Spontaneous ureterocolic fistula secondary to calculous pyohydroureteronephrosis.

We report a case of ureterocolic fistula secondary to urolithiasis in a 70-year-old female imaged with both CT and an antegrade nephrostogram. The ureterocolic fistula was managed with insertion of an antegrade ureteral stent.

Early experience with transurethral needle ablation of large prostates.

OBJECTIVE: To evaluate the safety and effectiveness of transurethral needle ablation (TUNA(R)) performed on benign hyperplastic prostates > 60 gms. Patients and methods: Ten patients with bilobar hyperplasia and without a large middle lobe received one TUNA(R) Treatment. The mean age was 67.5 years (range 56-80) and the mean prostatic weight was 76.89 (range 62-98 gms). Symptom scores, quality of life (QOL), maximum and average flow rates were measured before and 1,3, and 6 months post treatment. RESULTS: After 6 months patients showed mean improvements in symptom scores (19.9 to 12.11), maximum flow rates (8.63 mL/sec to 12.75 mL/sec) and QOL (4.2 to 2.33). Recurrence of symptoms occurred in one patient at 13 months post TUNA(R) and he was retreated. One patient developed urinary retention and received a TURP. CONCLUSIONS: Short term results in this small group of patients indicate that TUNA(R) is a safe technique for individuals with large prostates and in this small group of patients resulted in reduced symptoms, high patient satisfaction and acceptable morbidity.

An evaluation of quality of life in patients with continent urinary diversions after cystectomy.

OBJECTIVE: To determine the long-term results and assess the quality of life in patients with continent urinary diversions after cystectomy. PATIENTS AND METHODS: Eighty-six consecutive patients who received a continent urinary diversion from 1988 to 1994 at the Vancouver Hospital and Health Sciences Center were evaluated. The evaluation comprised a review of their hospital charts and clinic visits at 3 months and then yearly. Quality of life issues were assessed using a postal questionnaire pertaining to the patient's urinary symptoms. activity level and overall well-being while living with a continent urinary diversion. Two separate questionnaires were sent, addressing heterotopic or orthotopic diversions. RESULTS: There was an acceptable rate of complications, with stone formation and urinary tract infection as the most common morbidities. Continence was rated as good in most patients, with no patient reporting complete incontinence. Undesirable urinary symptoms occurred less often than 20% of the time in most patients. Although there was a significant effect on sex life, the overall quality of life appeared to be very good, as 70% of the patients had no limitations to their activities. CONCLUSIONS: The techniques currently evolved for urinary diversion produce good long-term results and quality of life. These diversions should be considered in a well selected patient population.

Transurethral electrovaporization of the prostate versus transurethral prostatic resection: a comparison of postoperative hemorrhage.

OBJECTIVES: To determine the acute and delayed hemorrhage rate of transurethral electrovaporization of the prostate (TEVP) versus standard transurethral resection of the prostate (TURP). METHODS: A retrospective review of 524 consecutive patients who underwent TURP and 302 consecutive patients who underwent TEVP was conducted. The indications for both procedures were identical and based on history, physical examination, American Urological Association symptom score, and uroflowmetry. Parameters of evaluation included the incidence of both initial and delayed hemorrhages, the time until a delayed bleed occurred, blood transfusion rates, and the average length of stay in hospital after a bleed. RESULTS: The overall hemorrhage rate for TURP and TEVP was 4.8% and 4.0%, respectively. In the TURP group, there was a 1.1% incidence of acute bleeds and 3.6% incidence of delayed bleeds. For the TEVP group, 0.3% had an acute hemorrhage, and 3.6% were readmitted for clot retention. The average length of time from original discharge to readmission was 12.9 days for the TURP group with a mean repeat stay of 5.7 days. For the TEVP group, the average interval to readmission was 15.4 days with a stay of 3.1 days. CONCLUSIONS: The overall rate of hemorrhage for the TEVP group was slightly lower than for the TURP group due to fewer acute bleeds. However, the incidence of delayed bleeds and clot retention between the two was identical at 3.6%. Because of improved hemostasis intraoperatively with similar functional results in the long term as shown by other investigators, we foresee TEVP continuing as a viable alternative to TURP.

