Terry W. Hensle

Transureteroureterostomy: Experience with 75 Cases

Since 1969 transureteroureterostomy has been done on 75 patients, mostly children. In the majority of cases the procedure was used simultaneously with reimplantation of the opposite ureter. The patients had been referred with previous failed ureteral reimplantation or for undiversion. The complication rate was low. Many of the cases could not have been reconstructed except by use of transureteroureterostomy or transureteropyelostomy. Transureteroureterostomy is a useful procedure that should be considered in a wide variety of urologic cases. By following certain general principles of avoiding tension, angulation and devascularization it can be done with a high success rate and few complications.

Primary closure of bladder exstrophy: Long-term functional results in 137 patients

Between 1945 and 1985, 207 patients were treated at our institution for exstrophy of the urinary bladder. Primary anatomical bladder closure was performed in 137 patients. In 97 patients treated prior to 1975, bladder closure was performed at a median age of 1 year and continence in this group was only 16%. Forty patients treated after 1975 underwent closure at a median age of 72 hours followed by staged reconstruction of the bladder neck. Continence in this group was 82%; however, the average number of surgical procedures was five as compared with two in the first group. Early bladder closure and staged reconstruction can achieve acceptable urinary continence, but multiple surgical procedures may be required.

Protein-sparing in cystectomy patients.

Forty-four patients undergoing radical cystectomy and urinary diversion for invasive bladder cancer were studied prospectively in order to evaluate the substitution of crystalline amino acids (A3W) for dextrose (D5W) in their postoperative fluid management. Nutritional assessment revealed 17 (39%) patients to be malnourished prior to operation; the postoperative complication rate in Group I (D5W) was 33% vs 17% in Group II (A3W). Nitrogen losses in both groups were low, secondary to the large amounts of albumin used postoperatively; however, more exogenous albumin was needed after operation to maintain serum albumin levels in Group I compared with Group II (77.5 +/- 3.1 gm vs 65 +/- 5.2gm). Cell-mediated immunity, determined by reactivity to a battery of recall antigens, revealed that 56% (5) of Group I patients were able to maintain their skin test reactivity throughout the postoperative course compared with 94% (17) in Group II. Four nutritionally depleted patients in Group I required conversion to a forced feeding regimen (IVH), while none of those in Group II required a change in nutritional regimen. Invasive bladder cancer represents a major injury, and preoperative x-ray therapy along with surgical extirpation is associated with considerable nutritional depletion. Early nutritional support in the management of these patients is mandatory, and where hypocaloric feeding regimens are appropriate, the use of A3W in place of D5W solutions would appear to be indicated.

Diagnosis and treatment of a urinary leak after ureteroileal conduit for diversion.

Of 1,120 cases of ileal loop urinary diversion reviewed from our hospital 21 postoperative loop leaks were noted (1.87 per cent). Definite indications for diagnostic studies of urinary extravasation include persistent postoperative azotemia, sepsis and/or urinary leakage via the drains. In this series 2 types of loop leaks were noted--an early postoperative leak within the first 24 hours and a leakage 6 to 12 days postoperatively. More aggressive management of postoperatively urinary extravasation is urged, especially in patients who had been irradiated and suffered leakage later on in the postoperative course.

Ileal conduit hemorrhage secondary to portal hypertension.

The clinical features and management of 3 patients who presented with the triad of massive hemorrhage from the ileal conduit, portal hypertension due to liver disease, and portosystemic varices related to the conduits are described. One patient, a class C cirrhotic, was treated conservatively and died of blood loss and hepatic coma. Two patients were managed with splenorenal shunts initially, followed by creation of colon conduits, and are currently doing well. Surgical approximation of areas draining in the portal and systemic circulation with subsequent development or adhesion-related varices probably explains the predilection for involvement of the ileal conduit and may explain the presence of varices in mild to moderate portal hypertension before other signs of hepatic decompensation are evident. Superior mesenteric angiography with special attention directed at the venous phase is necessary to document this entity.

The Diagnostic Approach to Ectopic Ureterocele and the Renal Duplication Complex

The child with ectopic ureterocele frequently presents a diagnostic challenge. The use of standard excretory urography combined with newer modalities, such as ultrasonography and radionuclide renal scanning, provides an orderly diagnostic approach to ectopic ureterocele. This integrated approach should ensure the highest yield in a diagnostic sense and aid in assessing upper tract function, thus, helping with the selection of the proper surgical management.

Minocycline Diffusion into Benign Prostatic Hyperplasia

Minocycline, a broad-spectrum, highly lipid soluble tetracycline that has generated interest in the treatment of chronic prostatitis, was evaluated for its possible ability to be concentrated in benign prostatic hyperplasia. Drug levels in the prostate, plasma, fat, muscle and urine were measured in patients undergoing open prostatectomy after preoperative intravenous minocycline. The concentrations of the drug in the prostate and serum were close (4.16 versus 3.01 microgram. per gm.), while drug levels in striated muscle and fat were consistently lower (2.92 and 0.77 microgram. per gm). Higher preoperative doses of drug yielded higher tissue levels. Drug delivery closer temporally to the operation yielded higher serum and prostatic levels as opposed to striated muscle and fat, suggesting a rapid diffusion of the drug into benign prostatic hyperplasia.

Posterior urethral valves in the newborn: Treatment and functional results

Between 1977 and 1984, 30 newborn boys were diagnosed and treated with posterior urethral valves. Presenting symptoms varied but included respiratory distress, oligohydramnios, urinary ascites, abdominal mass, urinary retention, and renal insufficiency. Diagnostic modalities consisted of excretory urography and voiding cystourethrography in all patients and ultrasonography in 20 (12 prenatal). Treatment consisted of valve ablation alone in 14, vesicostomy and later valve ablation in 4 premature infants, valve ablation and later upper tract reconstruction in 8, loop ureterostomy in 2, and valve ablation and immediate reconstruction in 2. Follow-up in our patients has demonstrated that even though surgical reconstruction may be technically successful, ultimate functional outcome may be dependent upon the degree of renal impairment at presentation.

Urologic manifestations of wegener granulomatosis

Wegener granulomatosis is a disease characterized by necrotizing granulomatous angiitis involving the upper and lower respiratory tracts and the kidneys. The introduction of cyclophosphamide in the treatment of Wegener granulomatosis has dramatically altered the rapidly fatal course of the disease and has altered our thinking regarding its management. Recently we have cared for 3 patients who demonstrated a dramatic spectrum of urinary tract pathology related to Wegener granulomatosis. The cases presented offer three points for consideration by the urologist: (1) the manifestations of the disease in the genitourinary tract can be varied and can present in a dramatic fashion; (2) the rapid progression of renal failure and the nearly uniform mortality associated with the disease have changed largely because of the use of cyclophosphamide; and (3) our approach toward patients with renal failure on the basis of Wegener granulomatosis can be altered, and renal transplantation is certainly feasible with the increased longevity afforded these patients by cyclophosphamide.

Autosuturing device in intestinal urinary conduits

The autosuturing device has been used to close the base of 41 urinary intestinal conduits: 12 colonic, 25 ileal, and 4 jejunal. The techniques are described. There were no urine or bowel leaks, although in one postoperative gastrointestinal bleeding occurred in association with a partial small-bowel obstruction probably related to the stapled enteroanastomosis. Use of the instruments reduced peritoneal contamination and facilitated conduit manipulation. Operating time was reduced. Four patients have passed stones composed of struvite and apatite with staples embedded within. The autosuturing device should be considered an alternative rather than a substitute for conventional proximal conduit closure and bowel anastomoses.