Politano-leadbetter ureteroneocystostomy. A 30-year experience.

PURPOSE: We evaluated the results and complications of children with reflux treated with the Politano-Leadbetter ureteroneocystostomy. In particular, we evaluated pre- and postoperative renal parenchymal scarring and the late development of hypertension. MATERIALS AND METHODS: From 1965 through 1996, 666 children (814 renal units) were reimplanted by nine urologists. The average postoperative evaluation was 10.3 years, and 68.8% of all patiens were evaluable 10 years after surgery. RESULTS: Postoperative complications occurred in 7.8% and consisted of small bowel serosal injury (0.3%), vesicocutaneous fistula (0.4%) and retrovesical hematoma (0.3%). Persistent reflux was the most common postoperative complication (5.6%) and was found to occur in higher grades of vesicorenal reflux. Ureteral stricture and hydronephrosis were seen in 1.2% of children, and was corrected with a secondary reimplantation. Late stricture occurred in all but 1 patient (0.2%). Renal parenchymal scarring was found in 21.2% of patients preoperatively, and this increased over time postoperatively to 27.7%. In 8.7% of these patients, hypertension developed between the 6th and 17th postoperative year. In 6.1%, nephrectomy was carried out, which normalized blood pressures in 87. 9% of these 30 patients. CONCLUSIONS: The Politano-Leadbetter ureteroneocystostomy was successful in 93.6% of all 814 renal units surgically treated. The operation is safe, but can be associated with late development of hypertension despite correction of the reflux.

Ectopic refluxing ureter entering a seminal vesicle cyst associated with ipsilateral renal dysplasia.

The unusual case of a 10-month-old infant with an ectopic refluxing ureter entering into a seminal vesical cyst associated with ipsilateral renal dysplasia is described. The embryology, differential diagnosis, and therapy are discussed.

Prepubic urethrectomy with urethral stripping.

PURPOSE: Prepubic urethrectomy is a simple, safe alternative to perineal urethrectomy. The lithotomy position can be avoided and, thus, operative time and risk of deep venous thrombosis are decreased. We developed a simple modification because of difficulty in dissecting the bulbous urethra. MATERIALS AND METHODS: From 1996 through 1998 prepubic urethrectomy was performed using a modified procedure in 21 patients with invasive bladder carcinoma undergoing radical cystectomy and supravesical diversion. After periurethral mobilization the urethra was cannulated with an 18F catheter, sutured distal and stripped free. RESULTS: Operative time decreased to 20 to 30 minutes with no significant postoperative complications. CONCLUSIONS: Our modification of prepubic urethrectomy is safe, fast and easy.

A possible ontogenic etiology for idiopathic left varicocele.

A total of 659 consecutive patients underwent venography for the evaluation of idiopathic left varicocele before sclerotherapy. In 484 cases no valves of the left spermatic vein could be demonstrated, while 172 patients demonstrated competent valves or absent insertions of the left spermatic vein at the typical point on the left renal vein plus retrograde flow over persistent intercardinal anastomoses. Stenosis of the renal vein occurred in 103 patients (15.7%). In only 3 patients was stenosis observed in the course of the left iliac vein, suggestive of the so-called distal nutcracker phenomenon. We propose that during embryogenesis disturbances in the development of the secondary venous system may result in the idiopathic left varicocele.

[Observations on the formation of the secondary venous system of the abdominal cavity with special reference to idiopathic left-sided varicocele]. / Betrachtungen zur Ausbildung des sekundären Venensystems des Bauchraumes unter besonderer Berücksichtigung der idiopathischen linksseitigen Varikozele.

Based on 1,778 radiologic investigations of vena cava inferior, left renal vein and left spermatic vein the anomalies due to incorrect transformations from the first to the second abdominal venous system are presented. A persistent vena cardinalis posterior could be demonstrated in two cases. Varicoceles were seen with and without insufficient valves of the spermatic vein and venous outflow obstruction of the renal vein, respectively. Based on the demonstrated phlebographies disorders of ontogenesis seem to be the cause of the idiopathic left-sided varicoceles.

