Chiang Cp

Percutaneous Drainage in the Treatment of Emphysematous Pyelonephritis: 10-Year Experience

PURPOSE We investigated the effect of percutaneous drainage for the treatment of emphysematous pyelonephritis. MATERIALS AND METHODS A retrospective analysis was done of 25 patients with emphysematous pyelonephritis who were treated initially with computerized tomography (CT) guided percutaneous drainage during a 10-year period. The patients were concomitantly treated with antibiotics, fluids, and correcting blood glucose and/or ureteral obstruction. We also compared our results of percutaneous drainage to CT findings. RESULTS CT identified 12 patients with emphysematous pyelonephritis who had gas with little fluid and 13 who had gas with renal or perirenal fluid collections. In 20 of 25 patients (80%) antibiotic therapy combined with percutaneous drainage constituted the only treatment required. Three patients (12%) whose clinical status improved after percutaneous drainage subsequently underwent elective nephrectomy without further complications. Two patients (8%) died of multiple organ failure. There was no correlation between the gas patterns of emphysematous pyelonephritis and initial success with the antibiotics and percutaneous drainage. There were no recurrences and no complications during a followup of 1 to 10 years (mean 5). Mean duration of treatment was 5.54 weeks (range 1 to 12.6). CONCLUSIONS CT is an efficient imaging method for diagnosis, guiding the drainage procedures and monitoring response to percutaneous drainage of emphysematous pyelonephritis. Antibiotic therapy combined with CT guided percutaneous drainage of emphysematous pyelonephritis is an acceptable alternative to antibiotic therapy with surgical intervention.

Study of the changes in collagen of the tunica albuginea in venogenic impotence and Peyronie's disease.

We identified the collagen type and content of the tunica albuginea in Peyronies disease and venogenic impotence compared with the tunica albuginea from the donor of the renal transplant and patients with penile injury. Type III collagen was detected obviously in Peyronies plaque and was also present in venogenic impotence. It can be hardly found in normal controls. The ratios of type III to type I collagen were significantly higher in Peyronies plaque while there was a moderate increase in venogenic impotence. The scarcity of type V collagen was noted in human tunica albuginea. The decreased percentage of glycine and alanine in Peyronies disease and venogenic impotence implied the abnormal composition of collagen or presence of noncollagen protein. The results suggest the biochemical aberration of the tunica albuginea might interfere with the normal function of the penile drainage system.

Experiences in the treatment of chyluria in Taiwan.

From 1967 through 1986, 55 patients with chyluria were treated by renal pelvic instillation of 10 ml. 0.5% silver nitrate solution and surgical disconnection of the renal pedicle lymphatics was done in 9 (16.3%) due to persistent chyluria after instillation therapy. Among these 46 renal pelvic instillation patients and 9 operated patients followed for 2 years chyluria recurred in 11 (22.7%) and 5 (55.5%), respectively. Renal pelvic instillation is a safe and effective method to treat chyluria.

Comparison of the effects of papaverine versus prostaglandin E1 on penile blood flow by color duplex sonography.

To compare the effects of papaverine (60 mg) and prostaglandin E1 (20 microgram: PGE1) on penile blood flow, the vascular response detected with color duplex ultrasound scanning and the clinical response in 34 impotent men were observed and recorded after they had received an intracorporeal injection of the respective drugs on separate days. The results demonstrate that PGE1 has the advantage of a slower onset, longer maintenance, less chance of priapism and is at least as effective as papaverine in inducing an increment of penile blood flow. In conclusion, PGE1 may be a better alternative to papaverine in the diagnosis and treatment of impotence.

Nerve - Sparing Radical Cystoprostatectomy: 3 - Year Experience

From June 1993 through January 1996, ten men underwent nerve-sparing radical cystoprostatectomy for carcinoma of the bladder. We describe a modification of surgical technique in which the puboprostatic ligaments are left intact and dissection of neurovascular bundle is performed immediately after the ligation of dorsal vein complex. Rigiscan was performed in 7 patients and 4 patients had good rigidity. Color duplex sonography revealed 8 of 10 patients had peak systolic velocity over 30 cm/sec after the injection of prostaglandin E1. Maintenance of sexual function was stated by seven (70%) patients. These is no positive surgical margin. We conclude that the nerve-sparing modifications are possible to preserve potency in most men undergoing radical cystoprostatectomy and do not compromise cancer control.

