Bilateral renal artery stenosis and renovascular hypertension.

Experience with the diagnostic evaluation and operative management of 38 hypertensive patients having bilateral renal revascularization is presented. Twenty-four patients had atherosclerotic occlusions and 14 had fibromuscular dysplasia. Renal vein renin assays (RVRA) and/or split renal function studies (SRFS) were performed in 37 of the 38 patients before operation. Although RVRA was negative in 29 percent and SRFS negative in 31 percent, 24 of 26 patients (92 percent) having both tests done had at least one positive study. Twenty-one patients had simultaneous bilateral repairs and 12 had staged bilateral reconstructions. The incidence of technical failures in these two groups was 21 and 9 percent, respectively. Excluding three uncorrected technical failures and two patients with recurrent branch renal artery lesions, 90 percent of patients with atherosclerosis and all patients with fibromuscular dysplasia had a favorable blood pressure response to operation. This study supports the use of both RVRA and SRFS in the diagnostic evaluation of hypertensive patients with renal artery stenosis. If these functional tests lateralize to one side, repair of that side only is recommended. If the functional studies do not lateralize, operation is suggested only when hypertension is severe and is not controlled readily with medications. In this circumstance reconstruction of the side that appears to be diseased most severely is recommended. Contralateral repair is undertaken only when hypertension persists and when repeat functional studies lateralize to the unoperated side.

Revascularization of the poorly functioning kidney.

The effect of renal vascularization on renal function in kidneys with poor preoperative excretory function is summarized in this report. Twenty-five patients with kidneys having preoperative creatinine clearance of less than 30 ml/min, as determined during split renal function studies (SRFS), which were revascularized for treatment of secondary renovascular hypertension and then were reevaluated by repeat SRFS form the basis of this report. There were 13 male and 12 female patients. The type of renal artery lesion was atherosclerotic in 21 patients and fibromuscular dysplastic in four patients. Eight individuals had total renal artery occlusion. Significant contralateral renal artery disease was present in 15 patients (60%). Preoperative creatinine clearances in the affected kidneys ranged from 0.27 ml/min (mean, 16 +/- 9 ml/min). after operation, creatinine clearances ranged from 0 to 72 ml/min (mean, 32 +/- 16 ml/mn). Fifteen of the 16 kidneys with preoperative creatinine clearances less than 20 ml/min had improvement in renal function following revascularization (P less than 0.01). Improvement (60%) or cure (36%) in hypertension followed revascularization in 24 of the 25 patients. The most dependable predictor of successful management of both hypertension and retrieval of renal function in these patients was the arteriographic demonstration of a patent distal vessel without evidence of severe intrarenal stenoses. These results support an aggressive attitude toward the use of revascularization in the operative treatment of such patients with renovascular hypertension, even when the residual excretory function is minimal or absent.

Sonographic evaluation of Peyronie disease.

In this case report we illustrate and discuss the use of high frequency, superficial organ, real-time ultrasound scanning in the evaluation of patients with Peyronie disease.

Testicular infiltrate in childhood acute lymphocytic leukemia. The need for biopsy in suspected relapse.

The testicle is a prime initial target for infiltration during relapse in male children with acute lymphocytic leukemia. Herein wer report our experience with management of this entity in 8 childre. It is stressed that a biopsy is essential to the diagnosis. The differential diagnosis is usually straightforward. One is admonished not to make presumptive diagnosis by palpation. Orchiectomy is unwarranted. The treatment of choice is testicular radiation with 2,000 rads in ten fractions in a twelve-day course plus reinsstitution of high-dose adjunctive chemotherapy in those children off chemotherapy, or reinduction therapy for children who relapse while still on chemotherapy. Prognosis of male children who undergo a bout of testicular infiltration is guarded.

Patient-reported sexual symptomatology in predicting functional and insufficient erectile capacity.

