John B. Graham

Percutaneous Caliceal Irrigation During Extracorporeal Shock Wave Lithotripsy for Lower Pole Renal Calculi

A percutaneous nephrostomy tube coiled in the lower pole calix was used to irrigate stone fragments during extracorporeal shock wave lithotripsy in a small series of patients. This procedure is suggested as a possible means of improving lithotripsy results for larger, lower pole stones.

Conservative Management of Twisted Testicular Appendages

We planned non-operative treatment of a twisted intrascrotal appendage in 23 consecutive patients, ranging in age from 6 to 45 years, in whom the diagnosis could be made confidently. Only 3 patients have required subsequent removal of the infarcted appendage because of persistent or recurrent pain. The remaining patients became free of pain within a week. Prompt surgical exploration to exclude torsion of the spermatic cord remains necessary if scrotal swelling obscures the diagnosis. At operation for the latter indication 5 additional boys were found to have a twisted appendix testis during the study interval.

The Effects of Ultrasound-Guided Shock Waves During Early Pregnancy in Sprague-Dawley Rats

Pregnancy is a contraindication to extracorporeal shock wave lithotripsy (ESWL) because of its possible harm to the embryo or fetus caused by shock waves or ionizing radiation. In this study timed-pregnant rats were subjected to shock waves early in gestation using a lithotriptor having ultrasound imaging. In a pilot group undergoing immediate laparotomy, it was determined to what extent the pelvic structures were effected. Then a test group was exposed to shock waves and carried to near term pregnancy along with an identical group of pregnant, sham procedure rats. A laparotomy all were inspected for fetal viability, fetal abnormalities, and maternal organ damage. Fetuses located nearest the focal area of maximum shock wave energy showed lower mean weight than controls. There was no recognizable gross or microscopic fetal damage.

Lithotripsy of Urinary Calculi by Tunable Pulsed Dye Lasers: A Randomized in Vitro Study

Pulsed dye laser lithotripsy has been used in the treatment of urinary calculi. We compared the efficacy of 2 pulsed dye lasers with different pulse durations in lithotripsy. A total of 20 pairs of human kidney stones was matched by size and composition, and randomized for laser lithotripsy under identical in vitro conditions. Each stone received 150 shocks at sequential energy settings between 40 and 140 mJ. while in a laser fiber compatible stone basket until complete fragmentation occurred. Stone fragments were separated by size and weight. We found that the laser with the shorter pulse duration fragmented stones with less total energy and produced fewer fragments greater than 3.35 mm. The differences were statistically significant.

Hemodynamic and catecholamine responses associated with extracorporeal shock wave lithotripsy

Patients undergoing extracorporeal shock wave lithotripsy (ESWL) for nephrolithiasis are anesthetized and immersed in water in a semisitting position. Hypertension and tachycardia have been reported to accompany ESWL, and it was hypothesized that those problems were a result of adrenal medullary release of epinephrine or norepinephrine. Therefore, the effects of ESWL on cardiovascular variables and circulating epinephrine and norepinephrine levels in nine patients anesthetized with 1.1% isoflurane in 50% nitrous oxide and oxygen were studied. End-tidal carbon dioxide (CO2) was maintained at 34 +/- 2 mmHg. Cardiac output (CO) and mean arterial pressure (MAP) were measured, and total peripheral resistance (TPR) was calculated at the following time points: (1) after immersion prior to shock wave therapy (control); (2) after 300 shocks; (3) after 800 shocks; and (4) 5 minutes after the completion of ESWL with the patient still immersed. Circulating epinephrine and norepinephrine concentrations were determined at the above times as well as before and after induction of anesthesia but prior to immersion. There was a statistically significant (p less than 0.05) decrease in CO and an increase (p less than 0.05) in MAP and TPR with ESWL treatment. These values returned to baseline levels when treatment was stopped. Plasma epinephrine and norepinephrine values did not change significantly throughout the study period. It was concluded that these ESWL-associated hemodynamic changes were probably not mediated via epinephrine or norepinephrine.

Prostatic aspiration biopsy: an assessment of accuracy based on long-term observations.

We present the results of transrectal thin needle aspiration biopsy of the prostate in 133 patients. Test specificity was 94 per cent and sensitivity also appeared to be high initially. However, with repeated rectal examinations and biopsies during an 11-year period a number of additional false negatives became apparent, which resulted in an apparent test sensitivity of 82 per cent, lower than most previously published reports. Our data suggest that aspiration biopsy has specificity and sensitivity similar to core biopsy, it is important to re-test patients who have a palpable abnormality and an initially benign biopsy, and aspiration biopsy simplicity allows for a low threshold of suspicion of subtle abnormalities and for repeating biopsies after negative findings.

Three-phase cystoscopic inspection of vesicoureteral valve

Abstract Attempts to visualize cystoscopically what happens to the ureterovesical valve mechanism before and during detrusor contractions, much as one does on voiding cystograms, are described. In some patients, especially those demonstrating reflux, the valve changes are remarkable as the bladder contracts.

Cavernous hepatic hemangioma simulating metastatic renal cell carcinoma

A case of cavernous hemangioma of the liver resembling a metastatic deposit is reported in a patient with renal cell carcinoma. The clinical and angiographic features that distinguish hepatic hemangiomas from metastatic renal cell carcinoma are discussed. The importance of this distinction in patient management is emphasized.

BILATERAL URETEROVAGINAL FISTULA Complication of Radiation Therapy

Abstract An unusual case of bilateral ureterovaginal fistula complicating radiation therapy for carcinoma of the uterine cervix is presented. The development of a bilateral fistula of this type without associated major pelvic surgery and without locally persistent tumor is unique. The choice of urinary diversion as treatment of this patient is discussed, and the clinical course with unsuccessful outcome is subjected to retrospective analysis.