Operative management problems in nephrobronchial fistula.

During left subcapsular nephrectomy in a patient with nephrobronchial fistula, the purulent material entered the bronchial tree through the fistulous tracts and flooded the dependent right lung. Patchy atelectasis and later massive consolidation of the lower lobe of the right lung ensued ultimately causing her death. A plea is made to use double-lumen endobronchial tubes for anesthesia to prevent such spillover of purulent secretions to the contralateral lung from the kidney. The fistulous tracts should be divided as the first step during surgery, before mobilization of the kidney. In a suspected case, retrograde pyelography should be done preferably under local or regional anesthesia, so that the patient could cough out the contrast material and purulent secretion that might enter the bronchial tree under pressure during the procedure.

Pedicled omental graft in repair of large, difficult vesicovaginal fistulae.

Large vesicovaginal fistulae, particularly those associated with urethral loss, present formidable repair problems. Omentum, recognized for its role in resolving abdominal infection, is successfully used for pedicle grafts in these complex situations. The authors present their experience in 25 cases, describing modifications of an earlier procedure.

Value and limitations of testicular scanning by in vivo labelling of RBC with 99mTc.

When a scrotal affection cannot be diagnosed confidently by correlation of clinical history and physical examination, testicular scanning with 99mTc is a useful adjunct diagnostic modality. In vivo labelling of red blood cells with 99mTc was achieved by prior oral administration of 200 mg of stannous chloride. This helped to obtain satisfactory scintigraphy with a rectilinear scanner. This procedure was found to be useful in the adult with recent tender testicle in whom the torsion of the testis could not be clinically differentiated from epididymo-orchitis. Another area of scan's valuable clinical application was in the early diagnosis of testicular abscess in patients with epididymo-orchitis not responding immediately to antibiotic therapy. The study also proved to be a useful, non-invasive method for follow-up assessment of a case of torsion of the testis where detorsion and orchiopexy was performed as well as in case of rupture of a testis after orchiorrhapy.

Fatal intra-peritoneal bladder rupture due to blocked catheter in a paraplegic.

A female paraplegic developed intraperitoneal rupture of urinary bladder seven weeks after institution of indwelling urethral catheter drainage. Blockage of the catheter precipitated this fatal event. Oliguria after an initial encouraging urinary output despite adequate fluid replacement led us to suspect bladder rupture which was confirmed by urgent cystography. Although emergency laparotomy to repair the rent in the bladder was performed, she succumbed to gram-negative septicemia. Other hazards of indwelling urethral catheter drainage even for short periods are highlighted (though the above complication itself is admittedly rare) with an oft re-emphasised plea to consider earlier the alternative modality of intermittent catheterisation or pharmacotherapy in female patients.

Non-operative management of a pelvic hydatid cyst communicating with the bladder.

Two cases are reported of spontaneous rupture of pelvic hydatid cysts into the bladder, which were managed conservatively. The resulting communication between the bladder and the cyst was used advantageously for intravesical instillation of 20% saline to destroy the germinal layer of the hydatid cyst and daughter cysts. Sequential cystographic studies showed disappearance of the extrinsic pressure effect on the bladder as the daughter cysts were evacuated repeatedly per urethram after instillations. Spontaneous sealing off of the communication was documented and confirmed by cytoscopy in 1 case. A plea is made to adopt a non-operative approach in such cases, which permits intravesical and, hence, intracystic scolecidal agent instillation and achieves spontaneous evacuation of daughter cysts. Other factors encouraging conservative management whenever possible are the reportedly high recurrence rate of hydatid cysts postoperatively, the morbidity described with complete excision of pelvic and other hydatid cysts, and the inherent slow process of recurrence (between 5 and 20 years) after complete evacuation of daughter cysts.

Vaginocystography in vesicovaginal fistulae.

The importance of vaginocystography as an additional tool to excretory urography and cystoscopy in assessment of vesicovaginal fistulae is emphasized. A simple technique applicable even to large and multiple fistulae or a capacious vagina is described and discussed.

Spontaneous rupture of renal pelvis during postobstructive diuresis.

A case of spontaneous rupture of the renal pelvis during postobstructive diuresis following spontaneous relief of anuria in a patient with postpyelolithotomy retroperitoneal fibrosis, is described. The unusual etiopathological setting which predisposed to the occurrence of such a rare phenomenon and its treatment implications are discussed.

Transurethral external sphincterotomy sans external sphincter.

Of 51 patients with detrusor-sphincter dyssynergia undergoing external urethral spincterotomy by transurethral resection, histological examination revealed no skeletal muscle in the resected tissue in six patients. The functional improvement which resulted in these cases despite this finding with an explanation for the same forms the topic of this paper.

Massive venous hemorrhage after bilateral internal iliac artery ligation following retropubic prostatectomy.

The possibility of massive venous hemorrhage after bilateral internal iliac artery ligation for postprostatectomy bleeding is illustrated by this case report. Emergency measures to differentiate the arterial from the venous sources of such a hemorrhage and their influence on the subsequent management are discussed.