John W. Konnak

Results of 1,469 Microsurgical Vasectomy Reversals by the Vasovasostomy Study Group

During a 9-year period, 1469 men who underwent microsurgical vasectomy reversal procedures were studied at five institutions. Of 1247 men who had first-time procedures, sperm were present in the semen in 865 of 1012 men (86%) who had postoperative semen analyses, and pregnancy occurred in 421 of 810 couples (52%) for whom information regarding conception was available. Rates of patency (return of sperm to the semen) and pregnancy varied depending on the time interval between the vasectomy and its reversal. If the interval was shorter than 3 years, the patency rate was 97% and the pregnancy rate was 76%; for intervals of 3 to 8 years the rates were 88% and 53%; for 9 to 14 years, 79% and 44%; and for 15 years or more, 71% and 30%. The patency and pregnancy rates were no better after 2-layer microsurgical vasovasostomy than after modified 1-layer microsurgical procedures, and they were statistically the same for all patients regardless of the surgeon. When sperm was absent from the intraoperative vas fluid bilaterally and the patient underwent bilateral vasovasostomy rather than vasoepididymostomy, patency occurred in 50 of 83 patients (60%) and pregnancy in 20 of 65 couples (31%). Neither presence nor absence of a sperm granuloma at the vasectomy site nor type of anesthesia affected results. Repeat microsurgical reversal procedures were less successful. A total of 222 repeat operations produced patency in 150 of 199 patients (75%) who had semen analyses, and pregnancy was reported in 52 of 120 couples (43%).

Randomized controlled trial of hand-assisted laparoscopic versus open surgical, live donor nephrectomy

BACKGROUND Laparoscopic live donor nephrectomy for renal transplantation is being performed in increasing numbers with the goals of broadening organ supply while minimizing pain and duration of convalescence for donors. Relative advantages in terms of recovery provided by laparoscopy over standard open surgery have not been rigorously assessed. We hypothesized that laparoscopic as compared with open surgical live donor nephrectomy provides briefer, less intense, and more complete convalescence. METHODS Of 105 volunteer, adult, potential living-renal donors interested in the laparoscopic approach, 70 were randomly assigned to undergo either hand-assisted laparoscopic or open surgical live donor nephrectomy at a single referral center. Objective data and subjective recovery information obtained with telephone interviews and validated questionnaires administered 2 weeks, 6 weeks, and 6-12 months postoperatively were compared between the 23 laparoscopic and 27 open surgical patients. RESULTS There was 47% less analgesic use (P=0.004), 35% shorter hospital stay (P=0.0001), 33% more rapid return to nonstrenuous activity (P=0.006), 23% sooner return to work (P=0.037), and 73% less pain 6 weeks postoperatively (P=0.004) in the laparoscopy group. Laparoscopic patients experienced complete recovery sooner (P=0.032) and had fewer long-term residual effects (P=0.0015). CONCLUSIONS Laparoscopic donor nephrectomy is associated with a briefer, less intense, and more complete convalescence compared with the open surgical approach.

Renal cell carcinoma as an incidental finding.

We reviewed the manner of presentation and tumor stage in 56 consecutive patients with renal cell carcinoma treated surgically between 1961 and 1973 (group 1) and compared them to 46 patients treated similarly between 1980 and 1984 (group 2). In group 1, 7 cases (13 per cent) were discovered incidentally compared to 22 cases (48 per cent) in group 2. The tumor stage was lower in the incidentally discovered cases than in cases when the diagnosis was suspected. The 5-year survival rates of the incidental cases in group 1 tended to be better. Routine use of excretory urography, computerized tomography, ultrasound, bone scans and other effective diagnostic studies has led to earlier diagnosis, lower stage and possibly better survival in incidentally found cases of renal cell carcinoma than in cases when the diagnosis was suspected.

REVISION RATE AFTER ARTIFICIAL URINARY SPHINCTER IMPLANTATION FOR INCONTINENCE AFTER RADICAL PROSTATECTOMY: ACTUARIAL ANALYSIS

PURPOSE We determined the actuarial revision rate for artificial urinary sphincters implanted in patients who were incontinent after radical prostatectomy. MATERIALS AND METHODS We reviewed the records of 70 consecutive patients who were incontinent after radical prostatectomy and who underwent primary artificial urinary sphincter implantation at the University of Michigan between 1984 and 1999. Questionnaires were mailed to all patients with an indwelling device, and telephone calls were placed to those who did not respond to the mailing. Information about surgical revision and current continence status was obtained from chart review and questionnaire response. The Kaplan-Meier curves for actuarial freedom from operative revision were constructed. RESULTS Of the 66 patients with available postoperative data 24 (36%) required reoperation at a mean followup of 41 months. The 5-year actuarial rate for freedom from any operative revision was 50%, and the corresponding rate for cuff revision was 60%. A single operative revision did not predispose the patient to further revision. Questionnaire data indicated a continence rate of 80% (range 0 to 2 pads). CONCLUSIONS Approximately half of the patients who were incontinent after radical prostatectomy may expect to undergo operative revision within 5 years after artificial urinary sphincter implantation. Despite this high reoperation rate, an excellent level of continence is maintained.