The gastroileal neobladder for renal insufficiency.

A major contraindication to continent urinary diversion is poor renal function and a contraindication to bladder substitution with an ileal neobladder is creatinine level greater than 2.5 mg.ldl.1 Patients with serum creatinine greater than 1.5 mg./dl. have not been considered good candidates for a rectosigmoid pouch.2 We report presemation of renal function in a patient with renal compromise using a reservoir that incorporated gastric and ileal segments. Our preliminary results show that the gastroileal neobladder may be an alternative method of urinary diversion in the presence of poor renal function when it is believed that the ileocolonic segment cannot be used. CASE REPORT

Recent Experience of Penile Fracture (1989-1993)

Penile fracture is an uncommon injury in the genitourinary organ which occurs following a blunt injury on the rigid penis. Penile fracture with urethral injury is even rarer. A total of 11 new patients with penile fracture were treated at our institution from 1989 to 1993. All of these injuries occurred during sexual intercourse and received immediate surgical repair to preserve the sexual function. Only one patient with complete transection of the urethra received end-to-end anastomosis of the urethra. Unfortunately, he suffered from urethral-cutaneous fistula ten days later. Suprapubic urinary diversion was performed in 3 patients with partial urethral tearing, and they enjoyed satisfactory outcomes during the limited follow-up. Immediate surgical repair of tunica albuginea is recommended for preserving penile function. If associated with partial urethral tear, suprapubic urinary diversion is sufficient to treat urethral lesions.

Experience in the morbidity associated with double-J catheter indwelling and its management.

Placement of internal ureteral stents for internal urinary diversion and prevention of urological complications has been well established. However, indwelling stents have occasionally been associated with patient morbidity and intolerance. A total of 255 patients while the internal ureteral stent had been used were analyzed. The symptoms including urinary frequency (42.0%), hematuria (41.6%) and suprapubic pain (20.4%), loin pain (17.3%) and micturition pain (16.9%) accounted for the major complaints of the stent indwelling patients. The major complications, i.e. stent migration, heavy encrustation, pyelonephritis, fragmentation, intolerance and penetration of collecting structure, were occasionally observed. These complications increase secondary morbidity in patients. The double-J stents should be used carefully with regard to the prevention and treatment of untoward conditions as early as possible.

A Comparative Study with Intracavernous Injection of Prostaglandin E1 versus Papaverine for the Diagnostic Assessment of Erectile Impotence

The intracavernous injection of vasoactive drugs is a valuable diagnostic aid and an important tool for the treatment of erectile failure. A comparative study with intracavernous injection of prostaglandin E1 (PGE1) and papaverine was performed in 60 patients with impotence. We evaluated the efficiency and side effects of both agents. The overall positive response rate was 85.0% in the PGE1 group and 65.0% in the papaverine group which suggests PGE1 has a stronger vascular effect. The mean onset of maximal erection was after 9.6 minutes in the PGE1 group and after 6.5 minutes in the papaverine group. The mean maintenance of erection was for 53.2 minutes in the PGE1 group and for 38.6 minutes in the papaverine group. There were no systemic side effects of either agent. Three instances of injection pain and 2 of burning sensation in the penis were noted in the PGE1 group, while in the papaverine group, there were 21 reports of injection pain, 4 of prolonged erection and 2 of burning sensation in the penis. These results suggest that PGE1 is a more desirable vasoactive alternative for the diagnosis of impotence.

The experiences of rectosigmoid pouch as a continent urinary diversion after radical cystectomy.

Thirty-five patients receiving cystectomy underwent rectosigmoid pouch. The technique of ureteral submucous implantation was described. The follow-up results were analyzed. The relationship of postoperative voiding frequency and preoperative anal closure pressure was assessed. The day and night time continence rate is 97% (34/35). There were no hydronephrosis, no ureterocolonic stricture or reflux. The complications are not unique to rectosigmoid pouch and not high when compared with other forms of urinary diversion. When the preoperative anal closure pressure reaches nearly 100 cmH2O a postoperative outcome with good quality of life will be predicted. With the advantages of high continence rate and simplicity of performance the rectosigmoid pouch will become one of the alternative forms of continent urinary diversion. For obtaining the favorable results a patient with normal renal function, good hepatic function and anal closure pressure more than 50 cmH2O is required.