Intraoperative treatment planning for radioactive seed implant therapy for prostate cancer.

We describe a procedure for intraoperative treatment planning for seed implantation. One hundred seven treatment plans have been analyzed at the Beth Israel Deaconess Medical Center and affiliated hospitals. The average time for the intraoperative procedure was 1. 74 hours. No significant difference in dose coverage to the prostate or normal tissues was evident.

Space shuttle flight (STS-45) of L8 myoblast cells results in the isolation of a nonfusing cell line variant.

Myoblast cell cultures have been widely employed in conventional (1g) studies of biological processes because characteristics of intact muscle can be readily observed in these cultured cells. We decided to investigate the effects of spaceflight on muscle by utilizing a well characterized myoblast cell line (L8 rat myoblasts) as cultured in the recently designed Space Tissue Loss Flight Module "A" (STL-A). The STL-A is a "state of the art," compact, fully contained, automated cell culture apparatus which replaces a single mid-deck locker on the Space Shuttle. The L8 cells were successfully flown in the STL-A on the Space Shuttle STS-45 mission. Upon return to earth, reculturing of these spaceflown L8 cells (L8SF) resulted in their unexpected failure to fuse and differentiate into myotubes. This inability of the L8SF cells to fuse was found to be a permanent phenotypic alteration. Scanning electron microscopic examination of L8SF cells growing at 1g on fibronectin-coated polypropylene fibers exhibited a strikingly different morphology as compared to control cells. In addition to their failure to fuse into myotubes, L8SF cells also piled up on top of each other. When assayed in fusion-promoting soft agar, L8SF cells gave rise to substantially more and larger colonies than did either preflight (L8AT) or ground control (L8GC) cells. All data to this point indicate that flying L8 rat myoblasts on the Space Shuttle for a duration of 7-10 d at subconfluent densities results in several permanent phenotypic alterations in these cells.

Cutaneous ureterostomy in adults.

In the patient with metastatic carcinoma, urinary diversion is usually achieved with indwelling ureteral stents or placement of a percutaneous nephrostomy tube. Most forms of surgical diversion carry an unacceptable morbidity rate, especially in the debilitated patient. Over a fifteen-year period (1974-1989), 29 adult patients with pelvic malignancy (32 ureters) underwent palliative cutaneous ureterostomy. This previously reported technique involves transverse nephropexy and construction of a stoma using a small skin flap. Indications included ureteral obstruction or severe urinary tract symptoms. Hydroureter, often considered a precondition for this procedure, was not present in several patients and was not a prerequisite to success. Complications related to the procedure included one postoperative death due to stroke, one death due to uremia and sepsis, and one instance of severe renal arterial stenosis resulting in renal failure. Preservation of renal function was possible in the 10 patients known to have survived from one to thirteen years postoperatively; only 3 patients eventually required stomal revision. By adherence to the surgical techniques described, the usually high incidence of stomal stenosis was avoided. Our experience reveals that although the indications for cutaneous ureterostomy are limited, this procedure can provide an alternative to permanent nephrostomy drainage or to a higher risk intestinal urinary diversion in carefully selected patients with a reasonable life expectancy.

Isolation of characteristic glycolipids possibly included in spherical droplets around M. leprae.

The main purpose of this work was to isolate the components in acetone soluble lipids of lepromas of the nine-banded armadillo by high performance liquid chromatography (HPLC), and then to examine the mass spectrometric characteristics of the two peaks (molecular weights 2000 and 1600) found by HPLC. The armadillo had been inoculated with Mycobacterium leprae isolated from a mangabey monkey with naturally acquired leprosy. According to the results of HPLC, gas liquid chromatographic and mass spectral analyses, the GPC peak I lipid at 2000 D was identified as phenolic glycolipid and the GPC peak II lipid at 1600 D, as phthiocerol dimycocerosate. It was thought that the GPC peak I lipid and the GPC peak II lipid were included in the spherical droplets (peribacillary substance) around M. leprae. It was concluded that the microorganisms causing leprosy-like changes in the mangabey monkey were either M. leprae or a very closely related bacillus.

Ultrasound diagnosis of small asymptomatic bladder carcinoma in patients referred for gynecological scan.

We report on 4 patients with bladder cancer detected during pelvic ultrasound for gynecological indications without urinary symptoms. Only 1 of the 4 patients had hematuria. All 4 patients were treated by cystoscopic excisional biopsy and no further operation was required. We stress that the bladder often is forgotten during pelvic ultrasound and that sonography is a sensitive, noninvasive tool to examine the bladder.

Fournier's gangrene: an approach to its management.

Treatment of Fournier's gangrene (necrotizing fasciitis of the male genitalia) traditionally has involved extensive débridement in concert with broad-spectrum antibiotic administration. However, our management of 4 patients with Fournier's gangrene indicates that limited débridement with placement of through-and-through drains may provide a good result, with far less tissue loss. After surgery and prompt, individualized antibiotic treatment the patients showed rapid improvement in their over-all condition with a brisk defervescence and normalization of leukocytosis. Granulation of the wounds progressed rapidly without secondary infection. In 2 of the 4 patients some skin grafting was required but the areas involved were quite small.

Results of inferior vena cava resection for renal cell carcinoma.