The Radiological Spectrum of Acute Pyelonephritis in Adults and Adolescents

Excretory urograms of 40 patients with a clinical and laboratory diagnosis of acute pyelonephritis were reviewed. Eleven (28%) had abnormal urograms attributable to the acute disease process. Of the 11 abnormal patients, 7 had obvious urographic abnormalities, while in 4 the findings were few and subtle. The most common findings were renal enlargement, decreased density of contrast material, delayed calyceal appearance time, and dilatation of the collecting system; of these, the last two most frequently correlated with the clinically abnormal side.

Ureteroscopic Treatment of Urothelial Carcinoma of the Ureter and Renal Pelvis

From June 1987 to September 1990, 12 patients were evaluated for ureteroscopic treatment of upper urinary tract neoplasms. Four patients were not considered candidates because of technical reasons. Each of these patients was treated by nephroureterectomy. A total of 8 patients underwent ureteroscopic therapy with a neodymium:YAG laser 1 to 11 times (median 2) for the treatment of 3 proximal ureteral or pelvic lesions and 7 distal ureteral lesions. One patient had local progression and 1 failed subsequent laser treatment for technical reasons. Both of these individuals were salvaged with an operation. Three patients were without recurrence for 15, 21 and 36 months. Two patients had multiple superficial local recurrences and continue to be managed endoscopically without local progression for 12 and 32 months. One patient was asymptomatic 16 months after treatment but he has refused followup evaluation. Of 7 patients with ureteral tumors who were believed to be candidates for endoscopic therapy 5 have had the tumors controlled by this method of treatment. Only 1 renal pelvic tumor has been successfully treated. Most patients with tumors in the renal pelvis are not candidates for rigid endoscopic therapy because of the tumor size and location. In selected individuals ureteroscopic laser treatment of upper urinary tract transitional cell carcinoma can achieve local control with renal preservation.

Renal Artery Embolism: Therapy With Intra-arterial Streptokinase Infusion

AbstractIntra-arterial infusion of streptokinase was used successfully to dissolve a 7-day-old main renal artery embolus in a 49-year-old woman. Renal artery patency was documented after 18 hours of thrombolytic therapy and secondary hypertension was ameliorated. Selective, intra-arterial fibrinolytic therapy may obviate the need for surgical embolectomy in poor risk patients in whom operative mortality rates appear unacceptably high.

Intraoperative Observations During Vasovasostomy in 334 Patients

This initial report from the Vasovasostomy Study Group concerns intraoperative data obtained during vasovasostomy from 639 vasa in 334 patients. These data are related to the obstructive interval (time from vasectomy to vasovasostomy) and to the presence or absence of histologically proved sperm granuloma at the old transected testicular end of the vas (vasectomy site). Rates of sperm absence from vas fluid at the testicular end increased with longer obstructive intervals and with absence of a sperm granuloma. If sperm were present in fluid at the testicular end of the vas, the quality was poorer when the obstructive interval lengthened and when sperm granuloma was absent. Vas luminal diameters at the testicular end were smaller when a sperm granuloma was present. These observations support the theory that a sperm granuloma at the vasectomy site may have a beneficial, pressure-releasing effect that could be favorable prognostically for fertility after vasovasostomy.

Results of combined nesbit penile plication with plaque incision and placement of Dacron patch in patients with severe Peyronie's disease

We treated 9 men with severe curvature of the penis secondary to Peyronies disease with penile plication and a previously unreported technique of incision of the Peyronie plaque and placement of Dacron patch. All men were potent before penile straightening. At a mean followup of 17.5 months all men achieved good to excellent correction of the deformity and they have remained potent. One patient initially complained of numbness of the glans penis and decreased penile rigidity distal to the Dacron patch but potency returned and the numbness resolved.

Treatment of renal transplant stones byextracorporeal shock-wave lithotripsy in the prone position

Two patients with renal transplant lithiasis were successfully treated with extracorporeal shock-wave lithotripsy (ESWL) in the prone position. Pathogenesis and treatment of transplant lithiasis are discussed. Performing ESWL on renal transplant patients in the prone position has advantages over standard positioning techniques.