Robert C. Flanigan

Suppression and Treatment of Urinary Tract Infection in Patients with an Intermittently Catheterized Neurogenic Bladder

We evaluated the optimal means of prevention and treatment of urinary tract infections in 46 patients with an intermittently catheterized neurogenic bladder. Suppression with nightly 160 mg. trimethoprim and 800 mg. sulfamethoxazole compared to placebo showed no difference in the rate of symptomatic or total urinary tract infections. Symptomatic urinary tract infections occurred at the same rate whether routine asymptomatic infections were treated or not. Three-day antibiotic treatment of urinary tract infections showed no decrease in the frequency of symptomatic or total urinary tract infections compared to 10-day therapy. The frequency of post-treatment urinary tract infection persistence, relapse and cure was identical in both groups. Suppressive antibiotics, treatment of asymptomatic urinary tract infections and full course antibiotic therapy offered no advantage over placebo, treatment of symptomatic urinary tract infection only and short course therapy in the management of urinary tract infection in patients with an intermittently catheterized neurogenic bladder.

Preoperative lymph node evaluation in prostatic cancer patients who are surgical candidates: the role of lymphangiography and computerized tomography scanning with directed fine needle aspiration.

A total of 53 consecutive patients who were candidates for surgical treatment of prostatic cancer underwent preoperative evaluation of the lymph node status by computerized tomography scanning and/or lymphangiography combined with skinny needle aspiration biopsy of any abnormal lymph nodes. In 7 of 14 patients (50 per cent) ultimately found to have stage D1 disease lymphatic metastases were confirmed histologically with needle biopsy alone, thus, obviating the need for pelvic lymph node dissection. Over-all sensitivity, specificity and accuracy rates were 50, 100 and 91.4 per cent, respectively, for computerized tomography scanning with biopsy and 53.8, 100 and 84.1 per cent, respectively, for lymphangiography with biopsy. Computerized tomography scanning and lymphangiography with aspiration biopsy are cost-effective means to identify approximately 50 per cent of the patients who ultimately have lymphatic metastases.

The Evaluation of Creatinine Clearance in Spinal Cord Injury Patients

The parameters of age, height, weight, serum creatinine and 24-hour urinary creatinine production were measured in 101 consecutive spinal cord injury patients (79 men and 22 women, 43 quadriplegics and 58 paraplegics) admitted to a rehabilitation hospital. Creatinine production was significantly lower than that of age and sex-matched hospitalized controls, upon whom commonly used nomograms for evaluation of endogenous creatinine clearance are based. Therefore, these nomograms grossly overestimate the creatinine clearance in paralyzed patients, which often results in aminoglycoside overdosage. Regression analysis identified the interval since injury and age as important determinants of creatinine production. We propose 2 simple equations and nomograms that should allow more accurate prediction of creatinine clearance in spinal cord injury patients.

Colonic Complications of Renal Transplantation

Colonic complications of renal transplantation occur in 1.9 per cent of the cases. In our series of 587 consecutive renal transplants recipients 3 (0.51 per cent) had colonic complications, including 2 with ischemic colitis and 1 with pseudomembranous colitis. A review of 8 large series describing 2,539 additional renal transplant patients revealed 55 with significant colonic complications. The most common complication was ischemic colitis, which occurred in 29 patients, followed by diverticulitis in 17, pseudomembranous colitis in 5, appendicitis in 3, hemorrhagic proctitis in 1, a disrupted appendiceal stump in 1 and fecal impaction in 1. Etiological factors that may be important in the development of these colonic complications are uremia, blood volume redistribution, immunosuppressive therapy, antibiotic therapy, irradiation and previous retroperitoneal surgery.

Urologic aspects of tethered cord.

Tethered cord syndrome, a form of spinal dysrhaphism, may involve vesical neurologic dysfunction. We present herein 60 cases of tethered cord syndrome, including 24 patients who underwent preoperative urodynamics studies. Preoperative cystometrography revealed areflexic bladders in 71 percent of cases and hyperreflexic bladders in 29 percent. Eight patients had serial pre- and postoperative urodynamics testing. Slight improvement was noted in postoperative urodynamics studies performed on 4 of 6 areflexic bladders and in the only hyperreflexic bladder studied. In addition, of the 3 patients in the serial urodynamics groups who had urinary symptoms preoperatively, 2 noted clinical improvement postoperatively. The urologists role is important in the early detection, evaluation, and treatment of tethered cord syndrome and the neuropathic bladders that may result.

