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Ureteral inguinal hernias are a well-described entity, within the spectrum of sliding hernias, with over 140 cases described since 1880. Though herniation of the ureter is relatively rare and complete ureteric obstruction is infrequent, a massive herniation may cause complete obstruction, leading to hydronephrosis. Management of these hernias is challenging and poses a significant danger of inadvertent injury and entrapment of a tortuous ureter. When faced with this type of hernia, extreme care should be taken to perform the appropriate preoperative workup and thoroughly plan the surgical approach. The present case describes a patient with a known ureteral inguinal hernia, who underwent a laparoscopic repair of the hernia with mesh placement.

The clinical presentations of 119 canine seizures from 41 Standard Poodles and 11 Dalmatians were classified according to a modified version of the International League Against Epilepsy (ILAE) seizure classification system. Standardized use of the ILAE system with dogs not only should facilitate research in veterinary medicine, which has no standard criteria for seizure classification, but also should facilitate comparisons between canine and human seizures. We found that for more than 80% of both breeds, at least some of their seizures had partial onsets. However, because it was common for partial seizures to secondarily generalize, the majority of Poodles (81%) and Dalmatians (91%) experienced at least some generalized seizures. Among partial seizures, complex partial were more frequent than simple partial. For both breeds, two thirds of those with partial onset seizures had exclusively complex partial. Among dogs with primary or secondarily generalized seizures, 80% of both breeds had tonic-clonic seizures.

Purpose: We describe a surgical modification of the Nesbit procedure to correct Peyronie's disease, and compare the results of this procedure with those of 2 other surgical techniques.Materials and Methods: In 30 patients a vertical incision in the tunica albuginea was closed in a horizontal fashion with permanent suture knots buried beneath the tunica in a running looped fashion, resulting in watertight closure with no exposed suture material. A standard Nesbit procedure and plaque excision with a polyethylene terephthalate mesh reinforced silicone sheet patch graft were done in 28 cases each.Results: Elimination of penile curvature, patient satisfaction and postoperative impotence rates were not statistically different for standard and modified Nesbit procedures. However, plaque excision and synthetic patch grafting resulted in less elimination of curvature (61%, p = 0.004), a lower rate of satisfaction (30%, p = 0.00002) and a higher incidence of impotence after surgery (18%, p = 0.04). The mod...

Purpose: We evaluated the relative use of RigiScan* *Dacomed, Minneapolis, Minnesota. measurement of radial rigidity compared to sleep laboratory measurement of axial rigidity and trained observer determination of erectile function in the diagnosis of organic impotence.Materials and Methods: A total of 28 patients underwent simultaneous 2-night formal sleep laboratory nocturnal penile tumescence and RigiScan monitoring. Standard normal values for radial rigidity and axial rigidity were tested for accuracy in predicting normal nocturnal penile tumescence compared to trained observer determination of the adequacy of an erection for penetration.Results: RigiScan tip measurements correlated poorly with buckling pressure, while base measurements strongly correlated (p = 0.0005). Observer determination of a functional erection was strongly associated with tip (p = 0.002), base (p = 0.0005) and buckling pressure measurements (p = 0.0005). Using observer determination as the gold standard receiver operati...

Erectile dysfunction can result from blunt or penetrating pelvic or perineal trauma. Rupture of the corpora cavernosa leading to loss of the veno-occlusive mechanism and penile artery occlusion have been found in these patients. We present a case of immediate loss of erectile function after penetrating perineal trauma resulting in corpus cavernosum rupture and traumatic occlusion of multiple arteries in the hypogastric-cavernous bed. Conservative management of the corpus injury resulted in post-traumatic aneurysmal dilation at the site of injury with venous leakage from aberrant veins. Penile arterial revascularization and aneurysm repair with deep penile venous ligation resulted in near-complete return of normal erectile function.

Purpose: We determine the colony counts of organisms present on culture of clinically uninfected genitourinary prostheses at reoperation for reasons other than infection. These results served as control data for comparison with cultures from infected devices to determine the relative incidence of organisms involved.Materials and Methods: Cultures were prospectively obtained from 65 penile prostheses and 22 artificial urinary sphincters. Patients were followed for a minimum of 12 months after reoperation or until development of infection (mean 27 months) at which time cultures were again obtained.Results: Low colony counts of Staphylococcus epidermidis were isolated from 40 percent of uninfected penile prostheses and 36 percent of artificial urinary sphincters. Only 3 of these devices later became infected (9 percent) and in all cases a higher colony count of another organism was found at explantation.Conclusions: While Staph. epidermidis can cause prosthesis infection, low colony counts of the org...

