John M. Palmer

Spontaneous Rupture of an Iliac Artery Aneurysm into a Ureter: A Case Report and Review of the Literature

A case of massive hematuria from spontaneous rupture of an iliac artery aneurysm into a ureter is reported. The vascular causes for gross hematuria are reviewed and the various arterial aneurysms are discussed. The need to consider vascular abnormalities when dealing with massive hematuria is emphasized.

Diuretic Doppler sonography in postnatal hydronephrosis

Renal resistive indexes were measured by Doppler sonography in 12 children undergoing other standard diagnostic studies to evaluate hydronephrosis. Measurement of renal resistive indexes was modified by prior placement of a bladder catheter, oral hydration and administration of 1 mg./kg. furosemide after baseline measurement. Renal resistive indexes were again measured at 10 and 30 minutes after diuretic. While diuretic administration had no measurable influence on 10 nonobstructed kidneys, the elevated 10-minute post-diuretic renal resistive indexes recorded in 10 obstructed kidneys differed significantly from the indexes recorded in the nonobstructed group (p less than 0.001). The highest elevations in renal resistive indexes were recorded in nonpaired kidneys, which included 7 of the 10 kidneys in the obstructed group. In the 3 unilaterally obstructed kidneys the 10-minute post-diuretic renal resistive indexes did not differ significantly. However, renal resistive indexes in these kidneys increased at least 15% over baseline readings after diuretic administration. Diuretic Doppler sonography appears to be another useful method for differentiating functionally significant hydronephrosis from nonobstructive hydronephrosis in children.

Conservative surgery in solitary and bilateral renal carcinoma: indications and technical considerations.

Seven patients presented with solitary or bilateral renal carcinoma. All 4 patients treated by partial nephrectomy are well and 3 are free of disease (followup of 24 to 32 months). A survey of similar series reveals a survival of 78 per cent in patients with solitary renal tumors undergoing partial nephrectomy (mean followup of 52 months). Since the projected survival in patients undergoing chronic hemodialysis for the same interval is only 65 per cent partial nephrectomy, when technically feasible, would appear to be the treatment of choice in solitary renal carcinoma. In cases involving bilateral lesions the survival rate after partial nephrectomy seems to be similar to that of cases on hemodialysis.

Ureteral Avulsion from Non-Penetrating Trauma

We report 6 instances of complete ureteral avulsion in 5 patients undergoing acute acceleration/deceleration trauma. One patient also had an unsalvageable contralateral renal arterial intimal injury. In all instances the ureteral avulsion injury was repaired successfully and in 4 patients only 1 surgical procedure was used. The injury, occurring primarily in children, seems to result from a sudden hyperextension of the trunk and the ureteropelvic junction appears to be the most susceptible to disruption injury. From our experience and from that of others, despite the occult nature of this injury and its tendency to be obscured further by associated injuries of greater immediate importance, persistence in diagnostic pursuit and surgical repair even when delayed will yield a satisfactory result.

Use of horseshoe kidney in renal transplantation Technical aspects

The incidence and etiology of horseshoe kidneys and their structural abnormalities are discussed. Previously, patients with horseshoe kidneys have been considered undesirable donors for renal transplantation. Two cases of horseshoe kidney transplantation are presented, apparently, the first reported utilization of such a donor for transplantation, along with important aspects of surgical technique.

Chylous ascites following retroperitoneal lymphadenectomy. Report of 2 cases with guidelines for diagnosis and treatment

Two cases of chylous ascites following retroperitoneal lymphadenectomy are presented. The first case, a 3‐year‐old girl, underwent a right radical nephrectomy and retroperitoneal lymph node dissection for Wilms tumor. Chylous ascites developed postoperatively and resolved after 3 months of supportive therapy. The second case, a 45‐year‐old woman, underwent a right radical nephrectomy and retroperitoneal lymph node dissection for renal carcinoma. Chylous ascites occurred postoperatively and resolved after a single paracentesis. Diagnosis, evaluation, and therapeutic modalities are outlined and the literature is reviewed.

Urologic Complications in Renal Transplantation

The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.

