Pleural effusion secondary to ureteral obstruction.

Urinary tract obstruction may produce a pleural effusion detectable by chest x-ray film. This uncommon finding must be differentiated from intrathoracic and intraperitoneal causes of pleural effusion, including intrathoracic metastases when a malignant tumor is the cause of the urinary tract obstruction.

Five-year survival following excision of renal cell carcinoma extending into inferior vena cava.

Fifteen consecutive patients having radical nephrectomy and excision of tumor extension from the inferior vena cava for pathologic Stage 3A renal cell carcinoma were followed up for a minimum of five years. Survival was compared with patients having radical nephrectomy for Stage 2 or Stage 3 renal cell carcinoma in the same time interval. Five-year survival in the Stage 3A group (47%) was similar to that for patients with Stage 2 tumors (54%) and significantly better than Stage 3 patients with positive lymph nodes at surgery (12%). Renal cell carcinoma with venous extension has a reasonable prognosis after surgical excision and warrants an aggressive surgical approach.

Effect of preoperative channel transurethral prostatectomy on complications of 125iodine implantation in carcinoma of prostate.

Patients receiving 125Iodine implantation and pelvic lymphadenectomy for clinically localized prostatic carcinoma were divided into two groups, with one group receiving a preoperative channel transurethral prostatectomy. The groups were matched according to clinical stage and histologic grade. Complications were classified as operative, short-term, and long-term. Although preoperative channel transurethral prostatectomy was associated with a greater incidence of surgical procedures after implantation, the overall complication rate did not differ between the two groups. The overall mortality rate and the incidence of progression of Stage C tumors did not differ between the two groups.

Atypical renal adenocarcinoma with features suggesting collecting duct origin and mimicking a mucinous adenocarcinoma.

We report a case of an atypical renal adenocarcinoma of the renal medulla associated with a marked desmoplastic response and interstitial mucin production. Collecting duct epithelium of the renal medulla throughout the kidney showed cytologic atypia. These features have been described by others as suggestive of a collecting duct histogenesis. This case represents the fifteenth reported case known to us of a renal adenocarcinoma of collecting duct origin. Prior reports, however, have not described the extensive mucin production that may be associated.

Ultrasonography and needle aspiration in diagnosis of xanthogranulomatous pyelonephritis.

Xanthogranulomatous pyelonephritis may present as a renal mass which can be difficult to differentiate from a hypovascular renal tumor by intravenous pyelography or selective renal angiography. Four patients are described in whom ultrasonography with or without fine-needle aspiration suggested or confirmed the diagnosis of xanthogranulomatous pyelonephritis.

Duplication of male urethra.

Male urethral duplication is an unusal anomaly with many variants including complete duplication from the bladder to the glans penis as well as incomplete and abortive forms. Two cases are presented of duplication of the male urethra of the epispadiac incomplete type. A chart has been constructed to facilitate categorization of the various forms of urethral duplication in the male.

Percutaneous nephrostomy and antegrade ureteral stent insertion.

Sixty consecutive percutaneous nephrostomies were attempted in 37 patients with a 97-per cent success rate. The patients ranged in age from three to seventy-three years. Twenty-eight attempted nephrostomies were bilateral and 32 unilateral. When possible, the percutaneous nephrostomies were converted into internal ureteral stents by antegrade techniques. In each case of apparent complete ureteral obstruction, the area was successfully negotiated, and an indwelling ureteral stent was placed. In 2 patients, combined antegrade and retrograde techniques were required for successful internal stent placement. There was one failure because of a subcapsular hematoma resulting from multiple punctures with an 18-gauge needle. One major complication occurred when a segmental branch of the renal artery was injured by the nephrostomy catheter.

Genitourinary leiomyomas.

Leiomyomas may originate from any anatomic location of smooth muscle in the genitourinary system but are uncommon neoplasms. Five unusual cases of leiomyomas arising from the renal pelvis, bladder, spermatic cord, and glans penis are presented. The leiomyoma arising from the glans penis in a three-year-old boy is the first case of a leiomyoma in that location noted in the literature. A review of leiomyomas from each genitourinary structure of origin is presented.

In vitro growth of renal cell carcinoma after preoperative renal infarction.

Renal cell carcinoma tissue was cultured from 2 patients who underwent embolization of the tumor before surgery and from 2 patients who did not have the tumor embolized. A combination of small Gelfoam particles and polyvinyl alcohol foam particles (250-590 mu diameter) was used to devascularize maximally the tumors that were embolized. The tumor cells from all 4 patients grew in short-term tissue cultures and demonstrated histology and growth properties characteristic of tumor cells. Successful embolization of renal cell carcinomas may not completely infarct the primary tumor, and local tumor growth may continue.

