Synchronous bilateral testis tumor: mixed germ cell and theca cell tumors.

Synchronous bilateral testis tumors of different histologic types are rare. All previous cases have demonstrated germ cell tumors on both sides. The simultaneous appearance of a germ cell tumor and a contralateral non-germ cell tumor has not been reported. We herein report a thirty-four-year-old man who presented with a mixed non-seminomatous germ cell tumor of the left testis and theca cell tumor of the right testis.

Extracorporeal shock wave lithotripsy treatment of lower caliceal stones: an update on the use of a cobra catheter for direct irrigation.

As the general experience with extracorporeal shock wave lithotripsy (ESWL) for renal calculi broadens, it is increasingly evident that the clearance of stone fragments in lower pole calices needs to be improved. The stone-free rate posttreatment for lower caliceal stones is consistently less than that for other upper tract locations. Utilization of a cystoscopically placed cobra catheter for directed irrigation during ESWL with a Dornier HM4 lithotripter resulted in an increase of our lower caliceal stone-free rate to 64% (29/45) at 1 month follow-up and 73% (33/45) at 3 months follow-up compared to 36% (15/42) of randomly selected controls at 1 month (p less than 0.007) and 54% (23/42) at 3 months (p < 0.070). Patients were included in the study if they had a solitary calculus, less than 2 cm in size, located in a normal lower pole calix and had no indwelling stent placed by the referring physician. The cobra catheter was positioned in the appropriate calix with fluoroscopic guidance under intravenous sedation. Statistical analysis was performed using Pearson's Chi-square test. We conclude that the pre-ESWL treatment placement of a cobra catheter into the lower pole calix and intermittent irrigation during the procedure is a useful adjunct in the successful treatment of lower caliceal calculi.

The use of a cystoscopically placed cobra catheter for directed irrigation of lower pole caliceal stones during extracorporeal shock wave lithotripsy.

As the general experience with extracorporeal shock wave lithotripsy (ESWL) for renal calculi broadens, it is increasingly evident that the clearance of stone fragments in lower pole calices needs to be improved. The stone-free rate after treatment for lower caliceal stones is consistently less than that for other upper tract locations. Use of a cystoscopically placed cobra catheter for directed irrigation during ESWL resulted in an increase of our lower caliceal stone-free rate at 1 and 3 months of followup to 71% (15 of 21) compared to 33% (8 of 24) of randomly selected controls at 1 month and 54% (13 of 24) at 3 months. We conclude that pre-ESWL placement of a cobra catheter into the lower pole calix and intermittent irrigation during the procedure are potentially useful adjuncts in the successful treatment of lower caliceal calculi.

An evaluation of 646 stone patients treated on the HM4 extracorporeal shock wave lithotriptor.

Extracorporeal shock wave lithotripsy (ESWL) has become the preferred treatment modality for the majority of urinary tract calculi. This form of treatment boasts excellent patient acceptance and has significantly reduced the need for surgical intervention. An evaluation of our first 646 patients undergoing 722 ESWL treatments at Walter Reed Army Medical Center revealed an overall stone-free rate at 1 and 3 months of 52% and 79%, respectively. The exact location of each stone within the kidney and ureter further determined the stone-free rates at 1 and 3 months. Stone-free rates at 3 months ranged from 89% for renal pelvic stones to 64% for lower pole caliceal stones. Upper third ureteral stones treated in situ without stenting resulted in a 74% stone-free rate at 3 months. This rate increased to 85% when these patients were stented and treated in situ. Although statistically insignificant, when the upper third ureteral stones were manipulated into and treated in the renal pelvis (31% of our patient population) the 3-month stone-free rate increased to 87%. Attempts were made to stent all ureteral stones before treatment. The stone-free rate at 3 months was 86% for mid third ureteral stones and 81% for lower third ureteral stones. The overall retreatment rate was 11.8% with a complication rate of 7.6% and a 6.3% post-ESWL intervention rate (open or percutaneous surgery, stent or percutaneous nephrostomy placement).

Endoscopically controlled placement of urethrovesical anastomotic sutures after radical retropubic prostatectomy.

Radical retropubic prostatectomy is a challenging surgical procedure. One of the technically demanding aspects of this surgery is the urethrovesical anastomosis. We have used a 21F cystoscope in selected patients to enhance the quality of our urethrally placed anastomotic sutures. This technique may be a beneficial adjunct in those cases in which delineation of the transected urethral margin is difficult to identify secondary to urethral retraction and should be considered an addition to the presently available armamentarium of maneuvers used to make the urethrovesical anastomosis technically easier and more precise.

Retroaortic left renal vein in testicular cancer patient: potential staging and treatment pitfall.

A 20-year-old man was diagnosed with a left mixed germ cell testicular tumor and clinical staging with computerized tomography suggested left para-aortic subhilar retroperitoneal adenopathy. The patient received 4 cycles of cisplatin, vinblastine and bleomycin chemotherapy but the mass in the left renal hilus area remained unchanged. Subsequent retroperitoneal lymphadenectomy revealed the mass to be a retroaoritc left renal vein type 2. Further confusion occurred during followup in differentiating this anomaly from recurrent neoplasm necessitating evaluation by magnetic resonance imaging. Retroaortic left renal vein represents a potential imaging pitfall in testicular cancer that may facilitate suboptimal staging, treatment and followup.

Spinal epidural abscess as a complication of Fournier's gangrene.

Fournier's gangrene is a rare, multi-organism infection of the perineum. The disease is most often confined to the groin area with distant spread being extremely unusual. A ase of spinal epidural abscess as a complication of Fournier's gangrene is presented. The infection appears to have spread by the hematogenous route. The patient had several symptoms, including fever, which could have provided an early diagnostic clue. Multiple fever workups were negative, however, and the diagnosis was not made until quadriplegia developed. A lumbar puncture as part of the fever workup might have allowed for an earlier diagnosis and more prompt surgery.

The management of chronic interstitial cystitis by substitution cystoplasty.

A total of 19 patients with interstitial cystitis symptoms intractable to conservative management underwent supratrigonal excision of the symptomatic bladder. Reconstruction to produce a low pressure reservoir was accomplished with a segment of remodeled intestine anastomosed to the bladder remnant. Patients were selected because of a history of typical intractable severe symptoms in the presence of characteristic endoscopic features. Of the patients 12 were cured of the pain and frequency, 4 experienced improvement, and 3 failed to improve and underwent urinary diversion. Preoperative features did not predict the outcome, although poor results occurred more often in those with large preoperative bladder capacities while under anesthesia and those who had postoperative voiding problems requiring self-catheterization.

Fournier's gangrene: a complication of penile prosthetic implantation in a renal transplant patient.

The management of erectile impotence in renal transplant patients remains problematical. The enhanced risk of surgical infection in this immunosuppressed patient population must be addressed if prosthetic implantation is contemplated. A case of Fournier's gangrene (synergistic necrotizing gangrene of the genitalia) following implantation of a Small-Carrion penile prosthesis is reported. This potentially life-threatening infection demonstrates graphically the surgical infection risk of this population and suggests extreme caution before proceeding with a prosthetic operation in this unique subset of impotent patients.