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Indoramin, which has great selectivity for alpha-1-receptors, was administered orally for 10 days to 21 patients with urinary retention or residual urine caused by neurogenic vesicourethral dysfunction. After indoramin therapy 17 patients were able to empty the bladder with residual urine less than 50 ml. There was a significant decrease in the maximum urethral pressure (23.87 plus or minus 4.13 cm. water) and in the functional profile length (0.53 plus or minus 0.19 cm.). A diminution in the sphincter electromyography activity was observed in 3 patients. Two paraplegics who were investigated during spinal shock could not achieve voiding after indoramin therapy. However, involuntary urine leakage associated with a change of posture occurred in 2 patients but subsided after the dosage of indoramin was decreased. No other side effect was observed. It may be desirable to use drugs with selective action upon alpha-1-receptors since blockade of noradrenergic autoreceptors (alpha-2) also by nonspecific alpha-adrenoceptor blocking agents, namely phentolamine, phenoxybenzamine and so forth, causes the overflow of norepinephrine, which would produce symptoms such as tachycardia by stimulating beta-receptors.

It has been observed in animal studies that 5-hydroxytryptamine produces bladder contractions. The role of 5-hydroxytryptamine in human vesicourethral function was studied by administering 75 mg. clomipramine daily for 4 days to 8 patients with neurogenic bladder dysfunction. Clomipramine inhibits the uptake of serotonin into 5-hydroxytryptamine containing presynaptic nerve endings and, thus, makes more neurotransmitter available to the postsynaptic site. The intravesical volume, at which first detrusor reflex activity was observed, showed a decrease from 329.5 to 178.5 ml. after clomipramine therapy. The residual urine also decreased from 111.25 to 30.0 ml. No side effect was observed. Further investigations involving a larger number of patients are indicated to study the possible use of serotonin activity in the bladder for promoting bladder emptying.

Two cases are reported of spontaneous rupture of pelvic hydatid cysts into the bladder, which were managed conservatively. The resulting communication between the bladder and the cyst was used advantageously for intravesical instillation of 20% saline to destroy the germinal layer of the hydatid cyst and daughter cysts. Sequential cystographic studies showed disappearance of the extrinsic pressure effect on the bladder as the daughter cysts were evacuated repeatedly per urethram after instillations. Spontaneous sealing off of the communication was documented and confirmed by cytoscopy in 1 case. A plea is made to adopt a non-operative approach in such cases, which permits intravesical and, hence, intracystic scolecidal agent instillation and achieves spontaneous evacuation of daughter cysts. Other factors encouraging conservative management whenever possible are the reportedly high recurrence rate of hydatid cysts postoperatively, the morbidity described with complete excision of pelvic and other hydatid cysts, and the inherent slow process of recurrence (between 5 and 20 years) after complete evacuation of daughter cysts.

Beta-adrenergic activity of the proximal urethra was studied in 11 patients. Maximum urethral pressure was recorded before, and 20 and 60 minutes after the intravenous administration of 0.5 mg. orciprenaline sulfate. There was a 40 per cent or more decrease in the maximum urethral pressure in 6 of the 11 patients. Beta-adrenoreceptor agonists could prove useful in facilitating vesical emptying by reducing urethral resistance in patients with neurogenic bladder dysfunction.

A case of blowout of the colonic segment of a colocystoplasty at its free end owing to late development of bladder neck obstruction is described. Prostatitis and secondary bladder neck contracture provided further hindrance to the already inefficient voiding mechanism and predisposed to the rupture of the decompensated bowel loop. This is an extreme example of proof that the colonic loop, except as an improved substitute for an ileal segment, cannot withstand high intraluminal pressures generated in the presence of bladder outlet obstruction.

Beta-adrenergic activity in the proximal urethra was studied in 15 patients with neurogenic bladder dysfunction owing to spinal cord injury or to neurogenic disease. Maximum urethral closure pressure was recorded before and after the administration of terbutaline, a beta-2 agonist. The average decrease in maximum urethral closure pressure after subcutaneous injection of terbutaline was 40.46 per cent and this was significant (p less than 0.001). The clinical implications of this finding are discussed.