Out-patient sclerotherapy of idiopathic left-sided varicocele in children and adults.

Between 1983 and 1989, 334 patients with idiopathic left-sided varicocele were referred for transfemoral sclerotherapy; 323 were adults and 11 were children. The standard site of injection of the sclerosing solution (Varicocid-Natriummorrhuat 55 mg, Benzylalkohol 20 mg) was the mid-portion of the spermatic vein. The upper third was injected only in cases where the catheter could not be negotiated further (e.g. abnormalities in the course of the spermatic vein or its drainage into the intrarenal veins). The amount of sclerosing material was predetermined fluoroscopically using contrast material. Occasionally, in cases of high catheter positioning, the Varicocid was injected fractionally. The amount injected was always between 1 and 3 ml. Of 80 patients studied 1 year later, varicoceles were still present in 3 (4%). The best results were achieved in patients with small varicoceles (Grade I), normal testicular volume and normal FSH levels; 29% showed an improvement in sperm count and 27% an increase in sperm motility, while sperm morphology improved in only 7%. The conception rate was 11%.

[Radiological findings in renal capsular tumors (author's transl)]. / Radiologische Befunde bei Tumoren der Nierenkapsel.

Renal capsular tumors are rare. Preoperative diagnostic is based on radiology. Typical urographical findings are marginal impression and dislocation of the entire kidney without deformation of renal pelvis and calices. Angiography is the most decisive method of investigation, especially in malignant mass lesions. These tumors generally have hypovascular neovascularity without puddling. They can be supplied both by capsular and renal, lumbar and intercostal arteries. The renal parenchyma is contrasted homogeneously without defects, the margin is sharply defined. Computer tomography can best demonstrate the extent of the lesion and distinguish it from neighboring organs; in lipomas and cysts even a histological prediction is justified with this method. Preoperative diagnostic accuracy is limited by the fact, that even the pathologist, in some cases, is not able to decide upon the origin of these tumors.

[Computer tomography in the investigation of renal trauma (author's transl)]. / Computertomographische Untersuchungen bei Nierenverletzungen.

Two patients with blunt renal injuries (Hodges grade I and II), and two further patients with spontaneous renal and/or retroperitoneal hemorrhage, were studied with excretory urography, isotope scanning, ultrasound, angiography, and computerized tomography. The most important additional information provided by the CT scan was the disclosure of small parenchymal lacerations, as well as the presence and extent of perirenal hematomas. These abnormalities could also be monitored with CT studies during the healing phases. Renal excursion studies during breathing and the usual tomography seem to be no longer necessary in renal trauma cases if one plans to utilize CT scanning. Likewise, the necessity for angiographic studies decreases. Ultrasound, however, may still be helpful in certain cases of perirenal hematoma.

[Considerations regarding the differential diagnosis during the angiography of non-functioning kidneys (author's transl)]. / Differentialdiagnostische Gesichtspunkte bei der Angiographie stummer Nieren.

Utilizing selective renal arteriograms and phlebograms in 7 patients, the differential diagnostic difficulties in separating poorly vascularized tumors from inflammatory lesions are discussed. Retrograde studies either offered no help, or could technically not be accomplished; arteriography proved equivocal in most cases. However, renal phlebography was found to be quite helpful, in that a non-visualized or reduced opacification of the intrarenal venous system, along with irregular extrinsic venous impressions, spoke more for a malignant tumor. When the contrast was able to fill the veins out to the periphery, a tumor could with great certainty be ruled out. Severe inflammatory conditions, while demonstrating a generalized reduction in the opacification of the venous system, did not show the bizarre venous wall irregularities seen with tumors. Retroperitoneal fibrosis and its special diagnostic difficulties are discussed.

Renal phlebography in diagnosis of poorly vascularized renal malignancies.

