Ruben F. Gittes

No-Incision Pubovaginal Suspension for Stress Incontinence

We describe a modified needle suspension for urinary incontinence that eliminates all incisions. The anterior vaginal wall is suspended from the rectus fascia with 2 heavy nonabsorbable monofilament mattress sutures. The sutures pass down through and back up through the full thickness of the vaginal wall, and are tied suprapubically to bury the knot into the fat in the suprapubic puncture site. The technique is based on our laboratory observation that in rats and guinea pigs monofilament mattress sutures that are tied under tension to include the outside abdominal skin will cut through the skin, and become internalized and accepted without any residual inflammation if the knot is buried initially. The simplified technique makes routine use of outpatient surgery and allows for the use of local anesthesia only in selected patients. At 2 1/2 years the continence rate in the first 38 patients exceeded 87 per cent. There were no failures among the last 14 patients after the technique was modified to include an extra full thickness pass of the mattress suture through the vaginal wall. There have been no significant complications.

Treatment Options for Proximal Ureteral Urolithiasis: Review and Recommendations

The treatment of proximal ureteral calculi has been altered markedly by recent developments in shock wave lithotripsy (bypass, pushback and in situ), ureterorenoscopy and percutaneous stone removal. In an effort to discern the proper role of these newer treatment options with respect to ureterolithotomy (flank approach or dorsal lumbotomy), we completed a multicentered study in which 142 upper ureteral stone patients in 7 different treatment categories were reviewed retrospectively and contacted for convalescence data. From these data we conclude that before extracorporeal shock wave lithotripsy an upper ureteral stone should be manipulated until it is either pushed back to the kidney or bypassed with a stent. This maneuver should result in successful extracorporeal shock wave lithotripsy in more than 90 per cent of the patients. For those few patients with an impacted upper ureteral calculus ureterorenoscopy is recommended. Given the presently available treatment modalities we conclude that less than 3 per cent of all upper ureteral calculi will require ureterolithotomy. In this last circumstance a dorsal lumbotomy incision appears to be less morbid and yet as effective as anterior ureterolithotomy.

Reconstruction of the Urinary Tract by Cecal and Ileocecal Cystoplasty: Review of a 15-Year Experience

AbstractOf 45 consecutive patients 22 underwent urinary tract undiversion by ileocecal cystoplasty and 23 underwent bladder augmentation by either ileocecal or cecal cystoplasty. Followup ranged from 1 to 15 years. Our experience shows the functional limitations of the cecum as a bladder substitute and emphasizes the need for careful patient selection and long-term followup.

Review of an 8-year experience with modifications of endoscopic suspension of the bladder neck for female stress urinary incontinence.

Several modifications of endoscopic suspension of the bladder neck for treatment of female stress urinary incontinence have been used during an 8-year period. Of 154 patients treated 25 failures occurred, for an over-all success rate of 84%. Fifteen patients had postoperative complications for an over-all complication rate of 9.8%. Hospital stay decreased steadily throughout the review period to a current average of 2.2 days, with many patients presently undergoing an operation on an outpatient basis.

Carcinoma of the Adrenal Cortex

Adrenal cortical carcinoma is a rare tumor that affects all ages and sexes and has a dismal prognosis. Half are functional, half are not. Early stages are uncommon and are detected by their endocrine effects, usually in females, as incidental findings at surgery or on computed tomography scans. Arteriography, venography, and CT‐scan define the local disease. Endocrine evaluations may delay surgery and do not affect the treatment. Radical local surgery with wide exposure is indicated in all adrenal tumors except the radiologically defined small tumor of pure primary hyperaldosteronism. Thoracoabdominal incisions, extra‐fascial dissection, nephrectomy, splenectomy, and partial pancreatectomy may be used. Adjunctive chemotherapy or radiation have not been tested. Cures are recorded only in widely‐excised, low stage tumors without evidence of metastases (T 1‐2 NOMO). Ortho‐p‐DDD is useful in less than half the cases, functional or not. Phase II studies and collaborative combined chemotherapy treatment studies are badly needed.

