Malakoplakia in a cadaver renal allograft: a case study.

Malakoplakia is an uncommon chronic inflammatory disease characterized by histocytes with intracellular Michaelis-Gutmann bodies. The etiology is uncertain, but it is thought that depressed macrophage phagocytosis of bacteria is important. This presentation describes a case of malakoplakia arising in a cadaver renal transplant. The association of long term immunosuppression and repeated E. coli urinary tract infections is discussed.

Tubulovillous adenoma arising 30 years after ileocystoplasty.

The possibility of recurrent colonic metaplasia occurring as a complication of pelvic ileal pouches after ileo-rectal anastomosis has been raised. Several reports have documented malignant bladder tumours developing in patients many years after an ileocystoplasty. The case of a 50 year old man, who developed a tubulovillous adenoma in the ileal patch 30 years after an ileocystoplasty had been performed to enlarge a tuberculous shrunken bladder, is reported. The adjacent small intestinal mucosa showed features suggestive of colonic metaplasia.

Pelvic lipomatosis with associated cystitis glandularis.

Pelvic lipomatosis and florid cystitis glandularis are rare. We report a case in which these two conditions were associated.

Obstructive uropathy from endometriosis after hysterectomy and oophorectomy; two case reports.

Two patients with obstructive uropathy as a result of post menopausal endometriosis are reported. They both illustrate the potential problems of hormone replacement therapy after bilateral salpingo-oophorectomy and hysterectomy in patients who have had extensive endometriosis. It is suggested that in such patients the potential of reactivation of the disease with hormone-replacement therapy should be recognised and ureteric involvement be excluded by intravenous urography or renograms.

Ectopic ureterocele in an adult with prolapse through the urethra.

Most ureteroceles in adults are incidental findings at excretory urography. Symptomatic ureteroceles are unusual and prolapse of the ureterocele is particularly uncommon. We describe a woman with prolapse of a ureterocele through the urethra, which resulted in strangulation and partial necrosis of the ureterocele wall.

Surgical technique for inguinal surgery and its effect on fertility in the Wistar rat model.

This study has explored the relatively neglected effects of operative manipulation of the vas deferens on fertility. Following unilateral vasectomy the contralateral vasa of 52 4-week-old Wistar rats were subjected to 7 different manipulations. After 7 weeks a fertility trial was conducted. All sham operated rats (n = 18) were fertile. Of the remaining 34 rats, 22 (65%) were sterile. All of those with tight ring reconstruction (n = 6) were sterile, due initially to venous obstruction. Nine of 14 rats with acute clip trauma (65%) remained fertile but 11 of 14 (78%) with full mobilisation were sterile owing to extensive avascular fibrosis of the vas deferens. These results suggest that overzealous cord handling and operative technique in the immature animal is counterproductive and leads to vasal occlusion. This may have important repercussions in paediatric inguinal surgery, with a subsequent higher incidence of azoospermia and male subfertility.

Effects of C. parvum on growth and induction of intracerebral tumours in mice.

An investigation was made into the effect of Corynebacterium parvum therapy on cerebral tumours in mice. I.v. C. parvum caused a slight but significant increase in the survival of BALB/c mice injected intracerebrally (i.c.) with not more than 50 Meth A cells. C. parvum was most effective if given on the same day or 5 days after tumour. If this interval was increased there was no effect. Multiple i.v. injections were no more effective than a single dose. I.v. C. parvum had no influence on the survival of C57BL mice injected i.c. with Lewis tumour cells, and had little effect on the induction of i.c. or s.c. tumours by methylcholanthrene. It was concluded that C. parvum therapy was of little use in the treatment of cerebral tumour in mice. The clinical implications of these findings are discussed.

Male lower urinary tract symptoms: is surgery always necessary?

A transurethral resection of the prostate is a good operation to relieve bladder outflow obstruction and has a low incidence of complications. However, recent work suggests that many men with symptoms may not require an operation, and it can probably be delayed in a majority for many years. This may be particularly important in old and frail patients. Many men with outflow obstruction have irritative symptoms such as urgency, frequency and nocturia; these could be treated with anticholinergics, provided they have normal flow rates and small or absent residual urine volumes. Pharmacological treatment to relieve outflow obstruction is disappointing. There may be some benefit from alpha-adrenoreceptor antagonists, but the place for 5 alpha-reductase inhibitors is still unsure. All drugs have side effects which are unacceptable in patients who are not bothered by their urinary symptoms and can wait for active treatment.

Retroperitoneal malignancy masquerading as ureteric colic.

This study reviews 6 patients who were referred with severe loin pain radiating to the groin and in whom a presumptive diagnosis of ureteric colic was made. Of these, 3 patients were found to have carcinoma of the pancreas and the remaining 3 had retroperitoneal lymph node metastases. Retroperitoneal malignancies rarely present with loin pain, but this diagnosis should be considered in patients with long-standing loin pain in whom an obvious diagnosis is not apparent.

Ureteroscopy and ureteric calculi: how useful?

The results of management in 134 patients admitted to hospital during 1985 with ureteric colic are presented in relation to the size and position of a ureteric stone. Spontaneous passage of a stone occurred in 100 patients and 34 required surgical intervention. Stones measuring 5 mm or less in maximum dimension passed spontaneously in 92% of cases; stones measuring 6 mm or more had only a 28% chance of passing. Of 34 surgical procedures 19 were endoscopic. In three cases a stone was removed under vision with ureteroscope and Dormia basket. In five patients ureteric dilatation before attempted ureteroscopy permitted later passage of the stone. In 1986 similar results were obtained with ureteroscopic stone removal performed in three cases. Fewer open operations and more Dormia basket extractions were performed in 1986. In this series the size of the stone was closely related to outcome. The high chance of spontaneous passage (75% in 1985 and 84% in 1986) puts the need for surgical intervention, and in particular ureteroscopy, into perspective in the management of patients with ureteric colic.

