) received a placebo (sterile water), 30 received thiotepa and 31 received doxorubicin. By 3 to 4 months postoperatively 71 per cent of the control group, and 30 and 32 per cent, respectively, of the patients treated with thiotepa and doxorubicin had recurrences (p less than 0.01). Additional treatment during the followup interval was ineffective in all groups. Patients studied also were classified according to grade, histological findings, multiplicity of tumors and history of bladder tumor. Treatment was most effective in reducing recurrence in patients with low grade, papillary or multiple tumors and in patients with a history of bladder cancer. No effect was observed in patients with single tumors and only modest effects were found in those with high grade tumors, carcinoma in situ or new tumors. The results support the concept that recurrences may arise from tumor cell implantation at the time of transurethral management of bladder tumors and may be reduced effectively by concomitant intravesical chemotherapy.

Pyeloscopy in urothelial tumors.

Intraoperative pyeloscopy was performed on 18 consecutive patients with indeterminate pelvic of caliceal filling defects, subsequently proved to be transitional cell carcinomas. After nephroureterectomy local tumor recurrence in the region of the renal fossa developed in 2 patients. Intraoperative pyeloscopy entails significant risks and the seeding of transitional cell carcinoma is possible.

Urinary tract reconstruction in renal transplantation. Mayo Clinic experience and review of literature.

Althrough rejection remains the most frequent cause of renal allograft failure, technical problems have contributed and continue to contribute to graft loss. Urologic complications may be caused by technical errors in the donor nephrectomy or in urinary tract reconstruction. During the past decade, however, with advances in medical and surgical management, the reported incidence of urologic complications in renal transplantation has declined steadily. This may be due to (1) more extensive donor and recipient preparation and evaluation for surgery, (2) improvement of surgical technique with increasing experience in donor and recipient, and (3) more refined diagnosis and treatment of urologic and infectious complications.

Gram-negative bacteremia after transrectal needle biopsy of the prostate.

Seven cases of bacteremia following transrectal needle biopsy of the prostate were reviewed. Symptoms developed within 24 to 72 hours after the procedure and required hospitalization and treatment with parenteral antibiotics. Escherichia coli was the causative agent in five patients and Klebsiella pneumoniae in two. Although relatively rare, this complication is associated with significant morbidity.

Intentional ureteral ligation in advanced pelvic malignant disease.

It is now widely accepted that debulking operative resections can provide effective palliation for some patients with advanced pelvic malignancy, particularly with those malignancies originating in the ovary. Some of these radical operations require the resection of long segments of the ureter and portions of the bladder. Although there is a variety of techniques that can be used in this situation to restore the continuity of the urinary tract, in some instances a simple ureteral ligation may represent the best method of managing the "short ureter." In our experience with 23 patients who underwent intentional ureteral ligation, the procedure was found to be safe, expeditious, and beneficial in managing some of the complex problems associated with advanced pelvic malignant disease.

Renal transplantation in patients with diabetes mellitus--revisited.

Sixty-one patients with end-stage renal failure due to diabetic nephropathy received 68 renal allografts from June 1970 to February 1978. Patient and graft survival results equaled those for nondiabetic patients, as reported by the Human Renal Transplant Registry (HRTR). Renal allografts from siblings or pretreated cadaver donors had a significantly longer survival time than did allografts from nonpretreated cadaver donors. It is concluded that renal transplantation with living related and pretreated cadaver donor kidneys continues to be the treatment of choice and is superior to other forms of treatment in the insulin-dependent diabetic patient with end-stage renal disease.

Unilateral essential hematuria.

