Hematogenous metastasis of nonseminomatous germ cell testicular cancer.

A case is reported of a twenty-five-year-old man in whom paraplegia developed due to spinal metastasis from a nonseminomatous germ cell tumor immediately after retroperitoneal node dissection in which all nodes were found to be negative. This case emphasizes deficiencies in knowledge concerning the routes of metastasis of testicular tumor and points out that retroperitoneal lymphadenectomy is not an infallible staging procedure in patients with this disease.

Sertoli cell tumor of testis.

A case is reported of a patient with Sertoli cell tumor of the testis, the second known to have had a lymphangiogram and the third with histopathologic examination of retroperitoneal lymph nodes. Lymphangiography was performed because of extension of the tumor through the tunica albuginea into the adjacent adherent scrotum at the site of previous testicular biopsy. The lymphangiogram proved to be falsely positive following retroperitoneal lymph node dissection. The patient has remained clinically free of tumor for eight years.

Intravesical CDDP therapy compared with combined CDDP and external radiation in noninvasive bladder cancer. Monitored with quantitative fluorescence cytology.

Results of intravesical CDDP or CDDP combined with external beam radiation are compared in a group of 13 patients with low-stage bladder cancer. Six patients with low-stage bladder cancer received 4 or 12 treatments of CDDP intravesically with an initial complete response in 3 patients. Within six months, recurrent disease developed in 2 of 3 patients. Seven patients received the combination therapy of 400 rad (weekly for six weeks) followed two hours later with 50 mg of intravesical CDDP. A positive response was observed initially in all 7 patients as determined by pathology, PAP cytology, fluorescence cytology, and quantitative nuclear fluorescence determinations. Therapy was discontinued in 1 patient in each group because of irritative symptoms. The results indicate combination therapy is of tolerable toxicity, and quantitative fluorescence cytology is a useful adjuvant for guiding future treatments in patients with low- and high-grade bladder tumors.

Transcervical resection of submucous uterine fibroids: an alternative approach to management.

Transcervical resection of submucous uterine fibroids can be an effective alternative to laparotomy and transuterine myomectomy in selected women. To date the authors have performed this procedure in three patients in an ambulatory environment. In two patients, transcervical resection was performed for giant intrauterine myomas which caused pathologic uterine bleeding and infertility. In a third patient the procedure was performed to resect multiple small submucous myomas causing infertility.

Management of genitourinary injuries in patients with pelvic fractures.

Associated injuries frequently occur in patients who sustain fractures of the pelvis. Hemorrhage from intrapelvic vessels, rupture of the urinary bladder and avulsion of the membranous urethra in males are among the integral risks in this trauma. Non-operative methods of managing hemorrhage have gained favor in recent experience. The case records of 282 male patients with pelvic fractures were reviewed to evaluate experience with lower genitourinary injuries. Early recognition is important in bladder injuries, and surgical repair is advised, except in selected patients who may be managed by catheter drainage alone. Delayed complications of bladder injury are rare. Membranous urethral injuries entail a high risk of chronic stricture disease and sexual impotence. The rationale of early repair versus delayed repair of these injuries is discussed. The results in this series show advantage for delayed repair.

Experience with management of posterior urethral injury associated with pelvic fracture.

Review of records from 205 patients with pelvic fracture and hematuria revealed that 121 underwent urologic and radiographic evaluation. Of these patients 20 had severe posterior urethral injuries documented by urethrography of voiding cystourethrography: 9 underwent primary repair and 11 had delayed scrotal-inlay urethroplasty after initial cystostomy alone. Patients who underwent primary repair had a 77 per cent incidence of stricture, a 22 per cent incidence of incontinence and a 33 per cent incidence of impotency. Patients who underwent delayed closure had no incidence of stricture, incontinence or impotence. Patients in both groups had urinary tract infections. Simple cystostomy followed by delayed scrotal-inlay urethroplasty appears superior to primary realignment in the management of patients with posterior urethral injuries.

Spontaneous extravasation of urine from the anterior urethra.

When urine extravasates from the diseased anterior urethra the subcutaneous tissues beneath Colles' and Scarpa's layers are suffused and necrosis of these tissues is inevitable. Traditionally, surgical treatment has been incision and drainage. Despite improvements in systemic antimicrobial therapy mortality rates remain high. Since necrosis of subcutaneous tissue is inevitable and since the extent of suffusion is discernible, we have treated these patients by primary excision of all edematous subcutaneous tissue. Using patients treated conventionally at our own institution as controls we have demonstrated a significant reduction in the mortality rate. We also have demonstrated that certain findings in the initial evaluation of the patient are of value in assessing prognosis.

Priapism: an unusual presentation.

A patient with an unusual form of priapism is described. Only the corpora cavernosa proximal to the suspensory ligament were erect. A well defined membrane was found in each corpus cavernosum at the penoscrotal junction, separating turgid and flaccid erectile tissue. When these membranes were removed the erect proximal corpora drained into the flaccid distal corpora and the entire penis remained flaccid 6 weeks later.

Severe hypertension associated with an intrarenal aneurysm.

A 26-year-old woman with regularly documented normal blood pressure had sudden onset of severe hypertension. Investigation revealed an intrarenal artery aneurysm involving the upper pole of the left kidney, as well as elevated levels of both renin and aldosterone. With ACE inhibitor therapy, blood pressure promptly returned to normal, and subsequent surgical removal of the upper pole of the involved kidney has resulted in normal blood pressure for 9 months of follow-up. Although uncommon, intrarenal aneurysms may lead to severe renal vascular hypertension that is relieved by surgery. This definitive procedure may not take place if one is not aware of the excellent response to ACE inhibitors in this situation.