Revision rate after artificial urinary sphincter implantation for incontinence after radical prostatectomy: actuarial analysis

PURPOSE

We determined the actuarial revision rate for artificial urinary sphincters implanted in patients who were incontinent after radical prostatectomy.

MATERIALS AND METHODS

We reviewed the records of 70 consecutive patients who were incontinent after radical prostatectomy and who underwent primary artificial urinary sphincter implantation at the University of Michigan between 1984 and 1999. Questionnaires were mailed to all patients with an indwelling device, and telephone calls were placed to those who did not respond to the mailing. Information about surgical revision and current continence status was obtained from chart review and questionnaire response. The Kaplan-Meier curves for actuarial freedom from operative revision were constructed.

RESULTS

Of the 66 patients with available postoperative data 24 (36%) required reoperation at a mean followup of 41 months. The 5-year actuarial rate for freedom from any operative revision was 50%, and the corresponding rate for cuff revision was 60%. A single operative revision did not predispose the patient to further revision. Questionnaire data indicated a continence rate of 80% (range 0 to 2 pads).

CONCLUSIONS

Approximately half of the patients who were incontinent after radical prostatectomy may expect to undergo operative revision within 5 years after artificial urinary sphincter implantation. Despite this high reoperation rate, an excellent level of continence is maintained.

Randomized controlled trial of hand-assisted laparoscopic versus open surgical live donor nephrectomy

BACKGROUND

Laparoscopic live donor nephrectomy for renal transplantation is being performed in increasing numbers with the goals of broadening organ supply while minimizing pain and duration of convalescence for donors. Relative advantages in terms of recovery provided by laparoscopy over standard open surgery have not been rigorously assessed. We hypothesized that laparoscopic as compared with open surgical live donor nephrectomy provides briefer, less intense, and more complete convalescence.

METHODS

Of 105 volunteer, adult, potential living-renal donors interested in the laparoscopic approach, 70 were randomly assigned to undergo either hand-assisted laparoscopic or open surgical live donor nephrectomy at a single referral center. Objective data and subjective recovery information obtained with telephone interviews and validated questionnaires administered 2 weeks, 6 weeks, and 6-12 months postoperatively were compared between the 23 laparoscopic and 27 open surgical patients.

RESULTS

There was 47% less analgesic use (P=0.004), 35% shorter hospital stay (P=0.0001), 33% more rapid return to nonstrenuous activity (P=0.006), 23% sooner return to work (P=0.037), and 73% less pain 6 weeks postoperatively (P=0.004) in the laparoscopy group. Laparoscopic patients experienced complete recovery sooner (P=0.032) and had fewer long-term residual effects (P=0.0015).

CONCLUSIONS

Laparoscopic donor nephrectomy is associated with a briefer, less intense, and more complete convalescence compared with the open surgical approach.

Renal transplantation at the University of Michigan 1964 to 1999

The Michigan Kidney Transplant Program has existed for 35 years. Outcomes have improved dramatically as the one-year survival of cadaver kidney grafts increased from 25% to 85-90%. Patient deaths in the first year are now uncommon. Indications for renal transplantation have been extended to infants, the elderly, diabetics and to patients with other significant health problems who would not have been candidates in the past. Chronic administration of large doses of corticosteroids is no longer necessary and the associated morbidity is largely avoided. Improvements in immunosuppression, especially the introduction of cyclosporine, account for much of this progress. With success has come increasing demand. Unfortunately, the gap between the number of available donor kidneys and the number of patients listed for a cadaver transplant continues to increase rather than diminish. Greater acceptance of volunteer donation, as has occurred in our own program, will help to reduce this shortage. If the past forecasts the future, we can anticipate extraordinary advances during the next 35 years.

Prospective, case matched comparison of hand assisted laparoscopic and open surgical live donor nephrectomy

PURPOSE

The technical difficulty of standard laparoscopic live donor nephrectomy has limited its application. Hand assistance, which takes advantage of the incision necessary for organ removal, facilitates laparoscopy without significant impact on patient recovery. We prospectively compared open surgical and hand assisted laparoscopic donor nephrectomy.

