Richard Bihrle

Indiana continent urinary reservoir.

AbstractCecoileal reservoirs were created in 29 patients. Tunneled ureteral implantations along the tenia of the cecum provided the antireflux mechanism. Plication or tapering of the terminal ileal segment along with the ileocecal valve provided the continence mechanism.The tubular configuration of the cecum was disrupted with either an ileal or sigmoid patch, or it was re-configured in a Heineke-Mikulicz type of closure to avoid bolus (unit) contractions. Shortterm followup examination with excretory urography showed no upper tract obstruction. X-rays of the pouch showed no reflux and interviews revealed satisfactory continence in 93 per cent of the patients.

Retroperitoneal Lymphadenectomy for Clinical Stage a Testis Cancer (1965 to 1989): Modifications of Technique and Impact on Ejaculation

Results with primary retroperitoneal lymphadenectomy in 464 patients with clinical stage A nonseminomatous germ cell testis cancer (1965 to 1989) were reviewed. The false-negative staging error by clinical methods remains at 30%. The relapse rate in pathological stage A cancer patients was 11% (37 of 323), with 2 deaths. For pathological stage B disease 64% of the patients were cured by retroperitoneal lymphadenectomy alone. With modern adjuvant chemotherapy no stage B tumor relapsed since 1979 and the survival rate was 100%. For all 25 years (464 patients) the relapse rate was 14% and the survival rate was 98.9% (3 cancer and 2 noncancer deaths). Because these results are based on preoperative clinical staging, they are directly comparable with series using radiotherapy or surveillance.

Nerve-Sparing Retroperitoneal Lymphadenectomy with Preservation of Ejaculation

The feasibility of sparing postganglionic fibers of lumbar sympathetic nerves during the course of retroperitoneal lymphadenectomy has been investigated at our university medical center beginning in 1978. We selected 75 patients for nerve-sparing retroperitoneal lymphadenectomy in an effort to preserve ejaculatory function postoperatively. This cohort of patients was selected on the basis of clinical stage. Of the 75 patients 73 had clinical stage I disease. However, 14 of these 73 patients had pathological stage II cancer. No patient was treated with adjuvant chemotherapy after nerve-sparing retroperitoneal lymphadenectomy. Of these 14 patients with pathological stage II disease 4 had relapse: 1 with proved retroperitoneal recurrence, and 3 with serological elevations of tumor markers and questionable clinical findings as to anatomical site of relapse. All 4 patients are free of disease after chemotherapy and/or surgical (1) rescue. There were no local recurrences in the 61 patients with negative nodes. All 75 patients ejaculate and had no evidence of disease more than 2 years after nerve-sparing retroperitoneal lymphadenectomy. It is clear that nerve-sparing retroperitoneal lymphadenectomy is a feasible technique. As noted, it can even be applied to selected patients with low volume positive nodes, yet maintaining relapse and survival figures that are acceptable. Ejaculation is reliably preserved when this nerve-sparing technique is applied accurately in retroperitoneal lymphadenectomy.

Genital Fournier's gangrene: Experience with 38 patients

OBJECTIVES Fourniers gangrene (FG) is an extensive fulminant infection of the genitals, perineum, or the abdominal wall. We report our experience with the management of this difficult infectious disease. METHODS Thirty-eight patients were admitted with the diagnosis of FG between May 1993 and May 1995. All patients were treated with broad-spectrum triple antimicrobial therapy, broad debridement, exhaustive cleaning, and application of unprocessed honey dressings. Patients then underwent split-thickness skin grafts or delayed closure as needed. RESULTS Patient ages ranged between 33 and 86 years (mean, 54) with a mean hospital stay of 17 days (range, 1 to 45). Sixty-six percent of the patients were diabetic, 16% had previous orchiepididymitis, and 5% had scrotal and urethral trauma. All the patients underwent surgical debridement and application of unprocessed honey to the wound. Cystostomy was performed in 60% of the patients and 21% underwent orchiectomy of the affected side. Free skin grafts were applied to 6 patients (16%) and the remaining wounds, once clean, were approximated. One patient died as a result of severe metabolic acidosis and sepsis. CONCLUSIONS The management of this infectious entity should be aggressive. Patients with FG need extensive debridement and cystostomy or colostomy when necessary. Broad-spectrum triple antimicrobial regimen and aggressive debridement are mandatory. Topical application of unprocessed honey is beneficial to the healing process. A minority of patients require split-thickness skin grafts on denuded areas.

Complications of post-chemotherapy retroperitoneal lymph node dissection.

The surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy there was a higher occurrence of postoperative chylous ascites. Most of the other complications (gastrointestinal, lymphatic, neurological and renal) were temporary and treated conservatively. Perioperative management of the post-chemotherapy testis cancer patient is different from that of the patient undergoing primary retroperitoneal lymphadenectomy. The latter operation is usually performed in physically fit patients and the surgical template of dissection is of a smaller scale. Thus, the complications in this group are minor and without mortality. Specific technical considerations and difficulties are common to post-chemotherapy patients. Factors, such as large volume of disease, post-chemotherapy desmoplastic reaction and extensive retroperitoneal dissection, make these patients more prone to have complications. Decreased pulmonary, renal and nutritional reserves add to the surgical morbidity. Knowledge of possible pitfalls and their causes can avoid unnecessary operative complications.

