Biomedical subjects
Publications and source records attributed to R H Comisarow.
We report a unique case of renal echinococcal disease. The patient presented with only a left renal pelvic filling defect without hepatic, pulmonary or other renal involvement. Management consisted of successful exploration and removal of the hydatid mass without sacrifice of renal tissue. The pathogenesis, diagnosis and treatment of echinococcal disease are reviewed.
Urethrotomy by direct visualization is highly successful in managing urethral strictures. The authors treated 55 patients by this method between 1978 and 1982. Thirty-four had undergone multiple dilatations previously and their unanimous agreement that visual urethrotomy was less painful and accompanied by fewer complications prompted the authors to use the latter method as the primary treatment in 21 patients, on an outpatient basis. The success rate in these 55 patients was 75%. The failure rate was 7%. The remainder were improved but had recurrent strictures, though less frequently than before visual urethrotomy. Because the procedure can be done on an outpatient basis, with a high success rate and minimal morbidity, the authors conclude that urethrotomy under direct vision should be the standard primary procedure for managing all urethral strictures.
We analyzed the case histories of 31 patients who initially had a diagnosis of seminoma and elevated serum levels of alpha-fetoprotein or human chorionic gonadotropin. We concluded that an elevated alpha-fetoprotein level is firm evidence of the presence of non-seminomatous germ cell tumor and that the patient should be treated accordingly. However, if the level of human chorionic gonadotropin alone is elevated the diagnosis may be either non-seminomatous tumor or seminoma. Patients with seminoma and an elevated level of human chorionic gonadotropin do respond well to radiation therapy if they have low stage disease but if metastatic seminoma is present an elevated human chorionic gonadotropin level appears to be a poor prognostic sign if conventional treatment is given. A plan of treatment is proposed for these patients.
Anticoagulated patients may have a characteristic syndrome of femoral neuropathy from an iliacus muscle hematoma. They may present with urologic signs and symptoms, including groin, flank and thigh pain, groin tenderness, an iliac fossa mass and hematuria. Urography may reveal an enlarged psoas shadow and hydronephrosis from ureteral obstruction. Prompt diagnosis is essential so that early operative decompression of the femoral nerve can be done. The urologist has an important role in the diagnosis and treatment of this syndrome.
A unique case is described of traumatic disruption of an intact collecting system (calices, renal pelvis and ureter) from an intact kidney. Evidence is presented for a congenital weakness at the level of disruption.
The electrohydraulic lithotrite generates high voltage discharges which, in a liquid medium, are converted to hydraulic shock waves capable of fracturing bladder stones. Electrohydraulic litholapaxy was successful in treating 28 of 30 patients with bladder stones. In nine patients other procedures were performed during the same anesthetic. In one patient, a calculus was removed from within a narrow-necked bladder diverticulum. Compared with conventional mechanical lithotripsy with serrated, jawed instruments, electrohydraulic lithotripsy is a safe, easy to learn and effective technique for treating bladder stones.
Current therapy for metastatic non-seminomatous testis tumors is effective but toxic. Careful investigation is needed to select those who need treatment and yet avoid needless toxicity in patients who have no disease. Current radiographic investigations and measurement of two biochemical tumor markers (AFP & BHCG) provided accurate monitoring in 19 patients. Preoperative urography and lymphography correctly predicted the presence or absence of retroperitoneal metastases in 9 of 12 patients but did not show microsocpic metastases in 3. There was good correlation between the clinical, readiographic and biochemical evidence of disease progression and regression. Serial ultrasonography and tumor marker determinations were particularly useful in following asymptomatic abdominal metastases. Radiography and tumor marker determinations each have specific advantages which make them complementary.
Vesical implantation and oral feeding studies in animals raised sufficient suspicion of the carcinogenic propensity of cyclamates to result in their withdrawal from sale throughout the world. The structural similarity to known carcinogens, an effect on human chromosomes in tissue culture and a high carcinogenic potential when combined with non-injurious co-carcinogens gave further support to this ban. On the other hand, numerous epidemiological studies failed to support any statistical relationship between cyclamate ingestion and vesical carcinoma in man. Three patients are described in whom vesical carcinoma developed after a prolonged period of ingestion of an unusually high amount of cyclamate sweetener. Moreover, the severity of the disease appeared to be proportional to the dose ingested. Although this is not a conclusive indictment of the role of cyclamates we believe that patients with bladder cancer should be questioned about intake of cyclamates either directly or in diet soft drinks.
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Patients with prune belly syndrome present a spectrum of abnormality, both in the abdominal wall and the urinary tract. Ureteral pathology has characteristic features and the ureter may be more severely involved at the bladder end than in its upper portion. Early neonatal investigation is required to determine which patient can be treated in a conservative manner and which require neonatal reconstruction or temporary vesical or upper tract drainage.
Prognosis has been poor for patients with retroperitoneal metastases from non-seminomatous testis tumors that are initially unresectable and persist after chemotherapy and irradiation or those that recur after initial lymphadenectomy. Eleven such patients have had re-explorations at our center and are described herein. In 4 patients only histologically benign teratoma and/or fibrosis was found. Therefore, the presence of a retroperitoneal mass in these circumstances does not necessarily mean that malignant tissue was present. The procedure provided an accurate diagnosis in all patients and permitted the elimination or reduction of subsequent chemotherapy or radiation in 4 patients who had no tumor. In addition, 5 of 7 patients with symptoms caused by bulky masses were improved and 3 patients with unresectable disease had radiopaque markers placed to facilitate subsequent radiotherapy. The operation was often difficult because of retroperitoneal adhesions from previous treatment but there was no significant morbidity and no mortality. Nine patients have survived from 6 months to 4 years and 7 have no evidence of disease. Two patients died of recurrent tumor 2 and 9 months after re-exploration. A good prognosis was indicated if the mass found at re-exploration was completely resectable and contained only histologically benign teratoma and/or fibrous tissue. We believe that re-exploration should be considered for selected patients with testis tumors who have 1) a retroperitoneal mass that appears after initial lymphadenectomy and persists after interval chemotherapy or radiation therapy and 2) retroperitoneal metastases that are initially unresectable and persist after subsequent chemotherapy or radiation therapy.
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