Sexual Impotence: The Overlooked Complication of a Second Renal Transplant

The incidence of sexual impotence in 20 men who have received at least 2 kidney transplants was 65% compared to 10% after the first transplant. The importance was transient (2 to 4 months) in both affected men after the first transplant but permanent (2 to 10 years) in 6 men after the second operation. We attribute this increased percentage of impotence to the second end-to-end arterial anastomosis that requires division of the internal iliac arteries. We suggest that the second transplant be placed end-to-side into the common iliac artery.

The Role of Germinal Epithelium and Spermatogenesis in the Privileged Survival of Intratesticular Grafts

The testis is an immunologically privileged site. Since earlier studies excluded testicular steroid production as an essential factor, the present study evaluates the role of germ cells and spermatogenesis in the privileged survival of allografts within the testis. We used a Sertoli cell-only testis model and adolescent unilateral cryptorchidism in inbred rats to eliminate germ cells and spermatogenesis selectively. Parathyroid allografts were implanted into these sites, normal testes and beneath the renal capsule (a nonprivileged site) in appropriately matched controls. With at least 15 rats in each group, privileged allograft survival was shown to be unaffected by eliminating germ cells and spermatogenesis (p less than .005). Experimental evidence suggests the presence of an active process which incidentally permits privileged allograft survival within the testis, but which exists teleologically to protect the developing sperm from autoimmune attack. This is in addition to the passive anatomical separation provided by the blood-testis barrier. Our cumulative data strongly implicates the Sertoli cell in this process.

Urological Management of Patients with Von Hippel-Lindau’s Disease

We present our experience with 7 patients with von Hippel-Lindaus disease. Five patients had bilateral renal tumors and 2 had pheochromocytomas. Staging is accomplished best with abdominal computerized tomography and renal angiography. Computerized tomography is the preferred method to follow the patients. Because of the tendency for these patients to have bilateral renal involvement, surgical efforts should be directed toward preserving renal parenchyma without compromising adequate tumor excision. Of the 7 patients 6 are alive 4 months to 8 years postoperatively. One patient had metastatic disease at autopsy. No patient required dialysis or renal transplantation. The relationship between the multifocal renal cysts and renal carcinomas in this disease remains unknown.

The physiologic basis of the TUR syndrome

To better assess the role of hyperammonemia versus hypoosmolarity versus hyponatremia in the TUR syndrome, we developed a rat model. Sprague-Dawley female rats received an intraperitoneal injection (250 cc/kg body weight) of either 1.5% glycine, 2.0% glycine, 2.0% glycine plus 1.5% mannitol, 3.0% mannitol, 5.0% mannitol, or 2.0% glycine plus 0.25% saline. Arterial blood samples were obtained prior to injection, at 2, 8, 16, and 24 hr and analyzed for osmolarity, sodium, and ammonia. Those animals receiving 2.0% glycine, 2.0% glycine plus 1.5% mannitol, and 5.0% mannitol all died within 24 hr with lethargy, convulsions, and coma. Hyponatremia developed in all animals; death, however, occurred only when the sodium concentration declined to 90-95 meq/dl. Mannitol maintained serum osmolarity but did not prevent coma and death. Including 0.25% saline in the initial injection, or an iv injection of 5.0% saline delayed 8 hr achieved 100% survival. Ammonia concentrations increased 15-fold by 8 hr in groups receiving 2.0% glycine; it rapidly decreased to near normal by 24 hr. Decreasing the rise in ammonia by 50% with iv arginine had no effect on survival. Our results suggest that hyponatremia rather than hyperammonemia or hypoosmolarity accounts for the major morbidity and mortality secondary to the TUR syndrome.

Dissolution of Residual Renal Calculi with Hemiacidrin

Hemiacidrin irrigation of the renal collection system via nephrostomy for the dissolution of residual postoperative calculi is described in 14 cases. The irrigation successfully dissolved 13 to 16 caliceal calculi. It did not dissolve any parenchymal calcifications. No known stones of pure calcium oxalate or apatite have been dissolved. Residual stones can safely be dissolved with hemiacidrin irrigation via nephrostomy if clear open drainage and scrupulously sterile urine are maintained.