Morton G. Glickman

Splanchnic and Peripheral Disposal of Oral Glucose in Man

Oral glucose (92 g) was administered to 22 healthy, young volunteers undergoing hepatic vein catheterization, and net splanchnic glucose output (SGO) was measured during the basal period and for 4 h after glucose ingestion. In the basal state, SGO averaged 1.90 ± 0.11 mg/min · kg. After glucose, SGO rose to a peak value of 6.65 ± 0.83 mg/min · kg at 30 min and returned to baseline by 3 h. Total SGO over 4 h was 69 ± 4 g; assuming complete absorption of the load, this amount represented 75% of the oral glucose. In a subgroup of six subjects, leg glucose uptake was simultaneously quantitated by femoral vein catheterization and leg blood flow measurement. In the postabsorptive state, glucose uptake by one leg was 24 ± 8 mg/min and increased to a mean value of 76 ± 7mg/min during the 4 h after glucose ingestion. Overall, 18 ± 2 g/4 h of glucose were taken up by one leg, which extrapolates to a total body muscle uptake of 65 ± 4 g over 4 h. We conclude that in normal man, well over 2/3 of an oral glucose load escapes splanchnic removal, and that the peripheral tissues quantitatively play the dominant role in glucose disposal.

Detection of urethral diverticula in women : Comparison of a high resolution fast spin echo technique with double balloon urethrography

PURPOSE We compared a rapid high resolution magnetic resonance imaging (MRI) technique to contrast urethrography for the detection of urethral diverticula in women. MATERIALS AND METHODS During a 19-month interval 13 patients with clinically suspected urethral diverticula were evaluated with MRI and contrast urethrography. All patients were referred by a urologist, and had clinical signs and symptoms suggesting the presence of a urethral diverticulum. Double balloon urethrography was performed in 12 patients and voiding cystourethrography was done in 1. MRI was performed using a fast spin echo T2-weighted pulse sequence and a dedicated pelvic multicoil. Following a sagittal localizer sequence 3 mm. thick axial sections were obtained from the bladder base through the entire urethra. Total imaging time was 15 minutes. RESULTS In 7 patients MRI and urethrography were negative for urethral diverticula, and in 3 cystourethroscopy was negative. In 1 patient MRI revealed a vaginal inclusion cyst confirmed by surgery. Three patients had no other studies or procedures performed. In 6 patients MRI was positive for urethral diverticula, including 4 in whom the diverticulum was confirmed at surgery, 1 who declined surgery and 1 who was lost to followup. Of the 4 patients (75%) with a surgically confirmed diverticulum double balloon urethrogram was negative in 3. CONCLUSIONS MRI is a valuable noninvasive technique for determining the presence of urethral diverticula as well as detecting other abnormalities. In our study MRI had a higher sensitivity for detecting diverticula and a much higher negative predictive rate.

Measurement of L-[1-14C]Leucine Kinetics in Splanchnic and Leg Tissues In Humans: Effect of Amino Acid Infusion

Although whole-body leucine flux is widely measured to study body protein turnover in humans, the contribution of specific tissues to the total-body measurement remains unknown. By combining the organ-balance technique with the systemic infusion of L-[1-14C]leucine, we quantitated leucine production and disposal by splanchnic and leg tissues and by the whole body, simultaneously, in six normal men before and during amino acid infusion. At steady state, disposal of arterial leucine by splanchnic and leg tissues was calculated from the percent extraction (E) of L-[1-14C]leucine counts: uptake = E × [Leu]a × flow. Tissue release of cold leucine (from protein turnover) into vein was calculated as the difference between leucine uptake and the net tissue leucine balance. In the postabsorptive state, despite substantial (P < .01) extraction of L-[1-14C]leucine by splanchnic (23 ± 1%) and leg (18 ± 2%) tissues, net leucine balance across both tissue beds was small, indicating active simultaneous disposal and production of leucine at nearly equivalent rates. Splanchnic tissues accounted for −50% of the measured total-body leucine flux. During amino acid infusion, the net leucine balance across splanchnic and leg tissues became positive, reflecting not only an increase in leucine uptake but also a marked suppression (by ∼50%, P < .02) of cold leucine release. This reduction in splanchnic and leg leucine release was indicated by a sharp decline in whole-body endogenous leucine flux. Conclusions: 1) combining the organ-balance method with systemic L-[1-14C]leucine infusion enables leucine kinetics to be measured simultaneously in the whole body and in specific tissues; 2) splanchnic tissues account for −50% of whole-body leucine flux in postabsorptive humans; and 3) amino acid infusion markedly suppresses leg and splanchnic tissue leucine release, which may indicate inhibition of proteolysis.

Fetal urinary tract obstruction: What is the role of surgical intervention in utero?

Abstract Urinary tract diversion in utero has become possible. The spectrum of findings associated with fetal urinary tract obstruction is presented and the small experience accumulated to date with surgical intervention prior to delivery is reviewed. Both the limitations and potential benefits of invasive therapy for genitourinary lesions in utero are discussed.