Suction electrocautery device: an aid to decreasing localized air contamination.

Airborne contaminants have been documented as a source of contamination for operating room personnel. Although electrocautery and LASER evaporation of venereal warts have been proven to release into the immediate environment, human papilloma virus DNA,(1) actual shedding and infectivity of viral particles has not been demonstrated. Surgical masks do remove viral particles. The unanswered question is whether they are effective filters of larger volumes of contaminated operating room air. Devices have been reported to aid in removal of such particles from the working operative environment.(2) Some of these techniques require purchase of new and expensive equipment. We describe our technique for suction-assisted cautery, at no added cost compared with standard operative setup.

Early experience with high-intensity focused ultrasound for the treatment of benign prostatic hypertrophy.

OBJECTIVE: To evaluate the safety and effectiveness of high-intensity focused ultrasound (HIFU) in patients with benign prostatic hypertrophy (BPH). PATIENTS AND METHODS: The study comprised 25 patients (mean age 67 years: range 47-84) with BPH treated using the Sonoblate HIFU device. Patients were evaluated before and after one treatment of HIFU using the American Urological Association (AUA) symptom score, peak urinary flow rate (Qmax) and a quality-of-life (QOL) score, and any complications were noted. RESULTS: Five patients with large glands were withdrawn because the failure rate was high in these patients. The remaining 20 patients showed a mean improvements in the AUA symptom score (20.25 to 9.56), Qmax (9.2 to 13.7 mL/s) and QOL score (4.75 to 2.50). There were no major complications. CONCLUSIONS: HIFU is safe, produces minimal side-effects or complications and relieves the symptoms of prostatism.

Endoscopic rollerball electrovaporization of the prostate--the sandwich technique: evaluation of the initial efficacy and morbidity in the treatment of benign prostatic obstruction.

OBJECTIVES: To evaluate the safety, initial efficacy and morbidity of a new treatment for benign prostatic hyperplasia (BPH), endoscopic rollerball electrovaporization (EREV) of the prostate. PATIENTS AND METHODS: Endoscopic rollerball electrovaporization with or without a modified transurethral prostatectomy (TURP) was performed in 51 patients (mean age 69 years). Before treatment, patients were evaluated by measuring maximum flow rate, post-void residual volume (PVR) and a symptom score. After undergoing EREV and modified TURP the operative and hospital records were reviewed and the duration of the procedure, hospital stay and the incidence of complications and/or morbidity were recorded. The urodynamic variables were re-evaluated after 3-8 months. RESULTS: Five patients were operated on for retention: of the remaining patients, the pre-operative mean symptom score was 18 (maximum 30), the mean maximum flow rate was 11.5 mL/s, the mean PVR was 159 mL and the mean duration of the procedure was 28 min. Of the 51 patients, 30 were discharged catheter-free on the first day after surgery. No patient required transfusion for associated blood loss, none had evidence of symptomatic bacteraemia and the transurethral resection syndrome did not occur. One patient who had a bladder carcinoma resected at the same operation was readmitted 2 weeks later with haematuria and clots. Three patients presented as emergencies within 8 weeks because of retention; one was admitted and required further EREV. On re-evaluation, the symptom scores decreased by a mean of 11 points, the maximum flow rate increased by a mean of 6.2 mL/s and the mean PVR decreased by 102 mL. CONCLUSIONS: EREV of the prostate is a safe, effective and economic alternative to a standard TURP.

Pathological review of female patients undergoing cystectomy for cancer of the bladder.