High-intensity focused ultrasound in the treatment of prostatic disease.

Beginning in 1987, high-intensity focused ultrasound was investigated experimentally in a canine model to determine whether or not prostate tissue could be destroyed with good aiming and control. Subsequently a transrectal probe was developed and used to treat canine prostates in a formal study to determine whether or not this technology could be used to treat human benign prostatic hypertrophy. Next, after FDA approval, 15 patients were treated at Indiana University in the fall of 1992. Both canine and human studies have shown that high-intensity focused ultrasound administered via a transrectal probe is capable of creating prostate lesions without injury to intervening and surrounding tissue.

Original Articles: Testis Cancer: Complications of Post-Chemotherapy Retroperitoneal Lymph Node Dissection

ABSTRACTThe surgical morbidity rate of 603 patients who underwent lymphadenectomy after primary chemotherapy for clinical stages II and III testis cancer from 1982 to 1992 was reviewed. There were 144 complications in 125 patients (20.7%). The majority of patients (93%) had a tumor volume of greater than 5 cm. Five patients died 3 to 47 days postoperatively, for an operative mortality rate of 0.8%. Pulmonary complications were the most frequent cause of severe morbidity: 6 patients had the adult respiratory distress syndrome and 5 needed prolonged ventilation. The underlying cause was a combination of bleomycin induced pulmonary toxicity, and large volume retroperitoneal and pulmonary disease resected in these patients. Limiting inspired oxygen concentration and perioperative volume replacement are imperative to minimize bleomycin related pulmonary morbidity. Additional procedures, such as nephrectomy and colectomy, did not add to the morbidity rate. Among patients undergoing concomitant venacavectomy the...

Complications of primary retroperitoneal lymph node dissection.

The surgical morbidity in 478 patients who underwent primary retroperitoneal lymphadenectomy for clinical stages I and II nonseminomatous testicular cancer from 1982 to 1992 was reviewed. There were 54 complications in 51 patients (10.6%) and no operative related mortality. Superficial wound infection was the most frequent complication, comprising 45% of the total number of complications. Most major complications were related to small bowel obstruction and atelectasis. No complications caused permanent disability. The complication rate was less in patients who underwent a modified unilateral procedure (9.4%) than in those who underwent bilateral dissection (19.3%). Complications were significantly less with procedures done during the latter 6 years of the study (1987 to 1992). The ejaculation rate of patients undergoing a nerve sparing procedure was 98%, which reflects the increase in experience gained with the technique of nerve sparing modified unilateral dissection for early stage testicular cancer. This study reinforces the view that primary retroperitoneal lymph node dissection is an operation with minimal morbidity and no long-term effects. Furthermore, this study serves as the basis for cost-benefit and risk-benefit analyses of primary retroperitoneal lymph node dissection in low stage testicular cancer, which can be set against surveillance and primary chemotherapy programs.

Noninvasive surgery of prostate tissue by high intensity focused ultrasound: an updated report.

Modern ultrasound transducer material and matching layer technology has permitted us to combine the ultrasound visualization capability with production of high-intensity focused ultrasound (HIFU) on the same ceramic crystal. This development has lead to the design of a transrectal probe for noninvasive surgery of prostate tissue by HIFU. The combined capability using the same ceramic crystal simplifies treatment planning, targeting, and monitoring of tissue before and during the HIFU treatment. This mechanically scanning transrectal probe was introduced for clinical use in 1992 for noninvasive surgery of the prostate to treat benign prostatic hyperplasia (BPH) condition. This paper reviews major steps progressing from conception to the present clinical trial status of the HIFU device. During these clinical studies generation of microbubbles and cavitation were observed. Data from microbubble generation, temperature monitoring in tissue, and autopsy of HIFU-treated animal prostates are presented. Results of human clinical studies are briefly summarized to indicate performance of the device.

High intensity focused ultrasound for the treatment of benign prostatic hyperplasia : early United States clinical experience

High intensity focused ultrasound via a transrectal approach was used to treat 15 patients with symptomatic benign prostatic hyperplasia. The first 10 of these 15 patients underwent continuous temperature monitoring of the periprostatic region throughout the treatment. Patients undergoing transperineal thermocouple placement for the purpose of thermometry were treated while under general or spinal anesthesia, whereas 4 of the 5 remaining patients were successfully treated using intravenous sedation alone. Of the 10 patients 9 did not demonstrate a significant temperature elevation. One patient with a small prostatic anteroposterior diameter had a transient elevation of 17C. No patient experienced a complication related to periprostatic heating. Followup was available at 90 days in all patients. At 90 days the symptom scores decreased from a pretreatment value (American Urological Association questions 1 to 7) of 31.2 (range 22 to 38) to 15.8 (range 8 to 31). Peak flow rate increased by a mean of 4.7 ml per second from 9.3 ml per second before treatment to 14.0 ml per second at 90 days. The most frequent complication was that of transient urinary retention in 11 of 15 patients (73.3%) and hematospermia in 7 (46.7%). No adverse reactions persisted at 90 days. This study represents an initial attempt using high intensity focused ultrasound to treat symptomatic benign prostatic hyperplasia. Overall, the safety and effectiveness of high intensity focused ultrasound demonstrated in this pilot study are encouraging.