To be a better leader, give up authority.

In chaotic times like these, an executive's instinct may be to strive for greater efficiency by tightening control. At least two companies, CSC Germany and ANADIGICS, have done the opposite--to impressive effect.

Nodular fasciitis of the bladder.

Nodular fasciitis is a nonneoplastic swelling consisting of fibroblastic proliferation and commonly occurring in the subcutaneous tissue of the extremities. We report a case of nodular fasciitis involving the wall of the bladder. It is important to be aware of the histological characteristics of this essentially benign condition so that unnecessary radical therapies can be avoided.

The impact of laparoscopy on modern urologic practice.

The original concept of laparoscopy developed as a branch of cystoscopy. Since the use of the Nitze cystoscope at its inception, laparoscopy has kept pace with the innovations in our cystoscopic inventory. The recently emerging interest of urologists in utility of the laparoscope for a variety of urologic surgery is a welcome renascence of this procedure, which has been used mainly by our gynecologic colleagues, in part because of our own lack of pursuit in its development. Laparoscopy should now become an integral part of our urologic teaching and practice.

Percutaneous nephrostomy for treatment of hydronephrosis of pregnancy.

Hydronephrosis of pregnancy is a common phenomenon that rarely requires invasive intervention. We describe a young woman with markedly obstructive hydronephrosis of pregnancy causing forniceal extravasation who was treated successfully by percutaneous nephrostomy. The rationale of such intervention and its advantages over retrograde ureteral catheterization or stenting are discussed.

Synchronous bilateral surgery for calculous disease of the upper urinary tract.

Bilateral calculous disease of the upper urinary tract frequently poses great difficulty in therapeutic decisions. Staged or sequential surgery is often recommended, with the side that is more obstructed, infected, or symptomatic operated on first. Despite all the rationalization for sequential surgery, we believe that a simultaneous surgical approach to bilateral calculous disease is feasible and advisable in some situations. On the basis of our experience with nine patients, we have categorized the indications for such surgery. In patients, with bilateral calculous disease for whom surgical intervention on both sides will at some point be necessary, simultaneous single-stage surgery is recommended. This is especially true: (a) with bilateral obstructive calculi; (b) in bilateral calculous disease with acute pyelonephritis when which side is affected is equivocal; (c) when anatomic proximity makes bilateral surgery easier, e.g. in bilateral lower ureteral calculi or bilateral calculi in horseshoe kidneys.

Dorsal lumbotomy for surgery of the upper urinary tract.

Between July 1978 and December 1985, 100 patients underwent an operation on the kidneys and ureter through the dorsal lumbotomy approach. A total of 12 patients underwent dismembered pyeloplasty for ureteropelvic junction obstruction. Compared to patients who underwent an operation via the standard flank incision, these 12 patients had significantly shorter hospitalization and fewer doses of analgesics. The treatment demonstrated improved cost-effectiveness. Similar advantages were noted in the remaining patients in whom removal of calculi (78), open renal biopsy (5), simple nephrectomy (4) and removal of a foreign body in the ureter (1) were done through the dorsal lumbotomy approach. We appeal for a renaissance of the dorsal lumbotomy approach in urological teaching and practice.

Vesical diverticulum associated with bladder carcinoma: therapeutic implications.

Of 146 patients with bladder diverticula during a 15-year period 9 had associated transitional cell carcinoma of the bladder: 3 (2 per cent of all patients with diverticula) in the diverticulum, 3 adjacent to the ostium of the diverticulum and 3 remote from the diverticulum. All 3 patients with carcinoma in the diverticulum died of metastases, whereas the other 6 patients survived more than 5 years. We propose aggressive treatment for patients with carcinoma in the diverticulum but we do not recommend routine diverticulectomy in cases of asymptomatic and uncomplicated diverticula.

Abdominal transposition of the female urethra.

Abdominal transposition of the female urethra, a rational choice for the surgical treatment of reflex neurogenic incontinence, has been used infrequently to date. We present a case to illustrate the steps in the surgical technique of transposition, emphasizing the principles we believe necessary to create a continent urethrovesical valve. If proper attention is given to surgical details the patient can achieve continence and require intermittent self-catheterization only.

Vesicoureteral reflux in women with primary bladder diverticulum.

In 22 years we treated 271 adults, including 149 women, for vesicoureteral reflux. We describe our management of vesicoureteral reflux in 12 women between 18 and 58 years old who had an associated primary vesical diverticulum. A vesical diverticulum located near the ureteral orifice caused reflux by destroying the ureterovesical valve in 11 of these 12 patients. In 1 woman a bladder diverticulum distant from the ureteral orifice acted as a reservoir of chronic infection, which perpetuated reflux in a marginally competent ureterovesical junction. The reflux disappeared after excision of the diverticulum. Reflux was bilateral in 3 and unilateral in 9 cases. Symptoms of acute pyelonephritis were noted in 3 women and radiographic changes of chronic pyelonephritis were noted in 4. Urinary infection was controlled successfully by medical management in 4 patients. Ureteral reimplantation after excision of the bladder diverticulum and repair of the bladder wall was successful in eradicating reflux in 5 patients. Each patient was followed for 3 or more years.

Upper urinary tract transitional cell carcinoma in patients with bladder carcinoma and associated vesicoureteral reflux.