Effects of alpha-adrenoceptor agents on norepinephrine release from vas deferens of several species including man.

Unlike the situation with the vas deferens of rats, guinea-pigs, rabbits and dogs, neither phentolamine nor yohimbine enhanced electrically-evoked release of [3H]norepinephrine from the in vitro human vas deferens. However, clonidine produced, by a phentolamine-sensitive mechanism, a concentration-related inhibition of release in the human vas deferens. The results indicate that, even though presynaptic alpha-adrenoceptors exist, a negative feedback regulation of release by norepinephrine, which occurs in the vas deferens of the other species, may not be functionally important in the vas deferens of the human.

A study of the atropine-resistant component of the neurogenic response of the rabbit urinary bladder.

Rabbit bladder body was stimulated to contract by a number of agonists, of which bradykinin was the most potent, and ATP one of the least potent substances tested. The atropine-resistant component of the neurogenic response was unaffected by 2 X 10(-5) M chlorpheniramine or 10(-6) M methysergide, doses which suppressed responses to histamine or 5HT. Indomethacin 10(-5) M, or 10(-5) M capsaicin both reduced the atropine-resistant component. Following treatment with 10(-6) M atropine and 10(-5) M prazosin, 10(-4) M ANAPP3 produced a further suppression of the response, but did not antagonize the response to ATP. In the bladder body, the transmitter(s) responsible for the neurogenic response may be acetylcholine and prostaglandins and possibly ATP and substance P.

Influence of estradiol on accessory reproductive organs in the castrated male rat. Effects of bromocriptine and flutamide.

Estradiol partially maintained the weights of the dorsolateral prostate and seminal vesicles in castrated adult male rats. One group of animals received subcutaneous injections of estradiol (0.01 mg/kg) daily, while a second group of animals received estradiol plus bromocriptine (4.0 mg/kg). Changes in weights of accessory reproductive organs were correlated with serum prolactin levels. Estradiol significantly increased serum prolactin levels while concomitant treatment with bromocriptine caused serum prolactin to remain at castrate levels. Bromocriptine slightly decreased, but did not abolish, the effect of estradiol on weights of the dorsolateral prostate and seminal vesicles. To determine if the effect of estradiol was mediated by androgen receptors in the dorsolateral prostate and seminal vesicles, a third group of animals was treated with flutamide. Flutamide, at a dosage (20 mg/kg) that abolished the effects of dihydrotestosterone on the weights of these tissues, produced no alternation of the effects of estradiol. Treatment of animals with a combination of flutamide, bromocriptine, and estradiol did not significantly alter organ weights from the results obtained with bromocriptine and estradiol. Scatchard plot analysis of the effect of estradiol treatment on cytosol binding of estradiol demonstrated increased quantities of estradiol binding in dorsolateral prostate and seminal vesicles which correlated with the changes in weights noted. Although part of the effect of estradiol on regression of male accessory reproductive organs of castrated rats may be mediated by prolactin, the principal effect appears to be a direct action on responsive tissues.

Lasertripsy of upper urinary tract calculi after unsuccessful extracorporeal lithotripsy or ureteroscopy: comparison with primary lasertripsy.

Lasertripsy of upper urinary tract calculi after unsuccessful extracorporeal lithotripsy (SWL) or ureteroscopy (Group 1; N = 26 patients, 36 calculi) was compared with primary lasertripsy (Group 2; N = 56 patients, 79 calculi). Access to calculi was achieved by a Candela miniscope or flexible ureteroscope, and laser fragmentation was performed with the Candela pulsed-dye laser. Laser alone or laser plus 1.9F basket extraction produced a stone-free rate of 80.6% in Group 1 and 79.8% in Group 2. Additional treatment methods were needed in similar proportions of both groups and in most patients consisted of SWL of fragments displaced into the kidney. The laser fragmentation failures rates were 2.8% in Group 1 and 7.6% in Group 2. One-month stone-free rates and major complication rates were similar in the two groups. Lasertripsy after unsuccessful SWL or ureteroscopy was as effective as primary lasertripsy.

Outpatient fragmentation of ureteral calculi with mini-ureteroscopes and laser lithotripsy.

