Fournier's gangrene: a monographic urology center experience with twenty patients

BACKGROUND

Fournier's gangrene (FG) is a fatal synergistic infectious disease with necrotizing fasciitis of the perineum and abdominal wall along with the scrotum and penis in males and the vulva in females. The aim of this study was to share our experience in the management of this infectious disease.

METHODS

A retrospective chart review was performed in 20 patients with a diagnosis of FG between January 1991 and December 2007. Patient's age, source and predisposing factors, microbiological findings, duration of hospital stay, treatment modalities, and outcome were analyzed.

RESULTS

The mean age of the patients was 53.9 +/- 9.56 (range 23-71) years. The source of gangrene was urinary in 5 patients, perirectal in 5, cutaneous in 1, and unknown in 9 patients. The main predisposing factors included diabetes mellitus in 9 patients (45%) and immunosuppression in 5 patients (25%). The mean duration of hospital stay was 39 +/- 10 (range 6-62) days. Although early intervention and intensive treatment were carried out, 4 patients died with an overall mortality of 20% as a result of septicemia complications. The mortality rate was higher in elderly patients and those with diabetes mellitus, but it was not statistically significant. Regarding the mortality rate, duration of symptoms, number of debridements, culture results and source of infection were not found to be significant factors.

CONCLUSIONS

FG is still a severe disease. Management of this infectious entity must be aggressive. Despite the use of contemporary effective antibiotic treatment, aggressive debridements, and state-of-the-art intensive-care conditions, FG still has high mortality and morbidity rates.

Endoscopic approach of the overinfected urachal cyst

The overinfected urachus cyst presents itself in quite different forms. In spite of the accuracy of ultrasound and abdominal CT scan, sometimes the diagnosis of this urachal abnormality is imprecise and even misleading. This article describes the transvesical endoscopic drainage of an infected urachal cyst with optimum result upon the treatment of this condition.

Intravesical bacillus calmette-gueÈrin for the treatment of superficial bladder cancer in renal transplant patients

BACKGROUND

Intravesical instillations with bacillus Calmette-Guérin (BCG) is considered the treatment of choice in the prophylaxis of high-grade superficial bladder carcinoma and in the treatment of carcinoma in situ (CIS) of the bladder.

METHODS

There is no previous experience with BCG treatment in patients with renal transplantation. Theoretically, immunosuppression is a contraindication because of the risk of severe morbidity and sepsis. We present our experience with endovesical BCG in three renal transplant patients, under immunosuppressive treatment, with high-grade superficial bladder cancer and CIS.

RESULTS

Two patients are free of disease at 17 and 60 months. One patient developed disease recurrence and underwent a radical cystectomy. There was neither change in renal function nor any clinical evidence of tuberculous infection.

CONCLUSIONS

Intravesical BCG in superficial bladder cancer and/or CIS is a valid option, with no added morbidity to renal transplant patients.

Balloon dilatation in the treatment of ureteral stenosis in kidney transplant recipients

OBJECTIVE

To assess the usefulness of balloon percutaneous dilatation as a starting treatment technique of ureteral stenosis in kidney transplant recipients.

PATIENTS AND METHODS

A total of 472 kidney transplants have been performed at our center between August 1981 and January 1997. The coexistence of high creatinine values and urinary tract dilatation in the postoperative period, after discarding concomitant causes, was managed with a percutaneous nephrostomy. Once renal function had recovered, antegrade pyelography was performed to confirm ureteral stenosis and to determine its location. The dilatations are performed by means of 5-french balloon-fitted angioplasty catheters.

RESULTS

Thirty patients were diagnosed with ureteral stenosis during follow-up, i.e. an incidence of 6.3%. Transluminal balloon dilatation was made as a first therapeutic option in 18 cases. No immediate complications were observed following dilatation. Disappearance of the stenosis as well as maintenance of the improvement in creatinine levels were verified in 39% of cases (7 patients).

CONCLUSIONS

Ureteral stenosis in kidney transplant recipients should be included as part of the differential diagnosis when there is a deterioration in renal function. Balloon dilatation is the technique chosen as initial treatment of juxtavesical ureteral stenosis because of its good reproducibility and its low morbidity.

Clear cell adenocarcinoma in a female urethral diverticulum

The incidence of a neoplasm within the female urethral diverticulum is rare. Clear cell adenocarcinoma, which is the most common neoplasm, arises from the metaplasia of surface transitional epithelium and the paraurethral ducts. These tumors are usually diagnosed at a late stage, which worsens their prognosis. The treatment of choice is surgery.

