The scrotal hitch for hemostasis and edema prevention in scrotal surgery.

Postoperative hematoma, edema, and echymosis are the most common complications in scrotal surgery. Without proper hemostasis intraoperatively or appropriate scrotal compression postoperatively, significant morbidity, including re-exploration and prolonged convalescence, can occur. The scrotal hitch provides hemostasis, minimizes edema and hematomas, and reaffirms other clinicians' findings.

Complication of penile injection of autologous fat.

A new penile enlargement procedure using injection of autologous fat obtained by liposuction has been publicized by the media. We report on a 36-year-old man who suffered 2 painful inflammatory nodules requiring surgical excision 3 months after undergoing this new penile enlargement procedure.

Percutaneous nephrolithotomy: spinal cord injury vs. ambulatory patients.

One hundred patients, 35 with spinal cord injury (SCI) and 65 who were ambulatory, underwent percutaneous nephrolithotomy (PNL). Success of complete stone excision, operative morbidity and mortality were compared in the two patient populations. Stone size and complexity were evaluated by X-ray and a single-stage PNL was done using general anesthesia, bi-planar C-arm fluoroscopy, Amplatz renofascial dilators, and two guide wires. Eleven percent of the patients had previously-placed percutaneous nephrostomy tubes for hydronephrosis and/or pyonephrosis. In the ambulatory group, 98.5% (64/65) were stone-free after the procedure as compared to 85.7% (31/35) in the SCI group. The success rate in those patients who followed postoperative instructions exceeded 96% in both groups of patients. One operative mortality, related to infectious complications, occurred in the SCI group. Major morbidity in the SCI population consisted of three perirenal abscesses, a hydrothorax, an aspiration pneumonia, a respiratory arrest and a nephro-colonic fistula for a rate of 20% (7/35), or 7% of all patients. One major complication, a nephroduodenal fistula, occurred in the ambulatory population. Four patients, three of whom were SCI, required open surgery related to infectious complications. Other significant complications consisted of hemorrhage requiring transfusion, and fever (101.5 degrees F). Minor complications included dislodged nephrostomy tubes, retained stones, and ureteral edema causing obstruction. These complications were three times more common in the SCI population. Percutaneous nephrolithotomy is an effective surgical means for stone removal for SCI and ambulatory patients. The SCI patient has a high incidence of infectious complications causing increased morbidity and mortality.

Separate annular strictures of the rectosigmoid colon secondary to unsuspected prostate cancer.

Rectal involvement from prostate cancer occurs in 1.5-11% of cases. A rarer presentation is that of a separate metastasis to the high rectosigmoid colon causing an annular stricture. We present our experience with six such cases who presented with gastrointestinal symptoms. Two of the cases had undergone intestinal resections. All 6 patients had radiographic evidence of an annular stricture in the rectosigmoid area. Retrospective review revealed evidence of metastatic disease in all cases in the form of abnormalities in one or more of the following: intravenous urography, radionuclide bone scan, liver spleen scan, acid phosphatase, or alkaline phosphatase. The mean survival was 9.3 months. This rare presentation of prostate cancer may be difficult to distinguish from primary colorectal cancer and therefore needs to be ruled out to avoid intestinal resections.

Treatment of renal calculus in inferior crossed renal ectopia.

Percutaneous nephrolithotomy is still the treatment of choice for selected cases of "surgical" stone disease. This is a case report of the surgical treatment for a renal calculus located in the inferior moiety of right-to-left inferior crossed renal ectopia. After a failed attempt at extracorporeal shock-wave lithotripsy, a successful percutaneous nephrolithotomy was done without complication.

Idiopathic anejaculation treated by vibratory stimulation.

Idiopathic anejaculation is a rare cause of infertility usually treated by psychotherapy. However, electrovibration may be a simple, noninvasive adjunct to the treatment of this disorder. In our two cases, we obtained ejaculate adequate for insemination in one patient and noted some gain in orgasmic sensation in the other. The success in these two infertile patients who had already undergone lengthy psychotherapy is promising. Nevertheless, psychotherapy will continue to be the standard of therapy until we have more experience with penile electrovibration.