Continuous vesical irrigation with 1 per cent alum solution was performed without anesthesia in 9 patients in whom massive bladder hemorrhage persisted despite evacuation of clots and normal saline irrigation for at least 24 hours. Hematuria ceased promptly in all patients, although the effect was transient in 3. No side effect was observed. Biopsy of the tumor subsequent to alum irrigation showed no alteration in the histological characteristics. Biopsy of the normal-appearing bladder mucosa also showed no evidence of epithelial damage. Ultrastructure of the tumor in 1 patient in whom transurethral resection was performed 2 weeks after alum irrigation revealed well preserved nuclear chromatin, thus, suggesting that whatever changes occur after alum irrigation are short-lived.

We report a case of an organized hematoma of the spermatic cord, resulting from direct blunt injury, and review the literature related to this condition. The probable factors accounting for the infrequent occurrence of this lesion in association with external genital trauma are discussed.

A case is reported in which a long upper ureteral stricture, resulting from a failed pyeloureteroplasty, was repaired using a pedicle bladder tube. A vesico-psoas hitch was performed as the initial procedure. A 17 cm. long bladder flap was based posteriorly and extended across the dome and the anterior wall onto the contralateral posterolateral aspect of the bladder. Stepwise stretching and hitching of the bladder flap to the psoas major muscle at 5 places ensured successful bridging of the gap without compromising its vascularity. At followup cystography the bladder tube was noted to accommodate the reflux of contrast material, preventing its entry into the pelviocaliceal system. The patient regained a bladder capacity of about 300 ml. This procedure should be considered before ileal ureteral replacement or autotransplantation in cases of extensive ureteral loss.

Vesical calculi were detected in 5 patients with a vesicovaginal fistula. Of these patients 3 had undergone unsuccessful repair of the fistula previously. The predisposing factors for vesical calculous formation in patients with a vesicovaginal fistula in whom urine leaks continuously into the vagina and urinary stasis does not occur in the bladder, as in patients with neurogenic bladder dysfunction or bladder outlet obstruction, are a foreign body (for example nonabsorbable suture material used during previous surgery), incrustation around an indwelling catheter and infection. The vesical calculus is removed transvaginally after enlarging the fistula by a vertical incision at the 6 o'clock position. The incised edges do not usually bleed because of fibrosis and scar formation, and they need not be approximated at that operation. Indwelling catheter drainage is not necessary after transvaginal cystolithotomy in this situation. This operation is preferable to suprapubic cystolithotomy, which may lead to more morbidity from urine leakage in the retropubic space and subsequent fibrosis, in addition to producing bladder scarring, hindering any future reconstructive surgery requiring the use of vesical flaps. Transvaginal cystolithotomy is contraindicated when the fistula is situated close to the bladder neck (for fear of damaging the bladder neck and the vesical continence mechanism) or when the stone is large. Repair of the fistula is undertaken after an interval of 3 months to allow for resolution of stone-induced edema and friability of the vesical wall.

An intravenous injection of 0.4 mg. naloxone enhanced detrusor reflex activity in 5 patients with chronic neurogenic bladder dysfunction caused by incomplete suprasacral spinal lesions. The intravesical volume at which detrusor reflex occurred showed a decrease from 498.2 to 346.2 ml. The naloxone-induced effect was short-lived, being absent 1 hour after the injection. In the same dosage naloxone did not induce detrusor reflex in 2 patients with areflexic bladder caused by complete suprasacral spinal lesions.

The spectrum for the use of retrograde pyelography in renal failure has been narrowed further by extending the facility of infusion urography to anuric patients. The latter study has helped greatly in sifting apart pre-renal and renal anuria patients from those with obstructive uropathy. In obstructive anuria infusion urography has proved comprehensive in influencing judgment about the exact site and nature of obstruction, in affixing laterality towards the better functioning renal unit and in deciding a suitable definitive operation or planned staged procedures.