MATERIALS AND METHODS

Our first 10 laparoscopic live donor nephrectomies were matched with 40 open donor nephrectomies by gender, age and body mass index. Data were obtained by pain scales, SF-12 survey instruments, questionnaires and chart abstraction.

RESULTS

Operative time was longer for the laparoscopic approach (mean 95 versus 215 minutes). However, laparoscopic group patients had a shorter hospital stay compared to those undergoing open surgery (mean 2.9 versus 1.8 days), returned sooner to nonstrenuous activity (mean 19.0 versus 9.9 days) and reported less pain 6 weeks postoperatively (mean 2.3 versus 0.6) (p </=0.03 for all). There were no differences between groups in terms of donor complications, allograft function and ureteral complications. Mean hospital cost was 23% greater in the laparoscopic group (p = 0.005) but global cost, which accounted for estimated loss of income from work during the recovery period, was only 15% greater (p = 0.10). Mean operative time was significantly improved for our second compared to our first 5 laparoscopic group patients (177 versus 254 minutes).

CONCLUSIONS

Laparoscopic live donor nephrectomy appears to be a safe and effective alternative to open donor nephrectomy. Indexes of patient recovery suggest patient morbidity similar to that reported following standard laparoscopic donor nephrectomy and significantly less than after open nephrectomy. Improvement in operative time in the first 10 cases suggests that hand assistance "shortens" the learning curve, which might encourage more surgeons to offer laparoscopic live donor nephrectomy.

Potential renal donors: comparison of conventional imaging with helical CT

PURPOSE

To assess helical computed tomography (CT) as a potential substitute for intravenous urography and renal angiography in the evaluation of living potential renal donors.

MATERIALS AND METHODS

Helical CT was performed in 32 potential donors both before and after administration of contrast material. Scans were reconstructed at 1.5-mm intervals for three-dimensional reconstructions. Helical CT images were blindly compared with urograms (n = 32) and renal angiograms (n = 24).

RESULTS

One small accessory artery was not depicted with helical CT, and angiography did not depict an accessory artery arising in proximity to the origin of the main renal artery. All eight kidneys with early dividing main arteries were identified with both helical CT and angiography. Three renal venous anomalies were depicted only with helical CT. Helical CT and urography equally depicted nonvascular findings.

CONCLUSION

Renal helical CT is a suitable replacement for intravenous urography and angiography in the assessment of living renal donors.

Long-term assessment of renal function following nephrectomy for stage I renal carcinoma

OBJECTIVE

To evaluate the impact of nephrectomy on renal function in people who are potential candidates for nephron sparing surgery, i.e. partial nephrectomy.

PATIENTS AND METHODS

A retrospective analysis was carried out of 109 patients (35 women, 74 men) who had undergone a nephrectomy for stage I renal carcinoma at the University of Michigan between 1960 and 1979. All patients had a functioning contralateral kidney and had undergone at least one post-operative serum creatinine evaluation. Statistical analysis was by Pearson's correlation coefficient.

RESULTS

One individual developed a transitional cell carcinoma in the remaining renal pelvis and was treated with nephroureterectomy. No other patient progressed to dialysis. Five patients had post-operative serum creatinine levels from 221 to 354 mumol/l, one of whom had undergone both a nephrectomy and a partial nephrectomy for bilateral renal tumours. The remaining four had renal disease including diabetes, hypertension, pyelonephritis and renal artery stenosis. There was a strong association between pre-operative and post-operative serum creatinine values.

CONCLUSION

Patients with low stage renal tumours and a normal contralateral kidney are at low risk of progression to renal failure.

Vesicopyeloplasty in renal transplant patients: a 20-year followup

Loss of a ureter in a renal transplant patient often results in transplant nephrectomy. In 1973 we used vesicopyelostomy with the bladder directly sutured to the renal pelvis as a method of reconstruction in 2 renal transplant patients following ureteral loss. These patients have been followed for more than 20 years and both renal allografts have functioned well. The status of these patients and a review of the literature on vesicopyelostomy are presented.

