Renal colic during pregnancy: a case for conservative treatment.

PURPOSE: We defined the merits of early evaluation and conservative treatment of pregnant patients admitted with renal colic. MATERIALS AND METHODS: We retrospectively evaluated 72 pregnancies in 70 patients who were hospitalized with the diagnosis of renal colic between 1984 and 1995. Urinalysis was performed in every case. Ultrasound was the primary diagnostic test in 65 patients. The patients were followed for 2 weeks to 3 months after delivery (mean 21 days). RESULTS: Mean patient age at presentation was 27.4 years. The majority of patients were multiparous (47 of 70) and presented in the third trimester (44 of 70). Microscopic urinalysis was not helpful in identifying stone disease in pregnant patients. The sensitivity of ultrasound for the diagnosis of renal calculi was 95.2%. Watchful conservative nonsurgical treatment resulted in spontaneous passage of stones in 64.3% of cases. Of the 19 pregnancies in which intervention was necessary cystoscopy and Double-J* silicone stent placement were done in 15, and ureteroscopy and stone basketing were done in 4. Two patients, who presented with pyelonephritis and premature ruptured membranes had fetal loss. Long-term antibiotic prophylaxis was maintained in all stented and bacteriuric patients. CONCLUSIONS: Renal colic in pregnant patients can be complicated by pyelonephritis and premature labor, especially if misdiagnosed or inadequately treated. Ultrasound is a safe and sensitive diagnostic test. Approximately two-thirds of renal calculi will pass spontaneously. For those who require intervention, placement of a Double-J stent is a safe and effective option.

The adequacy of screening, documenting, and treating the diseases of substance abuse.

In a large inner-city teaching hospital, only 28 percent of over 1000 consecutive hospital admissions received proper screening for diseases of substance abuse. Although the CAGE questions are currently considered the best screening test for quickly assessing an alcohol abuse history, not a single CAGE question was documented during our 23 day study. Of the 1010 patients in the study, 160 or 16% were found to be substance abusers. Of these, 57 (37%) were properly screened by the physician team and 8 (5%) received adequate follow-up treatment for their substance abuse by way of social service or psychiatric consultation, or documented counselling by their physician. Physicians are not adequately screening for the diseases of substance abuse, and are not appropriately evaluating and referring patients who are known to be substance abusers. Meaningful training of medical students and physicians is necessary to increase awareness and produce positive behavior change.

Percutaneous cholecystolithotomy.

We have successfully removed gallstones percutaneously from the gallbladders in two poor surgical risk patients using the standard equipment and the principles of percutaneous nephrolithotomy. No complication occurred in either patient. A brief review of percutaneous gallstone extraction is presented.

Salmonella enteritidis. A rare cause of pyelonephritis in children.

A previously healthy 2.5-year-old boy developed symptoms of acute pyelonephritis following an acute gastroenteritis. The patient received parenteral ampicillin and gentamicin for 72 hours and then ampicillin for an additional 11 days when the original urine and stool cultures grew Salmonella enteritidis, sensitive to ampicillin. The patient responded very well to treatment, but B-mode renal ultrasonogram revealed a left hydronephrosis and megaureter suggestive of longstanding obstruction of the ureterovesicular junction, later confirmed by other diagnostic studies and by surgical exploration and repair. Salmonella infection has been rarely documented to cause pyelonephritis in children. Obstructive uropathy appears to be a predisposing factor for this unusual complication of Salmonella enteritis.

Renal angiomyolipoma: 6 case reports and literature review.

We report 6 cases of renal angiomyolipomas and review the pertinent literature concerning this disease. One case involved the rare association of tuberous sclerosis and pregnancy. Another patient without tuberous sclerosis had renal cell carcinoma and later suffered a contralateral angiomyolipoma. The pathological conditions of renal angiomyolipomas with and without tuberous sclerosis are discussed. Since angiomyolipomas present with multiple clinical similarities to renal cell carcinoma, the primary task for the clinician is to differentiate this hamartoma from carcinoma. The distinguishing characteristics and the clinical management of renal angiomyolipomas are discussed.

Parastomal ileal loop hernia repair with marlex mesh.

We report a case of a complicated ileal conduit parastomal hernia that was repaired using marlex mesh. The characteristics of this material and the techniques of its use are described. When primary repair of a parastomal hernia is not possible without tension, marlex mesh may be used to reinforce or even to replace the fascia. The stoma may be brought out adjacent to or possibly even through the mesh.

The management of testicular tumors in children.

Of 43 testicular tumors in children seen at the Children's Hospital Medical Center and Sidney Farber Cancer Institute 33 were malignant. These tumors occurred primarily in young children. Any solid scrotal mass in an infant must be considered malignant until proved otherwise. Primary emphasis is placed on the 20 cases of embryonal cell carcinoma. Of 9 patients who underwent only orchiectomy 5 have died, whereas all 11 patients who received combination therapy have survived. We recommend radical inguinal orchiectomy, extended unilateral retroperitoneal lymphadenectomy and adjuvant chemotherapy in repeated courses for 2 years. Radiotherapy is withheld if the lymphadenectomy is negative.

Testicular tumors in infants and children.

Forty three children with testicular tumors have been presented. Eighty per cent of these tumors were malignant, and 60 per cent occurred in children less than two and one half years of age. Twenty of the 24 malignant germinal tumors were embryonal cell carcinomas. The mean age of the patients at presentation of these tumors was 18 months. Nine patients underwent orchiectomy alone, and five of these have died. Eleven received combined therapy, and all have survived. We currently recommend radical orchiectomy and extended unilateral retroperitoneal lymphadenectomy. If examination of the nodes reveals evidence of metastases, a bilateral dissection is done. Radiotherapy is given only in the presence of nodal metastases. Adjuvant chemotherapy with vincristine, actinomycin D, and Cytoxan is given for two years to all patients with malginant nonseminomatous germ cell tumors or sarcomas.

Disruption of the renal pelvis by blunt trauma.

Blunt trauma to the renal pelvis is exceedingly rare and such trauma of the ureter is only slightly more common. A tetrad of radiologic findings should suggest the diagnosis when there is a high index of suspicion. It would seem that early surgical treatment would be the preferred program but in the face of serious associated trauma there is little lost by waiting. Nineteen days elapsed between injury and repair in this case. That duration may be excessive, but as shown in this case the result was excellent and the patient's retroperitoneum was never infected. We do not advocate a purposeful delay of this duration but on the other hand there is no reason to assume that it is particularly harmful.