Biomedical subjects
Publications and source records attributed to G W Drach.
We report 4 cases of anastomotic stricture after radical retropubic prostatectomy caused by erosion of suture material used to ligate the dorsal vein complex. In 2 patients there was overlying stone formation. The clinical features of this complication, management options, and means of prevention are reviewed.
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Emphysematous cystitis is an uncommon condition in which pockets of gas are formed in and around the bladder wall by gas-forming organisms. Persons with diabetes, neurogenic bladder and chronic urinary infection are predisposed to the disease. Severity of illness ranges from an asymptomatic condition to life-threatening cystitis. We present 2 cases of emphysematous cystitis. One case was an incidental finding on evaluation of abdominal discomfort with resolution upon removal of predisposing factors. The other patient presented with an acute abdomen that progressed to severe necrotizing cystitis ultimately requiring cystectomy. The initial involvement of the urologist as a consultant is emphasized. A complete review of the literature describes the incidence, various presentations, associated diseases and organisms, pathogenesis, and available methods for diagnosis and treatment reported for this disease. Successful management depends on early diagnosis with correction of underlying causes, administration of appropriate antibiotics, establishment of adequate bladder drainage and surgical excision of involved tissue when required. Early detection and prompt treatment are encouraged.
The locations of extracorporeal shock wave treatment induced renal vascular injury and the sources of significant renal hemorrhage were determined in a rat model by means of two different vascular casting procedures. Silicone-rubber injected vascular preparations for light microscopy or corrosion casts for scanning electron microscopy were made following gross examination of the treated organs and their contralateral controls. After 1000 shock waves at 18 kV, five out of 20 treated kidneys appeared to be normal or minimally affected, while 15 showed gross evidence of marked vascular injury. Gross interstitial hemorrhage (15/20), subcapsular hematomas (7/20), and hemorrhages into the renal pelvis (5/20) were confirmed by extravasations of casting materials. These could be traced back to their vascular sources in several instances. Disruptions of interlobar and arcuate veins gave rise to most significant interstitial, subcapsular, and renal pelvic extravasations. On a microscopic scale cortical venules were among the most frequently injured vessels. The arterial vasculature was not spared. Arterial injury ranged from complete arcuate occlusion to small afferent arteriolar and glomerular capillary extravasations. The significance of shock wave induced vascular injury is discussed with respect to potential clinical side effects of ESWL.
We longitudinally followed serum prostate specific antigen (PSA) levels in 48 patients who were treated with either orchiectomy, monthly luteinizing hormone-releasing hormone injection or continuous diethylstilbestrol for stage D2 prostate adenocarcinoma and achieved an objective response. Of the patients 34 had clinical evidence of disease progression (median remission duration 19 months). Median length of followup for the 14 patients who remained in remission was 42 months. Pretreatment performance status, pretreatment extent of metastases as measured by a bone scan and post-treatment nadir PSA level were univariately correlated with remission duration. After adjustment for the 2 former pretreatment variables, a highly significant independent effect of the nadir PSA level on remission duration persisted. Patients whose post-treatment nadir PSA level decreased below 4 ng./ml. had a significantly longer remission duration than those whose nadir PSA remained elevated (median 42 versus 10 months, p less than 0.0001). No cases were observed to progress (as defined by our criteria independent of PSA level) while the serial post-treatment PSA levels continued to decrease or remained at a plateau after reaching the nadir. The time at which the PSA began to increase once the nadir was reached predated objective evidence of progression in all patients except 2 in whom the 2 events occurred simultaneously (mean lead time 7.3 +/- 5.0 months). We conclude that following serial PSA levels in patients treated with androgen ablation for metastatic prostate cancer can aid in distinguishing favorable from nonfavorable responders early in the course of therapy and greatly assist in monitoring for progression.
The acute scrotum generates a long list of differential diagnoses. An unusual etiology includes insect envenomation, which typically is an acute process with rapid onset of symptomatologies. Two patients with genital envenomation are reported. We review the reported cases at our institution with all types of bites and stings. Symptoms of pain and pruritus, and signs of ecchymosis and edema preceding exfoliating dermatitis were evident in both cases. Mild analgesics and antihistamines promoted resolution in each instance.
A rupture of a large, tense hydrocele is presented. The patient was chronically treated with steroids for asthma control. Scrotal ultrasound was used to document hydrocele presence, rupture and recurrence.
We report 2 cases of nephrolithiasis owing to hematin stones. One patient had no apparent explanation for this finding, while the other was receiving warfarin anticoagulation for a prosthetic aortic valve. The chemical nature, etiology and clinical features of hematin calculi are discussed.
