M.L.S. de Kock

TREATMENT OF MALE URETHRAL STRICTURES: IS REPEATED DILATION OR INTERNAL URETHROTOMY USEFUL?

PURPOSE We evaluate the efficacy of repeated dilation or urethrotomy as treatment of male urethral strictures. MATERIALS AND METHODS Between January 1991 and January 1994, 210 men with proved urethral strictures were prospectively randomized to undergo filiform dilation (106) or internal urethrotomy (104). Followup was scheduled at 3, 6, 9, 12, 24, 36 and 48 months. Dilation or internal urethrotomy was repeated at the first and second stricture recurrence. The Kaplan-Meier method was used to estimate survivor function for the treatment methods (survival time being the time to first stricture recurrence) and the log rank test was used to compare the efficacy of different treatments. RESULTS Followup (mean 24 months, range 2 to 63) was available in 163 patients (78%). After a single dilation or urethrotomy not followed by re-stricturing at 3 months, the estimated stricture-free rate was 55 to 60% at 24 months and 50 to 60% at 48 months. After a second dilation or urethrotomy for stricture recurrence at 3 months the stricture-free rate was 30 to 50% at 24 months and 0 to 40% at 48 months. After a third dilation or urethrotomy for stricture recurrence at 3 and 6 months the stricture-free rate at 24 months was 0 (p <0.0001). CONCLUSIONS Dilation and internal urethrotomy are useful in a select group (approximately 70% of all patients) who are stricture-free at 3 months, and of whom 50 to 60% will remain stricture-free up to 48 months. A second dilation or urethrotomy for early stricture recurrence (at 3 months) is of limited value in the short term (24 months) but of no value in the long term (48 months), whereas a third repeated dilation or urethrotomy is of no value.

Internal Urethrotomy Versus Dilation as Treatment for Male Urethral Strictures: A Prospective, Randomized Comparison

PURPOSE We compared the efficacy of dilation versus internal urethrotomy as initial outpatient treatment for male urethral stricture disease. MATERIALS AND METHODS A total of 210 men with proved urethral strictures was randomized to undergo filiform dilation (106) or optical internal urethrotomy (104) with local anesthesia on an outpatient basis. RESULTS Life table survival analysis showed no significant difference between the 2 treatments with regard to stricture recurrence. Hazard function analysis showed that the risk of stricture recurrence was greatest at 6 months, whereas the risk of failure after 12 months was slight. The recurrence rate at 12 months was approximately 40% for strictures shorter than 2 cm. and 80% for those longer than 4 cm., whereas the recurrence rate for strictures 2 to 4 cm. long increased from approximately 50% at 12 months to approximately 75% at 48 months. Cox regression analysis showed that for each 1 cm. increase in length of the stricture the risk of recurrence was increased by 1.22 (95% confidence interval 1.05 to 1.43). CONCLUSIONS There is no significant difference in efficacy between dilation and internal urethrotomy as initial treatment for strictures. Both methods become less effective with increasing stricture length. We recommend dilation or internal urethrotomy for strictures shorter than 2 cm., primary urethroplasty for those longer than 4 cm. and a trial of dilation or urethrotomy for those 2 to 4 cm. long.

Nonoperative Management of Renal Stab Wounds

A prospective clinical study of 54 patients with stab wounds and hematuria was conducted to evaluate the safety of selective nonoperative management compared to mandatory surgical exploration of these patients. In the absence of signs of severe blood loss, associated intra-abdominal injury or major abnormality on the excretory urogram patients were randomized to undergo mandatory surgery (group 1) or nonoperative management (group 2). Patients with signs of severe blood loss, associated intra-abdominal injury or gross abnormality on excretory urography were selected for an operation (group 3). The rate of probably needless operations (defined as minor renal injury without associated intra-abdominal lacerations) was 78 per cent in group 1 and 0 per cent in group 3. Pulmonary complications occurred in 33 per cent of the patients in group 1, 4 per cent in group 2 and 38 per cent in group 3. Despite an operation delayed renal hemorrhage occurred in 1 patient (5 per cent) in group 1 and 2 (15 per cent) in group 3, and resulted in nephrectomy in 2 of these patients. No instance of secondary hemorrhage occurred in group 2 patients. The mean length of hospitalization was 9, 5 and 11 days in groups 1 to 3, respectively. Our results indicate that the selective nonoperative management of patients with renal stab wounds can lead to a decrease in the rate of unnecessary operations, postoperative complications and length of hospitalization compared to a policy of mandatory surgical intervention.

