Hemostatic control with flexible compression tape used during partial nephrectomy and organ salvage.

PURPOSE: A secure method of achieving hemostasis during partial nephrectomy to accomplish guillotine polar amputation is described. MATERIALS AND METHODS: A common hardware item, the so-called cable tie, proved to be useful during removal of a block of neoplastic renal tissue from the lower central pole of a unilateral kidney. RESULTS: Complete hemostasis and resection of the renal parenchyma were obtained with ease and minimal expense. CONCLUSIONS: The use of a flexible plastic compression tape has proved valuable to adhere to organ contours closely, maximally control bleeding and marking a line of incision during amputation of a portion of the renal substance. This device may prove useful for analogous surgical purposes with other vascular organs.

Prenatal failure to visualize kidneys: a spectrum of disease.

OBJECTIVES: To better understand the outcomes and management of patients when there is a failure to visualize kidneys on prenatal ultrasound. METHODS: Nine thousand five hundred twelve prenatal ultrasound studies performed on 4900 patients were reviewed retrospectively for the findings of a failure to visualize kidneys. The prenatal ultrasounds, pregnancy outcomes, and postmortem studies were reviewed for each of the 10 patients identified. RESULTS: Nine of 10 patients experienced fetal death in the index pregnancy: 7 had therapeutic abortions, 1 had an intrauterine fetal demise, and 1 gave birth to a stillborn infant. One patient gave birth to a live infant with Bartter's syndrome and grossly normal kidneys, as diagnosed by ultrasound. Developmental renal anomalies were identified in only 4 of 10 cases, and only 2 patients had true bilateral renal agenesis. There was 1 case each of bilateral renal medullary cystic dysplasia and bilateral renal hypoplasia. Three cases had no renal anomalies and included 1 case each of Turner's syndrome, chronic abruption, and a cord accident. In 2 cases, postmortem examinations were not performed because of family wishes. CONCLUSIONS: Prenatal failure to visualize kidneys represents a spectrum of clinical problems not all of which are fatal. Close consultation with an experienced ultrasonographer is essential to provide informed counseling to expectant parents. Pathologic examination should be recommended when there is fetal demise and a suspicion of genitourinary anomalies. Screening of family members of the index patient and genetic counseling may be indicated.

Prenatal ultrasound characterization of the suprarenal mass: distinction between neuroblastoma and subdiaphragmatic extralobar pulmonary sequestration.

With the increased routine use of prenatal ultrasonography, subdiaphragmatic masses in the fetus are identified more frequently. Suprarenal masses often are presumed to be neuroblastoma and are removed surgically postnatally. We sought to better understand the natural history of subdiaphragmatic extralobar pulmonary sequestration, and to determine if subdiaphragmatic extralobar pulmonary sequestration can be distinguished preoperatively from neuroblastoma. The literature was reviewed for cases of prenatally diagnosed suprarenal masses that proved ultimately to be either subdiaphragmatic extralobar pulmonary sequestration or neuroblastoma. The distinguishing features of the two lesions were identified and an algorithm was created on the basis of these distinctions. Prenatally diagnosed subdiaphragmatic extralobar pulmonary sequestration is no longer rare, with one case being reported for every 2.5 cases of neuroblastoma. On prenatal ultrasonography subdiaphragmatic extralobar pulmonary sequestration usually is echogenic, is left-sided, and can be identified in the second trimester. Neuroblastoma is most often cystic, right-sided, and identified in the third trimester. In summary, subdiaphragmatic extralobar pulmonary sequestration must be considered in the differential diagnosis of the suprarenal mass identified on prenatal ultrasonography. Using the algorithm which we propose, the correct diagnosis can be determined prenatally in 95% of patients.

Prospective development of a cost-efficient program for the pubovaginal sling.

OBJECTIVES: We designed and implemented a cost-containment program for patients undergoing a pubovaginal sling procedure. We sought to test the hypothesis that preoperative patient education could reduce the length of hospital stay in these patients. Our goal was to decrease hospital charges while maintaining quality of care. METHODS: A multidisciplinary group of clinic and hospital staff identified factors that contribute to a patient's hospital charges for a pubovaginal sling procedure. A program of preoperative patient education to teach intermittent self-catheterization was combined with the elimination or control of items considered unnecessary to the delivery of safe, efficient care. Patient care was standardized from the preoperative visit to discharge planning. The difference in the mean values of 38 prestudy patients was compared with 15 study patients with a Wilcoxon rank sum test. RESULTS: Length of hospital stay was reduced from a mean of 2.8 to 1.1 days after implementation of the program (P < 0.0001). This decreased length of stay, combined with a reduction in routine laboratory studies (97% decrease; P < 0.0001), operating room charges (11% decrease; P < 0.01), and medications (35% decrease; P < 0.01), led to significantly reduced hospital charges. Total hospital charges decreased by 35%, from a mean of $4862 to a mean of $3153 (P < 0.0001). There was no increase in morbidity. Patient satisfaction with length of hospital stay did not change significantly following implementation of the program. CONCLUSIONS: With a program of preoperative patient education combined with a critical review of the factors contributing to a patient's hospital charges, it is possible to implement a cost-efficient program for a pubovaginal sling, leading to a 35% reduction in mean total hospital charges. This approach directed toward other incontinence procedures could be expected to yield comparative results.

Deflation techniques for faulty Foley catheter balloons: presentation of a cystoscopic technique.

The Foley catheter is used for drainage of the urinary bladder in < or = 15% of hospitalized patients and is self-retained by an inflatable balloon mechanism. Faulty balloon deflation, which leads to a retained catheter, is a condition treated by the urologist. In this article we describe a cystoscopic approach to deflation, evaluation, and recovery of retained fragments; review the techniques for deflation; and provide an algorithm to approach the retained Foley catheter.

Fatal genitourinary mucormycosis in a patient with undiagnosed diabetes.

We present what we believe is the first report in the world literature of penile necrosis due to mucormycosis, a rare and often fatal fungal infection. This case of rhizopus mucormycosis began with a penile lesion in a 27-year-old patient with undiagnosed diabetes; it led to necrosis of the phallus, lower urinary tract, rectum, and pelvic musculature and finally to death. Despite repeated aggressive surgical debridement in conjunction with medical therapy, we were unable to halt the progression of the fungal and synergistic bacterial infections.

How many oral cancers have you found--or missed--lately?

Oral cancers too often advance farther than they should before being diagnosed, because neither the patient's physician nor dentist has performed a thorough examination of the oral cavity. Only greater attention to this important area by both disciplines can improve the survival and quality of life of patients with a malignant oral lesion.