Treatment of renal transplant ureteral complications by percutaneous techniques

From January 1985 to October 1990, 487 adult renal transplantations were performed at our institution. Of 16 ureteral complications noted 15 were initially managed with percutaneous nephrostomy. Of the 8 complications that occurred during the last 2 years 5 resolved on percutaneous nephrostomy and stenting, or stenting with dilation alone. We conclude that percutaneous nephrostomy is indicated as an initial step in the diagnosis and treatment of urological transplant complications, and that it allows for nonoperative resolution of many of these complications.

Results of combined Nesbit penile plication with plaque incision and placement of Dacron patch in patients with severe Peyronie's disease

We treated 9 men with severe curvature of the penis secondary to Peyronie's disease with penile plication and a previously unreported technique of incision of the Peyronie plaque and placement of Dacron patch. All men were potent before penile straightening. At a mean followup of 17.5 months all men achieved good to excellent correction of the deformity and they have remained potent. One patient initially complained of numbness of the glans penis and decreased penile rigidity distal to the Dacron patch but potency returned and the numbness resolved.

Ureteroscopic treatment of urothelial carcinoma of the ureter and renal pelvis

From June 1987 to September 1990, 12 patients were evaluated for ureteroscopic treatment of upper urinary tract neoplasms. Four patients were not considered candidates because of technical reasons. Each of these patients was treated by nephroureterectomy. A total of 8 patients underwent ureteroscopic therapy with a neodymium:YAG laser 1 to 11 times (median 2) for the treatment of 3 proximal ureteral or pelvic lesions and 7 distal ureteral lesions. One patient had local progression and 1 failed subsequent laser treatment for technical reasons. Both of these individuals were salvaged with an operation. Three patients were without recurrence for 15, 21 and 36 months. Two patients had multiple superficial local recurrences and continue to be managed endoscopically without local progression for 12 and 32 months. One patient was asymptomatic 16 months after treatment but he has refused followup evaluation. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have had the tumors controlled by this method of treatment. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In selected individuals ureteroscopic laser treatment of upper urinary tract transitional cell carcinoma can achieve local control with renal preservation.

Results of 1,469 microsurgical vasectomy reversals by the Vasovasostomy Study Group

During a 9-year period 1,469 men who underwent microsurgical vasectomy reversal procedures were studied at 5 institutions. Of 1,247 men who had first-time procedures sperm were present in the semen in 865 of 1,012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the interval from the vasectomy until its reversal. If the interval had been less than 3 years patency was 97% and pregnancy 76%, 3 to 8 years 88% and 53%, 9 to 14 years 79% and 44% and 15 years or more 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures and they were statistically the same for all patients regardless of the surgeon. When sperm were absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses and pregnancy was reported in 52 of 120 couples (43%).

Treatment of renal transplant stones by extracorporeal shock-wave lithotripsy in the prone position

Two patients with renal transplant lithiasis were successfully treated with extracorporeal shock-wave lithotripsy (ESWL) in the prone position. Pathogenesis and treatment of transplant lithiasis are discussed. Performing ESWL on renal transplant patients in the prone position has advantages over standard positioning techniques.

Management of rectal injuries during radical cystectomy

We reviewed the incidence and management of intraoperative rectal injuries in patients who underwent radical cystectomy from January 1980 through July 1988 to assess the role of primary repair without diverting colostomy as definitive therapy. During this interval 163 radical cystectomies were performed and 125 charts were available for review. The incidence of rectal injuries was 9.6% (12 of 125 patients). The rate of rectal injury in patients who had previously received definitive pelvic radiation was 27% (3 of 11). The incidence of injury in patients who received 2,000 rad preoperative radiation (11%, 2 of 17) was similar to that noted in individuals who were not irradiated (7%, 7 of 97). Of the 12 patients with rectal injury 9 underwent primary closure without diverting colostomy. The remainder were treated with an initial colostomy. Only 1 patient who had not received prior radiation required a colostomy after initial treatment with primary closure. The 8 successful primary rectal closures were done in 2 patients who underwent definitive pelvic radiation, 2 who had received 2,000 rad preoperatively and 4 who had not been irradiated.