The Effect of Nutritional Status and Support on Morbidity and Mortality of Bladder Cancer Patients Treated by Radical Cystectomy

The role of nutritional assessment and support in patients with bladder carcinoma undergoing radical cystectomy is controversial. Morphometric, visceral protein and cell-mediated immune statuses were measured in 33 patients with bladder cancer treated by radical cystectomy. Malnourished patients had greater operative morbidity, operative mortality and days of intensive care than their nutritionally normal counterparts. Kaplan-Meier survival plots showed a tendency to early death of disease in the malnourished patients with convergence of survival rates after 36 months. Of the malnourished patients 7 had extensive nutritional support, and 6 had no parenteral and minimal enteral or oral support. Operative morbidity and mortality rates were higher in the nutritionally supported than in the unsupported groups. Nutritional support in the immediate perioperative period probably does little to alter operative complications.

Properties of anticancer agents relevant to in vitro determinations of human tumor cell sensitivity

SummaryThe physical properties of 59 anticancer agents have been examined with respect to solubility in tissue culture media, binding to ultrafiltration materials, and molecular absorbance and fluorescence behavior. Methods for dissolving these agents, which are compatible with in vitro sensitivity testing of human tumor cells to anticancer agents, are reported in this paper. The potential for anticancer agent binding to cellulose nitrate/cellulose acetate and teflon membrane ultrafilters was documented, and quantitation of these anticancer agents based upon absorbance and fluorescence spectroscopy was performed. Post-filtration quantitation of anticancer agents was found to be a reliable method for determining the actual drug concentrations available in tumor cell sensitivity testing in vitro. The properties documented herein are pharmacologically relevant parameters related to in vitro determinations of human tumor cell sensitivity to anticancer agents.

The Efficacy of Patient-Controlled Analgesia in Patients Recovering From Flank Incisions

We report on 13 patients undergoing flank incisions in whom the postoperative pain was managed with a patient-controlled analgesia device. An initial group of 7 patients was used to determine the optimal injection dose for each patient and to examine variability in narcotic requirement during the postoperative course. A progressive decrease in narcotic need was noted during the postoperative course with patient-controlled analgesia, resulting in excellent patient acceptance, no postoperative complications and no drug-seeking behavior. A second group of 10 patients was randomized prospectively to receive either patient-controlled analgesia or a standard regimen of intramuscular morphine sulfate. Based on nursing observations, an analgesia and sedation scale was developed that compared the 2 groups. Analysis of a questionnaire evaluating subjective perception of postoperative pain revealed significantly less pain, less sedation and greater activity among patients randomized to patient-controlled analgesia (95 per cent confidence limit).

Esterase Activity, Exclusion of Propidium Iodide, and Proliferation in Tumor Cells Exposed to Anticancer Agents: Phenomena Relevant to Chemosensitivity Determinations

Cellular esterase activity and the ability to exclude propidium iodide were examined after exposing tumor cells to anticancer agents. In general, esterase activity and the ability to exclude propidium iodide continued when cells proliferated and disappeared when proliferation was inhibited. However, with a number of preparations, drug exposure inhibited proliferation while esterase activity and propidium iodide exclusion persisted. These indications of persisting cell function or viability after drug exposure may be relevant to a potential for tumor cell recovery. When the viability of established cell lines progressively declined on days 4 and 7 following drug exposure, recovery did not occur. When proliferative recoveries occurred, viabilities remained elevated. Estimates of in vitro sensitivity by proliferation-related criteria were contrasted by persistent high viability estimates in 22% of the determinations performed with primary tumor cell preparations. The potential for recovery may explain the disappointing ability of proliferative chemosensitivity assays to predict clinical sensitivity.

A Trial of Prophylactic Thiotepa or Mitomycin C Intravesical Therapy in Patients with Recurrent or Multiple Superficial Bladder Cancers

There were 40 consecutive patients with recurrent or multiple superficial stage Ta or T1 transitional cell cancer assigned randomly to receive prophylactic thiotepa or mitomycin C intravesical chemotherapy. Patients received 8 weekly instillations followed by 22 monthly treatments of either 60 mg. thiotepa or 40 mg. mitomycin C. Of 25 patients randomized to receive mitomycin C 4 had recurrence in a total of 337 patient-months (1.19 per 100 patient-months), while disease recurred in 1 of 15 patients randomized to receive thiotepa who were followed for a total of 220 patient-months (0.45 per 100 patient-months). No significant difference in recurrence rate was noted for either drug group (p equals 0.18). Toxicity requiring cessation of therapy was observed in 7 patients (28 per cent) on mitomycin C and none on thiotepa.