A simplified technique for ureteroneocystostomy in renal transplantation

From October 1988 to December 1993, 148 kidney transplants were carried out at our institution. An extravesical ureteral reimplantation technique resulting in a submucosal tunnel in the bladder wall was performed on 101 of the patients. For this technique, two small incisions are made at the outer part of the bladder wall until the mucosa is seen, then a submucosal tunnel is dissected between them and the graft's ureter is introduced and advanced in it (Alférez-Barry). Afterward the bladder mucosa is opened at the distal incision and the ureter is introduced into the bladder and fixed by a single direct anchorage stich (Taguchi). The minimal patients' follow-up is 18 months. Complications deriving from ureter reimplantation with this technique were present in 12.8% of the patients and included 4 cases of stenosis (3.9%), 4 cases of urinary fistula (3.9%), and 5 cases of hematuria (4.9%). We conclude that submucosal tunnelled ureteroneocystostomy with direct anchorage is a technique that simplifies kidney transplant surgery with good results. Ureteral direct anchorage can be used in any kind of ureteral anastomosis.

Transurethral resection of the intramural ureter as the first step of nephroureterectomy

Nephroureterectomy is the standard surgical approach for upper urinary tract carcinoma. In 1952 a modified technique was described based on a prior endoscopic disconnection of the intramural ureter as an initial step for subsequent nephroureterectomy via a single lumbar incision. Since October 1989 we performed 31 nephroureterectomies with this technique in 26 men and 5 women (average age 64.5 years). Of the patients 9 had prior bladder carcinoma. The predominant pathological diagnosis of the nephroureterectomy specimens was high grade infiltrating tumor. There were no intraoperative complications except for 1 case of intra-abdominal extravasation detected in the immediate postoperative period and treated conservatively. With an average followup of 20 months, tumor has not recurred at either the resected trigonal area or the retroperitoneum. We believe that our experience assesses the feasibility of this technique to improve and simplify nephroureterectomy, thus, decreasing the morbidity rate and operating time while maintaining the same oncological radicality.

[Urologic complications in renal transplantation: our experience with 200 cases]

Urinary tract complications continue to be a major cause of morbidity in renal transplant patients. This paper is a review of the urological complications developed in in 200 renal transplants performed in our service over a 10-year period, from January 1980 to December 1989, with a follow-up of at least 1 year. We include a total of 29.5% urological complications, subdivided in two sections each corresponding to a distinct period during which different procedures were used in the renal transplantation unit. The report includes an analysis of the complications' etiopathogenic, diagnostic and therapeutic factors.

Renogastric fistula

During the study of chronic anemia in a 38-year-old woman, a nonfunctioning left kidney due to multiple asymptomatic ureteral calculi was found on excretory urography. She had self-limited episodes of left flank pain 10 years previously. Antegrade pyelography through the nephrostomy tube and computerized tomography showed a pyonephrotic renogastric fistula on that side.

[Treatment of lithiasis during pregnancy]

We report on 10 pregnant women with renal calculi who presented with fever and recurrent renal colic. They were treated with analgesics and fluids. Antibiotics were administered to those with fever and/or positive urine culture. Seven were submitted to endoscopic maneuvers. A flute tipped (Couvelaire) catheter was placed in 4 and a double-J in 3 patients.

Electrohydraulic and ultrasonic lithotripsy in 100 consecutive cases of primary ureteral stones

We have performed, between May 1985 and December 1988, in situ lithotripsy in 100 consecutive cases of primary ureteral stones, using electrohydraulic lithotripsy in 33 patients and ultrasonic lithotripsy in the remaining 67. After using similar instruments and surgical techniques in both groups, we have comparatively evaluated the complications encountered and the results obtained. With the electrohydraulic lithotripsy we have obtained a complication rate of 42% (operative and postoperative) and favorable results in 72.7% of the patients; using ultrasonic lithotripsy, the complication rate was 10.4%, and favorable results were obtained in 92.5%. We conclude that, at least in our experience, ultrasonic lithotripsy is less invasive and more successful than electrohydraulic lithotripsy in the treatment of primary stone disease.

[Complications of rigid ureteroscopy]

Peri- and post-operative complications higher than 37c (15%) encountered in 250 urethroscopies performed between May 1985 and January 1989 are presented in this paper. These experiences are compared to those from other 20 series (2,599 urethroscopies) representing 14.5% complications. In order to study their pathogeny, the sample was divided into four groups:

CONTROL GROUP

27 patients where normality of urinary tract was demonstrated in 92.6% of all evaluations made at intervals of about 20 months. Technical scope: Two groups chronologically different: 16% complications in urethroscopies performed in 1985 and 7% complications in those performed in 1986. Differences in the techniques applied: classic extraction (14%) vs. urethroscopy (13%) and electrohydraulic lithotrity (42%) vs ultrasonic lithotrity (12%). Finally, a description is made of those cause believed to be responsible for major complications: perforation, avulsion and ureteral stenosis.