There is controversy concerning the management of small unilateral renal cell carcinomas. The present study was undertaken to evaluate the relative efficacy of radical nephrectomy versus nephron-sparing surgery in such patients.Patients with a single, small (less than 4 cm), localized, unilateral, sporadic renal cell carcinoma (RCC) were identified from an institutional registry. From 1975 to 1992, 88 patients fulfilling these criteria were treated with either radical nephrectomy (n = 42) or nephron-sparing surgery (n = 46). The mean postoperative follow-up interval is 48 +/- 29 months.The radical and nephron-sparing surgical groups were well matched for patient age, sex, renal function, diabetes, hypertension, tumor size, tumor location, and tumor stage. All patients in both groups had low pathologic stage RCC. There was no difference between the two groups in terms of the mean hospital stay, the requirement for blood transfusions, or the occurrence of surgical complications. There was no difference in the mean preoperative and postoperative serum creatinine levels for patients in the nephron-sparing surgery group. However, the mean postoperative serum creatinine levels were significantly higher than the mean preoperative levels for patients in the radical nephrectomy group (P0.001). A single patient in each group developed recurrent RCC postoperatively. The cancer-specific 5-year survival rate for patients in the radical and nephron-sparing surgical groups is 97% and 100%, respectively.Radical nephrectomy and nephron-sparing surgery each provide safe and effective curative treatment for patients with a single, small, unilateral localized RCC. The long-term renal functional advantage of nephron-sparing surgery in this setting is not established.

From 1956 to 1992 nephron sparing surgery was performed in 216 patients with sporadic renal cell carcinoma. Renal cell carcinoma was suspected in 121 patients and was an incidental finding in 95. Compared to suspected renal cell carcinoma, incidental tumors were smaller (p = 6.0004), more often unilateral (p = 0.001) and of lower pathological stage (p = 0.001). Incidental tumors were also associated with improved 5-year cancer-specific survival (p = 0.003) and a lower rate of postoperative tumor recurrence (p = 0.001).The overall 5-year cancer-specific survival rate was improved in patients with stage I versus higher stage renal cell carcinoma (p = 0.0002), unilateral versus bilateral disease (p = 0.0001), a single versus multiple tumors in the operated kidney (p = 0.01) and tumors smaller than 4cm. versus larger tumors (p = 0.03). There were no postoperative tumor recurrences and the 5-year cancer-specific survival rate was 100% in patients with unilateral, stage I tumors smaller than 4cm. These ...

We treated 31 patients with renal oncocytoma. Renal cell carcinoma was found existing separately within the same or contralateral kidney in 10 patients (32%). Followup of 29 patients revealed 24 alive with no evidence of disease and 1 alive with recurrent oncocytoma, while 1 with coexistent tumors died of progressive renal cell carcinoma and 3 tumor-free patients died of unrelated diseases. Quantitative deoxyribonucleic acid analysis was performed on cell suspensions of fresh tumor by flow cytometry or by image cytometry on touch preparations from frozen tissue in 16 patients with renal oncocytoma. Ploidy analysis revealed all oncocytomas to be diploid. Frozen tissue immunohistology was performed using murine monoclonal antibody against human HLA-A, B and C (class I) antigens with the avidin-biotin peroxidase technique in 11 patients with renal oncocytoma. Ten oncocytomas did not express these self-recognition antigens and 1 was only weakly positive for antigen expression. In contrast, renal cell carcinomas strongly expressed HLA class I antigens. The high incidence of coexistence of renal oncocytoma and renal cell carcinoma has important clinical implications. Loss of HLA class I antigen expression by renal oncocytomas may provide an additional method for differentiating this lesion from renal cell carcinoma.

