Ultrasonic dilatation of the uterine cervix: morphologic evaluation of a new device in the sow.

The present study demonstrates that low-power ultrasonic activation of Hegar dilators reduces the mechanical force required for dilatation of the cervix. The acute and possible late effects of an ultrasonic dilator on the cervical mucosa in the sow were evaluated by histologic study and compared to the effects of similar mechanical dilatation. In both groups early effects were mild to moderate edema and vascular congestion of the cervical mucosa. The immediate changes were comparatively more pronounced after ultrasonic dilatation. No significant pathologic differences were noted five weeks after ultrasonic dilatation of the endocervical canal. Further study may prove the device useful for dilatation of the stenosed cervix and urethra in women.

Objective response and disease outcome in 59 patients with stage D2 prostatic cancer treated with either Buserelin or orchiectomy. Disease aggressivity and its association with response and outcome.

A comparative study was done in 59 recently diagnosed Stage D2 prostatic cancer patients treated with either long-term GnRH-A (Buserelin) (N = 42) or with orchiectomy (N = 17) and followed up for three years. The suppressed limits of plasma testosterone and estradiol levels after eight-week follow-up as well as the objective clinical response and disease outcome were found to be similar with either treatment. Hot flushes and loss of libido were noticed in both groups throughout the follow-up period; however, there were no other side effects. Analysis of Stage D2 patients based on their time of death enables us to identify nonhormonal variables which, in the form of an aggressiveness score, correlated well with both clinical response and disease outcome. These data confirm that (1) Buserelin is an effective and safe alternative to orchiectomy in advanced prostatic cancer, and (2) in clinical studies a multifactor aggressiveness score is useful for analyzing clinical efficacy data. Prospective application of that score may enable predictability of patient response and influence patient management.

Changing profiles in vasectomy subjects in the past decade.

Two groups of vasectomy patients were reviewed: 376 men operated upon between 1968 and 1971 and 608 between 1974 and 1978. Average age, length of marriage, and number of living children prior to vasectomy were greater in the first group (P less than 0.01). The results are compatible with the idea that couples are planning smaller families and turning increasingly to vasectomy as a reliable permanent birth control method immediately following the completion of their families.

Polytetrafluorethylene (PTFE) grafts for hemodialysis. 18 months' experience.

18 months clinical experience with 6 mm polytetrafluorethylene forearm grafts for hemodialysis access has been described. 35 grafts were implanted, all in patients who had unsuitable vessels for construction of a regular Brescia-Cimino forearm fistula. The overall patency was 71% with mean duration of 10.3 months, and at any one time more than 85% of the grafts at risk were functional. Complications, including undesirable flow rates, edema, thrombosis, aneurysm and cardiac failure have been discussed and rational methods of avoidance described. We believe the polytetrafluorethylene (PTFE) graft represents an important advance in hemodialysis access.

Vasectomy: benefits and risks.

Bilateral occlusion of the vas deferens, vasectomy, is progressively becoming the method of choice for couples seeking permanent contraception at a younger age, with smaller families. They are apparently well-informed and view the procedure as a natural step. Vasectomy is an inexpensively performed office procedure that causes minimal disruption of routine and has a high degree of community acceptance. The risks of significant hematoma, infection, discomfort and other sequelae are within acceptable limits. Improved techniques will continue to reduce the small failure rate. Antibodies observed in half of the patients have not been linked to systemic disease, although they are a hazard for the one patient in 500 returning for a vasovasostomy. Refinements in microsurgery and availability of artificial insemination enhance vasectomy as the method of choice. Evidently, extending the minimum time of sterility confirmation permits detection of occasional recanalization from technical failures. Adequate screening of the couple's motivation and expectations can prevent the rare psychologic disturbances, the greatest risk with this procedure and a problem associated with all options. For the male, there is no competitive technique at this time. In a world striving for equal rights, where the female still carries the burden of temporary contraception, the simplicity and popularity of vasectomy for permanent contraception add the desired undertones of social equilibrium.

Complete response of lung metastases caused by prostatic cancer after chronic administration of a gonadotropin-releasing hormone analog, buserelin (HOE 766).

A stage D2 prostate cancer patient with biopsy-proven lung metastases and negative work-up for metastases is discussed. Treatment consisted of hormonal therapy in the form of chronic administration of an analog of gonadotropin-releasing hormone (GnRH-A), Buserelin, with follow-up for 24 months. The complete response of the patient to GnRH-A therapy provides an interesting and unusual case in the understanding of the biological behavior of prostate cancer.

