Recovery of glomerular and tubular function in autotransplanted dog kidneys preserved by hypothermic storage or machine perfusion. Relation of initial function to long-term function.

Sixteen male dogs had split renal function studies prior to unilateral nephrectomy and autotransplant. Kidneys were preserved for 24 hr by either simple hypothermic storage in Collins C2 solution (SHS) or machine-perfused (MP) on a Waters machine (MOX 100) with plasmanate perfusate. Renal function studies were repeated at 1 hr and at 7, 14, and 28 days, and the statistical relationship between initial and 1-month function was determined for a number of parameters. All MP kidneys functioned immediately, whereas 1/3 of SHS kidneys had delayed function. Recovery was more rapid in MP kidneys and was essentially complete by 14 days, at which time MP kidneys had higher rates of creatinine clearance and sodium reabsorption. However, by one month 3/7 MP kidneys (P = 0.15 compared with SHS) had lower creatinine clearance rates than at 2 weeks, and para-aminohippurate (PAH) clearance and fractional sodium reabsorption were significantly decreased. During the same period SHS kidneys either showed continued improvement or maintained stable function. Thus, by one month there were no differences between the groups in clearances of creatinine and PAH, plasma creatinine and blood urea nitrogen concentrations, or fractional reabsorption of sodium, potassium, and water. For SHS kidneys, the 1-hr creatinine clearance and the absolute rate of sodium reabsorption were strong predictors of the eventual function of the kidneys at one month (r = 0.93 and r = .83, P less than 0.05, respectively). No such correlations were found in MP kidneys (r = less than .01, P greater than 0.9 for both variables). The data show that MP results in significantly better function early after transplant, but this advantage does not persist, and that SHS kidneys early function is a good predictor of long-term recovery, but this is not true for MP kidneys.

Early indices of warm ischemic damage in autotransplanted canine kidneys preserved by simple hypothermic storage.

After measurement of normal renal function, dog kidneys (n = 52) were subjected to 3, 15, or 30 min of normothermic warm ischemia (WI). After 24 hr of preservation by simple hypothermic storage (SHS) in a modified Collins solution, autotransplant was done and renal function was again measured beginning at 1 hr. Compared with preharvest values, kidneys with minimal (3 min) WI had significantly decreased clearances of creatinine (Cr) and para-aminohippuric acid (PAH), PAH extraction, absolute and fractional Na reabsorption, Na excretion, and urinary Na concentration; no change in urine flow rate or K excretion; and significantly increased fractional excretion of Na, K, and H2O. Compared with minimal WI, 30-min WI produced further significant decreases in clearances of Cr, PAH, and PAH extraction; and further increases in fractional excretion of Na, K, and H2O. Urine flow was also decreased by about half and urine Na concentration rose significantly. Several parameters were very significantly correlated with the length of WI, but the most reliable index was the fractional reabsorption of Na. When several functional parameters were used together, kidneys with significant (30 min) WI prior to preservation could be identified with a high degree of statistical reliability.

Use of labial tissue in repair of urethrovaginal fistula and injury.

Labial flaps were used during the delayed repair of urethrovaginal fistulas and during the immediate repair of an obstetric urethral injury. In two patients, the labial fat pad alone was used. In the third patient, the fat pad and the overlying labial mucosa were rotated to cover the urethral repair. Our favorable results suggest further use of labial tissue in the repair of urethrovaginal fistulas or urethral injury.

Cyclophosphamide-associated carcinoma of urothelium: modalities for prevention.

The relationship between the cyclophosphamide metabolite acrolein and hemorrhagic cystitis is well documented. Its role in inducing bladder cancer is not clear. There are at least 35 cases of cyclophosphamide-associated bladder cancer in the literature to date. We report 3 additional cases of transitional cell carcinoma of the bladder. Literature assessing the relative risk of bladder cancer associated with cyclophosphamide therapy is reviewed as are methods for decreasing the toxic effects on the urothelium of the metabolite acrolein.

Intratesticular papillary mucinous cystadenocarcinoma.

The first case of intratesticular papillary mucinous cystadenocarcinoma is described. The tumor was histopathologically different from other types of papillary carcinoma related to the testicle and is believed to have originated from an intratesticular müllerian duct remnant.

