M.J.V. Smith

Placebo Versus Allopurinol for Renal Calculi

Certain patients with recurrent calcium oxalate calculi will show a mild uricacidemia and/or uricosuria. A prospective blind study was begun in 1970, comparing placebo to allopurinol in the management of these patients. The 92 patients had been followed for a minimum of 6 months to 5 years before the code was broken. It is demonstrated clearly that there is a placebo effect in the management of renal calculous disease. It also has been shown that the only event that clearly separates the 2 groups is complete cessation of calculous formation. Allopurinol is effective in 61 per cent of the patients and these successes usually can be identified after 1 year of treatment.

Idiopathic rupture of the bladder.

Non-traumatic spontaneous rupture of the otherwise normal bladder is a rare occurrence. The literature is reviewed and 4 new cases are reported. Experimental data are presented and a theory is reviewed regarding the frequent intraperitoneal location of the rupture. The frequent paucity of symptoms compared to the high mortality rate is stressed.

Urethral strictures in boys.

Our experience with urethral strictures in boys during a 15-year period confirms the findings of others that the most common etiology is iatrogenic. Traumatic and inflammatory strictures are rare. The congenital stricture differs fundamentally from acquired types of urethral strictures and would be termed more appropriately congenital urethral membrane. Urethral dilation and/or urethrotomy was unsuccessful in 47% of our patients, leading to secondary formation of a new stricture in 2 instances. However, urethroplasty was successful in 83% of our cases and seems to be indicated when 2 or more dilations are required.

Deep vein thrombosis and prostatectomy

A research protocol to evaluate the prevention of deep vein thrombosis in sequential patients undergoing prostatectomy is presented. There is an overall incidence of deep vein thrombosis in 8 per cent of patients. There was no advantage with intermittent leg compression when compared with elastic stockings.

Hydroxyurea and infected stones

The formation of struvite stones is closely linked to the enzyme urease produced by certain bacteria found in urine. It has been shown that hydroxamic acids will block the activity of this enzyme. One of these, hydroxyurea, in a morning dose of 500 mg. was used in 21 patients for three months or longer. Most were then able to acidify their urine despite persistent urinary infection. After three months, treatment with nitrofurantoin (Macrodantin and hydroxyurea (Hydrea), 78.6 per cent of patients had persistently sterile urine. There are 11 patients who have been observed for one year, and no toxic effect of the drug has been found. Three patients have shown some decrease in size of their retained calculus. This experimental study has shown that hydroxyurea may be useful in the management of struvite stones and deserves further study.

Effects of Lithotripter-Generated High Energy Shock Waves on Mammalian Cells in Vitro

The effects of high energy shock waves on an established human prostatic carcinoma cell line (PC-3) were investigated. HESW were administered to PC-3 cell suspensions using an electrohydraulic lithotripter (Dornier HM3). Experimental variables included the number of shocks to which the cells were exposed, spark generator potential, and the position of the cell sample in the acoustic field. Two types of cellular damage were observed: immediate cell destruction (lysis) as measured by electronic particle counting and the loss of reproductive capacity (viability) among the remaining cells as determined by colony formation assay. Over the range of the experimental variables studied, cell lysis was dependent to a greater extent on the number of shocks administered than the generator potential. Viability was affected less but was also dependent on both the generator potential and shock number. Cell lysis was strongly dependent on the position of the sample in the acoustic field with the extent of damage increasing as the sample was moved along the central axis of the shock wave from the f2 focus towards the electrodes. Possible mechanisms of damage and the relationship of the in vitro effects to the damage observed in normal tissues of patients undergoing extracorporeal lithotripsy for kidney stone disease are discussed.

Genetics of Cystinuria in an Inbred Population

After the identification of 2 cystinurics in a large eastern Virginia isolate a population study was undertaken to identify carriers of the gene and others who could be affected by it. Of 102 individuals 3 additional homozygous cystinurics and 27 possible carriers were found. The cystinuria gene shows a highly variable expression, although all those affected and carriers could be traced to 1 couple who married about 1890. These studies demonstrate that there is considerable variation in urinary concentrations of cystine even in an affected population. No form of therapy should be based on random or isolated samples.

Violent injuries to the upper ureter

Frequently traumatic injury to the renal pelvis or upper ureter is overshadowed by multiple associated injuries. The diagnosis may be particularly difficult, due to the lack of hematuria and absence of pathognomonic findings. All too frequently the delayed manifestations of urinary wound drainage, retroperitoneal mass, or urinary ascites and sepsis first draw attention to the ureteral injury. A review of the problem and our experience with 16 such injuries is presented. As with other infrequent injuries the single and most important diagnostic factor is the prepared mind of the examiner. We feel all patients who have penetrating abdominal trauma, have fractured lumbar processes, or are involved in accidents where deceleration or extension occur should have infusion pyelography even in the absence of hematuria.

Ectopic penile testis

A case of a rare form of penile testicular ectopia is reported. The embryology is discussed, and ectopia is differentiated from cryptorchism.

Methylene blue in renal calculi results of five-year study

Methylene blue in a dose of 65 mg. three times a day has been reported to be useful in the management of chronic renal calculous disease. Sixty-eight patients with renal calculi, in whom there was no biochemical abnormality, were started on this drug five or more years ago. Forty-six per cent of formers of calcium oxalate stone have passed no further stones, and 20 per cent have been improved. Initial studies had reported success in the management of infected stones. However, only 27 per cent obtained any benefit in this study. Methylene blue is useful in the management of patients who form multiple small calculi that contain calcium oxalate dihydrate and may be useful in the prevention of new stone formation.