Microsurgical penile revascularization using the central corporeal penile artery

We treated 9 patients with vasculogenic impotence by penile revascularization using a microsurgical anastomosis between the inferior epigastric artery and the central corporeal penile artery. Diagnostic evaluation included penile brachial indexes and pelvic arteriograms, which were abnormal in all 9 patients. Revascularization was technically possible in 7 of 9 patients; 2 had inadequate central arteries. The penile brachial index initially was improved in all 7 patients, although 1 had an early occlusion at 2 months and 1 had a late occlusion at 4 years. Potency was improved initially in 6 of the 9 patients, with longer term improvement in 5 of 9 followed 1 to 8 years. Two patients remain potent currently. The advantages of this technique are a reasonably high technical success rate in selected patients, with improved initial potency in more than half. The disadvantages include technical difficulty, lack of clear-cut selection criteria and unknown long-term results.

Diagnostic value of routine bone scintigraphy renal imaging in renal cell carcinoma

Technetium-99m-phosphate compounds used in bone scanning are excreted by the kidney, and excellent renal images can be obtained on routine bone scintigrams. The preoperative bone scans of 49 patients who underwent radical nephrectomy for renal cell carcinoma between 1981 and 1985 were reviewed for renal imaging. Ninety-four percent of the patients had abnormal bone scan renal images (82% had focal decreased uptake, and 12% had focal increased uptake). Six percent of the renal images were symmetrical bilaterally. When bone scans are employed in the postoperative follow-up of patients with renal cancer, they can be used to assess the status of the remaining kidney.

Transrectal ultrasound. A case report related to the natural history of prostate cancer

This is a case report of a man with prostate cancer diagnosed 10 years ago by digital rectal examination and prostatic biopsy. He was followed with serial transrectal ultrasound examinations for the last 22 months. Transrectal ultrasound enabled us to observe the natural history of his cancer. Because of accelerated tumor growth, a radical prostatectomy was performed. The tumor was confined within the prostate capsule and thus considered a "cure." Transrectal ultrasound is an invaluable tool for continuous monitoring of patients with prostate cancer.

Primary carcinoma of the distal male urethra: a case treated with lymphadenectomy and interstitial radiation therapy

We report a case of primary squamous cell carcinoma of the distal male urethra with a single inguinal node metastasis. Treatment consisted of unilateral pelvic and inguinal lymphadenectomy, and a combined course of external beam and interstitial radiation therapy to the distal urethra and penis by the Henschke modification of the Paris technique.

Is radical cystectomy indicated in patients with regional lymphatic metastases?

The records of 21 patients who had radical cystectomies for the treatment of locally advanced bladder cancer and were found to have regional lymphatic metastases have been reviewed. Ten of these patients had only one lymph node involved (N1), and 11 patients had metastases in more than one lymph node (N2-3). Four patients with N1 disease and 1 patient with N2-3 disease survived tumor-free greater than forty months postoperatively. Radical cystectomy can produce long-term disease-free survival in some patients with limited pelvic metastases.

Extravesical ureteroneocystostomy in renal transplantation

From October 1970 to January 1986, 808 patients underwent renal transplant ureteroneocystostomy by an extravesical technique. Complications related to the anastomosis and/or ureter were reviewed. There were 23 total complications, for an over-all urological complication rate of 2.8 per cent. Of these complications 17 were related to the ureteroneocystostomy, for an anastomotic complication rate of 2.1 per cent. Complications were almost universally repaired by another operation. Two patients died and 1 lost the allograft because of urological complications.

Urodynamic evaluation of ileal conduit function

Bilateral hydroureteronephrosis following ileal conduit urinary diversion is not uncommon. It may be owing to ureteroileal stenosis, stomal stenosis or a poorly compliant ileal conduit. The standard evaluation of stoma size, conduit residual urine and a loopogram often fail to allow determination of the cause of ureteral dilatation. In addition to these standard tests, we have used conduit urodynamics to study conduit function with a triple lumen urodynamic catheter to measure simultaneously conduit pressure proximal and distal to the fascia during filling under fluoroscopy. In 4 control patients with normal upper tracts who were studied with this technique conduit leak point pressures ranged from 5 to 20 cm. water pressure. Six patients with bilateral hydroureteronephrosis were studied to evaluate conduit function. We found abnormalities in 5 patients, including functional stomal stenosis in 2, an atonic loop in 1, segmental obstruction in 1 and a high pressure noncompliant distal segment in 1.