Positive bethanechol supersensitivity test in neurologically normal patients.

A positive bethanechol supersensitivity test (BST) usually indicates neuropathic detrusor areflexia and warrants neurologic correlation. Seven females, average age thirty-three years, with straining to void and high residual urines, had detrusor areflexia, with a borderline or positive BST, ranging from 19 cm water to 55 cm H2O change in intravesical pressure after 5 mg of subcutaneous bethanechol. However, all patients had a normal neurologic workup, even though 2 patients had insignificant spina bifida occulta. Two of the patients also had prior pelvic surgery, 1 of whom was azotemic, and 4 of the patients had psychosocial problems; factors reported to be associated with a false positive BST. The positive BST is not diagnostic of neurogenic detrusor areflexia because of the many variables that can influence the test. Therefore, the bethanechol supersensitivity test should be interrupted in light of the complete neurourologic evaluation.

Distal ureteral obstruction complicating percutaneous nephrolithotomy.

Endourologic techniques for the treatment of surgical stone disease have proved cost-effective and safe with results comparable to open surgical procedures. Because these are new procedures, unexpected complications are going to occur. We have had 3 cases of complete distal ureteral obstruction unrelated to a ureteral calculus following a percutaneous nephrolithotomy. The obstruction resolved after extended nephrostomy tube drainage. These 3 cases and their treatment and pathogenesis are presented.

Percutaneous nephrostomy for palliation of metastatic ureteral obstruction.

Urinary diversion for palliation of metastatic ureteral obstruction has been associated with high rates of morbidity and mortality, especially with open surgical nephrostomies. An evaluation of percutaneous nephrostomy drainage for the palliation of metastatic ureteral obstruction in 27 patients revealed an increase in survival with decreased morbidity, and a follow-up ranging from three to twenty-five months. The mean survival of all patients was 6.63 months (N = 19), with 8 patients still alive. The histology was the main determinant of length of survival, with prostate, rectal, and cervical cancer patients surviving the longest. The perioperative mortality was 11.1 per cent (3/27), and the postoperative complications consisted of hemorrhage requiring transfusion 29.6 per cent (8/27), gastrointestinal bleeding 3.7 per cent (1/27), and dislodged nephrostomy tubes 44.4 per cent (12/27). Percutaneous nephrostomy drainage is a less morbid procedure than open surgical procedures, and the main determinant of length of survival is the histology of the primary tumor in patients with metastatic ureteral obstruction.

Metastatic transitional cell carcinoma to penis.

Metastatic tumors to the penis are becoming more common as patients with cancer are living longer. Four cases of metastatic transitional cell carcinoma to the penis are presented to emphasize the pathophysiology and management of this condition.

Percutaneous nephrolithotomy in the spinal cord injury population.

We evaluated 23 male spinal cord injury patients who underwent percutaneous nephrolithotomy for the success rate of stone removal and the incidence of operative complications. There were 18 quadriplegic and 5 paraplegic patients, and 5 had bilateral procedures. Of the kidneys 7 had staghorn calculi, 8 had pelvic and caliceal combinations, 6 had large multiple caliceal stones, 4 had large (more than 2.5 cm.) pelvic stones and 3 had pelvic stones less than 2.5 cm. Placement of a nephrostomy tube and stone extraction were performed as a single procedure with the use of general anesthesia in all but 4 patients. Our results showed that 19 of 21 compliant patients (90.4 per cent) were free of stone, with an average of 2.04 procedures per patient. A total of 47 procedures was performed, with an average operative time of 1 hour 45 minutes. Major complications were associated with 4 of the 47 procedures (8.5 per cent), and consisted of a respiratory arrest, 2 perirenal abscesses and a hydrothorax. Minor complications included fever (more than 101.5F) in 64.3 per cent and retained stones in 14.3 per cent of the kidneys operated upon, dislodged nephrostomy tubes in 12.6 per cent of the procedures (21.4 per cent of the kidneys operated upon), and anemia requiring transfusion in 17.0 per cent (8 of 47) of the procedures (27.8 per cent of the kidneys operated upon). The presence of infected stones, prior operative procedures and medical complexity of these patients make complications more frequent. Nevertheless, percutaneous nephrolithotomy is a safe and effective procedure for the spinal cord injury population.

