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To determine the effectiveness of a radiation awareness program in reducing the radiation exposure to patients treated by a Medstone lithotripter, the exposure was calculated at the end of each extracorporeal shockwave (SWL) treatment using a table of measurements of the estimated entrance exposure rates 70 cm from the X-ray tube port. The results, related to stone size and patient weight, were distributed every month to each radiologic technologist, and a summary was sent regularly to the treating urologists. The doses before and after the introduction of the radiation awareness program were compared to determine the effectiveness of the program, and the chi-square test was used to determine statistical significance. The average calculated radiation exposure before and after introduction of the radiation awareness program was 16.39 rad and 8.26 rad, respectively, for patients with single renal stones; 17.31 rad and 9.02 rad, respectively, with single ureteral stones; 18.45 rad and 9.39 rad, respectively, with multiple renal stones; and 20.59 rad and 11.28 rad, respectively with multiple ureteral stones. These reductions in calculated radiation exposure were statistically significant only with multiple ureteral stones (P = 0.03). The only statistically significant differences in the stone-free rates, retreatment rates, and post-SWL secondary procedure rates before and after the introduction of the radiation awareness program were seen in the stone-free rates with single renal stones: 70% v 65%, respectively (P = 0.02); in the retreatment rates with single ureteral stones: 10% v 6%, respectively ( P.01); and in the post-SWL secondary procedure rates with single renal stones: 4% v 2%, respectively (P = 0.01), and single ureteral stones: 7% v 4%, respectively (P = 0.05). The radiation awareness program resulted in a 51% reduction in the estimated radiation exposure to patients during SWL using Medstone lithotripters.

Some reports have shown a decreased effectiveness of extracorporeal shock wave lithotripsy (ESWL*) with newer lithotriptors. We used a first generation unmodified Dornier HM3 lithotriptor to treat 5,698 patients with renal and ureteral calculi and a second generation Medstone STS device to treat 8,166 patients with renal and ureteral calculi. The treatment results were compared using the chi-square test to determine statistical significance. The stone-free rate, retreatment rate and post-ESWL secondary procedure rate were 69.5%, 4.4% and 3.1%, respectively, with the Dornier HM3 device and 72.1%, 4.9% and 2.3%, respectively, with the Medstone lithotriptor for single renal stones, and 81.5%, 5.2% and 5.5%, respectively, with the Dornier HM3 and 83.2%, 5.2% and 5.0%, respectively, with the Medstone device for single ureteral stones. There were no statistically significant different results between a second generation tubless Medstone STS lithotriptor and the gold standard unmodified Dornier HM3 instrument. Kcr WORDS: kidney calculi, ureteral calculi, extracorporeal shockwave lithotripsy, lithotripsy There have been reports that the newer lithotriptors have a decreased effectiveness compared to the original gold standard Dornier HM3 The second generation lithotriptors have a dry table with easier patient handling and are less powerful with minimized anesthesia requirements. However, decreased effectiveness results in an increased number of shocks given, decreased stone-free rate and increased repeat extracorporeal shock wave lithotripsy (ESWLJ treatment rate. We reviewed the treatment results of an unmodified Dornier HM3 device with 5,698 renal and ureteral calculi, and of the Medstone STS lithotriptor with 8,166 renal and ureteral calculi. We used the chi-square test to determine any statistical significance for any difference in these results.

Objective. To determine if a ureteral stent or catheter was necessary to achieve satisfactory results with extracorporeal shock-wave lithotripsy (ESWL) for a stone in the ureter. Method. A retrospective review of 1 ,712 single ureteral stones treated in the ureter by ESWL using Dornier HM3 and Medstone STS lithotriptors was performed, 1,425 with a stent and 287 without a stent (in situ). Statistical analysis was performed using the chisquare test to determine the p value. Results. The stone site, size, and treatment parameters (average shocks, kV, and estimated radiation to the patient) were similar in both groups. The retreatment rate, post-ESWL secondary procedure rate, and stone-free rate were 5 percent, 5 percent, and 79 percent, respectively, with a stent and 6 percent, 9 percent, and 79 percent, respectively, without a stent. Conclusion. The results of ESWL for single ureteral stones were similar with or without a stent, making the presence of a ureteral stent unnecessary.

Concerns have been expressed by some in the United States that extracorporeal shock wave lithotripsy (SWL) for mid and lower ureteral stones could damage ovarian reproductive function, is difficult to perform with a Dornier HM3, and is not as effective as ureteroscopy. Seventy-nine patients with midureteral stones and 45 patients with lower ureteral stones were treated using Dornier HM3 and Medstone STS lithotripters. With the latter machine, the head and foot angle radiographs, the absence of the water-filled tub, and the easy prone positioning of the patient made the visualization and treatment of the mid and lower ureteral stones easier to perform. With single stones, the stone-free rate at 3 months was 77%, the retreatment rate was 2%, and the post-SWL secondary procedure rate was 15%. However, stone retrieval by ureteroscopy in the lower third of the ureter is a single procedure without the need for secondary or repeat treatments and, with reported stone-free rates of 83% to 93%, it is more efficient...

