Severity of aortic atheromatous disease diagnosed by transesophageal echocardiography predicts stroke and other outcomes associated with coronary artery surgery: a prospective study.

Advanced atheromatous disease of the thoracic aorta identified by transesophageal echocardiography (TEE) is a major risk factor for perioperative stroke. This study investigated whether varying degrees of atherosclerosis of the descending aorta, as assessed by TEE, are an independent predictor of cardiac and neurologic outcome in patients undergoing coronary artery bypass grafting (CABG). Intraoperative TEE of the descending aorta was performed on 189 of 248 patients participating in a randomized controlled trial of low (50-60 mm Hg) or high (80-100 mm Hg) mean arterial pressure during cardiopulmonary bypass for elective CABG. Aortic atheromatous disease was graded from I to V in order of increasing severity by observers blinded to outcome. Measured outcomes were death, stroke, and major cardiac events assessed at 1 wk and 6 mo. Nine of the 189 patients with TEE examinations had perioperative strokes by 1 wk. At 1 wk, no strokes had occurred in the 123 patients with atheroma Grades I or II, while the 1-wk stroke rate was 5.5% (2/36), 10.5% (2/19), and 45.5% (5/11) for Grades III, IV, and V, respectively (Fisher's exact test, P = 0.00001). For 6-mo outcome, advancing aortic atheroma grade was a univariate predictor of stroke (P = 0.00001) and death (P = 0.03). By 6 mo there were one additional stroke, three additional deaths, and one additional major cardiac event. Atheromatous disease of the descending aorta was a strong predictor of stroke and death after CABG. TEE determination of atheroma grade is a critical element in the management of patients undergoing CABG surgery.

Removal of a multicystic half of a horseshoe kidney: significance of preoperative evaluation in identifying abnormal surgical anatomy.

A rare case of multicystic dysplasia in half of a horseshoe kidney is presented. Proper evaluation led to a modified surgical approach necessary for adequate exposure, division of the isthmus, and removal of the diseased component. Considerations applicable to the treatment of multicystic dysplasia and renal fusion are discussed. The surgical anatomy of horseshoe kidney is reviewed.

Varicocelectomy: incidence of external spermatic vein involvement in the clinical varicocele.

The vascular anatomy of the clinical varicocele, and the incidence of involvement of the external spermatic vein were studied. Dilation of the external spermatic vein (4 mm) was found in 49.5 percent of 93 varicoceles in 67 patients. The location of this vein, its potential involvement in a varicocele, and its management were reviewed.

Deterioration of semen parameters over time in men with untreated varicocele: evidence of progressive testicular damage.

OBJECTIVE: To report observations of semen parameters in men with untreated varicocele over time. DESIGN: Semen parameters in 13 men with varicoceles were obtained at initial presentation, and re-evaluated at a 9 to 96-month interval because of persistent infertility. SETTING: Outpatient male fertility clinic. PATIENTS, PARTICIPANTS: Thirteen men who presented for fertility evaluation and who were found to have varicocele(s) and normal semen parameters. Re-evaluation was performed because of continued fertility problems. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Semen parameters, especially sperm density, sperm mobility, and total sperm. RESULTS: Statistically significant deterioration was noted from normal to abnormal. CONCLUSION: In males with varicocele(s), normal semen parameters should not routinely be expected to remain normal over time.

Surgical implantation of the artificial urinary sphincter.

The surgery necessary for sphincter placement is much more difficult than that required during the placement of penile prostheses, and there is definitely an associated learning curve. The risks of complications are present, but for a patient with the severe social and psychological disability of urinary incontinence, these risks are generally acceptable.

Followup of ureterosigmoidostomy diversion for bladder exstrophy--behavioral biofeedback as an alternative treatment for fecal-urinary incontinence: a case report.

A total of 6 children underwent primary ureterosigmoidostomy diversion between 1972 and 1979. Despite preoperative testing of rectal competence all 6 children now experience rectal leakage. Behavioral biofeedback has been used in a 7-year-old boy who had learned to isolate and to contract the perineal muscles appropriately by 12 months of followup. The incidence of incontinence has been reduced from 15 to 5 per cent of the total hours recorded. The amount of waking hours in which the patient is wet has decreased from 31 to 6 per cent. Satisfaction of the child and parents is high.

Scott's inflatable penile prosthesis: evaluation of mechanical survival in the series 700 model.

The series 700 penile prosthesis was implanted in 131 patients. Actuarial analysis revealed survival of the cylinders to be 98 per cent at 1 year and 92 per cent at 36 months. The only additional failures were leaks in the reinforced tubing in 9 cases. No tubing leaks have occurred since revisions were made by the manufacturer in October 1983.

Penile prosthesis: review of current models, mechanical reliability, and product cost.

A fifty-year experience with the modern penile implant has led urologists to conclusions as to the reliability, applicability, and cost of these devices. Product evolution has led to a more physiologic erection. However, with increased sophistication, further potential for failure must be considered. Each modification must undergo the test of clinical experience in addition to classic bench testing in order to predict reliability accurately.