Transpubic repair of vesicourethrovaginal fistula.

A patient with recurrent urinary vaginal fistula involving bladder, bladder neck, and urethra was treated by transpubic approach. This afforded excellent exposure for careful repair of the urologic defects. Difficulty with ambulation during the first few weeks postoperatively may be related to removal of larger segment of pubic bone than is usually reported.

Response of rat testis to localized induced hyperthermia.

A method is presented in which the rat testis is extensively mobilized through a low abdominal incision, but in which its blood supply is carefully preserved. Localized hyperthermia is induced in this mobilized testis by water bath immersion. The tissue temperature is measured during and after immersion by means of a thermocouple inserted into the tissue. The relative sensitivity of spermatogenic tissue to increased temperature is confirmed and the relative resistance of Sertoli and Leydig cells is noted. Minimal or absent inflammatory reaction to thermal destruction of testicular cells is found as long as the tubule is intact. A marked peritesticular inflammatory response is noted when the total testicular tissue is destroyed at the highest temperature tested.

Leydig cell tumor of testis.

In adult patients with Leydig cell tumor of the testis, endocrinologic signs occur in 30 per cent of the cases and often precede the onset of a palpable testicular mass. Gynecomastia is the most common endocrinologic manifestation and probably is due to increased estrogen secretion by the Leydig cells. In the patient with adrenogenital syndrome and testicular enlargement it is difficult to distinguish Leydig cell tumor from adrenal rest hypertrophy. Four patients with Leydig cell tumor and endocrinologic manifestations are discussed; three are adults who presented with gynecomastia and the fourth is a patient with congenital adrenogenital syndrome. In the adult patient inguinal orchiectomy is the treatment of choice, while in the patient with adrenogenital syndrome initial management by high-dose steroid suppression should be attempted prior to testicular exploration.

Prostatic mucinous carcinoma.

Four criteria are proposed for establishing the pathologic diagnosis of prostatic mucinous carcinoma. Twenty-one reported cases of this rare tumor are reviewed, and a new case is presented. The clinical and pathologic features of 16 authentic features of 16 authentic cases are analyzed.

Bilateral cervical transplantation of canine kidneys for study of canine renal preservation.

Bilateral cervical autotransplantation of canine kidneys is described for comparative study of renal preservation techniques. Data are obtained from kidneys preserved by (1) initial intravascular flushing with modified Collins' C3 solution (Ursol) followed by cold storage, and (2) pulsatile perfusion (MOX 100). Preharvest condition of the donor and ischemia times are identical, thus eliminating major sources of potential data variation. Renal function studies performed at periodic intervals demonstrated better initial function for machine preservation but no difference after one to two-month period.

Anterior transperitoneal approach for removal of renal stones.

An anterior transperitoneal approach was used for removal of stones from 15 kidneys in 13 patients. Exposure of the anterior portion of the pelvis was readily accomplished making excellent exposure of the interior of the kidney possible. Minimal urinary drainage was noted postoperatively. The operative procedures done with the patients in the supine position were well tolerated.

Changes in urinary magnesium, citrate, and oxalate levels due to cola consumption.

The serum concentration and urinary excretion of four potential stone constituents: calcium, oxalate, phosphate, and uric acid; and of two potential inhibitors of urinary stone formation, citrate and magnesium, were studied before and during ingestion of a carbonated cola beverage. Four participants, after baseline serum determinations, abstained for forty-eight hours from cola consumption and then attempted to drink 3 quarts per day of cola in the following forty-eight hours. One participant failed to drink more than two quarts per day of cola. In all 4 participants twenty-four-hour urinary excretion of magnesium decreased by an average of 2.6 mg. In the 3 participants who succeeded in drinking 3 quarts of cola per day, twenty-four-hour urinary excretion of oxalate increased an average of 8.3 mg and excretion of citrate decreased an average of 122 mg. These results demonstrate changes in urine constituents which could contribute to enhanced kidney stone formation in patients who drink large quantities of cola-flavored carbonated beverages.

Wallace method of ureteroileal anastomosis.