Antibiotic prophylaxis and secondary haemorrhage following transurethral resection of the prostate: a prospective trial.

One hundred and sixty-two patients were studied in a random double-blind controlled trial of co-trimoxazole to prevent secondary haemorrhage following transurethral resection of the prostate (TURP). There was a significant correlation between the incidence of post-operative urinary infection and secondary haemorrhage (P less than 0.05) but no difference between the incidence of bleeding in the treatment and placebo groups. Although infection may play a role in the development of secondary haemorrhage, co-trimoxazole for 10 days does not decrease the incidence of this complication.

Symptomatic renal angiomyolipoma.

Two cases of symptomatic renal angiomyolipoma not associated with tuberous sclerosis are presented. The clinical and radiological features, the pathology and the management of these rare but well documented tumours are briefly discussed. They pose problems in diagnosis and controversy still exists regarding their management. Recent radiological techniques such as CT may help in the diagnosis. When conservative surgery is not possible, or when an adenocarcinoma cannot be confidently excluded, nephrectomy should be performed.

The management of impotence in diabetic men by vacuum tumescence therapy.

The treatment of impotence in diabetic men with vacuum tumescence therapy was studied in a specialist clinic. Of 54 diabetic men referred with impotence, seven declined treatment, three chose self-injection with papaverine, and 44 chose vacuum therapy. Patients underwent autonomic function testing (heart rate response to respiration), measurement of penile blood flow (duplex Doppler scanning), and estimation of serum prolactin and testosterone levels. After 2 months, 33 men (75%) were able to have satisfactory intercourse using vacuum therapy. Three others could produce a satisfactory erection with vacuum therapy but their partners found it unacceptable. Eight men (18%) were unable to have satisfactory intercourse; six of these were later treated by self-injection. The median frequency of use of vacuum therapy was 5.5 (1-26) times a month. Outcome was independent of penile blood flow, autonomic function or endocrine status. Impotent diabetic men should be given counselling and offered a choice of the available treatments. Vacuum tumescence therapy is an effective and simple treatment which requires little investigation.

Factors influencing salvage cystectomy results.

Analysis of 86 patients who underwent salvage cystectomy following a radical course of radiotherapy for bladder cancer and 37 patients who underwent primary cystectomy has shown a greater survival for women than men. The following factors were associated with a significant deterioration in survival: 1. Age at time of cystectomy: post-operative mortality and tumour recurrence are greater over the age of 70. 2. Non-function of one kidney on IVU. 3. Grade 3 tumour on cystectomy specimen. 4. pT3 or pT4 tumour on cystectomy specimen.

Surgical management of idiopathic retroperitoneal fibrosis.

The management of 10 patients with idiopathic retroperitoneal fibrosis causing obstructive uropathy is presented. In all cases the obstruction was relieved by ureterolysis and corticosteroid therapy was not used during the initial treatment. In 9 patients the operation was well tolerated but one, who developed a pyonephrosis after pre-operative ureteric drainage, died of septiceamia 15 days post-operatively. In 2 patients further explorations and ureterolysis were necessary for recurrent fibrosis which may have been related to urinary leakage. A policy for the management of these cases is presented which recommends the use of silastic tubing splints after ureteric mobilisation and the use of an omental wrap.

Routine cross-matching is not necessary for a transurethral resection of the prostate.

Two hundred and fifty-five consecutive patients undergoing transurethral prostatectomy were studied prospectively to test a policy of not routinely cross-matching blood. Blood was ordered only for patients with anaemia, a major medical risk factor, a prostate gland estimated to be greater than 60 g, or the presence of red cell alloantibodies. Of the 203 patients who were "grouped and saved" only, 30 (12%) were subsequently cross-matched and 22 (8.5%) transfused. There were no significant problems as a result of the operation of this policy. The value of these pre-operative criteria for cross-matching was confirmed, apart from the clinical estimation of prostatic size. The use of such a policy could be of significant value to the hospital blood transfusion services.

A prospective study of the value of conventional CT, dynamic CT, ultrasonography and arteriography for staging renal carcinoma.

The value of dynamic CT scanning for staging renal carcinoma was studied prospectively in 28 patients and the results compared with those of ultrasonography, arteriography and conventional CT. Arteriography correctly staged 48% of tumours; ultrasonography and conventional CT correctly staged 50% and dynamic CT correctly staged 72%. Dynamic CT staged renal carcinoma more accurately than ultrasonography, conventional CT or arteriography and it is suggested that arteriography should be restricted to specific indications such as the mapping of arterial anatomy and therapeutic renal artery embolisation.

Renal imaging: a comparison of radionuclide, ultrasound, and computed tomographic scanning in investigation of renal space-occupying lesions.

Two studies were carried out in which 27 and 23 patients respectively with renal space-occupying lesions were assessed by different techniques and the results compared. Instead of proceeding to renal arteriography after the lesion had been found on urography, radionuclide and ultrasound scanning were used in the first study to clarify the nature of the lesions, while in the second study computed tomography was used as well. Results were good with all three methods, although ultrasonography and radionuclide scanning cannot resolve lesions of under 2 cm in diameter and the radiation dose with computed tomography is similar to that used in renal arteriography. Probably the best method of evaluating renal space-occupying lesions after urography is to use both ultrasound and radionuclide scanning. If further information is required computed tomography or arteriography is indicated.