Objective—To determine clinical characteristics and mode of inheritance of seizures in a family of Standard Poodles. Design—Case series. Animals—90 Standard Poodles descended from the same maternal bloodline (30 with probable idiopathic epilepsy [PIE] and 60 without any history of seizures). Procedures—Researchers contacted owners to determine whether dogs had ever had any seizures and, if so, the nature of any such seizures and any potential underlying causes. Dogs were considered to have PIE if they were between 6 months and 7.5 years old at the time of seizure onset and had no evidence of any underlying cause. To determine the mode of inheritance, segregation analyses were designed to allow the family to be analyzed as a whole, as opposed to as nuclear families. Competing models of inheritance were compared statistically for their ability to explain the data. Results—Of the dogs with PIE, 28 (93%) had focal onset seizures with or without secondary generalization. Median age of onset was 3.7 years; 6 dogs were > 5 years old at the onset of seizures. Segregation analyses strongly suggested that PIE was inherited as a simple recessive autosomal trait with complete or almost complete penetrance. Conclusions and Clinical Relevance—Results suggested that in this family of Standard Poodles, PIE was inherited as a simple recessive autosomal trait with complete or almost complete penetrance. Seizures often had focal, as opposed to generalized, onsets, and it was not uncommon for seizures to begin after 5 years of age.

Seventy-four people with Parkinson's disease (PD) completed questionnaires and were interviewed to determine the degree to which the severity of PD and perceptions of primary and secondary control over PD predicted psychosocial adjustment. Significant unique contributions to PD-related participation restrictions were made by disease severity (positive relationship) and perceived internal secondary control (negative relationship). Also, participation restrictions had a significant direct effect, and disease severity and perceived internal secondary control significant indirect effects, on both depressive symptomatology and life satisfaction. Results are consistent with theories that suggest the importance of enhancing internal secondary control processes in situations in which actual control over objective circumstances is limited, such as with chronic and progressive diseases like PD.

Despite the prevalence and availability of high-technology diagnostic tests, the history and physical examination continue to serve as the most important initial clinical tools in assessing a patient’s condition. In urology, a urinalysis complements the history and physical examination, and a diagnosis can often be made and others excluded based on these findings alone. In an era of cost containment, an accurate history, physical examination, and urinalysis in the office can speed clinical diagnosis and determine appropriate therapy without the use of unnecessary and sometimes costly testing.

Radical retropubic prostatectomy remains a popular therapy for localized prostate caner and is frequently performed in most urological practices. We describe our current technique for this procedure developed from watching many experienced surgeons, studying other published descriptions, and our own surgical experience over the last decade. We recognize that there are many ways to accomplish the goals of any operation and describe what has worked best for us in terms of pathological and functional results.

Objective: To study the effect of in vitro culture on the quality of human testicular sperm and the efficiency of intracytoplasmic sperm injection with in vitro cultured testicular sperm. Design: Clinical study. Setting: A private IVF center. Patient(s): Twenty consecutively seen IVF patients undergoing testicular biopsies for ICSI. Intervention(s): The testicular specimens were cultured in vitro for 24 hours and the isolated spermatozoa were microinjected. Main Outcome Measure(s): Preincubation and postculture sperm motility, and fertilization, implantation, and pregnancy rates after intracytoplasmic sperm injection. Result(s): Motility increased from initial nonmotile or twitching sperm to free motile sperm in 18 of 20 cases. The injection of in vitro cultured testicular sperm resulted in a fertilization rate of 58%, an implantation rate of 20%, and a pregnancy rate of 45%. Conclusion(s): A testicular biopsy procedure can be performed the day before egg retrieval. Despite the low initial sperm quality, a high percentage of the prepared testicular sperm showed increased motility after 24 hours of culture. The injection of in vitro cultured testicular sperm into matured oocytes resulted in fertilization, implantation, and pregnancy rates comparable to those obtained with ejaculated sperm.

In response to sexual stimulation, sildenafil effectively potentiates the natural dilatation of arteries supplying blood to the penis and corpora cavernosa. The drug is well tolerated and appears to have few significant side effects and a limited number of drug interactions. It adequately satisfies the medical and public desire for a discreet, noninvasive form of therapy for erectile dysfunction. Generally, however, patients with psychogenic erectile dysfunction and those with mild organic causes are most likely to benefit from sildenafil. The drug will likely not be as effective in patients with more significant medical problems. Despite direct marketing of the drug to patients, and media coverage that has bordered on sensationalism, it remains incumbent upon the physician to evaluate and counsel the patient thoroughly prior to prescribing the drug because its true efficacy and safety will not be known for some time.