The female patient undergoing cystectomy for invasive cancer of the bladder usually has some form of diversion to the skin. Recently, in the male patient there has been a major shift from cutaneous diversion to functioning orthotopic urethral reservoirs so that the patient can void per urethra. We were intrigued by Bartsch's anatomical studies of the female urethra. With this new information, it seemed feasible to perform the orthotopic urethral diversion in the female. In order to have guidelines in choosing which patients could undergo cystectomy preserving the urethra, we reviewed the pathological findings on female patients undergoing cystectomy at Vancouver General Hospital for 10 years.

Transplantation of pediatric cadaver kidneys into adult recipients.

Between July 1987 and July 1993, 762 renal allografts were transplanted into adult recipients at our institution. A total of 83 adults received cadaveric renal transplants from donors aged 5 months to 10 years, while 100 adults who received adult cadaver kidneys during the same period served as a comparison group. Cyclosporine based immunosuppression was used. No difference between the 2 groups was found with respect to recipient age, recipient sex, primary renal disease, HLA matching or the number of recipients with a previous transplant. Actual patient (graft) survivals at 1 and 3 years were 91% (77%) and 86% (68%), respectively, for recipients of pediatric kidneys compared to 99% (92%) and 90% (80%), respectively, for recipients of adult kidneys. Pediatric kidney recipients were more likely to encounter renovascular complications (13% versus 4%, p = 0.023) and more likely to have episodes of acute rejection (p = 0.018). Serum creatinine was equal in the 2 groups at 1 year following transplantation (p = 0.63).

Collecting duct carcinoma of the kidney: a case report and review of the literature.

Collecting duct carcinoma of the kidney is unique and rarely reported. The histological and ultrastructural characteristics of this tumor are well described in the pathological literature. However, there are few reports documenting the clinical presentation and long-term prognosis in patients with this unusual malignancy. Collecting duct carcinoma arises from the epithelium of the collecting tubules within the medulla and secondarily invades the renal cortex. The tumor occurs in a younger age group than is typical for renal cell carcinoma and most patients appear to have metastatic disease at presentation. We describe a case of this uncommon tumor and review the literature.

The quality of initial function following renal transplantation determined by creatinine elimination kinetics. Comparison of Minnesota antilymphocyte globulin and cyclosporine induction immunosuppression.

To compare the effect of type of induction immunosuppression on the quality of initial renal allograft function, we identified 35 cadaver donor kidney pairs in which one recipient of a kidney from a given pair received induction immunosuppression with Minnesota antilymphocyte globulin (MALG group) while the recipient of the contra-lateral kidney received cyclosporine from day zero (CsA group). In the absence of an existing quantitative measure to assess and compare the status of those grafts that function primarily, we defined the half-life of creatinine elimination (t1/2SCr) as such an outcome measure based on a review of creatinine elimination kinetics. All organs were procured with in-situ perfusion and en-bloc removal. Total cold storage times, rewarm times, and perioperative management were comparable for the two groups. In the MALG group, the mean t1/2SCr) was not different from that in the CsA group (1.38 +/- 0.96 days vs 1.35 +/- 1.2 days P = NS). Multiple regression analysis performed on the differences in recipient age, number of DR-B locus matches, total cold ischemia time, rewarm time, and central venous pressure at reperfusion of a given donor pair demonstrated no significant impact of any of these differences on the difference in t1/2SCr for the same pair set in this sample. The nadir of serum creatinine achieved in the first five days posttransplant was somewhat higher in the CsA group (234 +/- 131 mumol/L) as compared with the MALG group (200 +/- 132 mumol/L) but the difference was not significant. A similar nonsignificant trend was observed in the comparison of mean serum creatinine values at 30 days posttransplant (MALG group: 158 +/- 62 mumol/L vs. CsA group: 200 +/- 141 mumol/L). Only one of seventy recipients (CsA group) was dialyzed within the first 5 days posttransplant for an overall incidence of ATN of less than 2%. Fourteen of 35 (40%) recipients in both groups received treatment for acute rejection. The mean time to first treatment for acute rejection episode was shorter in the CsA group than the MALG group (10 +/- 8 days vs 23 +/- 24 days, P = 0.055). Graft survival at one year was not different for the two groups (92% vs. 87% for the MALG and CsA groups respectively, P = NS).(ABSTRACT TRUNCATED AT 400 WORDS)

Cytomegalovirus epididymitis following renal transplantation.

