Bladder hernias.

Six cases of bladder herniation are reported: 4 were associated with inguinal hernias, and 2 were situated in the lower midabdomen. In 1 patient a gangrenous intrascrotal ruptured bladder was found. In most instances simple fascial closure after reduction of the herniation sufficed for treatment. Bladder involvement in any low abdominal wall hernia should be suspected since failure to do so may lead to postoperative complications.

Treatment of postoperative ureteral stricture by catheter dilation: a forgotten procedure.

Some postoperative ureteral strictures can be managed successfully by simple catheter dilations as shown in the cases presented herein. It appears that only one or two dilations may be necessary for prolonged resolution of the obstructive process. Internal ureteral splints may be used with equally good results. Operating intervention should be reserved for those cases in which either ureteral catheterization cannot be accomplished or dense fibrosis renders adequate long-term management by catheter dilation impossible.

Hypoplasia of urinary bladder.

Three female patients with hypoplasia of the urinary bladder and associated congenital anomalies are described. All were first seen in early infancy with significant obstructive uropathy and were managed by early loop cutaneous ureterostomy. All have survived to adulthood and 2 patients have received a kidney transplant into an ileal conduit; 1 patient continues to do well with cutaneous ureterostomy only. Pathogenesis, management, and long-term outcome are discussed.

Application of smooth Teflon clip to inferior vena cava during radical cystectomy to prevent postoperative pulmonary embolism.

Between 1976-1986, a smooth Teflon clip was applied to the inferior vena cava of 56 patients who underwent radical cystectomy for bladder cancer. The purpose of the clip is to narrow the lumen of the inferior vena cava so that large emboli will be trapped and thus prevented from reaching the lungs. These 56 patients were compared with a group of 26 historical controls who underwent radical cystectomy without application of such a clip between 1967-1976. One patient (1.8%) whose vena cava was clipped had a pulmonary embolus which was fatal. Four (15.4%) of the 26 control patients had postoperative pulmonary emboli, the embolic event being fatal in 3 (11.5%). Application of the smooth Teflon clip to the inferior vena cava significantly lessens the incidence of pulmonary embolism following radical cystectomy.

Vasovasostomy. Experimental comparative study of polyglycolic acid and polypropylene sutures in the dog.

Experimental vasovasostomy in dogs using polyethylene tubing for splints and comparing polyglycolic acid to polypropylene sutures demonstrates the following: Polyglycolic acid sutures result in a higher vasovasostomy patency rate. Grossly and microscopically, polyglycolic acid sutures are associated with less vasal and perivasal fibrosis. Postoperative use of very small polyethylene tubing for splints appears feasible. Leaving splints entirely intraluminally at the time of surgery may be advantageous. It would necessitate vasotomy for removal of the splint postoperatively, but this is easily accomplished and not associated with increased morbidity. A transscrotal approach is associated with a much higher vasal patency rate than is an inguinal approach.

Splinted vasovasostomy. Comparison of polyglycolic acid and polypropylene sutures.

An experimental study was performed comparing 6-0 polypropylene and 6-0 polyglycolic acid sutures in vasovasostomy. An indwelling entirely intraluminal splint of PE-10 tubing was used which was surgically removed three weeks postoperatively. Three months after vasovasostomy patency was determined by vasography. Eighty-five per cent patency was achieved with polyglycolic acid compared with 58 per cent patency when polypropylene was used.

Subcutaneous estradiol pellet implantation in management of advanced prostatic carcinoma.

Thirty patients with previously untreated Stage C and D carcinoma of the prostate were treated with subcutaneously implanted estradiol pellets in an effort to determine the efficacy of this mode of therapy in the control of advanced prostatic carcinoma. Serum levels of gonadotropins, testosterone, and estradiol were obtained prior to institution of therapy and at monthly intervals thereafter. Twenty-eight patients were followed for at least one year. Sixteen patients were hormonally castrate at six months following 1-pellet implantation. In these 16 patients the means serum testosterone level was 43.6 ng./dl. with a serum luteinizing hormone (LH) of 13.3 mlU/ml. and a serum estradiol of 19.2 ng./dl. Twenty-two patients were hormonally castrate at twelve months following 1 or more pellet implantations. In this group the mean serum testosterone level was 51.5 ng./dl. with a serum LH of 16.2 mlU/ml. and a serum estradiol of 22 ng./dl. Fifteen patients who were taking narcotics for pain relief either became pain free or had a marked decrease in need for analgesics. Increased weight improvement in over-all well-being was noted in 86 per cent of patients. pellet implantation intervals ranged from four to ten months, with a mean interval of 5.85 months between implantations. Complications attributable to this mode of therapy were no more apparent than with oral estrogens. In addition to better compliance, subcutaneously implanted estrogen pellets appear to provide a safe, reliable, and effective method of tumor control and palliation in advanced carcinoma of the prostate.

Suction device therapy in the management of erectile impotence.

