Biomedical subjects
Publications and source records attributed to J K Lattimer.
Life-table techniques demonstrate a 98% ten-year survival, a 96% 20-year survival, and 91% 35-year survival of children with exstrophy of the bladder. These figures represent a vast improvement over the earlier figures, due in large part to technical advances that have been made in areas of surgery, anesthesia, and antibacterial and metabolic therapy.
Early attempts at orchiopexy should be avoided in children with exstrophy, since the testes will often descend spontaneously by puberty. In many cases the scrotum will grow much larger and will become pendulous by puberty. In a patient with a rudimentary scrotum orchiopexy will only result in fixing the testes in an abnormally high position owing to the lack of a sac into which to place them. If the scrotum develops later the testicles will probably be unable to descend further. Scrotal skin should not be used for urethroplasty operations in children with exstrophy and special techniques should be applied if it is necessary to repair hernias in these patients. In the child with partially descended testes but with only a small patch of wrinkled scrotum efforts may be undertaken to increase scrotal size by topical hormone treatment (or by injections) before the onset of puberty to help fertility and emotional development.
The concept of the exstrophy support team is reported. It has extended the care of children with exstrophy into a lifelong continuum of effective assistence, not just by way of medical and surgical interaction but through knowledgeable and sympathetic coordination. There has been a spectacular improvement in over-all lifetime survival and much greater patient interest and appreciation with better followup and maintenance so that we can help quickly and effectively when problems arise. Now that we have achieved an increased longevity for these patients, we must be able to assure them the best possible quality of life.
This paper describes an ongoing program, in a large metropolitan hospital, of weekly group meetings for hospitalized children on the Babies Hospital Urology Service, led by a pediatric psychiatrist and a psychiatric social worker. The purpose of the program is to help children cope with the multitude of fears and anxieties that can arise in the course of hospitalization. Although not described in detail, corollary weekly group meetings are also held with parents of the children. The authors describe the format of their meetings with child patient groups, whose composition is, by its nature, a constantly changing one. Examples are excerpted from typical group sessions, indicating the kinds of problems that surfaced and how they were dealt with. Ways in which group interaction and support contributed to the positive results of such meetings are also shown. The authors suggest that their program can be utilized in a variety of hospital settings.
Patients with ureterosigmoid urinary diversions always have some anal leakage of a malodorous mixture of feces and urine, especially at night or when passing gas. They obtain limited continence only by consciously keeping their buttocks tensed toegher. Their unusually high elimination frequency weds them to a bathroom for the rest of their lives. The universal prevalence of this truly severe burden of liquid fecal incontinence, which a patient is asked to bear after ureterosigmoidostomy diversion, is not well recognized and should be clearly revealed to the patient before a choice of procedure is made.
Comparisons of the bone marrow and serum acid phosphatase values obtained by counterimmunoelectrophoresis and the Roy biochemical test were made in 72 patients with and in 13 patients without prostatic cancer. The counter-immunoelectrophoresis test, when positive at more than 1 international unit per liter, showed only 4.4% falsely positive results. The Roy biochemical test, which uses sodium thymolphthalein monophosphate as the substrate, had 65% falsely positive bone marrow acid phosphatase levels. Conflicting reports regarding the value of bone marrow acid phosphatase determinations in patients with prostatic cancer result from the use of non-specific substrates in biochemical methods for measurement and from the trauma incidental to bone marrow aspiration, which releases many non-prostatic acid phosphatase enzymes. The use of immunoassay such as counter-immunoelectrophoresis minimizes this source of error.
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Little is known about pregnancies in women with bladder exstrophy. Of 28 women with bladder exstrophy who were evaluated 7 became pregnant and 5 delivered successfully. Problems seen during pregnancy, the long-term effects and the need for early, informed counseling by the urologist are discussed.
Now that we have observed the growth and development of 17 of our anatomically reconstructed exstrophy patients through 20 or more years of followup, we are convinced that reconstruction should be the preferred primary treatment. Most of these patients are healthy, attractive, well educated adults and have achieved emotional maturity and stability, despite their many problems. Anatomical reconstruction also has considerable advantages over other current treatments for exstrophy that were not apparent initially.
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Semen analyses from 9 male patients with bladder exstrophy revealed a high incidence of infertility (7 cases). Possible causes and measures that might help to preserve the fertility potential are suggested.
Preoperative bone marrow acid phosphatase determinations were elevated in 18 of 31 patients who underwent radical prostatectomies. A review of the surgical pathology and clinical followup demonstrated a higher incidence of metastasis in these patients.
A review of 159 patients treated by radical retropubic prostatovesiculectomy from 1951 through 1970 has reinforced our belief that this is a satisfactory method of treatment for prostatic cancer confined to the prostate. A 10-year survival of 55 per cent and a 15-year survival of 45 per cent compare well to the results reported for perineal prostatectomy. The postoperative mortality rate was 2.5 per cent and total incontinence was 12.5 per cent after radical retropubic prostatectomy. Completely normal voiding occurred in 108 of the 159 patients. Stress incontinence but no need for an incontinence device occurred in 31 patients. Improved methods for preoperative staging of the disease give promise for even higher cure rates in the future.
The possible activation of immunologic defenses against tumor by local ultrasonic irradiation was investigated. Sonication of one tumor of a dual implant destroyed that tumor only with no contralateral effect. Injection of tumor cells previously sonicated in vivo did not induced immunity to subsequent challenge with live cells. Immunofluorescent staining of host kidneys for antibody complexes was negative. It was concluded that sonication was only effective when directly applied to the tumor.
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