Combined radical retropubic prostatectomy and rectal resection.

OBJECTIVES: To present our experience with a small series of men who underwent simultaneous radical retropubic prostatectomy and rectal resection. METHODS: Three men with newly diagnosed prostate cancer were found to have concurrent rectal tumors requiring resection. All three men underwent non-nerve-sparing radical retropubic prostatectomy and abdominoperineal resection (APR) or low anterior resection (LAR) of the rectum at the same operation. In the 2 patients undergoing APR, the levators were approximated posterior to the urethra, and the bladder was secured to the pubis. The patient undergoing LAR had urinary diversion stents placed and a diverting transverse loop colostomy. RESULTS: All 3 patients had excellent return of urinary continence. One patient required reoperation in the early postoperative period for small bowel adhesiolysis and stoma revision. Another patient had a mild rectal anastomotic stricture and a bladder neck stricture; both were successfully treated with a single dilation. No other significant complications occurred in these patients. CONCLUSIONS: Radical retropubic prostatectomy can safely be performed with partial or complete rectal resection in a single operation. A few minor modifications of the standard radical retropubic prostatectomy in this setting are suggested.

Long-term histopathological changes observed in rats subjected to augmentation cystoplasty.

Possible development of proliferative lesions in bladders subjected to augmentation cystoplasty is a matter of concern for many clinicians. We have previously reported on the development of bladder papillomas in 5 of 15 rats approximately 18 months after gastrocystoplasty. We now report a followup study designed to investigate histopathological changes occurring in rat bladders approximately 2 years after augmentation cystoplasty using various gastrointestinal segments. Prepubescent Long-Evans female rats were randomly divided into 4 groups and underwent either gastrocystoplasty, ileocystoplasty, colocystoplasty or a sham operation (controls). Animals were sacrificed 14 to 27 months (average 21.5) postoperatively and bladders were examined histologically. Metaplastic and/or hyperplastic changes were observed in the gastrointestinal patches or surrounding urothelium in all bladders having undergone augmentation cystoplasty. Tumors occurred on or adjacent to the lumenal surface of the augmented segment in 4 of 10, 3 of 11 and 2 of 11 rats that underwent gastrocystoplasty, ileocystoplasty or colocystoplasty, respectively. None of the tumors was observed to invade blood vessels, lymphatics or the underlying muscle layers. However, histological features of malignancy characterized by varying degrees of cellular pleomorphism occurred in some tumors. Control rats (10) had only minor changes related to reapposition of tissues and remnants of suture. Possible etiologies and the potential significance of these augmentation cystoplasty related proliferative lesions are discussed.

Indomethacin suppositories versus intravenously titrated morphine for the treatment of ureteral colic.

STUDY OBJECTIVES: To develop a protocol for the blinded IV titration of morphine and to compare the analgesic efficacy and side effect profile of indomethacin suppositories versus IV morphine in the treatment of acute ureteral colic. DESIGN: Randomized, double-blind, double-dummy, two-period crossover study. SETTING: Emergency department of a central-city, teaching hospital. PARTICIPANTS: Patients 18 to 75 years of age with pain suggestive of ureteral colic. Exclusions included pregnancy, adverse reactions to the study drugs, chronic nonsteroidal anti-inflammatory drug (NSAID) therapy, or any pain medicine taken within four hours of ED admission. INTERVENTIONS: Patients were randomized to one of two groups: indomethacin 100-mg rectal suppository or morphine by IV titration (5-mg loading dose and up to two additional 2.5-mg doses if needed). At the end of 30 minutes, if adequate pain relief had not been obtained, treatment was crossed over. MEASUREMENTS: Verbal analog scale (initial pain) and visual analog pain relief scale. MAIN RESULTS: Seventy-five patients were entered into the study. Only data from those patients with stone presence confirmed by IV pyelogram or stone passage were analyzed. Twenty-four could not be evaluated (23 who did not meet criteria for stone presence and one whose pain resolved spontaneously before study medications could be administered). Of the remaining 51 patients, 31 received indomethacin first and 20 received morphine first. Morphine recipients reported more pain relief at ten minutes (P = .02), but at 20 and 30 minutes, no significant difference (P = .17 and .74, respectively) existed between the two groups. CONCLUSION: IV morphine produced more rapid analgesia than rectally administered indomethacin. There were no significant differences in vital sign changes or number of side effects between the two treatment groups. This study is the first to compare an NSAID with morphine administered by IV titration, considered by many to be the "gold standard" for relief of acute, severe pain. Future studies could evaluate the simultaneous administration of an opioid combined with an NSAID or compare an IV titrated opioid with an IV NSAID.

Urethral polyp presenting as interlabial mass in young girls.

We describe two young girls who presented with an interlabial mass. Histologic examination of each excised mass revealed a benign urethral polyp covered with transitional and squamous epithelium. Urethral polyps should be included in the differential diagnosis of an interlabial mass in young female patients.

Early clinical experience with the transverse colon-gastric tube continent urinary reservoir.

The clinical results of the first 4 patients undergoing reconstruction with the transverse colon-gastric tube urinary reservoir are presented. All patients had a minimum 1-year follow-up. All 4 patients are continent with stable or improved renal function. Two patients required reoperation. Indications as well as possible modifications of this procedure are discussed.

The clinical implications of brushite calculi.

The clinical history of 30 patients with a total of 46 proved brushite urinary calculi was reviewed. The patients were active metabolically with 87% having a history of multiple calculi. Of the brushite stones 61% appeared hyperdense on x-ray but they had no consistent shape. Of the patients who were metabolically evaluated 82% had treatable abnormalities. Treatment with percutaneous nephrostolithotomy or ureteroscopy and ureteral lithotripsy was 92% successful in rendering the patient stone-free, whereas, extracorporeal shock wave lithotripsy monotherapy resulted in a stone-free rate of only 11%. Brushite stone patients require aggressive treatment, full metabolic evaluation and close clinical followup.

Transverse colon-gastric tube composite reservoir.

We describe our technique for a new form of continent urinary diversion. This reservoir includes a detubularized segment of transverse colon to provide low pressure urine storage, tunneled ureteral reimplants to prevent reflux, and a tubularized gastric segment used as a continent catheterizable efferent limb. This technique provides a new option for continent diversion in a variety of patients.

Long term effects of gastrocystoplasty in rats.

Twenty prepubescent rats underwent microsurgical gastrocystoplasty by a technique which is described. An equal number of control rats had their bladders opened and closed. Rats were sacrificed at 16 to 18 months postoperatively. There were no differences in final weight, serum electrolytes, or renal function between the two groups. Prominent histopathologic changes of the bladder occurred in the gastrocystoplasty group. These changes included papillomas present in five of the 15 rats surviving long term. No significant changes occurred in the bladders of the control group of rats. Possible etiologies and the significance of the rats. Possible etiologies and the significance of the gastrocystoplasty related lesions are discussed.

Ureteral stump transitional cell carcinoma in a patient with recurrent superficial bladder cancer: an argument for complete nephroureterectomy in selected patients.

A 62-year-old white man had diffuse transitional cell carcinoma of a right ureteral stump 2 1/2 years after initial transurethral resection of a bladder tumor and right radical nephrectomy for renal cell carcinoma. This case and review of the literature suggest an indication for complete ureterectomy in nephrectomy candidates with prior or concurrent transitional cell carcinoma of the bladder.