Undiversion in patients with meningomyelocele.

Since 1981, 12 patients with neurogenic bladder due to meningomyelocele who had had previous ileal conduit urinary diversions underwent assessment for undiversion. Two important criteria for undiversion were motivation and a reconstructable bladder. Four patients either did not fulfil these criteria or refused surgery. Eight patients (six females and two males) underwent undiversions. Uretero-ureteral anastomosis was achieved in 13 ureters and ureteroneocystostomy in 2; transureteroureterostomy was necessary in 1 ureter. Augmentation cystoplasty and vesicourethropexy were important in establishing continence postoperatively; these procedures were not performed in two patients whose undiversion failed early in the series. The evolution of an investigation protocol, surgical technique and final approach to this complex problem are discussed.

Bladder-outlet reconstruction in neurogenic bladder due to myelomeningocele.

In a subgroup of children with myelomeningocele, urinary incontinence cannot be managed by clean intermittent catheterization and anticholinergic medication. The authors report on 24 such children who required bladder-outlet reconstruction. Twelve boys underwent the Young-Dees/Leadbetter procedure, 8 girls underwent the Burch procedure and the remaining 4 had a combination of the two. Augmentation cystoplasty was also carried out in seven girls and one boy. Results were most favourable in the girls, with improvement in 92%, in contrast to the boys in whom only 58% were improved. Artificial sphincter placement may be a more beneficial alternative for boys.

Testicular pain: an unusual presentation of polyarteritis nodosa.

We report a case in which the initial presentation of polyarteritis nodosa was alternating bilateral orchialgia. The diagnosis was confirmed by testicular biopsy. Testicular biopsy is an uncommonly reported diagnostic procedure despite the high incidence of testicular involvement in polyarteritis nodosa. We emphasize the value of testis biopsy, particularly when biopsy of other sites does not prove the diagnosis in suspect cases.

Carcinoma in the defunctionalized urinary tract.

Carcinoma developing in the lower urinary tract diverted from the urinary stream, although uncommon, does occur and must be sought carefully in the presence of intractable pyocystis. Our experience with this condition is presented with emphasis on early diagnosis and treatment.

Pathogenesis of urinary infection in patients with acute spinal cord injury on intermittent catheterization.

In a small pilot study urinary tract infection in patients with acute spinal injury was preceded by the establishment of Enterobacteriaceae on the introitus, glans and urethra. Those patients who retain the normal flora do not become infected. The first infection most commonly is by Escherichia coli with universal antibiotic sensitivities. Female patients with a history of urinary infections and male patients with a history of bacterial prostatitis are at risk for suffering recurrent infections. Saline or chlorhexidine gluconate pre-catheter preparation does not appear to relate to a continual status free of infection.

Malignant germ cell tumor of the testis: spontaneous regression of pulmonary metastases with 7-year survival.

A case of a malignant germ cell tumor of the testis in a 28-year-old man is reported. The patient showed spontaneous regression of pulmonary metastasis and is well 7 years after orchiectomy and irradiation of abdominal lymph nodes. A plea is made for further documentation of such cases.

Experiences with priapism.

During a 10-year period 11 cases of priapism were treated with a saphenocavernous bypass. Uniformly good functional results were obtained if the procedure was done within 36 hours of the commencement of priapism. Prior aspiration and irrigation appear to lengthen this interval. The formation of temporary cavernovenous communication with the superficial venous system of the penis by aspiration and irrigation with large needles is demonstrated and is postulated as a mechanism by which this method of treatment alone is occasionally successful. Persisting graft patency has been associated with impotence. If erection does not occur within 3 months of the saphenous bypass the shunt should be ligated.

Combined active-passive immunization against tetanus in man.

A schedule for the prevention of tetanus in the injured, which has been in operation in the emergency department of a large hospital for over two years, is proposed. For the majority of nonimmunized persons, it is recommended that a dose of toxoid and 50 units tetanus immune globulin (human) (TIGH) be given, in separate sites, to be followed later by additional doses of toxoid for the completion of active immunization. Combined active-passive immunization with tetanus toxoid and 50 units TIGH gives a low level of passive immunity and stimulates early onset of active immunization. In combined active-passive immunization, adsorbed tetanus toxoid produced a significantly higher response than the fluid toxoid. The injection of 400 units TIGH somewhat suppressed the induction of immunity following the first dose of AlPO(4)-tetanus toxoid.