Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.

Bilateral nephrectomy concomitantly with renal transplantation.

During a 2-year interval 206 patients underwent renal transplantation at a single center, 38 of whom underwent bilateral nephrectomy and other adjuvant operations as part of the transplant procedure. The indications for this type of procedure were reviewed, with special emphasis on the control of hypertension. The morbidity and mortality (16 per cent) in this group were compared in detail to those in patients not undergoing a concomitant adjuvant operation. The results with regard to renal function were similar to the group as a whole and the indications for appropriate patient selection are discussed.

Factors influencing the outcome of kidney transplants.

This study is a multifactorial analysis of 389 transplants performed from June 1977 to December 1981. Analysis of the effects of transfusions antilymphocyte serum (ALS), histocompatibility testing, gender, and patient risk factors (presence of concomitant disease, greater than 50 years of age, etc.) was done. Two-hundred fifty-three patients received cadaver kidneys and 136 patients obtained kidneys from a relative. Two-hundred eighty-three (73%) patients received blood transfusions prior to transplantation. Our data showed that recipients receiving transfusions prior to transplantation had a significantly higher graft survival than those who were not transfused in both cadaveric and related graft recipients. Two-hundred twenty-one (56%) patients received ALS following the transplant. This group had a 15% higher graft survival than a comparable group. Analysis of histocompatibility testing data shows approximately 5% higher functional graft survival between each match grade. Surprisingly, female patients receiving kidneys from living related donors had a 16% higher graft survival than male patients. In cadaver recipients female patients had a 10% higher patient survival as compared to male patients. The risk factor status of recipients affected not only graft survival but patient survival, which probably is due to the consequences of immunotherapy. The authors' conclusion is that the above mentioned factors may be additive in nature. Further, multivariable analysis is necessary in order to correctly transplant data.

Concurrent renal tuberculosis and contralateral transitional cell carcinoma of the renal pelvis: a case report.

We report a case of 2 concurrent serious renal problems in opposite kidneys. The patient presented with gross hematuria, which resulted in a diagnosis of transitional cell carcinoma of the renal pelvis and tuberculosis of the contralateral kidney. Intraoperative nephroscopy allowed for appropriate diagnosis and surgical therapy.

Practical experience with percutaneous nephrostomy: avoidance of common technical pitfalls.

In our 18-month experience with percutaneous nephrostomy (PCN) at Vanderbilt University Hospital and Veterans Administration Hospital (Nashville), a total of 47 PCNs were attempted with a success rate of 96%. The procedure is rapid, offers low morbidity, and has been readily accepted. Some variations of the standard procedure to avoid common technical difficulties include (1) using a combination of real-time ultrasonography and fluoroscopy as a guidance system, (2) maintaining the position of the Chiba needle during the entire procedure, (3) choosing the optimal puncture site, and (4) exercising care in tract dilatation.

Bacteremia and bacteriuria after transrectal prostatic biopsy.

To determine the efficacy of parenteral gentamicin versus povidone-iodine enema (P.I.E.) in preventing infectious complications, a randomized study was undertaken in 40 patients undergoing transrectal needle prostatic biopsy. In 69 per cent of patients not receiving P.I.E. bacteremia developed, and 32 per cent acquired bacteriuria; whereas only 19 per cent of patients given P.I.E. alone or in combination with gentamicin because bacteremic, and 9.5 per cent had postbiopsy bacteriuria. Thus, P.I.E. provided a safe and effective means for preventing most bacteremia and bacteriuria associated with transrectal biopsy of the prostate.

Cryptococcal septicemia associated with urologic instrumentation in a renal allograft recipient.

A case is presented of a renal allograft recipient with 2 episodes of cryptococcal septicemia temporally related to genitourinary manipulation, which preceded the usual signs of meningeal or cutaneous infection. A review of the literature suggests that cryptococcal disease may, occasionally, manifest itself initially in the genitourinary tract. Therefore, we suggest that cryptococcal infection be suspected in the compromised host who has symptoms of cystitis or bladder outlet obstruction during a short period.

Prostatic needle examination: current clinical concepts.

A survey of urologic training programs was undertaken to determine the clinical usage of needle biopsy technics in evaluating prostatic disease. The most popular procedure was transperineal (57%), performed on an inpatient basis (62%). Transrectal biopsy was slightly less popular (43%), with 100% of the surveyed institutions using prebiopsy antibiotic coverage versus only 24% with the transperineal technic. An average of 3.25 cores per biopsy procedure were obtained. Various advantages and disadvantages of each procedure including the use of anesthesia and analgesia are discussed and future direction is proposed.

Giant renal calculus with metastatic carcinoma.

A case of a massive renal calculus is described. The radiographic appearance is discussed, and attention is drawn to the more subtle radiographic finding of a metastatic tumor which proved fatal. No autopsy was done.

Anaerobic infection as a consequence of transrectal prostatic biopsy.

Reports on large series of prostatic needle biopsies have revealed many and varied complications but none has described anaerobic bacteremia as a complication. Herein are reported 2 such cases, with a discussion of the etiology various altered host factors and therapeutic modalities important to anaerobic infections. The consideration of anaerobic infection in the febrile patient after transrectal prostatic biopsy is emphasized.

Splenic cysts in the differential diagnosis of suprarenal masses.

Splenic cysts are uncommon and their preoperative diagnosis is suspected rarely from the clinical presentation. The urologist should be aware that on an excretory urogram these cysts appear as suprarenal masses, suggesting adrenal enlargement. Two recent cases are presented, with a discussion of their classification, incidence, diagnostic evaluation and therapy.

Vesicosalpingovaginal fistula.

The first reported case of a vesicovaginal fistula in which the fallopian tube serves as a conduit between the bladder and vagina is presented. Clinical manifestations, including recurrent urinary tract infection and cuff abscess, followed vaginal hysterectomy performed three years perviously.