The ErecAid System is based on the simple concept of entrapment of blood in the penis following vacuum-assisted penile engorgement by proximally placed elastic constriction bands. The SYNERGIST Erection System is a semirigid external appliance shaped like a condom that is left on the penis after vacuum tumescence has been achieved. Both devices can be used safely by any man who feels that he has an impotence problem, and the outcome is fairly predictable. These devices seem to be especially effective in men with partial impotence, and they offer the impotent man an alternative to surgical placement of penile prosthesis, a surgical revascularization procedure, intracavernosal injection of vasoactive drugs, or sexual abstinence. These devices appear to be safe and relatively inexpensive ways for the impotent man to make his penis rigid enough to engage in sexual intercourse. An impotent man who selects suction-device therapy may still be able to use other forms of treatment should he need or choose it.

Cryptorchism and approaches to its surgical management.

About 1 in 200 boys has cryptorchism, and orchiopexy remains the cornerstone of therapy. Inguinal orchiopexy is adequate for the palpable or low-lying testicle. The midline preperitoneal approach is particularly good for the high testicle, and it permits simultaneous orchiopexy in most instances of bilateral cryptorchism. For the very high testicle, microsurgical autotransplantation offers hope for functional and anatomic salvage.

Transvesical prostatic adenomectomy: a modification of Lower, Harris, and Hryntschak techniques.

A review of 226 transvesical prostatic adenomectomies performed by a modification of Hryntschak's technique over a 13-year span is presented. The technique incorporates closure of the vesical neck with transverse sutures of 2-0 plain catgut around a plastic Foley catheter and primary closure of the cystotomy following routine adenoma enucleation. Hemostatic suturing of the posterior vesical neck before placement of the transverse vesical neck sutures is routinely omitted. The results have been uniformly good with low incidence of mortality and morbidity. The average operative blood loss was 761 ml and postoperative bleeding was minimal. This technique is safe, simple and requires an acceptable operating time.

The Pyrah technique for ileal loop diversion: experience with 100 cases.

One hundred patients underwent ileal loop diversion using the Pyrah technique between 1959 and 1975. Sixty-seven were performed because of benign urinary tract lesions and 33 were performed as part of planned treatment of various malignant conditions. Neurogenic bladder dysfunction accounted for 56 of these diversions. There were 67 early and 69 late complications. Patients having preoperative irradiation therapy had a much higher incidence of complications. An alarming 19 per cent demonstrated progressive deterioration of the upper tracts following diversion. It is noteworthy that this rate of upper tract deterioration compares favorably with that reported in several other series. Early mortality was 6 per cent, and death occurred four times more often in patients with malignant conditions.

The midline preperitoneal approach to orchiopexy.

The midline preperitoneal approach has been used to facilitate delivery of 42 high undescended testicles into a suitable scrotal position. The gonads were situated preoperatively either within the abdomen (59.5%) or in a high inguinal position (40.5%). The technique described here has allowed marked lengthening of the spermatic cord and visibly shortened the distance between the spermatic vessel-great vessel juncture and the most dependent portion of the scrotum. It has virtually eliminated the necessity for staged orchiopexy in patients with heretofore difficult to manage cryptorchism. In this series an overall satisfactory anatomic result was achieved in 76.9 per cent of patients.

In situ dissection of cadaver kidneys.

Major anatomic injuries occurred in 18 of 151 (12%) en bloc kidneys. No injuries occurred among the in situ kidneys. The rates of delayed graft function were equal. All the kidneys removed by the in situ method were removed by one surgeon (ALH). The results are good enough to recommend the technique even without a randomized study.

Cytologic detection of urothelial cancer and other abnormalities in a cohort of workers exposed to aromatic amines.

A total of 541 members of a cohort at increased risk for occupational bladder cancer underwent a 33-month program of screening with urine cytology. Selected workers received further urologic study with cystoscopy and bladder biopsies. Eight workers had positive or suspicious cytologic findings. Only one of the eight had a prior history of bladder cancer. Biopsies showed invasive carcinoma and/or nonpapillary carcinoma in situ in five workers in this group, severe atypia in one, and no significant abnormality in two. Of 56 workers who had atypical cytologic findings, 16 had bladder biopsies, which showed atypia of flat urothelium in 11, nonpapillary carcinoma in situ in one, noninfiltrating papillary carcinoma in one, and no significant abnormality in three. The cytologic detection of urothelial abnormalities often required more than a single specimen. Since the cohort in this study may develop more bladder cancers with the passage of time, continued follow-up is indicated.

The 'acute' scrotum. Lesions that require immediate attention.

An "acute" scrotum may result from an interesting and fairly predictable array of diseases. A good history and physical examination remain paramount in evaluation. Scrotal ultrasonography and testicular radionuclide scanning are important additions to our diagnostic armamentarium and should be used whenever possible. Unfortunately, the equipment and expertise needed to perform these useful examinations are not always readily available. If these tests cannot be done promptly and rapidly, treatment should be instituted without delay. Most lesions that cause an acute scrotum should be treated expeditiously, since careful treatment can greatly reduce patient discomfort, morbidity, and even mortality. Additionally, testicular salvage often depends on early and appropriate management.

Penile lesions: a generalist's guide.

Penile lesions are a discomfiting affliction demanding skillful diagnosis and management by the primary care physician. This article discusses and illustrates 14 common types, delineating characteristics, course, and treatment.