Paraurethral vaginal leiomyoma.

A case of paraurethral vaginal leiomyoma becoming clinically apparent in the postpartum period is presented. As is frequently the case, the diagnosis was not apparent. Urinary tract origin is commonly suspected, since the majority of these tumors occur in the midline of the anterior vaginal wall. The tumors are often asymptomatic, but can cause dysuria, urinary frequency, urinary retention, and dyspareunia. Pathologically, they are well circumscribed and have the typical microscopic features of leiomyomas found elsewhere. Simple excision is usually adequate treatment.

Perineal urethrostomy to facilitate gaining ureterorenoscopic length.

A simple method of gaining ureterorenoscopic length via a perineal urethrostomy and its use in an obese, 6-foot, 6-inch man with a suspected renal pathological condition is described.

Chronic balanitis owing to pemphigus vegetans.

Pemphigus is an autoimmune bullous dermatosis in which intercellular antibodies are associated with loss of intercellular cohesion. Pemphigus vegetans, a rare variant of pemphigus, is manifested by vegetating plaques, usually in intertriginous areas of patients who probably have an increased resistance to the disease. We report a case of chronic balanitis owing to pemphigus vegetans, and discuss proposed pathogenic mechanisms and treatment.

Leydig cell tumor and metachronous Leydig cell hyperplasia: a case associated with gynecomastia and elevated urinary estrogens.

We report a case of unilateral Leydig cell tumor associated with gynecomastia and elevated urinary estrogens. Nine years after orchiectomy urinary estrogens became elevated and Leydig cell hyperplasia but no distinct tumor was identified in the remaining contralateral testicle.

Unsuspected intraperitoneal rupture of bladder presenting with abdominal free air.

We present a case of intraperitoneal rupture of the bladder discovered during exploratory laparotomy for abdominal free air associated with an indwelling Foley catheter found in the peritoneal cavity. This report emphasizes the need for systematic and thorough evaluation of the genitourinary tract in the patient with multiple trauma.

Contralateral renal hyperplasia and increased renal function after relief of chronic unilateral ureteral obstruction.

Following relief of 1, 2 or 3 weeks of unilateral ureteral obstruction, contralateral compensatory renal growth and increased renal function were measured 3 and 6 months later. Compensatory growth occurred predominantly by hyperplasia, demonstrated by a significant increase in DNA content and a decrease in the RNA:DNA ratio (p less than 0.04). This is in contrast to compensatory growth following nephrectomy or unrelieved unilateral ureteral obstruction, which occurred primarily by hypertrophy with no significant change in DNA content but a significant increase in RNA content and the RNA:DNA ratio (p less than 0.04). Contralateral renal function in animals with relieved unilateral ureteral obstruction was greater than in controls with 2 normal kidneys (p less than 0.05). The contralateral increase in renal function was greater than that in animals subjected to ipsilateral nephrectomy or unrelieved ureteral obstruction, but this did not reach statistical significance. Thus, when growth occurred by hyperplasia, there was a trend to greater increases in renal function than when growth occurred by hypertrophy. Contralateral compensatory renal hyperplasia and increased renal function occurred in conjunction with a decrease in renal mass and function of the ipsilateral post-obstructed kidney. These experiments suggest that the post-obstructed, poorly functioning kidney stimulates contralateral hyperplastic growth and increased renal function. This hyperplastic response is different from the hypertrophic response following nephrectomy or unrelieved unilateral ureteral obstruction, implicating the post-obstructed kidney as the stimulus of the hyperplastic response.

Carcinoma of the gallbladder and cholecystostomy.

Seven cases of carcinoma of the gallbladder after cholecystostomy were seen at the University of Virginia Medical Center, Charlottesville, between 1926 and 1979. These cases represented 6.7% of all cases of carcinoma of the gallbladder treated at that institution during that period. The interval between cholecystostomy and diagnosis of carcinoma ranged from three months to 40 years. Five patients had "gallbladder" symptoms intermittently during the interval, and two patients did not. One of the patients had a confirmed calcified or porcelain gallbladder five years before the development of carcinoma. At operation, none was found to have localized disease, and most had extensive metastatic disease. There were no survivors. Primary carcinoma of the gallbladder is an aggressive disease and difficult to diagnose. Few specific characteristics are available to the clinician and surgeon to detect this disease in its early stages. Patients who undergo cholecystostomy or have undergone cholecystostomy, with or without symptoms, should have elective cholecystectomy if they are acceptable operative risks. Such a policy would prevent a small, but substantial, number of cases of carcinoma of the gallbladder.

Is carcinoma of the gallbladder a curable lesion?

Carcinoma of the gallbladder is an uncommon, but not rare tumor that is associated with a 5% five-year survival rate after resection and this rate has not appreciably improved over the last decades in most series. Nevin et al.(20) however have reported that favorably staged gallbladder cancers (according to histologic grade and depth of invasion) have a relatively good prognosis. They quoted an overall five-year survival of 21% in 66 patients. Most of the surviving patients (11) were in the favorably staged category: Stage I (intramucosal cancer) and Stage II (invasion of mucosa and muscularis). The remaining few were in Stage III (invasion of all layers), Stage IV (cystic node metastases), or Stage V (extension of metastases to the liver or distant sites). Our data has been analyzed to determine whether microstaging of the primary cancer will select out a subgroup with a favorable prognosis, and whether there are survival benefits according to the type of surgical resection. A clinical and pathologic review was done of 100 patients treated at the University of Virginia Hospital from 1930 to 1978. There were 77 women and 23 men, with an average age of 65 years (range 21-89). Gallstones were described in 78% of the patients. Surgical procedures included cholecystectomy alone (23 patients), cholecystectomy with biliary drainage (17 patients), cholecystectomy and resection of the hepatic bed (8 patients), and exploration with biopsy or bypass (44 patients). Autopsy only was done in eight patients. There were only three long-term survivors (6 years, 11 years, and 24 years). Median survival was six months with cholecystectomy alone, five months with cholecystectomy and bypass, 14 months after partial liver resection, and 2.0 months after laparotomy/bypass/biopsy. The five-year survival rate was 5% after cholecystectomy alone or with bypass, and 13% (1/8) after cholecystectomy and partial liver resection (p = 0.07). Microstaging of the primary cancers showed no prognostically favorable subgroup. Of 46 patients with microstaged lesions, only 13% were in the very favorable Stage I and II groups (only one of six survived), 46% were Stage III (1/21 survived), and the remaining 41% were in the highly unfavorable Stage IV and V groups (1/19 survived). Most patients showed progression of disease either primarily or secondarily that was locoregional (liver and nodes). Although longterm survival may accompany cholecystectomy alone for a favorable early-staged cancer, this is still uncommon. There may be theoretical, although not proven, merit for resection of the hepatic bed and regional node dissection in the selected patient, possibly complimented by adjuvant therapy. Future advances in chemotherapy and radiation will be needed to augment the current poor cure rate of this disease.