Microsurgical anastomosis of rat carotid arteries with the CO2 laser.

In order to further evaluate the role of lasers in microvascular tissue closure, we modified an existing CO2 surgical laser (Xanar XA-20) by adding a partially reflecting mirror to attenuate the beam. This allowed the laser to operate at an output of approximately 100 mW, which was appropriate to achieve microvascular closures. In each of 43 rats, one carotid artery was transected and then anastomosed with standard suture technique with 10 to 12 simple interrupted sutures of size 10-0 Ethilon nylon suture (Ethicon, Inc.). The opposite carotid in each rat was anastomosed by the placement of three stay sutures followed by the application of laser irradiation to the tissue between the stay sutures at 90 to 100 mW, spot size of 0.2 mm, pulse duration 0.2 seconds, approximately 20 to 30 pulses per anastomosis. In vivo test periods were 1 hour, 1 day, 3 days, 7 days, 10 days, 14 days, 28 days, 91 days, and 180 days. All anastomoses were evaluated for patency, and selected samples were utilized for light microscopy, and mechanical testing (intraluminal pressure raised to 300 mmHg). It was determined that similar patency rates and slightly faster time to perform the same procedure could be achieved with the use of the low-powered CO2 laser. However, histologic evidence of significant medial damage raises concern about the long-term risk of a higher aneurysm rate. Vessel damage and the lack of simple intraoperative methods to verify the quality of the laser technique restrict these authors from advocating the clinical introduction of the procedure until further advances are made.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of acute renal colic: a comparison of non-contrast CT versus 3-T non-contrast HASTE MR urography.

With the introduction of a 3-T scanner, magnetic resonance urography (MRU) may be an alternative imaging modality for evaluation of acute renal colic. We performed a prospective study to compare the performance of computed tomography (CT) with half-Fourier single shot turbo spin-echo (HASTE) MRU in the evaluation of patients with suspected renal colic. Patients presenting to the emergency department with acute renal colic were eligible for inclusion. Following a standard CT stone evaluation, patients underwent a non-contrast HASTE MRU study with a 3-T scanner. The presence of perinephric fluid, hydronephrosis, ureteral obstruction, and calculus was assessed. A total of 22 patients completed the study. Twenty (91 %) were diagnosed with an upper tract stone by radiographic findings. MRU detected a discrete stone in 50 % of the patients with stones detected by CT. Perinephric fluid was noted in 12 MRUs, compared to 7 CTs. Using CT as the reference standard, the combination of stone or perinephric fluid and ureteral dilation gave MRU a sensitivity of 84 %, specificity of 100 %, and accuracy of 86 % (95 % CI 0.72-1.0). HASTE MRU with a 3-T MR scanner can reliably detect the presence of upper urinary tract obstruction. Although CT imaging remains the superior modality with which to detect calculi, MRU detects a greater number of secondary signs of upper tract obstruction. For situations in which the use of ionizing radiation is undesirable, MRU is a reasonable imaging alternative.

Renal histopathology of stone-forming patients with distal renal tubular acidosis.

To define the renal tissue changes in stone-forming patients with distal renal tubular acidosis (dRTA), we performed intra-operative papillary and cortical biopsies in five patients. The main abnormalities were plugging of inner medullary collecting ducts (IMCD) and Bellini ducts (BD) with deposits of calcium phosphate in the form of apatite; epithelial cell injury and loss was marked. Plugged ducts were surrounded by interstitial fibrosis, but the fibrosis was generalized, as well, and was a main feature of the histopathology even when plugging was not present. In contrast, common idiopathic calcium oxalate stone formers (SF) never manifest intra-tubule crystals or interstitial fibrosis. Patients with brushite (calcium monohydrogen phosphate) stones and those with cystine stones have many fewer IMCD and BD plugged with apatite (or cystine, in cystinuria), and interstitial fibrosis is limited to the regions around plugged ducts. Patients with dRTA often present a radiographic picture of nephrocalcinosis. Our direct surgical observations reveal that these may be surgically removable stones, especially in patients with well preserved renal function. In all, dRTA SF have a more diffuse papillary renal disease than other SF thus studied, and are also unusual for the degree of interstitial fibrosis.

Renal crystal deposits and histopathology in patients with cystine stones.

We have biopsied the papillae of patients who have cystine stones asking if this stone type is associated with specific tissue changes. We studied seven cystine stone formers (SF) treated with percutaneous nephrolithotomy using digital video imaging of renal papillae for mapping and obtained papillary biopsies. Biopsies were analyzed by routine light and electron microscopy, infrared spectroscopy, electron diffraction, and micro-CT. Many ducts of Bellini (BD) had an enlarged ostium, and all such were plugged with cystine crystals, and had injured or absent lining cells with a surrounding interstitium that was inflamed to fibrotic. Crystal plugs often projected into the urinary space. Many inner medullary collecting ducts (IMCD) were dilated with or without crystal plugging. Apatite crystals were identified in the lumens of loops of Henle and IMCD. Abundance of interstitial Randall's plaque was equivalent in amount to that of non-SF. In the cortex, glomerular obsolescence and interstitial fibrosis exceeded normal. Cystine crystallizes in BD with the probable result of cell injury, interstitial reaction, nephron obstruction, and with the potential of inducing cortical change and loss of IMCD tubular fluid pH regulation, resulting in apatite formation. The pattern of IMCD dilation, and loss of medullary structures is most compatible with such obstruction, either from BD lumen plugs or urinary tract obstruction from stones themselves.