Urinary incontinence in the elderly. Ways to relieve it without surgery.

Few studies of incontinence have been done on the elderly as a specific population, although epidemiologic reports reveal that incontinence is a debilitating condition that affects 15% to 30% of the elderly population of the United States. In diagnosing the problem, we use the simplest procedure that can supply the required information. However, if the diagnosis is uncertain or the treatment being considered is risky, urodynamic testing is necessary. Several nonsurgical treatments are available and have varying degrees of success in reestablishing continence. Some, such as pharmacotherapy and intermittent self-catheterization, are effective for some patients and are replacing bladder drill and bladder distention in popularity. Less conventional techniques (electrotherapy, biofeedback, and periurethral injection) are useful only in select cases and have had fewer clinical trials. Clamps and external devices for men and pessaries for women are prone to complications and generally are avoided in our practice. Long-term use of indwelling catheters is a last resort, to be considered only when all other alternatives have been exhausted. Further clinical research that considers the particular problems of the elderly is needed so that practical, humane, and effective treatment becomes possible.

Intermittent catheterization: evaluation of complete dryness and independence in children with myelomeningocele.

We studied 46 children in active followup who have been managed by nonsterile intermittent catheterization to achieve continence. All patients were given maximum therapeutic doses of supplemental medication to improve dryness. Of the patients 33 per cent were noncompliant and, therefore, wet, 30 per cent were wet despite full compliance with the program, and only 24 per cent were completely dry and wearing regular underclothing. Nine children experienced side effects from the supplemental medications that were severe enough to warrant discontinuation of the drug. Of the 46 patients 19 have been removed from the catheterization program and currently are being managed by other modalities. Only 11 of the remaining 27 patients currently managed by catheterization perform the procedure independently. Results suggest that intermittent catheterization does not provide independence or social continence in many patients.

The inflatable penile prosthesis, reoperation and patient satisfaction: a comparison of statistics obtained from patient record review with statistics obtained from intensive followup search.

Of 179 patients who received the inflatable penile prosthesis 43 per cent have required reoperation, 60 per cent of which were performed for mechanical failure. An attempt to evaluate the adequacy of chart review in assessing current function and patient satisfaction was made by comparing reports obtained by chart review to those obtained by direct patient interview. Results showed that if chart review alone was used malfunction would have been underestimated by 13 per cent and patient satisfaction overestimated by 21 per cent. The importance of direct followup in evaluating patients with the inflatable penile prosthesis is demonstrated.

The inflatable penile prosthesis: failure of the rear tip extender in reducing the incidence of cylinder leakage.

Of 184 patients who have received an inflatable penile prosthesis at our institution since 1974, 43 per cent have undergone reoperation, the majority of which were owing to cylinder leakage. Comparison by life-table analysis of cylinders placed before and after introduction of the rear tip extender does not show an improvement in cylinder survival to date.

The diagnosis and surgical management of vasculogenic impotence.

Thirty-two patients have been treated for organic impotence at our institution during a 16-month period. Of these patients 5 were found to have penile vascular insufficiency and underwent a femorocavernosal bypass with an autogenous saphenous vein graft. Initial results were excellent but late failures occurred. At 28 months all shunts were occluded. Microscopic examination of the cavernous tissue revealed fibrous thickening of the septa and loss of cavernous spaces. These findings suggested that late failure in direct revascularization may be associated with fibrotic changes that occur under high pressure inflow to the corpora cavernosa.

Aggressive management of bilateral renal cell carcinoma.

We review 4 cases of bilateral renal cell carcinoma. Treatment included extracorporeal surgery with subsequent autotransplantation in 2 patients and radical nephrectomy combined with contralateral partial nephrectomy in the remaining 2 patients. Absence of recurrence as well as length of patient survival supports this aggressive therapy.

Correlation of antibody-coated bacteria with intravenous pyelogram in children with refluxing and nonrefluxing units.

A fluorescent technique for detecting immune globulins on the surface of urinary bacteria has been used to differentiate upper from lower urinary tract infections. In an attempt to correlate positive fluorescence with deteriorative changes on the intravenous pyelogram, a total of 79 pediatric patients was studied. Twenty-three had ileal conduits with freely refluxing urine. The remaining 56 children had intact urinary tracts. Thirty of these had vesicoureteral reflux. Urine cultures were studied in conjunction with fluorescent antibody determinations. In patients with significant bacteriuria good correlation was seen with the presence of bacterial fluorescence and positive renal changes. This correlation was 88 per cent in patients with bowel conduits, 71 per cent in patients with vesicoureteral reflux, and 38 per cent in patients without reflux. Possible false positive and false negative results were relatively low, each occurred in 10 per cent of the specimens examined. It is concluded that the combindation of urinary tract infection and positive bacterial fluorescence is seen when upper tract deterioration has occurred and is seen most frequently in association with urinary reflux. In these instances aggressive therapy is often indicated.