Retrosternal goiter.

BACKGROUND: Retrosternal goiter is a common cause of compression of adjacent structures, and it may harbor cancer. METHODS: During a 22-year period, we treated 44 patients with intrathoracic multinodular goiter. RESULTS: The goiter was resected in 40 patients; 4 patients were rejected because of prohibitive risk. There were three minor complications and no deaths. CONCLUSIONS: The specific indications for resection include compression of adjacent structures, prevention of future complications, and obtaining a diagnosis. Fine-needle aspiration for diagnosis is not always possible and rarely reliable, and there is no effective medical therapy. Cervical incision is nearly always adequate, with few exceptions, such as very large posterior goiter, mediastinal blood supply, or carcinoma necessitating mediastinal dissection.

Neglected lung cancer.

Pulmonary nodules of unknown nature may be cancerous and are best treated by early resection. During the past 20 years we have seen 65 patients in whom asymptomatic pulmonary nodules from 5 to 20 mm in diameter were discovered on routine roentgenograms between 1 and 4 years prior to their referral to surgery. These patients have not been investigated for cancer. Instead, they had been 'observed' or treated with antibiotics while their nodules increased in size. At the time of referral, 29 patients had widespread metastases, 28 had locally invasive State III lung cancer, eight had Stage I or Stage II lesions. Only 16 patients had their tumors resected. Sixteen patients (24.6%) survived 1 year or longer; six patients (9.3%) survived more than 2 years. Early resection of all undiagnosed pulmonary nodules is essential. 'Expectant' or antibiotic treatment of these lesions should be condemned. Educational programs for family physicians are urged.

Acute primary Chlamydia trachomatis infection in male adolescents after their first sexual contact.

BACKGROUND: Chlamydia trachomatis infection occurs primarily among youth sexually active persons. Few studies have evaluated the kinetics of markers of infection in male adolescents after their first sexual contact. DESIGN: Primary C trachomitis infection in 4 young male adolescents after their first sexual contact was diagnosed by polymerase chain reaction and antigen detection in sequential first voiding urine and urethral specimens, respectively. Serial serum samples were assessed for the presence of specific IgA and IgG antibodies. RESULTS: Both polymerase chain reaction and antigen detection correctly identified all cases of primary C trachomatis infection. The polymerase chain reaction method was, however, an earlier marker of infection. Three patients were seronegative at presentation. Two of these subsequently seroconverted to either IgA or IgG, while the third remains seronegative. The time interval from onset of symptoms to seroconversion ranged from 10 to 25 days. CONCLUSIONS: Although polymerase chain reaction and antigen and serologic detection have previously been described in primary C trachomatis infection, this report documents the variability of these markers during the first phase of infection in non-sexually active young male adolescents. C trachomatis can be acquired by male adolescents after their first sexual contact; however, there is a prolonged period when the patient is seronegative, yet infections can occur.

Clinical significance of tumor angiogenesis in patients with localized renal cell carcinoma.

OBJECTIVES: To determine the relationship between angiogenesis and various histopathologic features as well as clinical outcome in patients with localized renal cell carcinoma (RCC). METHODS: Microvessel density was quantified by using immunocytochemical staining of endothelial cells for factor VIII-related antigen of 36 specimens taken from patients with pathologic Stage pT1 or pT2 RCC. All patients underwent radical nephrectomy and were followed for a mean time of 97.3 months. RESULTS: No association was noted between microvessel count (MVC) and either cell type, architecture, or tumor size. Inverse correlation was noted between MVC and nuclear area (P = 0.006), nuclear elipticity (P = 0.016), nuclear roughness (P = 0.039), and histologic grade (P = 0.047). Patients having tumors with low MVC had significantly better survival rate compared with those with high MVC neoplasms (P = 0.0014, by Cox proportional hazards method). CONCLUSIONS: Despite lack of correlation with known predictors of survival, MVC provides independent prognostic information for patients with localized RCC.

Bilateral ureteral atresia.

Congenital, bilateral, distal ureteral atresia with severe renal dysplasia in a preterm infant is presented. This rare anomaly is caused by a variable degree of failure of the ureteral bud development. Prognosis is usually dependent on the severity of the obstruction.

Bladder neck suspension using bone anchors for the treatment of female stress incontinence.