Stomal construction and reconstruction

Urinary diversion plays an important role in the therapeutic repertoire of urologists. The stoma is often the weak link of any diversionary procedure. Some of the more common stomal problems include peristomal dermatitis, stomal stenosis, parastomal hernias, malposition, prolapse, and retraction. Depending on the nature and severity of the problem, it may be treated by local wound care, urinary appliance adjustment, dilatation, or surgical intervention. Careful site selection and stomal creation will keep stomal problems to a minimum.

Renal cell carcinoma as an incidental finding

We reviewed the manner of presentation and tumor stage in 56 consecutive patients with renal cell carcinoma treated surgically between 1961 and 1973 (group 1) and compared them to 46 patients treated similarly between 1980 and 1984 (group 2). In group 1, 7 cases (13 per cent) were discovered incidentally compared to 22 cases (48 per cent) in group 2. The tumor stage was lower in the incidentally discovered cases than in cases when the diagnosis was suspected. The 5-year survival rates of the incidental cases in group 1 tended to be better. Routine use of excretory urography, computerized tomography, ultrasound, bone scans and other effective diagnostic studies has led to earlier diagnosis, lower stage and possibly better survival in incidentally found cases of renal cell carcinoma than in cases when the diagnosis was suspected.

Salvage cystectomy following failed definitive radiation therapy for transitional cell carcinoma of bladder

Between 1971 and 1983 we performed 18 salvage cystectomies on patients with recurrent transitional cell bladder cancer initially treated with definitive radiation therapy (5,500-6,820 R). The interval between tumor diagnosis and radiation ranged from zero to twenty-one years (mean 3.5 years), and the interval between radiation therapy and cystectomy ranged between six months and twelve years (mean 2.5 years). Early major complications occurred in 5 patients, and there was one early and one late postoperative death. The overall patient survival from the time of diagnosis to death or the present (1985) ranged from two to thirty-one years (mean 9.8 years), and from the time of radiation to the present or death ranged from one to nineteen years (mean 6.2 years). The overall crude five-year survival from the time of cystectomy excluding 2 patients operated on in 1982 and 1983 was 50 per cent, however 3 of these patients died of cancer after five years. Breakdown of survival of these patients by stage demonstrated the best survival in patients with carcinoma in situ and Stage A or no neoplasm at the time of cystectomy. This report confirms the value of salvage cystectomy after radiation failure in invasive transitional cell bladder cancer.

Transient fertility after vasovasostomy in 892 patients

We report on the low incidence of transient fertility in 892 patients who underwent microsurgical vasovasostomy. Of the 892 patients in whom fertile sperm concentrations (as defined by us) developed 2 to 8 months postoperatively 28 later suffered azoospermia or severe oligospermia. The wives of 5 of the 28 patients with such transient postoperative fertility became pregnant before the patients became azoospermic or severely oligospermic again.

Potential pitfalls of the 2-hour calcium-to-creatinine ratio and urinary cyclic adenosine monophosphate excretion in the differential diagnosis of idiopathic hypercalciuria

We studied 44 patients with calcium urolithiasis on high (900 mg. daily) and low (400 mg. daily) calcium diets. With 24-hour urinary data, we categorized the patients as normocalciuric or hypercalciuric and subdivided the hypercalciuric patients into absorptive and renal types. Abbreviated tests, including the 2-hour fasting urinary calcium-to-creatinine ratio and 24-hour urinary (nephrogenous) cyclic adenosine monophosphate, did not predict accurately whether hypercalciuria was of the idiopathic, absorptive or renal type. However, 24-hour urinary calcium excretions on the low calcium diet had a sensitivity and specificity of more than 90 per cent for reproducing the categorized diagnoses.