Canadian clinical trial of antilymphocyte globulin in human cadaver renal transplantation.

A multicentre, randomized clinical trial of antilymphocyte globulin (ALG) was conducted among patients who had undergone cadaver kidney transplantation; follow-up was continued for a minimum of 1 year. Of the 179 patients 92 were given conventional treatment only, while 87 were given in addition ALG (from a standardized, highly immunosuppressive, common pool of equine ALG), 20 mg/kg-d intravenously for 10 days after transplantation. The ALG-treated group had better accumulated graft survival, fewer nephrectomies, better graft function, less than half the number of acute rejection episodes and less prednisone use. There was a beneficial drug (ALG)-related effect in both the graft and the host during the first 3 months after transplantation.

Bilateral nephrectomy for massive pulmonary hemorrhage in Goodpasture's syndrome.

A case of Goodpasture's syndrome is described in which bilateral nephrectomy was undertaken because of massive pulmonary hemorrhage. Similar cases recorded in the literature are reviewed. Various hypotheses to explain the beneficial effects of renal ablation on lung purpura are considered. It is suggested that the pulmonary hemorrhage in Goodpasture's syndrome is mediated in part by a non-antibody humoral factor with permeability-increasing properties that is released from the nephritic kidney.

Possible teratogenic effects of artificial insemination by donor.

Three trisomic offspring conceived by artificial insemination by donor (AID) were observed in a population in which a total of about 400 babies were so conceived. To test whether this excess represented a random fluctuation or a real effect of the AID procedure we surveyed, by questionnaire, a group of women who had born children conceived by AID. A significantly higher number of trisomic offspring were found than expected in a population with the observed age distribution. Further data are needed to test the validity of this observation.

An artificial kidney system suitable for multiple simultaneous dialysis.

The standard twin-coil Kolff artificial kidney has been redesigned to a single-pass system employing cold dialysis, bath-heated and recirculated within the coil. With considerably reduced bath requirements, a comparable dialysis is achieved in spite of a lower bath-to-blood urea gradient. Coil pressure is monitored by a simplified high-and-low pressure control system linked to a specially designed roller blood pump. The re-use of priming blood and disposable coils have proved economical and feasible. A considerable reduction in bacterial growth has been achieved. The Kolff system retains its capacity in the management of acute renal failure and has proved efficient in twice-weekly six-hour chronic hemodialyses.

Effect of bromocriptine in patients with apomorphine-responsive erectile impotence: an open study.

An open pilot study was undertaken to investigate the therapeutic effect of the dopaminergic agent, bromocriptine (BC), in impotent patients who developed an erectile response to the dopamine receptor agonist, apomorphine. Eight out of 17 patients reported improvement in ability to obtain an erection; five of these 8 subjects were able to achieve penetration. The optimum dose of BC was 2.5 - 11.25 mg/day. A double-blind placebo-controlled study is merited.

Experience with polytetrafluoroethylene grafts in patients on long-term hemodialysis.

Expanded polytetrafluoroethylene (PTFE) is a new material now being used to create subcutaneous arteriovenous anastomoses for vascular access in hemodialysis. The authors have been impressed with the versatility of grafts made from this material and, where failure occurs, the ease with which surgical revision can be carried out. Two cases are described to illustrate the adaptability of this material to reconstruction. The authors' initial impression based on 22 months' experience is that PTFE grafts have appreciably modified the management with respect to vascular access, of many patients on long-term hemodialysis.

Multicenter trial in North America of UroLume urinary sphincter prosthesis.