Most publications citing the effectiveness of renal extracorporeal shock wave lithotripsy have used plain abdominal radiography to assess residual calculi after treatment. We compared radiologist sensitivity and specificity in the detection of calculi on plain abdominal radiographs versus conventional film-screen and digital renal tomograms in extracorporeal shock wave lithotripsy patients. Of the patients 50 were imaged before and within 24 hours after lithotripsy. Six radiologists evaluated the resultant 300 studies for the presence and location of calculi. The mean sensitivity for digital tomograms was 83% for pre-lithotripsy and post-lithotripsy studies, which was significantly higher than for plain abdominal radiography and conventional tomography after lithotripsy. However, there were significantly more false positive stone diagnoses associated with digital tomogram interpretation. Signal detection analysis verified the over-all superiority of digital tomography for post-extracorporeal shock wave lithotripsy imaging. Calculus detection by conventional and digital tomography is superior to detection by plain abdominal radiography. However, because we did not perform delayed imaging, it is not possible to say what impact digital tomography might have on the management of extracorporeal shock wave lithotripsy patients.
Patients with cardiac pacemakers currently are treated by extracorporeal shock wave lithotripsy only by agreement between individual physicians and patients. We present the results of a survey of patterns of extracorporeal shock wave lithotripsy treatment (or nontreatment) of patients with pacemakers in the United States and Europe. Letters of inquiry regarding treatment of pacemaker patients were sent to 141 United States extracorporeal shock wave lithotripsy sites and 55 sites in Europe. Responses were received from 81 (57%) and 17 (31%) sites, respectively. A total of 131 patients received 142 treatments and pacemaker-related complications occurred in 4 (none was lethal, 3 were minor and all were corrected immediately). No patient required replacement of the pacemaker. No correlation existed between complications and pacemaker type or manufacturer. Urologists who treat patients with a pacemaker required previous clearance of the patients by the cardiologist, a cardiologist in or near the extracorporeal shock wave lithotripsy suite and standby of corrective equipment or temporary pacemakers.
Concerns about the safety of extracorporeal shock wave lithotripsy include the risk of vascular damage and the genesis of hypertension. We evaluated gross specimens and barium microangiograms of the right kidneys of 14 rabbits exposed to shock waves; the untreated left kidneys served as controls. Six rabbits were assessed immediately after shock wave treatment, whereas the other eight rabbits had the same procedure 3 months later. All six acute phase animals showed microangiographic changes indicative of shock wave trauma, including cortical, subcapsular, and medullary extravasation of barium and patchy loss of efferent vessels. No significant vascular abnormalities were seen in the control kidneys. All kidneys treated from the animals that had delayed microangiography showed macroscopic evidence of fibrotic capsular thickening and parenchymal scarring. Microscopically, there was crowding of glomeruli and areas of avascularity. In this model, shock waves damaged the cortical circulation and resulted in persistent alterations of the microvasculature that potentially could be responsible for the abnormal secretion of renin.
Since the inception of extracorporeal shock wave lithotripsy 9 years ago treatment strategies have changed. Patients currently are receiving larger numbers of higher voltage shock waves. However, upper limits of safety for these treatments have not been established. In an attempt to address this question a comparative study of effects of extracorporeal shock wave lithotripsy on laboratory values between 2 stone centers, Munich and Tucson, using different treatment strategies 3 to 4 years apart was done to identify possible differing effects. Patient stone burdens were similar. However, Tucson patients received almost twice the number of shock waves. Both groups showed a significant decrease in hematocrit (by 8.7 per cent in Munich and 6.4 per cent in Tucson). Both groups had a significant increase in white blood count (14.5 per cent in Munich and 22.7 per cent in Tucson). In addition, both groups had increased serum levels of glutamic oxaloacetic transaminase of 43.3 and 59.7 per cent, respectively. However, only the Tucson group showed increases in serum glutamic pyruvic transaminase, lactic dehydrogenase and total bilirubin in 51.5, 40.8 and 46 per cent of the patients, respectively. Further analysis indicated that extracorporeal shock wave lithotripsy was associated with 2 significant short-term changes of blood or serum laboratory values: 1) those presumed to be dilutional from related infusions, rather than extracorporeal shock wave lithotripsy treatments themselves and 2) those presumed to be related to cellular injury after high energy treatments. Elevated serum glutamic pyruvic transaminase, lactic dehydrogenase and total bilirubin values of Tucson patients clearly were related to higher kilovolts and number of shocks or to treatments on the right side.(ABSTRACT TRUNCATED AT 250 WORDS)
Urinary stones usually require surgical therapy because of impaction, associated infection, unremitting pain or economic hardship created by the presence of the stone. During the last 100 years stones of the kidneys and ureters have overtaken bladder calculi in incidence and importance. In a pattern that parallels development of therapy of bladder stones, surgical treatment of upper urinary tract stones has progressed rapidly through development of safer open operations to percutaneous manipulative procedures to minimally invasive extracorporeal shock wave lithotripsy. Each of these progressions contributed to a significant decrease in immediate morbidity, although therapeutic results remained similar. However, some deficiencies in our data about long-term problems with extracorporeal shock wave lithotripsy exist, including effects on renal function, effects on surrounding organs and development of new hypertension. A most important question that still must be answered is whether the apparent low morbidity associated with extracorporeal shock wave lithotripsy obviates the necessity for medical prophylaxis of urinary stone disease.