Relationship of gross appearance of vas fluid during vasovasostomy to sperm quality, obstructive interval and sperm granuloma

To study its intraoperative significance the gross appearance of the vas fluid found during vasovasostomy was compared to the quality of sperm in the fluid, obstructive interval and presence or absence of a histologically proved sperm granuloma. Data were obtained from 648 vasa in 340 patients. As the gross appearance increased in opacity, there was a small decrease in the proportion of morphologically normal, motile sperm (23 to 7 per cent) and a corresponding small increase in the proportion of sperm without tails (2 to 12 per cent). These minor trends had statistical but no intraoperative surgical significance. There was no variation in the proportion of vas fluid azoospermia with gross appearance. There was no significant difference in the gross appearance of the vas fluid with increasing obstructive interval. Finally, the presence or absence of a sperm granuloma had no effect on the gross appearance of the vas fluid, and the appearance had no predictive value relative to sperm granuloma. We conclude that the gross appearance of the vas fluid should not be used as a basis for operative decision-making during vasovasostomy.

Diuretic radionuclide urography in the diagnosis of suspected ureteral obstruction following renal transplantation

The diuretic radionuclide urogram has been shown to be an effective method to discriminate obstructive from nonobstructive hydronephrosis in nontransplanted renal units. This test was evaluated in 9 renal transplant patients with suspected partial ureteral obstruction. An obstructed pattern in 2 patients was confirmed and relieved by an operation. Nonobstructed patterns in 7 patients were verified by long-term clinical followup and subsequent ancillary testing. Accurate in all 9 cases, this investigation appears to provide a safe, noninvasive method to diagnose suspected post-transplantation ureteral obstruction.

Intraoperative observations during vasovasostomy in 334 patients

This initial report from the Vasovasostomy Study Group concerns intraoperative data obtained during vasovasostomy from 639 vasa in 334 patients. These data are related to the obstructive interval (time from vasectomy to vasovasostomy) and to the presence or absence of histologically proved sperm granuloma at the old transected testicular end of the vas (vasectomy site). Rates of sperm absence from vas fluid at the testicular end increased with longer obstructive intervals and with absence of a sperm granuloma. If sperm were present in fluid at the testicular end of the vas, the quality was poorer when the obstructive interval lengthened and when sperm granuloma was absent. Vas luminal diameters at the testicular end were smaller when a sperm granuloma was present. These observations support the theory that a sperm granuloma at the vasectomy site may have a beneficial, pressure-releasing effect that could be favorable prognostically for fertility after vasovasostomy.

Renal calculi associated with incomplete distal renal tubular acidosis

We report 5 cases of renal calculi associated with incomplete type I renal tubular acidosis. The patients presented with a history of recurrent calculi and demonstrated bilateral calculi with corticomedullary junction calcification on x-ray. Stone analysis revealed primarily calcium phosphate stones and metabolic studies demonstrated hypercalciuria, mild depression of serum bicarbonate and inability to lower the pH of a fasting morning urine to less than 5.8. The 24-hour urinary citrate excretion was depressed markedly. The diagnosis was confirmed by an ammonium chloride loading test. Treatment consisted of alkalization of the patients, which corrects the hypercalciuria and increases the urinary citrate level and should decrease the tendency to form stones. The diagnosis of incomplete type I renal tubular acidosis should be considered in patients with recurrent renal calculi.

Etiology and management of early and late peritransplant infections

Subfascial peritransplant infection is a life-threatening complication of renal transplantation with multiple etiologies, early onset, and subtle or catastrophic presentation. Thirteen such deep space infections were encountered in 160 consecutive transplants followed for up to 4 years. Difficult management decisions were required frequently. Three patients presented with acute peritonitis. In each instance the source of infection was obscure until abdominal exploration revealed transperitoneal rupture of an infected peritransplant fluid collection. Gray scale ultrasonography and ultrasound guided needle aspiration of fluid collections proved valuable in the clarification of often confusing clinical situations. The transplant was left in situ, with good function and complete wound healing in 5 cases. Transplant nephrectomy was required in 8 patients. Three patients died despite transplant nephrectomy and discontinuation of immunosuppression.