A new technique and related devices for the treatment of urinary incontinence in women was developed and tested. The technique involves soft tissue to bone fixation by means of miniature bone anchors and a bone anchor inserter. The novel bone anchors are made of a shape-memory nickel titanium alloy (Nitinol) attached to Polypropylene or Gortex suture. A spring-loaded bone anchor inserter drives the anchors through the vaginal wall to a predetermined depth into the pubic bone medulla regardless of the bone's hardness, with no incision or drilling required. The device allows for the performance of a minimally invasive transvaginal bladder neck suspension. The procedure has minimal morbidity and a short learning curve. This technique was evaluated clinically in 15 women with incontinence, with a mean follow-up of 6 months. Good urinary continence was achieved in all patients, with no mechanical failures.

A new intraurethral sphincter prosthesis with a self contained urinary pump.

An intraurethral sphincter prosthesis with a self contained urinary pump for the management of atonic bladder in women was developed and tested. The prosthesis is comprised of a short, self retaining silicone catheter in which there is a valve and pump. Available in a range of lengths and diameters according to urethral size, its insertion is similar to that of a urethral catheter. The prosthesis is secured by a novel fixation method that has soft expandable silicone fins at the bladder neck and a flexible flange at the external meatus. It is activated by a small hand-held control device. To urinate, the activator is placed on the lower abdomen area and the "on" button is pressed, providing energy to the pump by a magnetic coupling method. Once activated, the valve opens and the pump rotates at a high speed, drawing urine from the bladder and pushing it forward, allowing the patient to "void" with a urine flow of 10 to 12 cc/sec. When the bladder is completely evacuated, the pumping ceases and the valve closes, restoring continence. The device was evaluated clinically in 17 women. Fifteen of the patients had a range of use of 2 weeks to 16 months during which they were dry and had complete bladder emptying. Two patients did not tolerate the device because of uninhibited detrusor contractions and, in both cases, it was removed without complication after 5 days.

Prognostic score for patients with localized renal cell carcinoma treated by nephrectomy.

OBJECTIVE: To evaluate the feasibility of using combined clinical and histomorphometric features to construct a prognostic score for the individual patient with localized renal cell carcinoma. PATIENTS AND METHODS: We studied 39 patients with pT1 and pT2 RCC who underwent radical nephrectomy between 1974 and 1983. Univariate and multivariate analyses were used to determine the association between various prognostic features and patient survival. RESULTS: The most important and independent predictors of survival were tumor angiogenesis (P = 0.009), nuclear DNA ploidy (P = 0.0071), mean nuclear area (P = 0.013), and mean elongation factor (P = 0.0346). Combination of these variables enabled prediction of outcome for the individual patient at a sensitivity and specificity of 78% and 89%, respectively. CONCLUSION: Our results indicate that no single parameter can accurately predict the outcome for patients with localized RCC. Combination of neovascularity, DNA content and morphometric shape descriptors enabled a more precise stratification of the patients into different risk categories.

Low inguinal approach for correction of recurrent varicocele.

The purpose of this study was to evaluate the efficacy of low inguinal (or subinguinal) approach in the treatment of recurrent or persistent varicocele after surgical treatment. Recurrent varicocele was diagnosed in 23 patients who previously underwent surgical treatment. The technique used consisted of low inguinal incision at the level of the external inguinal ring without opening the external oblique aponeurosis. External spermatic veins (cremasteric veins) were dissected and selectively ligated. Then the spermatic fascia was incised and the internal spermatic veins were identified and ligated individually. Postoperative radioisotope scan, scrotal examination and sperm analysis were used for treatment evaluation. Twenty-one (91.3%) had negative postoperative scan and no signs of varicocele on physical examination. A marked improvement of sperm analysis was noted in 19 patients (p<0.05), while two had only minor improvement. Two patients had positive postoperative scans without improvement of semen analysis. Neither atrophy nor azoospermia were detected on follow-up examination in any of these men, however, one patient developed hydrocele. This study indicates a good surgical outcome and improvement of semen quality without significant complications.

Anuria and acute renal failure caused by multiple bladder calculi.

A rare case of multiple bladder stones (more than 300) is described. Acute renal failure and anuria complicated by urosepsis were the presenting symptoms.

[Results of cataract extraction and lens implantation].

