Biomedical subjects
Publications and source records attributed to M S Fletcher.
Fifteen hundred consecutive cases of renal and ureteric calculi were treated in an integrated stone centre; 1464 of these were treated by extracorporeal shockwave lithotripsy, percutaneous nephrolithotomy, ureterorenoscopy and ureteroscopic lasertripsy. Only 36 (2.4%) required open surgery.
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One thousand patients underwent extracorporeal shockwave lithotripsy for renal and ureteric calculi at this clinic. An overall success rate of 91.8% was achieved (stone free or less than 2 mm fragments at three months) and for stones measuring 1 cm 96.3%. Lithotripsy produced extremely low morbidity, and no deaths have occurred at the clinic. Patients who had lithotripsy alone had a mean hospital stay of three days and in most instances were able to perform their full range of activities on discharge. Planned combination of lithotripsy with minimally invasive endourological procedures such as percutaneous nephrolithotomy and ureterorenoscopy has allowed us to extend the range of treatable cases to include large stones. Prophylactic use of Double-J ureteric stents in selected cases has reduced the incidence of obstruction by stone fragments after lithotripsy, thereby decreasing morbidity and hospital stay.
The possibilities for treating children with renal stone disease by extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PCNL) have not been widely explored. We report ten children, aged between 5 and 16 years, treated by PCNL, and six children, aged between 6 and 15 years, treated by ESWL alone. A 16-year-old spina bifida child with a staghorn calculus was treated electively by a combination of the two methods. Hospital stay was 3 to 8 days for treatment by PCNL or ESWL, and was only 11 days for the combination treatment. Complete stone clearance was achieved in 12 children followed for 3 months. No significant complications occurred. ESWL and PCNL are suitable methods for the management of renal calculi in children.
Control of significant hematuria by embolization of angiographically demonstrated vascular malformations of the prostatic and membranous urethra is reported in a patient with multiple diffuse superficial hemangiomas.
Extracorporeal shockwave lithotripsy has been shown to be a safe and effective method of treating most upper urinary tract stones. Major complications, although few, include haemorrhage, septicaemia, "Steinstrasse" formation and cardiac arrhythmias. The experience from 600 consecutive cases is reviewed and methods of prevention are discussed.
Open surgery for large or complex renal calculi may be difficult, particularly in patients with recurrent stones, and may require special operative techniques to preserve renal function. With the advent of percutaneous nephrolithotripsy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) new approaches are now available for the treatment of these difficult cases. A review of 67 patients who presented between November 1984 and May 1986 has shown that it was possible to clear large stones in 71% of patients using a combination of PCNL and ESWL. There was no mortality; the morbidity for both procedures was low and was less than when either procedure was used alone for the treatment of complex stones.
Superficial lesions of the glans penis can pose diagnostic difficulties. Plasma cell balanitis is such a condition and it may be confused clinically with erythroplasia of Queyrat. It is unresponsive to topical medication and curable only by circumcision.
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Eighteen patients with a cholangiocarcinoma involving the hilum of the liver, and one patient with a carcinoma of the gall bladder causing obstruction of the common hepatic duct, have been treated with bile drainage using a U-tube (8 patients) or a percutaneous transhepatic catheter (11 patients) followed by internal radiotherapy with 192iridium wire. The median survival is 11 months, and 9 patients (47 per cent) have survived for 12 months or longer. The addition of internal radiotherapy may be beneficial to patients with hilar cholangiocarcinoma causing biliary obstruction in whom bile drainage can be established.
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The delayed clearance of endotoxins in obstructive jaundice may cause renal impairment by inducing renal vasoconstriction and glomerular fibrin deposition as a consequence of intravascular coagulation. As endotoxins activate arachidonic acid metabolism we have examined the effects of selective inhibitors on mortality, plasma TXB2 and 6-oxo-PGF1 alpha production and renal fibrin deposition in rats with obstructive jaundice following endotoxin administration. Jaundiced rats had a high mortality following endotoxin--58 per cent at 4 h and 83 per cent at 24 h. Pretreatment with indomethacin 3 mg/kg i.p., dazoxiben 3 mg i.p. or prostacyclin 300 ng/kg i.v. produced significant improvements in survival. Endotoxaemia was associated with significant elevations of plasma TXB2 and early inhibition of plasma 6-oxo-PGF1 alpha generation. Renal fibrin deposition, assessed using indirect immunofluorescence and a 125I-labelled fibrinogen uptake ratio, occurred in jaundiced kidneys following endotoxin and could be prevented using indomethacin, dazoxiben and prostacylin. These results suggest that endotoxin-induced TXA2 production can cause renal fibrin deposition in obstructive jaundice, thus contributing in the pathogenesis of the renal impairment.
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The long term results of 28 interposition mesocaval shunts performed between 1971 and 1975 are analysed over a follow-up period of 5-9 years. There were 6 emergency operations and 22 elective operations, with an overall operative mortality of 14.3 per cent and a 5-year survival for the complete series of 31.5 per cent (class A patients 55.5 per cent, class B 33 per cent and class C 0 per cent). Shunt patency at 7 months was 95 per cent but by 5 years this had fallen to 53 per cent. Further variceal bleeding occurred in 6 patients (31.5 per cent) in 4 of whom shunt occlusion was confirmed.
In a retrospective review of 81 patients with renal carcinoma 34 (42%) had abnormalities of one or more liver function tests. Fifteen patients (18.5%) had abnormalities of 3 or more liver function tests but without evidence of hepatic metastases. There was a significant association between these patients and the presence of fever, anaemia, weight loss and a raised ESR (P less than 0.001) compared with those whose liver function was normal. Following nephrectomy, liver function returned to normal in 5 patients. Median survival in these patients was 35 months, whilst in those whose liver function remained abnormal the median survival was 8 months (P less than 0.01).
The cause of haemospermia was determined in 70 (86%) of 81 patients. Inflammatory lesions accounted for the bleeding in most men under 30 years of age. Neoplasia (6), trauma (3) and amyloidosis (2) of the seminal vesicle were diagnosed in the other patients. Persistent haemospermia should always be investigated since clinically unsuspected tumours may be the source of bleeding in the older age groups. Analysis of the semen, prostatic fluid and urine should be performed initially. Cystourethroscopy should then be carried out if the initial investigations are negative and, if this too is negative, vasography is indicated.