Joseph J. Kaufman

Renal Artery Embolism: Clinical Features and Long-Term Follow-up of 17 Cases

Spontaneous renal artery embolism is not rare, but a correct diagnosis and appropriate treatment are often delayed. Clinical features and follow-up of 17 cases are reported. Cardiac disease or arrhythmias pre-existed in 16 patients. Initial symptoms included flank pain (seven cases), abdominal or chest pain alone (seven), and nausea and vomiting (eight). Fever (greater than or equal to 37.5 degree C) occurred in 10 cases and flank tenderness in only eight. Laboratory findings included leukocytosis, proteinuria, hematuria, and elevated levels of lactic dehydrogenase, serum glutamic-oxalacetic transaminase, serum glutamic-pyruvic transaminase, and alkaline phosphatase. Serum creatinine level exceeded 1.3 mg/dl in 88% and 4.0 mg/dl in 65%; four patients required dialysis. The diagnosis, made by scintiscan, arteriography, or both was often delayed. Renal embolization was bilateral in seven patients and unilateral in 10, with serum creatinine level above 4.0 mg/dl in five of the latter. Emboli to other organs caused early death; cardiovascular disease led to later death. With anticoagulants, renal function returned in patients surviving more than 1 month, even those with bilateral emboli. Thus, renal embolism is recognizable if the disease is considered, and a favorable outcome is common with long-term anticoagulants.

Replacement of the Ureter by Small Intestine: Clinical Application and Results of the Ileal Ureter in 89 Patients

Partial or total replacement of the ureter by small intestine was performed at the University of California/Los Angeles Hospital and affiliated hospitals 94 times in 92 patients from 1954 to 1978. Indications included recurrent calculi, ureteral stricture, fistula, congenital obstruction of the ureter and ureteral carcinoma with a solitary kidney. A special use has been for undiversion of an ileal conduit. Followup evaluation was possible in 95% of the patients and ranged from 6 months to 23 years. Thirty-six patients were followed for more than 5 years. The operation was judged successful in 81% of the cases. Serum creatinine was unchanged or decreased in 75.7% and the pyelogram was unchanged or showed decreased dilatation in 84.6% of the patients. Although reflux was seen in 40 of 55 patients who had cystograms 39 (97.5%) were considered to be treated successfully. Indications for and results of the operation are discussed. The procedure is recommended as optimal therapy for carefully selected situations when the normal urinary tract cannot be used.

Radical Prostatectomy for Carcinoma of the Prostate: 1951–1976. A Review of 329 Patients

Surgical therapy for early adenocarcinoma of the prostate has been an effective mode of cure since it was described by Young in 1905. The retropubic and perineal approaches of radical prostatectomy have been used at our hospitals for 25 years. Herein we examine 329 cases at the 2 hospitals. Although there were only 2 deaths (0.61 per cent) immediately attributable to the operation the surgical morbidity was significant. Patients of the attending staff had a 46 per cent complication rate while that of patients of the resident staff was 59 per cent. The 5 and 10-year survival rates of patients with stages A and B prostatic adenocarcinoma were 82 and 63 per cent, respectively, and the 5 and 10-year survival rates of patients who had stage C prostatic adenocarcinoma were 67 and 29 per cent, respectively. Our survival rates compare favorably to the national average survival for patients of all ages with localized or regional adenocarcinoma of the prostate. We believe that these data support the position of urologists who believe in radical surgical treatment of prostatic cancer.

Complications of penile prosthesis surgery for impotence.

Complications and their management in 1,207 cases of semirigid rod prosthesis for erectile failure are presented. Major complications occurred in 7.8 per cent of the cases. Complications and management of 84 cases of impotence treated with inflatable penile prostheses also are discussed. Mechanical problems occurred in 44 per cent of the cases and medical complications occurred in 10 per cent.

Complications of radical cystectomy for carcinoma of the bladder.

A total of 165 consecutive patients underwent radical cystectomy for bladder cancer, 19 patients without preoperative radiation therapy, 109 patients after planned preoperative radiation therapy and 37 patients after failure of definitive radiation therapy (salvage cystectomy). The operative mortality was 2.4 per cent of the entire group: less than 1 per cent of the 128 patients undergoing cystectomy as primary treatment and 8.1 per cent of the 37 patients undergoing salvage cystectomy. Early complications occurred in 28 per cent of the 165 patients and included wound infeciton, urine leak, ureterointestinal obstruction, small bowel obstruction, intestinal leak, rectal fistual and/or medical complications. Postoperative hospitalization for those patients suffering any complication averaged 27 days compared to the average hospitalization of 12.7 days when no complications occurred. Selective use of the initial perineal approach in male patients who had received more than 6,000 rad and of staged cystectomy after urinary diversion in some high risk patiens, associated with salvage cystectomy, can reduce the postoperative mortality and morbidity significantly. The addition of a meticulous pelvic iliac lymph node dissection did not increase the operative mortality or morbidity compared to simpler procedures. Results of this study support the early aggressive use of single stage radical cystectomy with pelvic iliac lymph node dissection and urinary diversion in the management of patients with bladder cancer.