Laser lithotripsy with mini-ureteroscopes is a minimally invasive method to fragment ureteral calculi. This study reviewed the efficacy and morbidity of outpatient laser lithotripsy for the treatment of ureteral calculi. The 248 patients were initially treated by outpatient ureteroscopy and laser lithotripsy with the Candela pulsed-dye laser over a period of 3 1/2 years. Thirty-six patients had prior unsuccessful fragmentation of ureteral calculi by SWL. Twenty-eight patients had undergone unsuccessful ureteroscopy with attempted basket extraction or attempted fragmentation with methods other than laser. Calculi were located in the upper ureter in 31% and in lower ureter in 69% of these patients. The 1-month stone-free rate was 92% for upper ureteral calculi and 96% for lower ureteral calculi, with an overall success rate of 94.7%. Ninety per cent of the patients were discharged the same day and 96% within 23 hours. Hospital admission was needed in only 4% of patients. Parenteral analgesia was required in 18% of patients, and major complications occurred in 0.8%. The combination of mini-ureteroscopes and laser lithotripsy is an effective method for fragmentation of ureteral calculi in outpatients with low morbidity and few complications.

Endoscopic management of urolithiasis in the morbidly obese patient.

A retrospective review of 48 consecutive morbidly obese patients with urolithiasis who were treated successfully by endoscopic modalities over 3.5 years was performed. Of the 73 endoscopic procedures, 48 were ureteroscopic laser lithotripsy (UL), 4 were ureteroscopic basket extraction, and 21 were percutaneous nephrolithotripsy (PCNL). The patients' weight ranged from 205 to 385 lbs. (average 286 lbs.). Their abdominal girth ranged from 53 to 65 inches (average 59 inches). Twenty-six patients had one procedure, eight patients had bilateral procedures, eleven patients had two procedures, and three patients had three procedures with utilization of either multiple ureteroscopic treatments or the combination of percutaneous and ureteroscopic techniques. The stone-free rate after one procedure was 77.8% for UL and 60% for PCNL. The stone-free rate after planned repeat procedures was 97% for UL/UL and 89% for PCNL/UL. There were two minor complications. Forty-eight procedures were performed on an outpatient basis, and the remaining 25 procedures necessitated hospital admission (average 3.6 days). Morbidly obese patients with urolithiasis who are unable to have SWL because of their body weight and abdominal girth can be treated successfully with UL, ureteroscopic basket extraction, and PCNL with efficacy comparable to that in patients of normal weight and with minimal morbidity. Many renal calculi were treated with UL alone with a high success rate.

Ureteral foreign body after laser lithotripsy.

We report an unusual ureteral foreign body resulting from a complication of pulsed-dye laser lithotripsy: a retained laser fiber fragment. It was removed with two endoscopic procedures without long-term problems.

Current concepts in vasectomy reversal.

PIP: The most widely used vasovasostomy techniques and the patency and pregnancy results achieved are reviewed. The number of patients requesting vasectomy reversal is increasing. The usual reasons given for requesting the procedure are remarriage, death of a child, the original social motivation for the vasectomy is no longer meaningful to the patient and a change in economic status. In the macroscopic technique, 4-8 sutures are placed joining the cut ends of the vas. An absorbable stent may or may not be used. The microscopic technique emphasizes mucosal approximation. The cut ends of the vas deferens are resected and the penile end dilated. Resection is repeated until seminal fluid is observed. The anastomosis is performed utilizing a microvascular clamp to maintain approximation. 6 sutures are placed over a stent. The fascia is approximated to remove tension from the anastomosis. A review of the research literature suggests that surgeons obtain higher patency rates and pregnancy rates using magnification. In 1 study, the authors used direct vision and a monofilament nonabsorbable stent to achieve a patency rate of 90% and a pregnancy rate of 46%; and used an operating microscope and no stent to achieve a patency rate of 96% and a pregnancy rate of 54%. Modern techniques have resulted in significant improvements in patency rates, but a marked discrepancy in pregnancy rates remains. 2 factors that potentially contribute to low pregnancy rates are the formation of epididymal granulomas after the vasectomy and the stimulation of antisperm antibodies cause by absorption of sperm. Several factors can optimize the end results. At surgery, the vas deferens can be resected until fluid is seen, although the dissection should not be carried onto the epididymis unless the surgical team has the equipment and capability to perform an epididymovasostomy. Another factor which appears to affect the pregnancy rate is the duration between the vasectomy and reversal. Better results are achieved when the vasovasostomy is performed within 10 years of the vasectomy. Although no single procedure in vasectomy reversal has been proven statistically superior, modern techniques, e.g, absorbable stents and magnification, have led to an improved potential for pregnancy.^ieng