Diuretic Doppler Sonography Following Successful Repair of Renal Obstruction in Children

The measurement of resistive index (RI = [peak systolic velocity--end diastolic velocity]/peak systolic velocity) by Doppler sonography has demonstrated variable reliability as an indicator of pediatric urinary obstruction. By modifying Doppler studies with the addition of furosemide (diuretic Doppler sonography), we previously found significant differences between 10 nonobstructed and 10 obstructed kidneys in children (median age 7 months). The obstructed kidneys have since undergone surgical repair, and postoperative reevaluation has been performed by diuretic Doppler sonography and diuretic renography. Diuretic Doppler sonography was performed on well hydrated catheterized patients, with resistive index measurement of the renal interlobar and arcuate arteries obtained before and 10 minutes after 1 mg./kg. furosemide infusion. Following surgical repair of obstruction all 10 kidneys had stable glomerular filtration rate with improved pelvic emptying times as demonstrated by half-time. Of 6 kidneys evaluated by diuretic Doppler sonography before 3 months 2 had resistive index levels greater than 75. Of the 9 kidneys measured at 3 months or more postoperatively all had resistive index values of less than 75, even after furosemide infusion (5 kidneys underwent repeat evaluation). In our study the previously demonstrated post-diuretic elevation of resistive index in pediatric urinary obstruction was eventually reversed following surgical repair. Diuretic Doppler sonography appears to be a promising noninvasive method for evaluating pediatric hydronephrosis, providing an alternative physiological parameter with which to measure renal obstruction.

Diuretic Enhanced Duplex Doppler Sonography in 33 Children Presenting with Hydronephrosis: A Study of Test Sensitivity, Specificity and Precision

PURPOSEnWe assessed the value of diuretic enhanced Doppler sonography in the diagnosis of pediatric renal obstruction as well as its reproducibility, sensitivity and specificity.nnnMATERIALS AND METHODSnWe studied 33 children (68 kidneys) by standard diagnostic techniques and diuretic Doppler sonography. A total of 20 obstructed kidneys was compared to 48 without obstruction and we performed surgery on 13. An average of 2.3 resistive index measurements were made per test and 436 total resistive index values were assessed by Students t distribution and chi-square analysis before and after surgical repair. The assessor was blinded to the clinical diagnosis.nnnRESULTSnThe obstructed mean resistive index before (0.71) and after (0.74) furosemide administration differed significantly from the nonobstructed mean resistive index (0.65, p < 0.02). Postoperative mean resistive index (0.68) was not affected by the diuretic and did not differ from the mean resistive index of nonobstructed kidneys. Resistive index test sensitivity was 76% and specificity was 88%. The precision for 3 values per test was +/- 0.11.nnnCONCLUSIONSnWhen at least 3 values are obtained per test, diuretic Doppler sonography predicts the actual resistive index average with 98% confidence limits 90% of the time.

Stricture incidence related to suture material in hypospadias surgery

PURPOSEnTo report the complication rates after hypospadias surgery, with stratification according to the type of suture used for the urethral anastomosis (rapid/intermediate absorbable v prolonged absorbable.)nnnMATERIAL AND METHODSnDuring a 7-year period (1986 to 1992), 117 boys aged 5 to 124 months (mean, 14) underwent surgical correction of hypospadias. The urethral anastomoses were performed with chromic sutures before 1987 (n = 15), with polydioxanone (PDS) between 1987 and 1990 (n = 46), and with polyglycolic acid (PgA) after 1990 (n = 56). The patients were separated into two groups: those whose operations were performed before 1987 and after 1990 (using chromic or PgA sutures), and those whose surgery occurred in the intervening 3 years (using PDS). A successful result was defined as good cosmesis without urethral stricture or urethrocutaneous fistula on long-term follow up (mean follow-up period, 15.9 months).nnnRESULTSnOf the cases that had PgA or chromic sutures, 76.1% were corrected in a single operation, as opposed to 50.9% when PDS was used (P = .002). In the chromic/PgA group, 6.8% had strictures, compared with 23.6% of the PDS group (P < .02). This contrast was most evident in cases with pedicled tube flaps; strictures occurred in 43.8% of the PDS group but in only 9.5% of the chromic/ PgA group (P < .02). There was no significant difference in the incidence of postoperative fistulas between the two groups. In some patients, the PDS sutures remained present in the urethra, without absorption, up to 7 months after the initial repair.nnnCONCLUSIONnSutures with rapid or intermediate absorption rates provide the best results for hypospadias surgery. The extreme delay in in vivo absorption of polydioxanone should preclude its use as an interrupted suture in small-caliber urethral anastomoses.