Cytomegalovirus infection is an important cause of morbidity and mortality in immunocompromised individuals. The disease is usually systemic in expression although localized infection can occur, particularly in the lung, liver, retina and gastrointestinal tract. We report a case of cytomegalovirus epididymitis with limited systemic manifestations occurring 2 months after renal transplantation in a patient immunosuppressed with azathioprine, prednisone and cyclosporine. Diagnosis was confirmed by observation of typical cytopathic changes in epididymal cells. Clinical resolution occurred with epididymo-orchiectomy and 9-(1,3-dihydroxy-2-proproxymethyl)guanine therapy. To our knowledge this presentation has not been described previously in the transplant literature and it is extremely rare in other forms of inherited or acquired immune deficiency.

Radical prostatectomy for localized prostatic carcinoma in the renal transplant patient.

Three renal transplant patients had prostatic carcinoma after transurethral prostatectomy at 2 weeks, 2 months and 12 years following transplantation. One patient had stage A1 disease, while 2 had stage A2 prostatic carcinoma. All patients underwent radical retropubic prostatectomy and pelvic lymph node dissection. All patients had residual cancer in the radical prostatectomy specimen but none had nodal or capsular involvement. The surgical technique and rationale for management are discussed.

Return of sexual functioning following penile replant surgery.

The penis, scrotum, and testicles of a 31-year-old man were cut off in a fight. Fourteen hours later the penis and one testicle were reattached, but the testicle later had to be removed. By 3 weeks normal urinary function returned but the penis was misshapen. The patient had suicidal intentions. His partner was sexually supportive but afraid to touch the penis. By 10 weeks penile swelling occurred in response to a movie with frank sexual content. By 12 weeks the penile swelling was sufficient for entry but the partner was acutely afraid that her vaginal contractions would tear the scars. The man was concerned because he experienced only mild sexual tensions. Physical examination reassured both, and they gained hope for recovery. At 16 weeks erections were still not full but active intercourse was attempted and he experienced seminal seepage and mild orgasmic sensations; she was relaxed enough to have orgasm. Testosterone was administered at regular intervals from the 19th week on, with immediate improvement of erection. By 32 weeks full erection, ejaculation, and orgasmic functions returned and the couple resumed their normal sexual practices.

Transurethral resection of the prostate in the outpatient setting.

Transurethral resection of the bladder neck (8 patients) or prostate (142) was performed in the outpatient setting. Of the patients 5 required hospitalization for post-prostatectomy hemorrhage. This method has proved to be safe and cost-effective in the treatment of patients with outlet obstruction.

Early hydronephrosis following aortic bifurcation graft surgery: a prospective study.

The true incidence and natural history of ureteral obstruction following reconstructive vascular surgery have not been determined previously. A series of 101 patients undergoing aortofemoral and aortoiliac reconstructive surgery were studied prospectively to determine the frequency of hydronephrosis in the first postoperative year. Serial real-time ultrasound examinations were performed preoperatively as well as at 1 week, 3 months and 1 year postoperatively. Ninety-three patients completed the study, with a total of 181 kidneys at risk. Hydronephrosis of mild to moderate degree developed in 15 kidneys (8 per cent) in 11 patients (12 per cent). All patients were asymptomatic, and the obstruction resolved spontaneously in 10 of 11 patients, including 9 within 3 months of onset. Only a single case persisted at 1 year. This study confirms that the hydronephrosis that occurs within the first year after aortic bifurcation graft surgery is not uncommon but it is rarely of clinical significance in the asymptomatic patient.