Eight cases are presented to demonstrate the value and limitations of renal phlebography in the diagnosis of poorly vascularized renal malignancies. Because of the easier compressibility of the thinner venous channels, malignant tumors may cause more pronounced phlebographic changes than seen in corresponding arteriographic studies. Changes include venous compression and amputation, tumor thrombus, and venous neovascularity. It is believed that the supplementary use of renal phlebography at the same time arteriography is being accomplished may increase the chances of preoperatively diagnosing such hypovascular renal malignancies as papillary-tubular adenocarcinomas, metastatic and necrotic malignancies, and invasive transitional cell carcinomas.

Selective renal phlebography in the diagnosis of renal pelvic and ureteric varices.

4 cases are presented in order to demonstrate the efficacy of renal phlebography in the diagnosis of renal pelvic and ureteric varices. It is believed that this simple procedure should also be used as a supplement to renal angiography in cases of unexplained gross haematuria and/or persistent renal colic.

Carcinoma in the defunctionalized bladder: report of a case and review of the literature.

There are few reports in the literature of carcinoma developing in the post-diversionary bladder. The sixth such case is reported and the pertinent literature is reviewed. All cases of carcinoma in defunctionalized bladders have been associated with chronic inflammation of the bladder and all tumors became apparent within 4 years of diversion. Simple cystectomy at the time of diversion should be considered for patients with a long history of bladder inflammation.

Segmental replacement of the ureter using Sparks' mandrils. An experimental study.

Segmental ureteral replacement with free autogenous fibroelastic Dacron tube grafts in three dogs was unsuccessful during preliminary trials. However, a proliferation of urothelium, smooth muscle, and blood vessels throughout the length of the grafts was demonstrated, providing an encouraging potential for further investigations. Technical refinements are suggested that may provide for improved success with experimental ureteral replacement.

Renal phlebography: an aid in the diagnosis of the absent or non-functioning kidney.

There are clinical situations that may preclude the use of retrograde pyelography and renal arteriography in the differential diagnosis of the absent, dysgenetic and non-functioning kidney. At times these procedures are non-diagnostic. We present 8 cases to demonstrate the efficacy of selective renal phlebography as an aid in the diagnosis of these entities.

Retroperitoneal teratoma.

Retroperitoneal teratoma is the third most common primary retroperitoneal neoplasm of childhood ranking behind neuroblastoma and nephroblastoma. Ten per cent of these tumors are malignant. Two cases of benign retroperitoneal teratoma are reported, and the first description of the angiographic appearance of such a tumor is presented.

Benign fibrous paratesticular tumors.

Utilizing the criteria of Goodwin, a case each of chronic proliferative periorchitis and multiple fibromas of the tunica vaginalis testis causing paratesticular tumors is presented and discussed. Both of these rate processes appear to be distinct and separate clinical entities, although they appear to be similar histologically. With increased awareness by those treating intrascrotal masses, these processes may be correctly recognized and more testes may be salvaged.

Chronically infected and postdiversionary bladders: cytologic and histopathologic study.

Cytologic and histopathologic study of 36 patients demonstrated an 86 to 92 per cent incidence of squamous metaplasia of the bladder among patients with chronically infected bladders and a 64 per cent incidence in patients with postdiversionary bladders left behind. The relationships of infection, inflammation, squamous meetaplasia, and squamous cell carcinoma of the bladder are reviewed. It is postulated that the same carcinogenic factors which induce transitional cell carcinoma might cause squamous cell carcinoma if the epithelium had previously undergone squamous metaplasia.

Chronic seminal vesiculosis. Distressing syndrome with surgical cure.

Six cases in which a symptom complex suggestive of chronic seminal vesicular dysfunction are described. Transvesical seminal vesiculectomy was performed with good results and no disturbance of sexual potency. Seminal vesiculectomy appears to provide a reasonable means for cure of those patients who meet the specific criteria outlined.