The use of collagenase in the treatment of Peyronie's disease

Purified clostridial collagenase was administered intralesionally in 31 men with Peyronies disease. Within 4 weeks of treatment 20 patients showed an objective improvement. Pain was eliminated in 13 of 14 patients with this complaint at presentation within the same 4-week period. The ability to have intercourse was restored in 3 of 4 patients with this problem. Except for a small corporeal rupture at the site of injection in 1 patient, no significant untoward effects were noted. During the mean 9.8-month followup 1 recurrence of bending was noted.

Augmentation Enterocystoplasty: A Critical Review

Augmentation cystoplasty appears to offer a successful long-term solution for patients with small contracted bladders of almost any etiology. If proper indications are observed the procedure is well tolerated. With refined urodynamic diagnostic techniques our over-all failure rate of 35 per cent can be expected to decrease. Contraindications of the procedure include azotemia (creatinine clearance less than 40 cc per minute), vesical malignancy, neurogenic bladder with spastic pelvic floor (that cannot be modified) and young boys (mucus problems). In addition, patients with a strong psychiatric history should be approached with caution. The non-functional contracted bladder in which the cause of prior diversion is unclear or was performed because of an apparent outflow obstruction that spontaneously has been corrected by rest during the period of supravesical diversion also should be approached with care.

Radical cystectomy for carcinoma of the bladder: 16 years of experience.

The records of 141 consecutive patients who underwent simple or radical cystectomy between 1955 and 1971 were reviewed. Symptoms, interval before diagnosis, and stage and grade of lesion were analyzed and correlated with survival rates. Although stage was the most critical determinant of survival, grade, presence or absence of dysuria and delay in diagnosis were also important. Preoperative radiotherapy caused downstaging in 41.2 per cent of patients, with complete disappearance of tumor in some. Postoperative complications from cystectomy and from various forms of urinary diversion were correlated with the type of diversion, type of ureteral anastomosis, radiotherapy and stents. Improved operative techniques, method of fluid balance, and preoperative and postoperative care have led to a progressively decreased operative mortality in patients with carcinoma of the bladder.

The Management of Superficial Bladder Tumors and Carcinoma in situ with Intravesical Bacillus Calmette-Guerin

A phase II study was performed to assess the role of bacillus Calmette-Guerin as a prophylaxis against recurrent stages O and A bladder tumors, and in the treatment of existing superficial bladder tumors and carcinoma in situ. Tice strain bacillus Calmette-Guerin (1 vial, 2 to 8 times 10(8) organisms in 60 cc saline) was instilled intravesically without cutaneous inoculation. Instillations were given weekly for 6 weeks and then monthly or until recurrence in 22 patients with a history of recurrent tumors, while 22 with existing stages O and A transitional cell carcinoma, and 19 with carcinoma in situ were treated weekly for 8 weeks and then monthly for 12 months or until failure. Complications included cystitis in 88 per cent of the patients (severe in 20 per cent), fever in 15 per cent, a flu-like syndrome in 13 per cent, edema and pruritus in 1.5 per cent, and ureteral stenosis in 1.5 per cent. Twelve patients (19 per cent) did not complete the study owing to toxicity. Of the patients in the prophylaxis group 67 per cent have had no tumor recurrence 10 to 26 months (mean 15 months) after therapy. Of the patients with existing tumors 36 per cent had complete regression following bacillus Calmette-Guerin therapy and 23 per cent had a partial response. Among the patients with carcinoma in situ 13 (68 per cent) had reversal to normal urothelium and 3 (16 per cent) had marked improvement. None of the patients had recurrence at 11 to 20 months. Intravesical Tice strain bacillus Calmette-Guerin is effective as a prophylaxis against recurrent superficial bladder tumors and in the treatment of carcinoma in situ.

Bilateral Renal Cell Carcinoma and Renal Cell Carcinoma in the Solitary Kidney

We report on 43 patients with renal cell carcinoma in a solitary kidney, 39 of whom underwent a potentially curative resection. Of 36 patients who had a nephron salvaging procedure only 4 required ex vivo surgical resection. The survival curves of patients with solitary or bilateral lesions are similar, and depend more on the adequacy of tumor resection and tumor stage than on the fate of the contralateral kidney. Crude survival in this series was 64 per cent for patients followed for more than 1 year.