Of 269 patients with bladder neoplasms treated during a 20-year period 47 had associated vesicoureteral reflux. All 47 patients were followed for 3 years or more, or until death. Upper urinary tract transitional cell cancer developed in 3, each of whom had recurrent bladder cancer. Among the 222 patients who had vesical cancer without reflux transitional cell carcinoma of the ureter developed in only 1, 11 years after transurethral resection for a bladder tumor. The incidences of upper tract transitional cell cancer in patients with and without vesicoureteral reflux were 6.4 and 0.44 per cent, respectively, which support the suggested role of reflux in disseminating or seeding of cancer cells from the bladder into the upper urinary tract. Patients with bladder cancer and associated vesicoureteral reflux have an approximately 15-fold greater risk of upper tract cancer developing compared with those without reflux. We recommend vigilant scrutiny of patients with recurrent bladder cancer and associated vesicoureteral reflux for early detection of upper urinary tract transitional cell carcinoma.

Vesicoureteral reflux in patients with obstructive prostatic disease.

We present our experience during a 22-year period with the management of 53 patients in whom vesicoureteral reflux was associated with obstructive prostatic disease. There were 45 cases of benign prostatic hyperplasia and 8 cases of carcinoma of the prostate. After prostatectomy medical management of reflux was successful in controlling urinary infection in 34 patients and an operation was performed in 19. Each patient was followed for at least 1 year.

Surgical management of benign renal cysts causing obstruction of renal pelvis.

During the last fifteen years, 6 adult patients were treated in whom obstruction of the ureteropelvic junction or the renal pelvis was caused by a benign renal cyst. The cyst extended from the renal hilus in each case and had turgor sufficient to overcome the pressure of intrapelvic urine. Operative unroofing of the cyst relieved the obstruction in each. In 5 of 6 cases, the postoperative radiographic appearance of the kidney showed marked improvement. Each patient was followed for at least five years, and no recurrence of the obstruction was noted. Operative treatment is recommended when a renal cyst causes significant obstruction of the major calyceal or renal pelvic outflow.

Pre-cystoscopic diagnosis of bladder tumour by modified intravenous urography.

Intravenous urography is the primary radiographic procedure used to evaluate patients with haematuria. During the last 15 years a modification of intravenous urography, using delayed films of the bladder, has aided the correct pre-cystoscopic diagnosis of bladder tumor in 82 of the 95 patients seen with this condition at our medical centre. After injection of contrast medium, anteroposterior and oblique views of the abdomen are obtained up to 15 min. Our modification consists of taking delayed films of the full bladder 1/2 h and 1 h later, followed by a post-voiding film. A bladder tumour appears as a filling defect or space-occupying lesion and can be distinguished from other lesions. Such delayed films increase the yield in the radiographic diagnosis of bladder tumours.

Ureteropelvic junction obstruction with associated renal anomalies.

Ureteropelvic junction obstruction when associated with other congenital anomalies of the kidney often presents a diagnostic and therapeutic dilemma. These anomalies include fusion abnormalities, malrotation, renal ectopia and duplicated systems. We report our experience in the management of 27 patients with ureteropelvic junction obstruction and associated renal anomalies, including horseshoe kidney in 9, duplicated systems in 12, ectopic kidney in 5 and malrotation in 1.

Vesicoureteric reflux in patients with bladder tumours.

In the course of treatment of 224 patients with bladder neoplasms over an 18-year period, 44 patients were noted to have associated vesicoureteric reflux, bilateral in 12 and unilateral in 32. Reflux was suspected in 8 patients because of associated ureterotrigonal abnormalities such as paraureteric diverticulum, complete duplication of the ureter and gaping ureteric orifice, and it was diagnosed by micturating cystography obtained before the bladder tumour was treated. In the remaining 36 patients reflux developed after treatment of the bladder tumours. In most patients with reflux the clinical course was benign, but it caused recurrent pyelonephritis in 9 cases and secondary struvite calculi in 2. Five patients had antirefluxing ureteric reimplantation to control episodes of recurrent pyelonephritis. The pathogenesis and implications of vesicoureteric reflux in association with bladder tumours are discussed.

Surgery of male genital lymphedema.

Incapacitating male genital lymphedema most commonly results from filariasis, which is endemic in the tropical and subtropical countries. However, with the advent of extensive ablative surgical and radiotherapeutic measures against abdominopelvic malignancies, more cases of iatrogenic lymphedema of the genitalia can be expected in other parts of the world as well. Surgical treatment of male genital lymphedema is essentially divided into 1) excision of subcutaneous lymphedematous tissues with genital reconstruction using the remaining skin and 2) complete excision of lymphedema followed by split thickness skin grafting of the denuded phallus. The rationale behind our preference for the latter procedure is discussed with illustrative case profiles and important salient surgical steps are outlined.

Dorsovertical lumbotomy approach for surgery of upper urinary tract calculi.

During a 30-month interval 26 patients underwent pyelolithotomy or upper ureterolithotomy through the dorsovertical lumbotomy approach. The intraoperative course and postoperative performance were compared to those in a similar group of patients operated upon using the standard flank incision. Our analysis established the superiority of the dorsovertical lumbotomy incision for all factors evaluated, especially postoperative drainage, analgesic use and hospital stay. The surgical steps are described in detail and the relative contraindications are discussed.

Peyronie's disease: excision of the plaque and grafting with tunica vaginalis.

In patients with refractory Peyronie's disease, satisfactory sexual rehabilitation with correction of chordee and amelioration of local pain and tenderness can be achieved with wide excision of the plaque, followed by grafting with the tunica vaginalis from the testes. However, one must be extremely careful in assessing and selecting patients for surgery, and at least six months of observation must be allowed. The surgical outcome is most gratifying in patients with "mature" or well-demarcated plaques with progressive chordee. Finally, strict adherence to surgical principles to prevent graft contracture or to minimize its effects is urged.