We evaluated the clinical utility of patient-reported erectile functioning information in discriminating Rigiscan-determined functional (greater than or equal to 70% penile tip and base rigidity and greater than or equal to 10 minutes' duration) from insufficient (less than 40% penile tip and base rigidity and less than or equal to 6 minutes' duration) erectile capacity, in a population of chronically ill men presenting with erectile dysfunction. Forty-three male veterans completed an extensive medical and psychologic evaluation, including a detailed assessment of sexual functioning, and then underwent two consecutive nights of supervised in-hospital Rigiscan sleep evaluations. Results of discriminant function analysis indicated that patient reports of morning erections and ejaculatory ability accurately predicted group membership for functional (96.7%) and insufficient (100%) categories. Careful attention to patient self-report is suggested for the urologist's initial appraisal of erectile dysfunction in populations of older, chronically ill men.

True hermaphroditism: a rational appraoch to diagnosis and treatment.

Eight previously unreported cases of true hermaphroditism are presented, and their basic characteristics are described and discussed with regard to diagnosis and management. Two basic groups are identified: those diagnosed prior to establishment of gender role and those diagnosed at a later date. The latter group should benefit from therapy designed to enhance and maintain their sex of rearing, while the former group should be reconstructed according to functional considerations first and fertility considerations second. Diagnostic criteria are evaluated, and the value of the exploratory laparotomy is stressed.

Osteomyelitis of the symphysis pubis: a separate disease from osteitis pubis. Report of three cases and review of the literature.

We reviewed the case of three of our own patients who had osteomyelitis of the symphysis pubis, as well as those of twenty-five patients described in the literature. The early symptoms of osteomyelitis of the symphysis mimic those of osteitis pubis. Osteomyelitis almost invariably is preceded by urological or gynecological surgery (often when a technical complication has occurred), and does not respond to shortterm antibiotic treatment. Characteristic radiographic findings develop. Osteomyelitis of the symphysis pubis should be treated by debridement and curettage, together with long-term treatment with an appropriately high dose of antibiotics.

Hypertension secondary to complete occlusion of the renal artery.

In summary, we feel the results of this study support an aggressive approach toward the diagnostic evaluation and operative management of patients with renovascular hypertension secondary to complete occlusion of the renal artery. Further, the frequent presence of contralateral disease and the progressive nature of renal artery occlusions represent a significant threat to renal function. Since renal function is frequently compromised but potentially retrievable by revascularization, nephrectomy should be employed only when hypertension is difficult to control, revascularization is impossible, and excretory function in the affected kidney is minimal.

Desaturation of eicosa-11,14-dienoic acid in human testes.

The metabolism of [1-14C]eicosa-11,14-dienoic acid was investigated in human testes using whole tissue minces and microsomal preparations. Both types of preparations catalyzed the desaturation of the labeled diene to eicosa-8,11,14-trienoic as well as eicosa-5,11,14-trienoic acid. The reported results, therefore, indicate that human testicular tissue, as well as rat testicular tissue (reported previously), is capable of utilizing eicosa-11,14-dienoic acid as a precursor of arachidonic acid. Since it is known that there is no delta 8 desaturase activity in rat liver and brain, these studies support the concept that there is a tissue variation in this enzymatic pathway.

Fluorescent products and polyunsaturated fatty acids of human testes.

Lipid soluble fluorescent pigments from human testis were fractionated by silicic acid column chromatography and silica gel thin layer chromatography. Fluorescence analyses revealed a family of at least 3 compounds with similar fluorescence properties, including excitation and emission maxima, reversible fluorescence quenching by alkaline pH, and fluorescence quenching by heavy metal chelation. These fluorescence characteristics strongly indicated the presence of the conjugated Schiff base fluorophore-N=C-C=C-N-. The chromatographic separations employed enabled a more definitive fluorescence characterization of the lipid soluble pigments known to accumulate late in tissues with age and as a result of lipid peroxidation. Total lipids and fatty acid composition of the total lipids were determined. Polyenoic acids constituted about 40% of the total fatty acids. Histological examination of the tissues revealed some degeneration and edema, but significant spermatogenesis and normal complement of Leydig cells.