98 patients were invited for a follow-up examination 2 years after cataract extraction. They then completed a questionnaire dealing with their daily functioning, comparing the situations prior to and 2 years after the operation, and were asked as to their satisfaction with the results of the operation. Statistically significant improvement was found in measurements of both near and distance vision and in performance of most aspects of daily functioning. Most patients were pleased with results of the operation.

[Transurethral microwave thermotherapy for benign prostatic hypertrophy in patients with high risk for surgery].

The effectiveness of transurethral microwave thermotherapy (TUMT) for benign prostatic hypertrophy in poor surgical risk patients (ASA class IV) with indwelling catheters, was assessed. All had had an indwelling catheter for 1-12 months. Removal of the catheter was possible in 14 out of the 24 (58.3%). Urinary peak flow rates were 12.2 +/- 3.5 ml/sec at 3 months of follow-up and post-voiding residual urine volumes of less than 50 ml were recorded in 13 catheter-free patients. Our data suggest that TUMT is an effective procedure for management of high risk patients with indwelling catheters in whom surgery or anesthesia are contraindicated.

[Diagnostic and therapeutic approach to sexually transmitted diseases].

In an ongoing study we evaluated 71 males and 32 females attending our sexually transmitted diseases (STD) clinic. Intraurethral or endocervical swab specimens were cultured for Neisseria gonorrhea (NG), Ureaplasma urealyticum (UU), Mycoplasma homines (MH), Herpes simplex virus (HSV) and Chlamydia trachomatis (CT), using an ELISA technique and the polymerase chain reaction (PCR). HIV antigen, hepatitis B (HBV) and Treponema pallidum (TP) seropositivity were tested by ELISA. Mean age was 33.4 and range 15-72 years. 83 patients (81%) used condoms only rarely, 35 (35%) had multiple sexual partners and 83 (81%) were treated empirically prior to evaluation. Dysuria and urethral discharge were found in 47 (45.6%), of whom 34 (33%) were males; the majority of females were asymptomatic. A specific etiology for STD was found in 53 patients (51.4%) and 1/3 had more than 1 pathogen. CT, UU, MH, HSV, NG and TV were found in 27, 24, 5, 3, 2 and 1, respectively. 8 patients were seropositive for HBV and 1 for TP; all were seronegative for HIV. CT was the most prevalent pathogen found. All patients with STD symptoms should be screened for all sexually transmitted pathogens, since many of them have more than 1 pathogen. STD clinics in Israel should be developed in conjunction with microbiology laboratories for better management of STD in the community.

[Acute urinary retention secondary to clear cell adenocarcinoma of the urethra]. / Rétention urinaire aiguë secondaire à un adénocarcinome à cellules claires de l'urèthre.

The authors report a case of primary clear cell cancer of the urethra in a woman presenting with acute urinary retention. The diagnosis was based on cystoscopy and confirmed by histological examination of urethral biopsies. Treatment consisted of urethrocystectomy with creation of an "Indiana pouch". The pathological stage was T3N2M0 [1]. Three months postoperatively, the patient presented with inguinal lymph node metastases. She was treated with 3 courses of chemotherapy (mitomycin and 5-fluorouracil) combined with radiotherapy. With a follow-up of 10 months, the patient is still alive and inguinal lymph nodes have regressed. This case report emphasizes the rarity of this histological type and describes the management of urinary retention in a woman when an underlying specific disease is suspected.

Thoracic splenosis.

BACKGROUND: Thoracic splenosis is an uncommon side effect of thoracoabdominal trauma involving injury to the diaphragm and spleen. Only 20 patients with a similar problem have been reported previously. METHODS: Two patients with thoracic splenosis were studied. RESULTS: One of the patients had undergone thoracotomy for resection of a "pulmonary nodule". The other remains under observation. CONCLUSION: Presence of a pulmonary nodule in a patient with history of injury to the diaphragm and spleen should arouse suspicion of splenosis. Appropriate investigation may prevent an unnecessary and potentially harmful operation.

Postirradiation vesicovaginal fistula completely resolved with conservative treatment.

Postirradiation vesicovaginal fistulae (VVF) pose a great challenge for the urologist. The poorly vascularized radiated tissue surrounding the fistula impairs healing and makes operative repair technically demanding. Conservative treatment for postirradiation VVF is considered inappropriate, and to our knowledge has never previously been described. We present a case of a woman with postirradiation VVF that was resolved after transurethral coagulation and 3 weeks of catheterization.