We investigated the effectiveness and associated complications of treatment with an endoluminal urethral sphincter prosthesis in 153 spinal cord injury men (mean age 36 years, range 16 to 74 years) with urodynamically diagnosed detrusor-external sphincter dyssynergia. These patients were prospectively treated with a urethral sphincter stent at 15 centers in North America. Followup ranged from 2 to 33 months. Voiding pressures averaged 76 +/- 28, 42 +/- 21, 44 +/- 38, 35 +/- 18 and 32 +/- 20 cm. water, respectively, before prosthesis insertion in 153 patients and at 3 months in 123, 6 months in 114, 12 months in 98 and 24 months in 22. A significant decrease in voiding pressure was noted in the 22 patients at 24 months compared with matched preoperative data (80 +/- 25 cm. water, p = 0.03). The residual urine decreased from 181 +/- 154 ml. before insertion to 82 +/- 93 ml. at 24 months (p = 0.01). Maximum cystometric capacity remained constant, with a mean of 195 +/- 158 ml. before insertion to 248 +/- 122 ml. at 24 months (p = 0.17). No significant differences were apparent after 24 months of followup in any of the urodynamic parameters between 44 patients with and 109 without previous external sphincterotomy. Hemorrhage requiring blood transfusion, obstructive hyperplastic epithelial overgrowth and soft tissue erosion did not occur. No deleterious effects were observed on renal or erectile function. Of the patients 43 (28.1%) required 2 prostheses to bridge the external sphincter completely. Stent removal was required in 10 patients. Seven explantations were required for prosthesis migration, 1 for pain and urethral edema, 1 for inability to maintain a condom catheter, and 1 for nonepithelialization and secondary bladder neck obstruction. A total of 13 patients (8.5%) required a subsequent operation for bladder neck obstruction. Therefore, the sphincter prosthesis is an attractive modality for the treatment of external sphincter dyssynergia in patients with and without previous external sphincterotomy because of its ease of deployment and minimal associated morbidity.

Removal of UroLume endoprosthesis: experience of the North American Study Group for detrusor-sphincter dyssynergia application.

PURPOSE: We present the experience of the North American UroLume Multicenter Study Group with removal of the UroLume endoprosthesis. MATERIALS AND METHODS: A total of 160 neurologically impaired patients were enrolled in the North American UroLume Multicenter Study Group for detrusor external sphincter dyssynergia application. Analysis was performed in 2 groups of patients in which the device was removed during insertion and after implantation, respectively. RESULTS: Device retrieval was required during insertion in 21 patients (13%) mainly due to misplacement or migration in 17. Extraction was done with minimal complications and in all but 2 cases subsequent UroLume implantation was successful. Of 158 men with the device in place 31 (19.6%) required removal. In 34 procedures 44 devices were removed, mainly due to migration. Time from implantation to removal ranged from 4 days to 66 months (mean 22 months). The UroLume was removed en bloc in 20 cases and in parts or wire by wire in 19. The majority of patients had no or minimal complications after extraction. Only 2 patients had serious temporary complications, including bleeding and urethral injury, with no lasting consequences. No malignancy developed as a result of UroLume insertion. CONCLUSIONS: While there is a potential for urethral injury and bleeding, UroLume endoprosthesis removal is largely a simple procedure with minimal complications and consequences.

Long-term followup of the North American multicenter UroLume trial for the treatment of external detrusor-sphincter dyssynergia.

PURPOSE: We determine the long-term efficacy and safety of the UroLume stent as minimally invasive treatment for external detrusor-sphincter dyssynergia in spinal cord injured men. MATERIALS AND METHODS: A total of 160 spinal cord injured men with a mean age plus or minus standard deviation of 36.3 +/- 12.1 years (range 16 to 74) were prospectively treated with an endoprosthesis at 15 centers as part of the North American UroLume trial for external detrusor-sphincter dyssynergia. Urodynamic parameters, including voiding pressure, residual urine volume and bladder capacity, were compared before treatment and at 1, 2, 3, 4 and 5 years after treatment. RESULTS: Mean voiding pressure was 75.1 +/- 28.2 cm. water before treatment in the 160 patients, and 37.4 +/- 23.9 at year 1 in 97, 39.5 +/- 22.2 at year 2 in 84, 42.6 +/- 27.3 at year 3 in 61, 46.3 +/- 33.2 at year 4 in 57 and 44.2 +/- 28.9 cm. at year 5 in 41 after stent insertion (p <0.001). Residual urine volume decreased after stent placement and was maintained throughout the 5-year followup (p <0.001). Mean cystometric capacity remained constant from 269 +/- 155 before insertion to 337 +/- 182 ml. 5 years later (p = 0.17). Hydronephrosis and autonomic dysreflexia improved or stabilized in most patients with functioning stents. Stent explant was necessary in 24 patients (15%), of whom 4 (16.7%) had another stent implanted. CONCLUSIONS: The UroLume stent demonstrates long-term safety and efficacy for the treatment of external detrusor-sphincter dyssynergia. The outcome was similar in men with and without previous sphincterotomy.