The Wallace technique for ureteroileal anastomosis was used in 28 consecutive patients requiring urinary diversion. Details of the surgical technique are reported. The method is found to be appropriate for children and adults, for primary ureteroileal anastomosis, or for revision of previous ureteroileal anastomosis done by other techniques, and for patients with one or two ureters. Its continued use appears to be indicated.

Cadaver donor nephrectomy.

Optimal preservation of renal and ureteral structure and function is attempted by maintenance of renal circulation during heart-beating cadaver nephrectomy. Modifications of Ackermann's en bloc procedure for removal of cadaver kidneys are suggested to adapt this procedure to the heart-beating cadaver situation.

Percutaneous kidney biopsies. Complications and their management.

Six hundred thirty-two percutaneous renal biopsies were performed in 479 patients between 1965 and 1978. Complications occurred with 86 biopsies, an incidence of 8.5 per cent. Most complications (seventy-six of eighty-six) were minor, and either resolved spontaneously or did not require intervention. There were ten major complications, including 6 patients with gross hematuria requiring blood transfusions, 3 with hemorrhage treated with arterial embolization, and 1 with a symptomatic arteriovenous fistula that was treated with partial nephrectomy. Major complications of percutaneous renal biopsy and the modes of therapy are discussed.

Simplified new approach to endoscopic photography.

Information obtained by endoscopic examination can be shared with others by viewing sequentially through the same endoscope, "teaching attachments" allowing viewing ports through the same instrument, drawings based on the observers' recollection of the findings, and by endoscopic photography. Of these methods, endoscopic photography has the important advantages of speed and faithfulness of reproduction. Herein, we describe a simple technique for endoscopic color still-photography with illustrations of normal and pathologic findings.

Ultrasound and spermatogenesis in the rat.

Using exposure conditions comparable to those which have been associated by others with positive results, we tested for effects of ultrasound on sperm production over a period of 12 weeks following treatment. Continuous wave exposure with spatial average intensities of 1, 2 and 4 W/cm2 and exposure times up to 10 minutes were used. In some experiments, the exposures were repeated after an elapsed time of 48 h. No significant changes in spermatogenesis were related to any of the exposure conditions in spite of the fact that some of the treatments caused thermal tissue damage near bone. No effects of exposure were found in weights of the testis, prostate, seminal vesicle, or whole body.

Histomorphologic features of ultrasonic renal injury.

Fifteen-second exposure of rabbit kidneys to 2 MHz focused ultrasound with approximately 900 w/sq cm acoustic power consistently produced localized parenchymal destruction. Evolution of the lesions was followed histologically over a one-year period. The lesions were sharply delineated from outlying renal tissue and had a concentric multizonal structure. Resorption of the damaged tissue with scarring was completed in 6 to 12 months following intermediate phases characterized by cellular infiltration. The lesions are compared to other models of renal injury, particularly with respect to cellular infiltration. A combination of mechanical, thermal, and ischemic factors seem to be responsible for development of ultrasonic lesions. The sharply circumscribed nature and ultimate complete scarring of the lesions suggest the feasibility of ultrasound in achieving selective complete destruction of renal parenchyma.

Twenty-four hour canine renal preservation by pulsatile perfusion, hypothermic storage, and combinations of the two methods.

A comparison of the effectiveness of two renal preservation techniques was studied in 30 cannine renal pairs. In the absence of warm ischemia, 24-hr preservation by pulsatile perfusion was not significantly superior to hypothermic storage. When 15 min of warm ischemia was added as an additional insult, pulsatile perfusion afforded significantly better early function than cold storage. Combinations of pulsatile perfusion and hypothermic storage following 15 min of warm ischemia were superior to hypothermic storage alone, but inferior to pulsatile perfusion. Kidneys initially perfused for 6 hr and then cold-stored functioned slightly better than kidneys perfused for 18 hr after initial cold storage.

Blunt renal trauma in the pediatric patient.

Injury to the kidney from blunt trauma occurs rather frequently in the active, pediatric patient. Early evaluation and treatment of these children is essential in order to preserve maximum renal function. Ninety cases of pediatric renal trauma from blunt injury have been reviewed. The majority of these responded well to careful conservative, non-operative management. Many of those requiring surgical intervention responded well to initial conservative treatment followed by surgical intervention conducted as an elective procedure within the first week after injury. Five case reports with associated radiographic studies are presented.