Pelvic lipomatosis associated with cystitis glandularis and adenocarcinoma of the bladder

Pelvic lipomatosis is a rare condition characterized by an overgrowth of normal fat in the perivesical and perirectal spaces. Cystitis glandularis, cystica or follicularis has been observed in 75% of the patients with pelvic lipomatosis. Although cystitis glandularis is widely regarded as premalignant few reports have documented its transition to adenocarcinoma. We describe a 41-year-old man with pelvic lipomatosis in whom primary adenocarcinoma of the bladder developed 6 years after a histological diagnosis of cystitis cystica and glandularis was established. To our knowledge this is the second case reported of pelvic lipomatosis associated with proliferative cystitis and adenocarcinoma of the bladder, indicating that intestinal metaplasia of the urothelium may be a precursor of malignancy in these patients.

Stab wounds associated with hematuria--a review of 67 cases.

The clinical records of 67 patients who underwent surgical exploration for stab wounds associated with hematuria were reviewed in an attempt to evaluate the need for mandatory operation and to define criteria for possible nonoperative of such cases. Minor renal injuries without associated intra-abdominal lacerations were found in 61 per cent of the patients. Delayed renal hemorrhage occurred in 15 per cent of the patients despite early exploration, suture and drainage of the kidney, and antibiotic prophylaxis. Of 7 nephrectomies 5 were performed for secondary hemorrhage. Postoperative pulmonary complications arose in 28 per cent of the patients. A policy of mandatory operation on all patients with stab wounds and hematuria led to apparently needless surgery in 61 per cent of the patients in this series. Retrospective analysis revealed that the rate of probably unnecessary operations could have been reduced to 24 per cent by selecting for operation only those patients with signs of severe hemorrhage, associated intra-abdominal injury or major extravasation of contrast material on excretory urography.

Local Excision and Topical Thiotepa in the Treatment of Transitional Cell Carcinoma of the Renal Pelvis: a Case Report

We report a case of transitional cell carcinoma of the renal pelvis in a solitary kidney. Management included local excision of the renal pelvis followed by thiotepa instillation into the kidney via a retrograde ureteral catheter. There has been no recurrent tumor in the renal pelvis for 6 1/2 years.

The Cape Town burn profile

Summary An account is given of the burn problem experienced in Cape Town. The treatment and results obtained in the Tygerberg Hospital Burn Unit are discussed. The Tygerberg Hospital Burn Unit is a modern well-equipped unit consisting of 64 beds. Each year approximately 500 patients are seen with burns severe enough to warrant admission to the unit. In addition, a further 500 patients are seen with minor burns and these are treated on an outpatient basis.

Pelvic Lipomatosis: The Nuclear Magnetic Resonance Appearance and Associated Vesicoureteral Reflux

We report a case of pelvic lipomatosis with ureteral obstruction and vesicoureteral reflux. In addition to computerized tomography, nuclear magnetic resonance imaging provided definite and graphic proof of the diagnosis. Operative treatment consisted of ureteroileocystostomy.

Topical burn therapy comparing povidone-iodine ointment or cream plus aserbine, and povidone-iodine cream

Summary A trial comparing three topical agents was carried out in patients with burns. The substances investigted were 10% povidone-iodine (PVP-I) ointment mixed with a proteolytic agent, 5% PVP-I cream alone and in combination with the same proteolytic agent. Differences were observed in healing times and bacteriological cultures. Shorter healing times were observed in burns treated with PVP-I cream. The addition of a proteolytic agent to the cream made no difference to the results. Fewer positive cultures for Staphylococcus aureus and Pseudomonas aeruginosa were obtained in the groups treated with the cream. It was concluded that 5% PVP-I cream is a safe and effective topical agent in burns.

A histological study of the urethra of the male baboon--is it similar to man's?

A comparative morphologic study of the male urethra was performed in 5 humans and 11 baboons. The corpus spongiosum is essentially the same in both humans and baboons, forming a definite organ with a lumen lined chiefly by a pseudo-stratified columnar epithelium, a lamina propria, vascular space and smooth muscle, and an investing collagenous layer. Although present in the same anatomical areas there are fewer submucosal and periurethral glands in the baboon.