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An animal model was developed to investigate the effect of extracorporeal shock wave lithotripsy (ESWL) on a normal kidney. Rabbits were treated with 3,000 shock waves at 18 kV to each kidney. Blood and urine samples were collected daily before and after shock wave treatment. Serum levels of hemoglobin, creatinine, lactic dehydrogenase (LDH), creatinine phosphokinase (CPK), and total protein were determined. Urine determination of volume, total protein, hemoglobin, and creatinine were also made. All kidneys, after sacrifice, were subjected to histologic analysis. The average pre-treatment creatinine clearance of our rabbits was 8.3 ml./min. After the treatment, a significant (p less than 0.01) reduction in creatinine clearance was noted for four days. The reduction was to 0.61 ml./min. on day one, 0.87 on day two, 1.04 on day three, and so forth. Urine hemoglobin rose significantly (p less than 0.01) for the first three days from 0.0 to 1.5 gm./dl. Histologic examination at seven days showed focal subcapsular hemorrhage, tubular dilation, and interstitial hemorrhage. Histologic evaluation at two months revealed focal interstitial fibrosis. In conclusion, this study reveals that shock waves to the kidney have short term physiologic effects on renal function and permanent focal histologic effects, which do not effect long term physiologic function. Further research on the effects of ESWL on renal function and structure could be facilitated with the use of this model.
Based on the experience with the Dornier HM-3 lithotripter, the author analyzes herein the adverse effects caused by extracorporeal shock wave lithotripsy. Although admittedly empirical, an attempt is made to establish the number of shock waves and pressure required to achieve stone fragmentation without causing injury to the kidney. The effects of lung, stomach, colon, and skin or muscle contusions, hematoma, renal scarification, decreases in renal function, elevations in liver enzymes, and pancreatitis are reported, as well as systemic effects such as hemoglobinemia and hemoglobinuria, hearing change, and potential excessive radiation exposure, etc. The estimate of shock wave energy is discussed, highlighting the importance of the number of shock waves over the energy of the shock wave, and attention is focussed on the concept of stone fragility. Although we can nearly define the upper limits of energy related to safety, the author concludes that currently many questions remain unanswered.
Current therapy for urolithiasis patients includes instructions to increase water intake and 24-hour urine output. Previous studies have measured changes in the 24-hour urine volume to evaluate the efficacy of fluid therapy in each patient. We used paper test strips to monitor urine pH and specific gravity in 22 of our stone clinic patients: 10 were instructed to increase water intake just before the study (group 1) and 12 were not so instructed (group 2). Mean specific gravities of 1.0222 (1.0238 corrected for pH) for group 1 and 1.0197 (1.0220 corrected for pH) for group 2 did not differ significantly. Urine specific gravities also were compared for 3 intervals: 1 to 9 a.m., 9 a.m. to 5 p.m. and 5 p.m. to 1 a.m. Of the 22 patients 10 (3 from group 1 and 7 from group 2) had significant diurnal variations in the urine specific gravities, corrected and uncorrected, among these 3 periods. In addition, both groups had a significantly higher mean specific gravity from 1 to 9 a.m. (1.0234 uncorrected and 1.0248 corrected) than from 9 a.m. to 5 p.m. (1.0194 uncorrected and 1.0218 corrected). The 5 p.m. to 1 a.m. (mean of 1.0220 uncorrected and 1.0239 corrected) specific gravity did not differ significantly in either group. If 1.015 is the highest acceptable specific gravity of urine in stone patients, the findings suggest inadequate dilution of urine in these patients, whether or not they were instructed to increase water intake. Also, the significant diurnal variation in urine specific gravity would allow a nighttime triggering event at these hours of higher urine concentration.