Biomedical subjects
Publications and source records attributed to V Colapinto.
A case of primary amyloidosis of the urethra is described. Although rare, this entity is important since its antecedent causes, clinical symptoms, and panendoscopic and radiographic appearance are similar to and must be differentiated from carcinoma of the urethra. The prognosis of this disorder is excellent, and aggressive therapy is not indicated.
Currently, discrepancies exist in published reports regarding both the site and the extent of the urethral injury in fractured pelvis, as well as in the incidence of the major postoperative complications, namely, stricture and impotence. There is also debate as to the best method of initial treatment of the injury, this is, primary vs. delayed repair. We believe that much of the controversy is the result of inaccurate diagnosis of the site and extent of the initial injury. In the past, diagnosis has depended upon clinical criteria or on the failure of a catheter to traverse the urethra. These methods fail to pinpoint the site of the injury, nor do they tell us whether the rupture is incomplete, partial or complete. Fortunately, much of this information can be obtained by dynamic retrograde urethrography. Using dynamic retrograde urethrography routinely in the initial diagnosis, we have found that: the urethral rupture occurs most often below the urogenital diaphragm rather than above it as is traditionally believed; the patient may have the clinical criteria for complete rupture when his urethra is actually intact or only partially severed; an incomplete or even a small partial rupture may be present in spite of negative clinical criteria. These new concepts have contributed greatly to clarifying current controversies regarding the incidence of posttraumatic stricture and erectile impotence, and will have an influence on surgical techniques in the future. Unfortunately, the value of dynamic retrograde urethrography is not yet common knowledge. Our aim is to convince the orthopedic surgeon, who usually sees the patient first, to postpone urethral catheterization in patients with fractured pelvis until dynamic retrograde urethrography has been done. The technique is simple, takes little time, and requires no special equipment. In a severe emergency it can be done by the attending staff without the help of a radiologist. Ideally, dynamic retrograde urethrography should be obtained in all severe pelvic fractures regardless of the lack of clinical criteria of urethral injury.
Balanitis xerotica obliterans (BXO) is known to affect the urethral meatus, glans, and prepuce. We describe a case of biopsy-proved BXO that involves not only the usual areas but the anterior urethra as well. Of added interest is the subsequent development of squamous cell carcinoma in the fossa navicularis. The literature is reviewed.
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.
Radiological localization of the membranous urethra requires visualization of the whole urethra with dynamic retrograde urethrography and voiding cystourethrography. These methods are described together with a critical analysis of other methods of urethrographic examination, that is static retrograde urethrography alone and voiding urethrography alone. The normal radiological landmarks allowing accurate localization of the membranous urethra are described and correlated with anatomical dissections from 9 autopsy specimens.
We herein outline the radiological and clinical criteria that will aid the surgeon in deciding whether transphincter urethroplasty is required in patients whose primary stricture is in the proximal bulbous urethra. Sinc proximal bulbous urethral strictures are common the urologist frequently is called upon to make this important decision. The criteria described herein will help him to do so and, thus, avoid urethroplasty failure because of proximal stenosis in the membranous urethra. The concept of paradoxical dilatation of the membranous urethra on voiding urethrography also is described. Paradoxical dilatation means that in the presence of a primary obstructive bulbous urethral stricture the membranous urethra, although containing significant scar tissue, is dilated on the voiding study because of the distal obstruction. Relief of the bulbous urethral stricture alone may result in rapid contraction and stenosis of the previously dilated membranous urethra.
The present criteria to diagnose a ruptured posterior urethra in cases of a fractured pelvis do not provide accurate information on the degree and site of the urethral injury. A method of retrograde urethrography in such patients is described and the results obtained in 15 cases are reported. On the basis of these results a new classification of membranous urethral rupture in cases of fractured pelvis is proposed: type 1--the prostate or urogenital diaphragm is dislocated but the membranous urethra is merely stretched and not severed, type 2--the membranous urethra is ruptured above the urogenital diaphragm at the apex of the prostate and type 3--the membranous urethra is ruptured above and below the urogenital diaphragm. The clinical significance of these lesions is discussed and a plea is made for the more widespread use of retrograde urethrography in patients with a suspected posterior urethral rupture.
Most investigators agree that a urethral stricture is a predisposing cause of primary carcinoma of the urethra. The etiology of the carcinoma is probably chronic irritation. The role of squamous metaplasia in the etiology is discussed briefly. A case of primary squamous cell carcinoma of the urethra occurring 4 years after a first stage urethroplasty is reported and 2 cases from the literature are described. The suggested origins of urethral malignancy after urethroplasty are 1) unrecognized malignancy at operation, 2) premalignant mucosal changes that progress postoperatively, 3) recurrence of stricture with continued irritation leading to malignant metaplasia and 4) malignant change in the urethroplasty skin flaps. Although rare, primary male urethral carcinoma is a deadly disease. The hope for early diagnosis is a high index of suspicion during urethroplasty and in subsequent followup studies. The patient presented herein also exhibited pseudohyperparathyroidism as a result of the malignancy.
We reviewed 38 patients treated by an immediate realignment of the urethra after a traumatic rupture by urethrography, panendoscopy and clinical assessment. Of these 38 patients 19 have not required urethral dilatation for 4 years or more and 26 for 2 years or more, thus accomplishing with 1 operation satisfactory urinary tract function without stricture. We believe that an immediate repair offers the best results to patients with minimum surgical procedures insofar as the formation of strictures is concerned. Evaluation of the interference with potency will have to await further study.
Prostatectomy by open or transurethral techniques usually destroys the function of the internal sphincter (bladder neck), which is the first line of defense against incontinence. Urinary continence then depends upon the intrinsic smooth muscle sphincter of the membranous urethra and the striated external sphincter. Unfortunately, a significant incidence of membranous urethral stricture occurs after a prostatic operation. Most such strictures can be managed with periodic dilatation but some are difficult and dangerous to dilate. Complications such as recurrent acute retention, bacteremia, false passages, stone formation, fistulas and so forth are indications for surgical cure of the stricture. However, can urethroplasty of the membranous urethra be carried out in these patients without inevitable incontinence? At our center 33 prostatectomized patients have had a 2-stage urethroplasty for refractory membranous urethral strictures. Nine patients had troublesome stress incontinence after the first-stage operation but only 4 of these had continuing incontinence after the second-stage operation. These patients had been noted to have transient postoperative stress incontinence after the prostatectomy. Although there is a risk of incontinence after urethroplasty of the membranous urethra in prostatectomized patients, the risk is sufficiently low that the operation should not be denied patients with refractory strictures in whom the only alternative eventually will be some form of urinary diversion.
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