At the Mayo Clinic between 1961 and 1975, 54 patients presenting with gross hematuria had "essential hematuria" of unilateral origin diagnosed. Criteria for this diagnosis included normal findings on excretory urogram, unilateral bleeding demonstrated at cystoscopic examination, the absence of infection, and a negative history for bleeding diathesis, analgesic abuse, renal surgery, or trauma. Of these patients, 52 responded to follow-up inquiry; 2 died of unrelated causes. Ancillary studies such as renal arteriography, renal biopsy, and repeated excretory urography and cystoscopic examinations were not helpful in establishing a cause, and no explanation for the hematuria was ever found in any of these patients. Although contributing no information as to the cause of unilateral essential hematuria, the study suggests that the patient who fulfills the above criteria need not undergo an extensive workup beyong excretory urography and cystoscopy and that repeated examinations are unnecessary and unrewarding. Most patients continue to do well despite intermittent or persistent hematuria. Essential unilateral hematuria probably is a benign condition that seldom requires surgical intervention.

Immunological donor pretreatment in combination with pulsatile preservation in cadaveric renal transplantation.

The extended experience on the efficacy of pretreating the cadaveric renal allograft donor by means of large doses of cyclophosphamide and methylprednisolone (group A, 36 kidneys) was compared with the experience regarding untreated renal allografts (group B, 32 kidneys). Kidneys in both groups were perfused by pulsatile means using cryoprecipitated plasma. There was a significant difference in allograft survival (72% in group A versus 36% in group B at 3 years by actuarial means). Also, large doses of cyclophosphamide and methylprednisolone as pretreatment did not cause any detrimental effect to the allograft kidney when used in combination with cryoprecipitated plasma and pulsatile perfusion.

Urinary tract complications with rectal surgery.

The possibility of urinary tract injury should always be considered in the course of anterior resection or combined abdominoperineal resection of the lower colon and rectum. Controlled studies of ureteral and other injuries and fistulas cannot be made; but fortunately, unanticipated damage to the lower urinary tract does not occur often. The surgeon operating in the pelvis should be aware of the problems rarely encountered and should be capable of their management. If a urologic surgeon is available, consultation often is desirable. Prompt intraoperative recognition is most important so remedial procedures can be carried out immediately. Delay in recognition and treatment jeopardizes the patient's course and the function of the urinary tract. Postoperative urinary tract infections should be diagnosed early so prompt treatment can be instituted.

Late ureteral obstruction mimicking rejection after renal transplantation.

Ureteral obstruction occurring five years or more after renal transplantation is uncommon and may mimic allograft rejection. In 2 patients who had received cadaveric renal allograft, ureteral obstruction was detected six and one-half and five and one-half years after transplantation. In both patients, surgery was needed to restore normal renal function and to prevent further renal damage. Excretory urography is important in the follow-up of patients who have undergone renal transplantation, and conditions such as ureteral obstruction should be ruled out before antirejection treatment is started.

Renal transplantation in patients with insulin-dependent diabetes mellitus.

Forty patients (including 37 juvenile diabetic patients) with insulin-dependent diabetes mellitus and end-stage renal failure received 42 renal allografts during the interval from June 1970 to December 1975. Of the 30 patients who are alive (between six and 72 months after transplantation; average, 29 months), 19 have been fully rehabilitated. Gangrene of peripheral extremities occurred in 30% of the survivors. The use of "pretreated" cadaveric kidneys in the diabetic patient may become an attractive alternative to grafts from living related donors. Renal transplantation with living related and pretreated cadaveric donor kidneys is the treatment of choice and is superior to dialysis in the insulin-dependent diabetic patient with end-stage renal disease.

Supravesical urinary diversion in renal transplantation.

Urinary diversion may be used in patients without a bladder or with irreversible, lower urinary tract abnormalities who might not otherwise be suitable candidates for renal transplantation. Three cases have been described to illustrate three different methods of supravesical urinary diversion that have been employed in association with renal transplantation.

The effect of intravesical formalin on the destruction and regeneration of the canine bladder.

Instillation of cytotoxic compounds into the bladder elicits an effect that is based on contact of the agent with the mucosal cells. In the female dog, the distribution of this contact is characteristically in the lower portion of the bladder, and the dome of the bladder is almost invariably spared. Study with formalin indicates that the amount of mucosal contact is best increased by distention of the bladder to full capacity. These findings have significance in the use of topically active agents for the treatment of bladder cancer.