Objectives. To assess the effect of preservation of the bladder neck and other factors on the rate of postoperative urinary continence and cancer control after radical prostatectomy. Methods. Prospective analysis of clinical and pathologic findings in 206 consecutive patients undergoing radical prostatectomy with a surgical technique that emphasizes preservation of periurethral supporting tissue, urethral length, incorporation of the posterior periurethral fascia into the vesicourethral anastomosis, and preservation of the bladder neck. Results. Uni- and multivariate statistical analysis demonstrated that patient age(p = 0.033) and vesical neck contracture (p = 0.047) were predictive of incomplete return of urinary control. Preservation of the vesical neck had no impact on return of continence, but was associated with a trend to a lower incidence of vesical neck contractures. A positive bladder neck margin occurred in 6.8% of surgical specimens and was associated with a higher grade, more advanced local stage, and other positive margins in all cases. The rate of local recurrence or prostate-specific antigen (PSA)-only failure was similarly independent of whether the vesical neck was preserved or resected and reconstructed. Conclusions. Age greater than 65 and occurrence of a vesical neck contracture are adversepredictors for return of urinary continence after radical prostatectomy. Preservation of the bladder neck does not have an impact on return of urinary control but may be associated with a lower risk of vesical neck contracture. Preservation of the bladder neck does not compromise cancer control as assessed by local or PSA-only failure rates.

To assess the impact of shortened hospital stay after radical retropubic prostatectomy for localized prostate cancer on complication rates and hospital costs.A comparison of results between 171 consecutive patients undergoing radical retropubic prostatectomy between July 1989 and January 1993 (group 1) and 101 consecutive patients operated on since February 1993 (group 2) during a prospective effort to reduce hospital length of stay by home-based preoperative bowel preparation, direct admission to the operating room on the day of surgery, earlier and more extensive postoperative ambulation, earlier initiation of postoperative oral intake, earlier use of oral analgesics, and routine pelvic drain removal at 72 to 96 hours after surgery independent of volume of drainage.Median length of stay was reduced from 8 to 5 days (p0.0001, group 1 versus group 2), with 10% of patients in group 2 having hospital stays of 4 days or less. The overall nature and rate of complications (13.5% versus 11.9%, p = NS) were similar in both groups. Reduced length of stay was associated with a 32% decrease in hospital-associated cost per case in group 2 versus group 1 for patients in diagnosis-related group (DRG) 334 (radical prostatectomy with comorbidity) and a 26% decrease for DRG 335 (radical prostatectomy without comorbidity).Reduced hospital length of stay after radical retropubic prostatectomy results in significant cost savings without increasing morbidity.

The technical results of 259 nephron sparing operations for renal cell carcinoma or renal oncocytoma were reviewed. Local or renal related complications occurred after 78 procedures (30.1%). The incidence of complications was less for operations performed after 1988 (22% versus 37%, p = 0.009) and for incidentally detected versus suspected tumors (p = 0.009). The most common complications were urinary fistula formation (45 operations) and acute renal failure (33). Significant predisposing factors for urinary fistula formation included central tumor location (p = 0.001), tumor size greater than 4 cm. (p = 0.001), the need for major reconstruction of the collecting system (p = 0.001) and ex vivo surgery (p = 0.001). Only 1 urinary fistula required open operative repair, while the remainder resolved either spontaneously (30) or with endoscopic management (14). Significant predisposing factors for acute renal failure included a solitary kidney (p = 0.001), tumor size greater than 7 cm. (p = 0.008), greater than 50% parenchymal excision (p = 0.001), greater than 60 minutes of ischemia time (p = 0.035) and ex vivo surgery (p = 0.001). Acute renal failure resolved in 28 patients, of whom 9 required temporary dialysis, while 5 required permanent dialysis. Overall, 8 complications (3.1%) required repeat open surgery for treatment while all other complications resolved with noninterventive or endourological management. Surgical complications contributed to an adverse clinical outcome in only 7 patients (2.9%). Nephron sparing surgery can be performed safely with preservation of renal function in most patients with renal tumors.