Bladder dysfunction and neurosyphilis.

Neurosyphilis today is a rare problem. We describe a man who presented with organic brain syndrome, psychosis and incontinence, and diagnosis was neurosyphilis with resultant bladder dysfunction. Urodynamic studies defined the voiding dysfunction as detrusor areflexia with a positive bethanechol test. This case reminds us of the necessity of obtaining a test for venereal disease to rule out neurosyphilis in patients with idiopathic voiding dysfunction.

Carcinoma of the prostate in a 25-year-old man: a case report and review of the literature.

Prostatic carcinoma in the third decade of life is a rare occurrence. We describe a 25-year-old man with prostatic cancer, as well as discuss the literature and the natural history of the disease in the young adult.

Computerized tomography scan in the preoperative staging of renal cell carcinoma.

Forty-two patients with renal cell carcinoma were evaluated with computerized tomography (CT) followed by surgical exploration, extirpative surgery, or autopsy to determine the accuracy of the CT scan in assessing the extension of the disease. There was an overall accuracy of 95 percent (40/42 patients). The two staging errors were misinterpretation of renal vein involvement and liver invasion. The CT scan is an accurate preoperative indicator of the diagnosis, state, and extension of renal cell carcinoma. Other radiologic studies (arteriography and inferior venacavography) should be used as complementary studies in selective patients.

Nephro-duodenal fistula: a complication of percutaneous nephrolithotomy.

We report a case of a nephro-duodenal fistula complicating percutaneous nephrolithotomy that was managed conservatively. The patient was discharged from the hospital 14 days postoperatively, free of stone and doing well. The etiology and treatment of this problem are discussed.

Voiding dysfunction in Shy-Drager syndrome.

The neurological syndrome described by Shy and Drager includes urinary symptoms of incontinence and retention. We present the urodynamic evaluation of 2 patients with this syndrome, which demonstrated different sources for the symptoms and led to 2 separate effective treatments.

Inferior epigastric varix masquerading as a pelvic mass.

We report a case of an inferior epigastric varix as another disease entity to be considered in the differential diagnoses of pelvic masses.

Cell-mediated immune competence in patients with prostatic carcinoma.

The immune competence of 65 patients with prostatic cancer was evaluated by 2 in vivo and 2 in vitro tests to study the contribution of host factors to the progress of the disease. Patients with benign prostatic hypertrophy served as controls. Our results indicate that the delayed skin hypersensitivity response to common microbial recall antigens (streptokinase/streptodornase, purified protein derivative, dermatophytin 0 and dermatophytin) is unaltered in advanced stages of malignancy. The ability to be sensitized by dinitrochlorobenzene declines significantly in patients with metastatic disease. Blastogenic response of peripheral blood lymphocytes to phytohemagglutinin stimulation is not depressed in late stages of malignancy, although in the circulating T cells per cent and absolute values are somewhat lower in patients with metastases. Herein we show that immune competence (measured by the 4 tests) of patients with prostatic carcinoma does not decrease markedly even in the late stages of the disease. Primary sensitization to dinitrochlorobenzene is the only test showing a decline in responsiveness related to the tumor stage.

Experience with intermittent catheterization in chronic spinal cord injury patients.

Intermittent catheterization was used as a method to achieve reflex voiding and a catheter-free status in 111 chronic spinal cord injury patients. Of this group 70 patients achieved reflex (automatic) voiding within 90 days, or a mean of 19 days. Five patients required transurethral incision of the external urethral sphincter after achievement of automatic voiding because of elevated residual urine. Chronic urinary tract infection persisted in 16 per cent of the patients after completion of the program. No sequelae occurred because of the coexistent urinary tract infection. An 18-month followup disclosed stability in renal function and appearance of pyelograms. Urethral, scrotal and bladder complications secondary to chronic indwelling urethral catheters have been eliminated in these patients. Patient endorsement and enthusiasm have been spectacular and have overwhelmingly contributed to an ongoing, successful program.