A total of 24 patients with renal cell carcinoma involving the inferior vena cava underwent thoracoabdominal radical nephrectomy with removal of tumor thrombus by an open or closed technique. The tumor extended in the inferior vena cava to the level of the renal or lower hepatic veins in 18 patients and it reached the level of the diaphragm or right atrium in 6. Of the 24 patients 3 with preoperative findings minimally suggestive of disseminated disease were shown later to have metastases in the questionable areas, 3 with disease at the level of the diaphragm had incomplete resections, 4 had metastases to regional lymph nodes and 1 had questionable preoperative findings and lymph node metastases. Only 13 of the 24 patients (54 per cent) did not have either disseminated or residual tumor postoperatively. The mean survival duration of this subgroup (20 months) was comparable to that of the group as a whole (21 months). However, 4 patients from this subgroup are free of disease, with a mean followup of 30 months. There was 1 postoperative death. Morbidity, including renal failure, intraoperative hypotension and sepsis, was common. The results in this series suggest that the prognosis for patients with renal cell carcinoma and inferior vena cava involvement is guarded.

Renal hemangioma: diagnostic aspects and management techniques.

Renal hemangiomas are rare lesions that demonstrate a spectrum of clinical, radiographic, and pathologic presentation. Angiographic differentiation from renal cell carcinoma is usually possible, and in such cases conservative management should be attempted. Hemangiomas are in some ways similar to arteriovenous malformations, but lack the rapid and pronounced pre-capillary shunting that characterize the latter. Three cases are presented, two managed surgically with one requiring nephroscopy for diagnosis, and one managed non-operatively. Brush biopsies of lesions with pyelographic characteristics of renal hemangioma should not be attempted without prior angiography.

Obstructing polyps of the posterior urethra in boys: embryology and management.

Solitary fibrous polyps are in uncommon but important cause of obstructive uropathy, infection and hematuria in boys. The clinical presentation and management in 5 boys are discussed and the literature is reviewed. Emphasis is placed on the pitfalls in diagnosis and recent endoscopic techniques of treatment.

Useful technique for long-term urinary drainage by inlying ureteral stent. Six-year experience.

Endoscopically placed inlying ureteral stents have proved useful in the conservative management of patients with ureteral obstruction, urinary fistula, and malignancy and have obviated the need for operative intervention. In high-risk symptomatic patients with widespread malignancy, internal urinary diversion offers the opportunity for an improved quality of life without the surgical risk or potential morbidity of supravesical diversion. Potential candidates for this simple, safe, and effective technique include: those with postsurgical obstruction and/or fistula, retroperitoneal fibrosis, metastatic carcinoma, congenital ureteropelvic junction obstruction, as well as those with reversible obstruction from lymphoma and carcinoma of the prostate who are undergoing radiotherapy and/or chemotherapy. The focus of this report is on the technique we have found successful in providing us with stents that fit our individual patients. Readily available fabricated graduated ureteral catheter can be cut and shaped to particular measurements unlike prefabricated catheters. Minimal preparation time is demanded, and there is no need for extensive stocking of various catheter sizes.

Cyclophosphamide and carcinoma of bladder.

A case of carcinoma of the bladder developing in a patient who received cyclophosphamide (Cytoxan) therapy for carcinoma of the breast is presented. Hemorrhagic cystitis si a well-documented complication of such therapy. Several recent reports of carcinoma of the bladder in patients receiving cyclophosphamide should make physicians aware of this potential association.

Functioning and nonfunctioning cysts of the adrenal cortex and medulla.

Adrenal cysts are rare clinical and pathologic entities. The vast majority are minute in size, unilateral, and found in females at autopsy. They come to the physician's attention when they produce symptoms or are identified on x-ray studies. When symptomatic, they generally produce lumbar discomfort and gastrointestinal symptoms, and occasionally are palpable by abdominal examination. There is no significant agreement as to cause and pathogenesis of the disease. The most common histologic types are lymphangiomatous endothelial cysts, secondary to lymphangiectasis, and the fibrous wall or hemorrhagic pseudocysts. In many patients preoperative diagnosis is now possible with high quality nephrotomography, ultrasonography, and adrenal arteriography. The presence of a suprarenal mass with peripheral or laminar calcification strongly suggests the presence of an adrenal pseudocyst. Selective biochemical studies are mandatory to rule out the presence of an occult cystic pheochromocytoma, and adrenal cortical tumor. Adrenal cysts must be differentiated from all space-occupying lesions of the upper abdomen. Surgical exploration is recommended in almost all patients for accurate diagnosis and to rule out malignant disease or occult pheochromocytoma. The choice of the surgical approach should be planned to provide for safe and adequate exposure, depending on the size and location of the lesion. Careful dissection with preservation of the adjacent kidney, liver, and pancreas should be performed.

An improved non-intubated cutaneous ureterostomy technique for the normal and dilated ureter.

Cutaneous ureterostomy is a simple procedure to perform but is attended by high morbidity owing to recurring abscesses, strictures and stenosis of the stoma. An improved technique applied to the diversion of 4 normal renal units and 3 dilated ureters is described. We have not experienced the complications mentioned in previous studies and none of the patients has required ureteral intubation in this small series with a 3-year followup.

Venacavography, corticosteroids and surgery in the management of idiopathic retroperitoneal fibrosis.

Four patients with idiopathic retroperitoneal fibrosis were found to have characteristic obstruction and anterior displacement of the lumbar vena cava. Varying degrees of venous collateral circulation were present, depending on the degree of vena caval compression. All 4 patients underwent ureterolysis to relieve the hydronephrosis and to confirm diagnosis by biopsy. Two patients were treated with corticosteroids postoperatively. Followup venacavography demonstrated improved filling and decrease in the collateral circulation in these 2 patients. Of the remaining 2 untreated patients 1 was lost to followup and the other revealed no change. Diagnosis of idiopathic retroperitoneal fibrosis can be made if characteristic changes are present on inferior venacavography and may provide an objective measure for following the basic disease process during medical treatment.