James I. Harty

Open pelvic fractures.

Open pelvic fracture is a devastating injury with a reported 50% mortality rate from massive bleeding and pelvic sepsis. Utilizing a graded approach to management of hemorrhage that included wound packing, anti-shock trousers, angiographic embolization, and hemipelvectomy, we controlled bleeding in all but one of the 35 patients in this series. Patients lost an average of 15 units of blood. The overall survival rate was 94.5% in this series, with one death each from hemorrhage and head injury. Prevention of invasive infection by a diverting colostomy in patients with buttock wounds or perineal wounds was stressed, while anterior soft-tissue wound were managed selectively. Debridement and frequent dressing changes under anesthesia were necessary to prevent and/or treat soft-tissue infection. Associated injuries occur commonly with genitourinary and peripheral nerve trauma and account for the majority of the long-term morbidity.

Complications of Whole Bladder Dihematoporphyrin Ether Photodynamic Therapy

Photodynamic therapy with dihematoporphyrin ether was used to treat superficial bladder tumors in 7 patients with a followup of at least 1 year. Each patient received treatment to the whole bladder and those with papillary lesions received additional focal treatment. At 3 months 4 of the 5 patients with papillary tumors (stages Ta and T1) and 1 of the 2 with diffuse carcinoma in situ (Tis) were free of disease. However, at 1 year only 3 patients remained free of disease. Of 5 patients with an increase in irritative bladder symptoms 4 had a contracted bladder, hydroureteronephrosis and vesicoureteral reflux. Deep bladder biopsies showed replacement of smooth muscle by fibrous tissue. Six patients had mild to moderate skin phototoxicity. We conclude that although photodynamic therapy is an attractive and exciting method to treat cancer, its use with dihematoporphyrin ether in cases of bladder carcinoma can be associated with significant complications. The correct treatment parameters for safe, effective therapy are not known to date.

Posttraumatic renovascular Hypertension after occult renal injury

OBJECTIVE Hypertension secondary to renal injury is an unusual problem, but one that occurs with some frequency in an active trauma unit. The incidence and management of posttraumatic renovascular hypertension at our Level I trauma center was reviewed. METHODS A retrospective review of a trauma database was performed on patients treated by our trauma service between 1977 and 1996. Seven patients were identified who developed arterial hypertension as a direct result of a renal injury. RESULTS All of the patients sustained multiple injuries, with five requiring celiotomy to control bleeding. Renal injuries were occult, and there was no compelling reason to suspect injury to the kidney. No patient had a history of hypertension or elevated arterial pressure on admission; however, sustained arterial hypertension was noted within 2 weeks to 8 months of injury. Arteriography was positive in all seven patients, with findings that included lacerations of the main renal artery, its major branches, or intrarenal constriction of the renal artery (presumably from scarring). Renal-vein renin assays localized to the injured kidney in six patients. Treatment included nephrectomy in four cases, revascularization in one case, and medical management in two cases. All of the patients treated operatively had prompt relief of their hypertension. The two patients treated soley by medical therapy had prompt, durable control of their arterial pressure with a single medication. However, medical treatment had failed before operation in several of the patients. CONCLUSIONS Because of the serious complications associated with undiagnosed hypertension, new-onset or sustained hypertension after major trauma should be evaluated with attention to a possible renal cause.

Diethylstilbestrol in treatment of postorchiectomy vasomotor symptoms and its relationship with serum follicle-stimulating hormone, luteinizing hormone, and testosterone

Vasomotor symptoms such as hot flushes and profuse sweating have been described after bilateral orchiectomy. We evaluated 26 patients who had undergone bilateral orchiectomy for prostatic carcinoma to determine the incidence of vasomotor symptoms and the efficacy of low-dose diethylstilbestrol (DES) in the treatment of those symptoms. Measurements of serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and testosterone were performed to look for endocrine patterns which may be related to the presence of vasomotor symptoms. Fourteen patients (54%) reported the presence of vasomotor symptoms beginning one to four weeks after surgery. These patients were treated with DES or placebo in a double-blind crossover trial. The frequency and severity of hot flushes were significantly reduced during the time DES was given. This was accomplished with a low dose of 1 mg daily of DES which avoids the cardiovascular complications of higher doses. We found no correlation between the presence, severity, or frequency of hot flushes and serum gonadotropin or testosterone concentrations.