Treatment of vasculogenic erectile dysfunction by direct anastomosis of the inferior epigastric artery to the central artery to the corpus cavernosum

We present a case of vasculogenic erectile dysfunction following trauma, which was treated successfully by direct anastomosis of the inferior epigastric artery to the central artery of the corpus cavernosum. This is the first report of this operative technique. Its theoretical advantages over previously described revascularization techniques include an end-to-side vascular anastomosis, possibly decreasing perianastomotic fibrosis, and regulation of new blood flow into the corporeal bodies by the neurovascular mechanism of the central artery.

The use of a portable dental x-ray unit for intraoperative renal roentgenograms

We herein describe a simplified technique for intraoperative roentgenograms of the kidney using a portable dental x-ray unit.

Otis internal urethrotomy in the treatment of urethral stricture disease

Internal urethrotomy was done on 216 urethral strictures in 192 patients at our medical centers from 1969 to 1978. Of these cases 71 per cent were treated successfully, with a 12 per cent complication rate. Results were analyzed separately for different characteristics of the strictures and for several methods of internal urethrotomy. It is concluded that nearly all types of strictures can be treated by internal urethrotomy, with a reasonable rate of success and a minimum of morbidity.

Conservative management of low grade neoplasms of the male urethra: a preliminary report

Between 1965 and 1977, 8 men with low grade urethral neoplasms were treated with local excision or a combination of local excision and local chemotherapeutic agents. The tumors were in the anterior urethra in 5 cases and the posterior urethra in 3. Histology included 2 transitional cell papillomas, 3 squamous cell carcinomas, 1 transitional cell carcinoma, 1 mesonephric carcinoma and 1 intraductal transitional cell carcinoma in situ. All neoplasms were controlled by local measures for 1 to 13 years. This experience suggests that local treatment may be an acceptable alternative to a radical operation in certain well localized low grade urethral neoplasms in men.

Simultaneous, contralateral hypernephroma and renal transitional cell carcinoma

The second case of simultaneous, contralateral hypernephroma and renal transitional cell carcinoma is described. Methods of managing bilateral renal tumors are reviewed.

Malacoplakia of the prostate in an immunosuppressed patient

Malacoplakia predominantly affects the bladder but occasionally involves other sites. The third case of malacoplakia of the prostate, occurring in a renal transplant patient who was receiving prednisone for immunosuppression, is reported. Modification of phagocytosis and the normal inflammatory response to bacterial infection by the steroid may have been of major importance in the genesis of malacoplakia.

The urographic findings in acute pyelonephritis: non-obstructive hydronephrosis

Excretory urography was performed on 4 patients early in the course of acute pyelonephritis. These studies showed dilatation of the involved collecting system without obstruction. The dilatation resolved after therapy in 3 patients and was not present on a previous excretory urogram in the fourth. Although previous studies have shown that the excretory urogram is usually normal in cases of acute pyleonephritis these cases demonstrate that this disease can produce dilatation of the collecting system and mimic obstruction.

The radiological spectrum of acute pyelonephritis in adults and adolescents

Excretory urograms of 40 patients with a clinical and laboratory diagnosis of acute pyelonephritis were reviewed. Eleven (28%) had abnormal urograms attributable to the acute disease process. Of the 11 abnormal patients, 7 had obvious urographic abnormalities, while in 4 the findings were few and subtle. The most common findings were renal enlargement, decreased density of contrast material, delayed calyceal appearance time, and dilatation of the collecting system; of these, the last two most frequently correlated with the clinically abnormal side.

Extravesical ureteroneocystostomy in 170 renal transplant patients

Urinary tract reconstitution was done in 170 consecutive renal transplant patients, using an extravesical ureteronecystostomy. The urologic complication rate was 8.5 per cent but complications associated directly with the anastomosis occurred in only 5 per cent of the cases. There have been no anastomotic complications in the last 104 transplants. Vesicoureteral reflux occurred in 20 per cent of 50 patients surveyed. Death in 2 cases and loss of the kidney in 1 were associated with urologic complications.