Purpose To evaluate the ability of an expanding hydrogel lung biopsy tract plug ("plug") to reduce rates of pneumothoraces and other complications associated with computed tomography (CT)-guided lung biopsy. Materials and Methods A total of 339 subjects (mean age, 67 years) who underwent lung biopsy of indeterminate masses, without immediate postsample CT evidence of a pneumothorax, were randomized at 15 U.S. centers. Treatment subjects ( n = 170) received a plug deployed through the coaxial needle just before the needle was removed. Control subjects ( n = 169) did not receive a plug. The primary end point was defined as the absence of pneumothorax on chest radiographs at all three required postprocedure assessments (30- to 60-minute, 24-hour, 30-day); analysis was stratified by any smoking history and study site. A central laboratory performed blinded independent interpretation of the radiographs. Results Among the 287 subjects who completed all postprocedure assessments, significantly more treatment subjects than control subjects achieved the primary end point (127 of 150, 85% vs 95 of 137, 69%; P = .002). Among all 339 randomized subjects, the odds of achieving the primary end point were 4.4 times greater for nonsmokers than they were for smokers (95% confidence interval, 1.7, 11.0; P = 0.002); study site had no statistically significant effect. Compared with control subjects, treatment subjects had fewer pneumothoraces (30 of 170, 18% vs 53 of 169, 31%), fewer chest tubes placed (6 of 170, 4% vs 18 of 169, 11%), and fewer postbiopsy hospital admissions (16 of 170, 9% vs 23 of 169, 14%). Conclusions The lung biopsy tract plug significantly reduced rates of pneumothorax in patients undergoing CT-guided lung biopsy. Rates of chest tube placement and postprocedure hospital admission were also reduced.

The ability of school-based measures of child behavior to predict differentially the IOWA Conners teacher rating scale Inattention/Overactivity (IO) and Aggression (A) factors was evaluated in a sample of 71 school-aged boys. Multiple measures and multiple methods of assessment were utilized to provide a comprehensive assessment of social and academic behavior. These included direct observations of children in the classroom and on the playground, examination of the organization of children's desks, measures of academic performance, peer nominations of popularity and rejection, and sociometric ratings using the Pupil Evaluation Inventory. Despite moderately high correlations between the teacher rating factors (r = .60), considerable evidence was provided for differential validity on measures of academic performance, peer rating measures, and measures of disruptive or inappropriate classroom and playground behavior. These differences between IO and A factors indicated that the factors were logically independent in important ways, supporting prior work validating separate hyperactivity and aggression dimensions.

We compared the effects of infused norepinephrine (NE) to another alpha-adrenergic agonist, phenylephrine, in order to understand better the influence of circulating NE on plasma renin activity (PRA) in man. In matched groups of normotensive men, NE (80 ng/min/kg) or phenylephrine (800 ng/min/kg) raised blood pressure by 15 to 20 mm Hg and caused reflex decreases in heart rate of 8 to 10 beats per minute. Infused phenylephrine suppressed PRA by about 15%, whereas NE increased PRA by about 40% (P less than .02). This differential effect of alpha-agonists on PRA defines an important humoral effect of NE, which should be considered to be a "cardiovascular hormone."

Chronic responses of systemic hemodynamics and blood pressure counterregulatory ("pseudo-tolerance") mechanisms were investigated in matched groups of patients with essential hypertension after 1 month of vasodilator therapy with pinacidil (a direct arterial dilator), prazosin (an alpha 1-adrenergic blocking drug) or captopril (an angiotensin-converting enzyme inhibitor). For equivalent decreases in mean arterial pressure compared with placebo baseline (approximately 8 mm Hg supine and 12 mm Hg upright), prazosin and captopril did not increase cardiac index or heart rate. In contrast, marked decreases in systemic vascular resistance with pinacidil (approximately 25%, p less than 0.05) were accompanied by reflex increases in cardiac index (approximately 20%, p less than 0.05). Activity of the sympathetic nervous system, measured by supine and upright plasma norepinephrine (NE), increased approximately 50% with pinacidil and prazosin (p less than 0.001 each), whereas captopril decreased supine plasma NE by 12% (p less than 0.05) and did not change upright plasma NE. All 3 drugs caused an expansion of height-adjusted blood volume (approximately 14%). Pinacidil and prazosin caused reversible weight gains of 0.9 and 0.7 kg, respectively, whereas captopril reversibly decreased body weight by 0.8 kg (p less than 0.05), suggesting differential effects of the 3 drugs on interstitial fluid volume. During chronic therapy, all 3 drugs may require concomitant diuretic therapy, whereas concomitant sympatholytic therapy may be required with the potent vasodilator pinacidil. Captopril may be associated with the lowest cardiac risk because of its lack of stimulatory effects on the sympathetic nervous system and cardiac index.