Successful term delivery by cesarean section in a patient with a continent ileocecal urinary reservoir.

Childbirth in a mother with a continent urinary reservoir to our knowledge has not been previously reported. The effects of the gravid uterus on the reservoir are presented, as well as management of the pregnancy and delivery.

Prostatic occurrence of transitional cell carcinoma after intravesical chemotherapy.

Thirteen patients with Stage Tis, Ta, or T1 transitional cell carcinoma (TCC) of the bladder treated by transurethral resections and intravesical chemotherapy developed TCC of the prostate. Among the 13 cases, cytology specimens were obtained from 10 at the time prostatic disease was diagnosed; 9 demonstrated TCC. One was treated successfully by transurethral resection of a Ta lesion involving the prostatic urethra only. One of 2 patients declining radical surgery is alive with residual disease at twenty-four months, and the other died of progressive disease at nineteen months. Of the 10 patients who underwent radical cystoprostatectomy, 7 are alive with no evidence of disease eight to forty-two months postoperatively, with 2 of these 7 having received 4 courses of systemic methotrexate, vincristine, Adriamycin, and cisplatinum (MVAC) for metastatic disease. Two of the 10 died of metastatic disease six and thirteen months postoperatively, and one frail patient died of surgical complications. When treating patients with intravesical chemotherapy for superficial TCC, biopsy of the prostate should be done during follow-up examinations, especially in the presence of cytologic or palpable prostatic abnormalities.

Acute lumbosacral plexopathy in diabetic women after renal transplantation.

Renal transplantation is an accepted treatment for patients with end stage renal disease from insulin-dependent diabetes mellitus. Acute lumbosacral plexopathy developed following renal transplantation in 4 female patients with insulin-dependent diabetes mellitus between January 1, 1981 and June 30, 1988. In all 4 patients the internal iliac artery was used for revascularization of the renal allograft with ligation of the anterior and posterior divisions. Within 24 hours of surgery they complained of ipsilateral buttock pain, numbness in the leg and weakness below the knee. This complication has not been observed in nondiabetic patients at our institution, nor in diabetic patients when the internal iliac artery was not used. However, lumbosacral plexopathy occurred in 4 of 27 (14.8%) female patients with insulin-dependent diabetes mellitus when the internal iliac artery was used (p less than 0.001). Age, duration of insulin-dependent diabetes mellitus, hypertension, cigarette smoking history and kidney donor were not significant predictors of this complication. This unusual and newly recognized complication appears to result from ischemia of the lumbosacral plexus following ligation of the internal iliac artery in patients with severe small vessel disease.

Intra-arterial infusion of 5-fluorouracil for recurrent adenocarcinoma of bladder.

We report a case of recurrent adenocarcinoma of the bladder treated by intra-arterial infusion of 5-fluorouracil (5-FU). The use of this agent in the treatment of adenocarcinoma of the bladder is reviewed.

Time-related recurrence rates in patients with upper tract transitional cell carcinoma.

Disagreement exists about the necessity and frequency of contrast medium imaging of the upper urinary tract in patients with transitional cell carcinoma. During a 10-year period 39 patients were treated for upper urinary tract transitional cell carcinoma. There were 3 contralateral recurrences in 33 patients treated by nephroureterectomy for the initial lesion. Of 4 patients treated initially by segmental ureterectomy or partial renal pelvectomy 1 had an ipsilateral recurrence 3 years later. Two patients with bilateral upper tract transitional cell carcinoma were treated by simple nephrectomy combined with simultaneous contralateral segmental ureterectomy or renal pelvectomy. Both patients had no evidence of recurrent tumor after 4 years of followup. Of the 39 patients with upper tract transitional cell carcinoma 6 had multiple bladder tumors or carcinoma in situ documented on biopsy before the development of an upper tract tumor. The interval between the treatment for the last bladder tumor or carcinoma in situ was 1 year in 4 patients, 2 1/2 years in 1 and 5 years in 1. Of these 6 patients 2 had bilateral upper tract tumor occurring at different times. Both patients had multiple bladder tumors diagnosed between the development of each upper tract lesion. Annual contrast medium imaging of the upper urinary tract is recommended in patients who have had multiple bladder tumors and in those who have undergone treatment for upper urinary tract transitional cell carcinoma.

Preservation of 32 human kidneys by simple cold storage for more than 48 hours.

Transplant centers are reluctant to use kidneys stored cold for more than 48 hours. During a 6-year interval we transplanted 32 kidneys preserved by intracellular electrolyte flushing that were stored cold for 48.2 to 61.4 hours. Of the recipients 91 per cent required dialysis within 1 week after transplantation. The mean serum creatinine nadir within 1 month was 3.0 mg. per dl. and graft survival at 1 month was 81 per cent. Short-term kidney graft function was not influenced significantly by the addition of magnesium sulfate to the flush solutions or by cyclosporin immunosuppression. The 1 and 2-year actuarial kidney graft survival rates were 72 and 58 per cent, respectively. The 1 and 2-year mean serum creatinine levels were 1.9 and 1.6 mg. per dl., respectively. Kidneys can be transplanted successfully after 48 hours of simple cold storage following flushing with an ice-cold intracellular electrolyte solution.

The value of excretory urography in staging bladder cancer.

Disagreement exists about the accuracy of excretory urography in the staging of bladder cancer. During a 10-year period 38 of 524 patients with carcinoma of the bladder had ureteral obstruction on excretory urography at the time of the initial diagnosis. All 38 patients had lamina propria invasion and 35 had muscle invasion at staging transurethral resection. Of those patients 22 had exploratory laparotomies, 11 after 4,000 to 5,000 rad. Of the patients undergoing laparotomy 55 per cent had metastases. Ureteral obstruction at the time of initial diagnosis of bladder cancer usually indicates muscle invasion and/or metastases.

Klinefelter syndrome in identical twins.

A rare case of Klinefelter syndrome in identical twins is reported. Salient features and clinical recognition of the syndrome are discussed.

Micturition neuropharmacology.

Applying the basic principles, therapy guides to our hypothetical cases can be constructed. The 60 year old man with postoperative abdominal perineal resection with hypertension and parkinsonism may well need a transurethral resection of the prostate; however, other options include decreasing his anticholinergic-type medications, such as antiparkinsonism medications, changing his hypertensive therapy from beta blockers such as propranolol and metoprolol to alpha blockers such as methyldopa and prazosin. Bethanacol would seldom be helpful alone, but with an alpha blocker could help if not contraindicated by the presence of vascular disease. The second example, a 45 year old woman with stress incontinence, may be assisted with improved storage by an anticholinergic agent, an alpha enhancer, a mucosal enhancer, and if pertinent, switching hypertensive therapy from an alpha blocker to a beta blocker. The last example, a T10 paraplegic with a spastic, hyperreflexic bladder, can have improved storage with anticholinergics, decreased sphincter tone with alpha blockers, as well as decreased sphincter tone with alpha blockers, as well as decreased spasms through suppression of hyperactive spinal cord activity with baclofen.