J. William McRoberts

Adenovirus-Associated Hemorrhagic Cystitis Treated with Intravenous Ribavirin

Adenovirus hemorrhagic cystitis following bone marrow transplantation occurs in 2 to 16% of the patients. While usually self-limiting, this disease can cause significant morbidity and even mortality in the immunocompromised patient. Risk factors include graft versus host disease and pre-transplant seropositivity to adenovirus. Standard treatment of this disorder consists of hydration, diuresis and analgesics. Failure of these measures leads to multiple blood transfusions, severe patient morbidity and possible death. When conservative therapy is unsuccessful, there is no proved standard of care. We recently used ribavirin, a broad-spectrum antiviral agent against adenovirus infection in vitro, to treat refractory adenovirus hemorrhagic cystitis after bone marrow transplantation. The hematuria and urinary symptomatology resolved without demonstrable side effects. We present ribavirin as a therapeutic alternative when conservative treatment for adenovirus hemorrhagic cystitis fails.

Oxybutynin Chloride Combined with Intermittent Clean Catheterization in the Treatment of Myelomeningocele Patients

Oxybutynin chloride has been with intermittent clean catheterization to achieve urinary continence in 21 of 25 myelomeningocele patients (84 per cent success rate). The regimen, results, problems and implications of this new method of treatment are discussed.

Preoperative lymph node evaluation in prostatic cancer patients who are surgical candidates: the role of lymphangiography and computerized tomography scanning with directed fine needle aspiration.

A total of 53 consecutive patients who were candidates for surgical treatment of prostatic cancer underwent preoperative evaluation of the lymph node status by computerized tomography scanning and/or lymphangiography combined with skinny needle aspiration biopsy of any abnormal lymph nodes. In 7 of 14 patients (50 per cent) ultimately found to have stage D1 disease lymphatic metastases were confirmed histologically with needle biopsy alone, thus, obviating the need for pelvic lymph node dissection. Over-all sensitivity, specificity and accuracy rates were 50, 100 and 91.4 per cent, respectively, for computerized tomography scanning with biopsy and 53.8, 100 and 84.1 per cent, respectively, for lymphangiography with biopsy. Computerized tomography scanning and lymphangiography with aspiration biopsy are cost-effective means to identify approximately 50 per cent of the patients who ultimately have lymphatic metastases.

Laparoscopic Retroperitoneal Renal Cystectomy

Laparoscopic manipulation of retroperitoneal organs is usually performed by the transperitoneal approach primarily because of the ease of access by way of the pneumoperitoneum. However, difficulty in adequately accessing structures that are surrounded by bowel, liver, spleen or postoperative adhesions makes this approach suboptimal in certain cases. We describe the use of the retroperitoneal laparoscopic approach to the upper pole of a kidney for marsupialization of a symptomatic, recurrent, complex renal cyst. An algorithm for current management of symptomatic renal cysts is discussed.

The Health and Cost Implications of Routine Excretory Urography Before Transurethral Prostatectomy

After critically reviewing 601 patients who had undergone transurethral resection of the prostate we conclude that the routine use of excretory urography is not indicated. In the vast majority of patients with only obstructive symptoms or acute urinary retention excretory urography is an expensive test, with an extremely low incidence of useful information. However, its selective use is indicated in cases in which hematuria or a history of renal disease coexists with obstructive symptoms. The time has arrived for physicians to re-evaluate the practices of the past. We all need to participate actively and to make specific recommendations, not generalities. We believe that if the guide lines suggested herein are considered the annual health costs would be decreased by an estimated

Normal Size of the Urethral Meatus in Boys

75,000,000 and the quality of urologic care would not be jeopardized.

Hematuria in Childhood: Significance and Management

Statistically valid sizes have been obtained for the normal male urethral meatus in children from 6 weeks through 12 years old. It is hoped that these values will allow the diagnosis of meatal stenosis to be made on an objective rather than a clinical basis and that such evaluation will allow for a more rational approach to the therapy of meatal stenosis in boys.

The Efficacy of Patient-Controlled Analgesia in Patients Recovering From Flank Incisions

Of 164 children presenting with gross or microscopic hematuria during a 5-year period 111 (68 per cent) were proved by clinical features or renal biopsy to have glomerulonephritis. Extraglomerular origin of hematuria was documented in only 25 (15 per cent). No definite diagnosis could be made in the remaining 28 (17 per cent) with isolated hematuria but the clinical picture was similar to that of the patients with mild glomerular lesions. Followup in 59 of 68 children confirms previous reports that isolated hematuria in childhood is usually a benign condition. Although excretory urography, urine cultures and serum complement measurements should be done to eliminate uncommon causes of hematuria, invasive studies, such as renal biopsy and cystoscopy, are not indicated routinely.

The surgical management of scrotal and penile lymphedema.

We report on 13 patients undergoing flank incisions in whom the postoperative pain was managed with a patient-controlled analgesia device. An initial group of 7 patients was used to determine the optimal injection dose for each patient and to examine variability in narcotic requirement during the postoperative course. A progressive decrease in narcotic need was noted during the postoperative course with patient-controlled analgesia, resulting in excellent patient acceptance, no postoperative complications and no drug-seeking behavior. A second group of 10 patients was randomized prospectively to receive either patient-controlled analgesia or a standard regimen of intramuscular morphine sulfate. Based on nursing observations, an analgesia and sedation scale was developed that compared the 2 groups. Analysis of a questionnaire evaluating subjective perception of postoperative pain revealed significantly less pain, less sedation and greater activity among patients randomized to patient-controlled analgesia (95 per cent confidence limit).

Evaluation of closed suprapubic cystostomy

Presented here are 3 cases of penile and scrotal lymphedema of different etiologies and the results of surgical treatment. Also presented is a brief discussion of the etiology, pathophysiology and surgical techniques useful in treating scrotal and penile lymphedema.