Treatment of Radiation or Cyclophosphamide Induced Hemorrhagic Cystitis using Conjugated Estrogen

Five patients with severe hemorrhagic cystitis induced by radiation and/or cyclophosphamide were systematically treated with conjugated estrogen. Two patients received conjugated estrogen twice each day (1 mg. per kg.) intravenously, followed on day 3 and thereafter by 5 mg. per day orally. Hematuria decreased markedly 6 to 8 hours after the initial dose and urine color became light yellow within 1 to 3 days. The other 3 patients received 5 mg. conjugated estrogen per day orally and urine color became clear within 4 to 7 days. Hematuria did not recur during 12 to 22 months in 4 patients who received daily conjugated estrogen (1.25 mg.). However, transient episodes of mild hematuria persisted in 1 patient during the 3-month followup despite a higher dose of conjugated estrogen (10 mg. per day). Complications, including thromboembolism and other side effects associated with conjugated estrogen, were not observed in these patients. We postulate that conjugated estrogen controls hematuria in hemorrhagic cystitis by decreasing the fragility of the mucosal microvasculature of the bladder.

Living donor nephrectomy: factors influencing morbidity.

Recent interest in transperitoneal live donor nephrectomy prompted us to review our experience with 104 live donor nephrectomies performed through a standard flank extraperitoneal approach. There were no deaths and 14.4 per cent of the patients had minor complications that were managed easily. Factors influencing morbidity in the voluntary donor are analyzed.

Autogenous Tunica Vaginalis Graft for Peyronie’s Disease: An Experimental Study and its Clinical Application

Tunica vaginalis autografting was done after patches of tunica albuginea of the penis were excised in 5 dogs. Examination of these grafts 4 to 12 weeks later showed that they were well accepted. A selected group of 5 patients with Peyronies disease underwent excision of Peyronies plaques and autogenous tunica vaginalis grafting with satisfactory results in all cases.

The Response of the Rat Urinary Bladder Microcirculation to Photodynamic Therapy

Light activation of dihematoporphyrin ether (photofrin II) has been used in the treatment of bladder tumors, yet the effects of this treatment on the normal urinary bladder microcirculation have not been determined. This study involved the use of in vivo television microscopy to observe the effects of light activation (530 to 560 nm., 175 mW/cm.) on the urinary bladder microcirculation of female Sprague-Dawley rats. Animals pretreated with dihematoporphyrin ether 30 minutes prior to light activation had high serum and low tissue concentrations of the photosensitizer and activation resulted in a statistically significant reduction of red blood cell column diameter in both arterioles and venules. The reduction was primarily due to mural thrombus formation with the occlusion remaining 60 minutes after activation. Animals pretreated 48 hours before activation had low serum and high tissue concentrations of dihematoporphyrin ether and activation had no microcirculatory effects apart from occasional platelet aggregation. These results suggest that the photodynamic effect on normal (non-neoplastic) tissue treated more than 48 hours after administration of dihematoporphyrin ether is probably due to a direct effect of light and the sensitizer on the smooth muscle of the bladder rather than an effect on the microcirculation.

Renal Abscess: Emerging Concepts of Diagnosis and Treatment

A retrospective review of 12 cases of renal abscesses disclosed that gram-negative bacteria were the most common infecting organisms. There was a high incidence of underlying renal disease. Excretory urography was the most reliable investigative procedure, although renal arteriograms were necessary frequently. In carefully selected patients conservative non-operative management can be successfully but an operation was required for the majority of our patients.

Verapamil Enhancement of Chemotherapeutic Efficacy in Human Bladder Cancer Cells

The calcium influx blocker verapamil has been used to overcome drug resistance in several tumor systems. The possible in vitro enhancement of drug efficacy was assessed in bladder cancer cell line T24. Combination of thiotepa and doxorubicin hydrochloride with verapamil significantly reduced the survival and growth of T24 cells after as little as 1 hour of drug exposure. An increase in doxorubicin hydrochloride-induced inhibition of [3H]thymidine uptake resulted when verapamil was administered. However, this trend was not demonstrated when combined with thiotepa. It appears that verapamil enhances thiotepa-induced cytotoxicity while it potentiates the antimitotic nature of doxorubicin hydrochloride. The data presented is consistent with the postulate that verapamil alters active efflux of drug from malignant cells and suggests that verapamil has a role in the clinical management of bladder cancer.