Paul C. Peters

Is selective therapy of recurrent nephrolithiasis possible

We evaluated, in 128 patients with recurrent nephrolithiasis, the efficacy of special treatment programs for some of the common causes of nephrolithiasis, chosen on the basis of their ability to correct underlying physicochemical and physiologic derangements. Therapy included sodium cellulose phosphate for 18 patients with absorptive hypercalciuria, thiazide diuretics for 27 patients with absorptive hypercalciuria and for 10 with renal hypercalciuria, orthophosphate for eight patients with hypophosphatemic absorptive hypercalciuria, allopurinol for 21 patients with hyperuricosuric calcium oxalate nephrolithiasis, thiazide and allopurinol for 26 patients with absorptive hypercalciuria with hyperuricosuria, and high fluid intake and/or low calcium diet for 22 patients with normocalciuric nephrolithiasis. Patients in all seven groups had a significant reduction in stone formation during 1.70 to 3.37 years of treatment, as compared with the pretreatment period of three years. Remission was found in 70 to 91 percent of patients and reduced stone formation rate was encountered in 88 to 100 percent. Each treatment program produced a significant decline in stone formation rate from 1.90 to 2.28 stones per year to 0.09 to 0.55 stones per year. The actual number of stones formed during treatment was significantly lower than the number predicted from the pretreatment frequency of stone formation (less than 26 percent). The results provide evidence supporting a selective approach to therapy of nephrolithiasis.

Long-Term Patient Survival after Cystectomy For Regional Metastatic Transitional Cell Carcinoma of the Bladder

The records of 280 patients who underwent pelvic lymphadenectomy and radical cystectomy for transitional cell carcinoma of the bladder between 1971 and 1986 were reviewed. A total of 42 patients had either 1 (stage pN1) or more than 1 (stage pN2) positive lymph nodes (20 and 22 patients, respectively). The over-all 3-year survival rate for patients with positive lymph nodes was 27%, and it was 30 and 18.5% for stages pN1 and pN2 disease, respectively. Kaplan-Meier survival curves revealed a sustained survival advantage for stage pN1 over pN2 disease for the first 3 years (p less than 0.05) but the difference was not significant at 5 years of followup. Eleven patients with negative lymph nodes but local extension of tumor into the prostatic stroma and/or ducts had a 5-year survival rate of 36%, which equaled the survival of 49 stage pT3b,pN0 cancer patients in the same series. Surgical mortality for the entire population of 280 patients was 2.1% and there was no increase in mortality or morbidity among the node positive patients. Based on the findings of improved survival of stages pN1 and pT3b,N0 cancer patients compared to stage pN2 cancer patients, the tumor, nodes and metastasis classification offers more specific prognostic information than does a single designation of Jewett stage D disease.

Intraoperative albumin administration affects the outcome of cadaver renal transplantation

The prognostic significance of early malfunction or delayed function after cadaveric renal transplantation is controversial. This study examines the influence of intraoperative management in 438 cadaveric renal transplant recipients on seven posttransplant outcome measures: (1) time of onset of urine output, (2) urine volume, (3) renal function, (4) incidence of delayed function, (5) never-functioning kidney, (6) graft survival, and (7) patient survival. Delayed function, defined as the need for hemodialysis during the first posttransplant week, decreased from 46% in 1982 to 15% in 1990 and was associated with a 25% lower 1-year graft survival rate and a mortality rate of 10% at 3 months, compared with 3% when immediate function was present. The most important factors influencing the outcome were cold ischemia time (P = 0.007), intraoperative administration of albumin (P = 0.0027), duration of surgery (P = 0.020), and recipient age (P = 0.041). A high albumin dose (1.2-1.6 g/kg bodyweight) induced urine output within 30 min in 75% of patients and induced larger urine volumes (7.3 L/24 hr), as compared with the effects of a low dose (0-0.4 g/kg), which induced urine output within 30 min in 39% and only 3.7 L/24 hr. Serum creatinine at 1 week was 3.4 and 5.8 mg/dl for the high and low albumin doses, respectively (P less than 0.0001). Similarly, mean glomerular filtration rates at 1 and 7 days were 33 and 21 ml/min, compared with 47 and 28 ml/min, for the high and low albumin doses, respectively (P less than 0.01). The incidence of delayed function and of never-functioning kidneys declined from 34% and 9% for the low dose to 12% and 1% for the high dose, respectively. Finally, with increasing albumin dose, the graft survival rate at 1 year improved from 59 to 78% (P less than 0.002), and the patient mortality rate at 3 months dropped from 6% to 2%. For albumin dose intervals between the high (1.2-1.6 g/kg) and low (0-0.4 g/kg), the effect on all seven outcome measures was intermediate, generally describing a linear relationship. Weighted least-squares analysis of the relationship of delayed function with high vs. low doses of albumin, mannitol, furosemide, and volumes of crystalloid solutions showed significance only for the albumin effect. High-dose albumin infusion likely produces intravascular volume expansion and achieves a prompt restoration of blood flow, minimizes hypoxic injury, and helps preserve renal tissue. The possibility of other beneficial effects of albumin unrelated to intravascular volume also exists.(ABSTRACT TRUNCATED AT 400 WORDS)