Ultrastructural observations of cells at the interface of a biodegradable polymer: Polyglactin 910.

Transmission electron microscopy was used to study the ultrastructure of cells at the interface with an implanted biodegradable polymer, Polyglactin 910. Various stages of implantation were observed from 1 day to 63 days, when absorption of the polymer was essentially complete. Events occurring at the interface include initial adhesion of macrophages on the implant surface; phagocytosis of wound debris; and subsequent erosion, invasion, and phagocytosis of the polymer by macrophages and giant cells. A vascular perfusion technique for fixation of the polymer sites implanted in soft tissue is also described.

Polyglactin 910 suture absorption and the role of cellular enzymes.

Enzyme histochemical procedures for both hydrolase and oxidoreductase enzyme activity were applied to cryostat sections of polyglactin 910 suture implant sites. Sutures were implanted either solely in tissue or in a combination of in vitro incubation followed by implantation in vivo for total time periods of seven to 56 days. Suture absorption rates were also measured. It is concluded from the results that neither cellular nor enzyme activity is necessary for the degradation and absorption of polyglactin 910 sutures. This conclusion is based on similar absorption rates for sutures implanted solely in vivo and sutures treated in vitro and then implanted in tissue to give equivalent time spans. There were strong indications, however, that the products of suture hydrolysis are probably metabolized through the oxidative enzyme systems of cells adjacent to the suture. This mechanism of polyglactin 910 suture absorption is quite different from that observed and reported for catgut absorbable sutures.

An approach to the numerical quantitation of acute tissue response to biomaterials.

The hydrolytic enzyme activity associated with the tissue reaction to implanted polyvinyl chloride rods containing graded concentrations of an organotin stabilizer was quantitated by microphotometry of tissue sections. The procedure was more sensitive to the effects of the additive than the usual histologic evaluation. It is considered that this type of approach offers a sensitive and objective index to supplement the more subjective morphologic observations in judging the acute histotoxicity of implants.

The rabbit ear chamber: a unique in vivo model for the continuous observation of implanted biomaterials.

The rabbit ear chamber provides a unique system for viewing an in vivo environment from outside the body. The plastic chamber, modified for our use, is described. Once surgically implanted into the ear of a Laboratory Lop rabbit, a thin tissue bed which grows between the layers of the chamber can be viewed through the microscope. The absorption of biomaterials placed into the chamber can then be observed as a dynamic process.

Tissue response to implanted polymers: the significance of sample shape.

Studies were designed to demonstrate the need for standardization of shape of samples used as implants to evaluate histotoxicity of polymer materials. Six medical-grade polymers (polypropylene, polyethylene, polyurethane, silicone rubber, poly(vinyl chloride), and Teflon) were extruded as rods with circular-, triangular-, and pentagonal-shaped cross sections, and were implanted in rat gluteal muscles for 14 days. Evaluation of the tissue response was assessed by quantitating cellular lysosomal acid phosphatase enzyme activity by using microspectrophotometry. All triangular-shaped implants showed the highest enzyme activity and cellular response; pentagon shapes showed less, and circular rods showed the lowest activity. The results demonstrate the need for standard sample shape for valid comparative studies of tissue response to implanted polymers.

An anastomotic device for microvascular surgery: evolution.

A new anastomotic device is demonstrated that is suitable in microvascular surgery for repairing severed blood vessels and inserting vein grafts. Initial pilot studies indicate a 100% patency rate for vessel anastomosis, and a one-year study produced a 96% success rate. However, histological examination revealed notable vessel deterioration with a rigid device. Therefore, an absorbable anastomotic coupler was developed that demonstrates a high patency rate (92%) in both arteries and veins, with substantial absorption of the device by 70 days. Healing at the anastomotic site was qualitatively similar to that obtained with a sutured anastomosis; there was endothelialization by 14 days and absorption of the device by 70 days.

Transrectal ultrasound and biopsy in the early diagnosis of prostate cancer.

BACKGROUND: Historically, the prostate was evaluated for cancer by simple digital rectal examination, and biopsy to obtain a tissue diagnosis of cancer was performed blindly. The advent of ultrasound technology offered a new way to evaluate the prostate, and biopsy techniques were soon developed to incorporate ultrasound guidance. METHODS: The authors review the role of transrectal ultrasound (TRUS) of the prostate and ultrasound-guided biopsy of the prostate in the diagnosis of prostate cancer. These techniques are traced from their origins to the current standards of care, with attention paid to developments and controversies in recent literature. RESULTS: Early experience with TRUS led to the description of "classic" sonographic findings of prostate cancer. To obtain a tissue diagnosis of cancer, these regions were initially targeted in ultrasound-guided biopsies. Concomitant with the development of TRUS, though, was the development of the prostate-specific antigen (PSA) assay. Over the past decade, there has been a profound stage migration due to earlier detection of prostate cancer. Most patients now diagnosed with prostate cancer have no palpable abnormality or specific sonographic findings. In response, ultrasound-guided biopsies have become more systematic, rather than lesion-specific, in nature. CONCLUSIONS: TRUS continues to play an important role in the evaluation of the prostate when malignancy is suspected. Although the optimal method of prostate biopsy is controversial, ultrasound is critical in ensuring accurate sampling of the gland.