Antibiotic Treatment of Renal Carbuncle

Renal carbuncles in seven young males were successfully treated with long-term administration of penicillinase-resistant antibiotics. Selective renal arteriography provided an accurate means of diagnosis and permitted a trial of medical therapy. All patients experienced a prompt and sustained clincial remission; surigical exploration was thus obviated in all but one instance, in which post-treatment radiographic changes persisted.

Clinical Implications of Gonadal Venography in the Management of the Non-Palpable Undescended Testis

Selective gonadal venography was used on 28 patients with a total of 34 non-palpable undescended testes. The data obtained in this study suggest that 1) an internal spermatic vein with a pampiniform-like plexus indicates the presence of a testis, 2) a blind-ending vein on venography suggests the absence of a testis, 3) an internal spermatic vein or vas deferens may be present without a testis, 4) a testis probably cannot be present without a gonadal vein, 5) a testis may be present without a vas, 6) a blind-ending vas deferens does not necessarily indicate the absence of a testis and 7) a blind-ending vas deferens in a patient in whom a blind-ending gonadal vein is localized to the same region probably indicates the absence of a testis. Gonadal venography may localize a non-palpable undescended testis or suggest testicular agenesis. In addition, gonadal venography has aided in the selection of the operative approach and, in the future, may provide criteria under specific circumstances for determining whether an operation is necessary and, if so, the extent of surgical exploration.

Venographic Localization of the Non-Palpable Undescended Testis in Children

In cases of bilateral non-palpable undescended testes in which human chorionic gonadotropin stimulation has shown the presence of testicular tissue and in cases of unilateral non-palpable undescended testes selective transfemoral gonadal venography with a modified Seldinger technique has been used for the preoperative localization of the non-palpable testis. since the undescended testis may be located anywhere along the course of its embryologic descent, that is from the level of the renal fossa to its exit from the inguinal canal, preoperative localization will aid in the surgical management. Gonadal venography has proved to be accurate and safe, and has aided in the determination of the extent of surgical exploration in 9 children with 12 non-palpable undescended testes (6 right and 6 left).

Technical aids in investigation and management of urethral diverticula in the female

Three aids in the diagnosis and management of urethral diverticula are described. First, the technique of double-balloon urethrography has been modified. Diluted contrast medium is used to inflate the intravesical and external balloons so that improved delineation of the anatomy of the diverticular pouches is obtained with undiluted contrast medium. Second, for identification and irrigation with antibiotic solution of the nondraining pouches of compound diverticula, an angiographic catheter is placed in the most distal pouch using fluoroscopically guided manipulation, and then this catheter is replaced with a pigtail-shaped nephrostomy drainage catheter. Third, a 7 F Foley catheter balloon is placed in thin-walled and friable diverticular pouches to facilitate dissection.

Ureteropelvic junction obstruction after percutaneous nephrolithotripsy.

Percutaneous nephrolithotripsy is reported to have few complications. However, we have treated 6 cases of complete ureteropelvic junction obstruction that occurred at a number of centers after percutaneous nephrolithotripsy. In 2 patients stones were impacted at the ureteropelvic junction, 3 had pre-existing stenosis and 1 had had no previous structural abnormality. All stones were less than 2 cm. in size and 5 were removed by ultrasonic disintegration. A nephrostogram after percutaneous nephrolithotripsy showed complete ureteropelvic junction obstruction in 4 cases and partial obstruction that progressed to total obstruction in 6 days in 1. In 1 case the nephrostogram was normal but occlusion was noted 2 weeks later. Initial management consisted of nephrostomy drainage for an average of 3.2 months. One patient was treated successfully with a ureteral stent for 6 weeks after balloon dilation, 1 had unsuccessful balloon dilation and 1 had undergone an unsuccessful endoscopic pyelolysis. Pyeloplasty was successful in 3 cases. In 1 patient 2 attempts at pyeloplasty failed and nephrectomy was performed. In the remaining patient ureterocalycostomy failed and interposition of a small segment of ileum was done. Pre-existing stenosis of the ureteropelvic junction or a stone impacted at the junction probably contributed to the obstruction and stenosis in 5 patients. The passage of ureteral guide wires should be avoided in these patients and impacted stones should be dislodged before endoscopic removal. Extracorporeal shock wave lithotripsy is an option in these cases if the stone can be dislodged or bypassed with a stent. Patients with pre-existing ureteropelvic junction obstruction might be treated best by open nephrolithotomy and pyeloplasty or by percutaneous nephrolithotripsy and endoscopic pyelolysis for ureteropelvic junction narrowing.

Localization and Management of Nonpalpable Undescended Testes

Preoperative radiologic localization of nonpalpable undescended testes has been attempted as an aid in the selection of the operative approach and in determining the extent of surgical exploration. The authors prefer the technique of transfemoral gonadal venography, and discuss its indications, methods, findings, and complications.