The Endocrinology of Human Chorionic Gonadotropin-Secreting Testicular Tumors: New Methods in Diagnosis

Serum from 59 men with testicular masses was examined for the presence of human chorionic gonadotropin-beta. Results indicate: 1) In patients with testicular tumor human chorionic gonadotropin-beta serves as a sensitive and specific marker of tumor activity with an incidence of 28%. 2) Because human chorionic gonadotropin-beta levels correlate with response to therapy this test will be useful in selecting men for adjunctive irradiation or chemotherapy. 3) Radioimmunoassay for human chorionic gonadotropin-beta is far more sensitive and specific than conventional methods for detecting human chorionic gonadotropin production. 4) After unilateral orchiectomy for carcinoma of the testis elevated serum luteinizing hormone levels are common and may be unrelated to the presence or activity of residual tumor. 5) Human chorionic gonadotropin-beta-producing tumors were associated with increased estradiol and testosterone levels and significantly depressed serum follicle stimulating hormone levels in this series. 6) The prognostic implications of the presence of human chorionic gonadotropin-beta are not yet fully understood. The importance of this study is the fact that men with testicular tumors have a high incidence of human chorionic gonadotropin-beta secretion and this fact provides the physician with a powerful new tool for examining the various aspects of tumor activity. It also shows the feasibility for prospective screening of patients with a wide variety of neoplasms of differing histologic types.

Renal trauma requiring surgery: an analysis of 185 cases.

Successful management of patients with renal trauma requires definition of the extent of injury and knowledge of the indications for exploration. The 185 consecutive cases of renal trauma requiring surgery at Parkland Memorial Hospital between 1976 and 1980 are reviewed. Injury was due to penetrating trauma in 85% of cases, and blunt trauma in 15%. The most common associated injuries following penetrating trauma were to liver, small bowel, stomach, and colon; splenic injury was more common in blunt trauma. Renal pedicle injuries in 26 patients (14%) had an operative mortality of 12% compared to 5.4% for the entire group. Renal salvage occurred in 85, 70, and 64% of stab wounds, gunshots, and blunt trauma, respectively. The importance of prompt and accurate radiographic assessment of injury with aggressive use of renal arteriography is stressed.

Renal ablation with absolute ethanol. Mechanism of action.

The mechanism of renal ablation by intra-arterial ethanol was studied in 16 mongrel dogs. Ethanol injection rates were varied, and light and electron microscopic studies were performed to detect early parenchymal changes in the kidneys. Pure ischemic injury was also studied as a control. Findings showed extensive parenchymal injury plays a significant role in renal ablation with permanent thrombosis as a delayed event. Acute arterial occlusion occurred with slow ethanol injection rates due to embolization by damaged blood components.

Urologic Complications in 505 Renal transplants with Early Catheter Removal

Of 505 consecutive renal transplants urologic complications occurred in 4.1 per cent of cadaver, 2.6 per cent of living related, 1.9 per cent of diabetic and 3.8 per cent of nondiabetic allografts. Over-all, patient survival and graft salvage rates were 94 and 83 per cent, respectively. Principles of prevention, diagnosis and management of these complications are discussed. In contrast to prior standards the bladder catheter was removed within 36 hours postoperatively in nearly all cases without any increase in morbidity.

Fracture of the Penis with Associated Laceration of the Urethra

Two patients with rupture of the urethra secondary to sexual trauma are described. Our results with the surgical treatment of such injuries are reported and the potential etiologies are postulated. One patient had an excellent result, while the other had a residual urethral stricture.

Ureteral injuries due to external violence: 10 years' experience with 59 cases.

Fifty-nine cases of traumatic ureteral damage are presented. Gunshot wounds comprise the majority (52/59). Need for a high index of suspicion and aggressive diagnostic measures is stressed. The effects of missile velocity on the ureter are noted. Prompt operative management is advocated: choice of procedure depends on the location of the ureteral defect. Urinary complications occurred in 11/59 (19%). Four complications resulted from operative techniques no longer recommended. The death rate of 10% is related to the high incidence (57/59) of associated visceral and vascular injuries.

Significance of Hematuria After Trauma

There were 142 consecutive patients with post-traumatic hematuria evaluated prospectively during a 7-month period. Of these 142 cases 22 involved penetrating injuries and 120 were secondary to blunt trauma. There were 19 patients with 24 demonstrable genitourinary injuries at urologic injury. Only 8 of the 142 patients required an operation for the urologic injuries. The degree of hematuria did not correlate with the severity of injury. Liberal use of arteriography and renal scanning is proposed to delineate precisely the urologic injury.