Technique and follow-up of percutaneous management of caliceal diverticula.

Between June 1985 and July 1992 we treated 20 patients who had symptomatic caliceal diverticula (13 in upper calix, 6 in middle calix, and 1 in lower calix) in whom long-term (3 months to 3 years) evaluation of persistent symptoms, physical condition, and radiologic findings was possible. Of the 20 patients, 19 had had stones in the diverticulum preoperatively, and the other had a huge diverticulum but no stones. Eighteen patients (95%) with stones preoperatively had been rendered stone free, and the other patient demonstrated only small residual stones in the area of the obliterated diverticulum. Sixteen patients (80%) had obtained complete resolution of their diverticula, and the remaining 4 had at least a 50 percent diminution of the original size of the lesion. All patients had been rendered free of infection and symptoms. Percutaneous management of caliceal diverticula is the most effective approach to rendering patients with caliceal diverticula stone free and achieving diverticular ablation.

Fibrin glue vasal anastomosis compared to conventional sutured vasovasostomy in the rat.

Vasectomy reversal has become a frequently performed surgical procedure with best results obtained with the use of the operating microscope and microsurgical technique. The present study was undertaken to evaluate the use of fibrin glue ("Tisseel", Immuno U.S., Inc.) for vasovasostomy and to compare this technique to conventional sutured vasovasostomy. Utilizing 60 male Sprague Dawley rats, a conventional two layered sutured anastomosis of vasovasostomy (30 rats) was compared to a fibrin glue technique of vasal anastomosis (30 rats). The fibrin glue technique was performed with two transmural sutures, was unstented, and utilized the biological glue to seal the anastomosis. The contralateral vas of each animal underwent vasectomy and reapproximation of unligated ends so that the rate of spontaneous recanalization could be accessed. Rats were sacrificed at 24 hours, one week, four weeks, and three months postvasovasostomy. The vasal specimens were evaluated for gross patency, presence and size of sperm granuloma, mean flow rates at varying infusion pressures, tensile strength measurements and histologic studies. Combining the one and three month groups, a similar patency rate was obtained by either technique; 83% (n = 18) for the sutured group, and 90% (n = 21) for the fibrin glue group. The rate of spontaneous recanalization of the contralateral vasa in the one and three month animals was 8% (n = 38). The mean flow rates obtained at high and low infusion pressures were not statistically different for the two techniques. The tensile strength of the glue anastomosis averaged 78% of the tensile strength achieved by the conventional sutured technique. The incidence of sperm granuloma after vasovasostomy was 28% for the fibrin glue group and 61% for the sutured group. Additionally, 67% of granulomas were small (less than 3 mm.) in the glue group, compared to only 36% in the sutured group. Histology revealed similar morphological changes in the area of anastomosis with either technique. Operative time for sutured vasovasostomy averaged 24 minutes, compared to an average of 11 minutes for the glue assisted vasovasostomy. The use of fibrin glue allowed the performance of a sperm tight patent anastomosis that had the advantages of reduced incidence of sperm granuloma formation, reduced operative time, and less microsurgical skill required to perform the anastomosis.

Management of benign prostatic hyperplasia. Alternatives to standard therapy.

Benign prostatic hyperplasia is a significant cause of morbidity in the elderly male population. The standard therapy for symptomatic prostatic obstruction has been prostatectomy by transurethral resection (TURP) or, less frequently, by open surgery. Innovative alternative treatments of benign prostatic hyperplasia, both surgical and nonsurgical, will be discussed. Additionally, an appraisal of TURP will be made.

Management of ureteroscopic ureteral injuries.

Ureteroscopy will continue to have a place in the management of renal stone disease and is invaluable to evaluate other types of ureteral lesions. Although ureteroscopy can be performed safely in most cases, it is invasive and there is a potential for ureteral injury. The well-trained urologic surgeon should be familiar with techniques to minimize the incidence of complications of ureteroscopy. However, faced with a ureteral complication, no matter the severity, the surgeon should have the ingenuity and expertise to restore anatomic integrity to the renal unit.

Alterations in regional myocardial function after heterogeneous cardioplegia.

Coronary stenoses lead to heterogeneous delivery of cardioplegic solution during cardiac operations. This situation was simulated by occlusion of the circumflex artery during cardioplegic infusion in canine right heart bypass preparations. Regional myocardial function (systolic shortening by sonomicrometer) was often diminished, despite preservation of global function. The correlation between recovery of circumflex regional function and recovery of stroke work or dP/dt (at constant aortic pressure, heart rate, and left atrial pressure) was poor (r = 0.17 and 0.07). The response of damaged regions to hemodynamic manipulations was studied. Increases in afterload after arrest did not lead to further deterioration of damaged regions. Volume loading (cardiac output 2 to 5 L/min) improved regional function even in severely damaged, bulging regions (p less than 0.05). Regional distensibility (delta length/delta left atrial pressure) decreased by 41% (p less than 0.02) in regions with poor protection and by 22% (p less than 0.01) in regions with good cardioplegic protection. There was also an increase in resting length (p less than 0.001) in both circumstances (5.2% and 3.7%). These changes in diastolic properties have not always been apparent in other experimental studies with less precise hemodynamic control. Heterogeneous cardioplegia causes heterogeneous changes in both diastolic distensibility and systolic function. These changes are poorly detected by examination of global ventricular function.