De novo extracorporeal shock wave lithotripsy (SWL) for ureteral stones is appealing because no instrumentation is used and stone-free rates of 90% + are reported with low-power lithotripteis using minimal or no anesthesia. This makes SWL an attractive alternative to ureteroscopic stone extraction and to ureteral stent/ SWL, which give similar stone-free rates but require instrumentation and major anesthesia. De novo SWL using high-power lithotripters (Dornier HM3 and Mestone STS) and general anesthesia was used on 100 patients with impacted ureteral stones of 2 weeks' duration or longer (upper ureter 80, mid 6, lower 14). There were 78 single stones and 22 multiple stones. The retreatment and post-SWL secondary procedure rates with single stones were 6% and 14%, respectively, and with multiple stones were 9% and 18%, respectively. The stone-free rate at 3 months was 78% with single stones and 73% with multiple stones. The difference in stone-free rates between low- and high-power lithotripters performing...

Although mobile renal lithotripsy appears to be a cost-efficient method for a urologist to treat patients at the local hospital the quality issue has been raised with occasional use of a mobile lithotriptor. We reviewed 4,278 kidneys in 3,900 patients treated by 129 urologists using a mobile Dornier HM3 and a mobile Medstone lithotriptor at 21 mobile sites in 6 upper midwest states during 3 1/2 years. These results were compared with those in 524 kidneys in 480 patients treated by our fixed Medstone lithotriptor. After the procedure auxiliary treatments were needed in 3% of the patients treated with the mobile units and 2% of those treated with the fixed unit. The rate in 2 large published series was approximately 9%. The retreatment rates were 5% with the mobile lithotriptors and 6% with the fixed (reported average 16%), and the over-all stone-free rates at 3 months were 69% and 68% (versus 66%). Of note, the mobile units were as effective as the fixed unit against difficult stones. A mobile lithotriptor with a constant support staff that is used 1 or 2 times per month by many trained urologist will perform as well as fixed lithotriptor used regularly by a small unvarying staff of trained urologists.

While reports differ on the effect of extracorporeal shock wave lithotripsy (ESWL*) on renal cysts, little has been written on the stone-free status following ESWL for renal calculi with renal cysts present. We studied 13 patients with renal stones plus renal cysts, and only 6 (46%) were stone-free at 3 months after ESWL. While the number of cases is small, it is believed that renal cysts may interfere with the passage of stone fragments due to the impediment of drainage, and urinary stasis from the stretching and distortion of the caliceal system by the renal cysts.

While reports differ on the effect of extracorporeal shock wave lithotripsy (ESWL*) on renal cysts, little has been written on the stone-free status following ESWL for renal calculi with renal cysts present. We studied 13 patients with renal stones plus renal cysts, and only 6 (46%) were stone-free at 3 months after ESWL. While the number of cases is small, it is believed that renal cysts may interfere with the passage of stone fragments due to the impediment of drainage, and urinary stasis from the stretching and distortion of the caliceal system by the renal cysts.

Management of urolithiasis in morbidly obese patients is usually associated with higher morbidity and mortality compared to nonobese patients. In morbidly obese patients, since the kidney and stone are at a considerable distance from the skin (compared to nonobese patients), difficulty may be encountered in positioning the patient so that the stone is situated at the F2 focal point of the lithotriptor. Using various aids, such as the extended shock pathway and abdominal compression, we treated 81 patients weighing more than 300 pounds using the Medstone STS tubless second generation lithotriptor. The stone-free rate at 3 months or longer was 68%, with another 10% having asymptomatic fragments of 4 mm. or less in diameter. Thus, a clinical stone-free rate of 78% was achieved. The retreatment rate was 11% and the post-lithotripsy secondary procedures rate was 3%. Since these results are comparable to those obtained when treating patients less than 300 pounds, extracorporeal shock wave lithotripsy can be used successfully to treat urolithiasis in morbidly obese patients.

We reviewed the results of ureteral stent use with extracorporeal shock-wave lithotripsy (ESWL) in 3,096 patients with renal calculi less than 3 cm in diameter. The 2,595 patients with indwelling ureteral stents required lower total power (shocks × voltage) and less radiation and had a lower secondary procedure rate but a higher retreatment rate than the 501 patients without stents. However, the only statistically significant difference was in the average radiation dose in patients with or without stents and single stones no larger than 10 mm (16 vs. 18 rad). The hospital stay was one day or less in 98 percent of the patients in both groups. With an 80 percent follow-up rate at three months indwelling ureteral stents were associated with a higher stone free rate in patients with a single stone but a lower stone free rate in patients with multiple stones, compared with those treated without a stent. An indwelling ureteral stent may result in urinary frequency and bladder discomfort in some patients, and with no statistical difference in the results with or without a ureteral stent it is questionable whether or not the high use of an indwelling ureteral stent is justified in patients admitted for one day or less.

Our unit has performed bilateral renal extracorporeal shock wave lithotripsy (SWL) on 388 patients, with treatment being given in a single session in 369 (95%). No cases of clinically apparent acut...

Extracorporeal shock wave lithotripsy (SWL) monotherapy with mobile Dornier HM3 and Medstone STS lithotripters was performed by occasional users to treat 156 large (> 3 cm) renal calculi. For the cases with 3 months of follow-up, stone-free rates were 50% and 41% respectively, for single(N = 26) and multiple (N = 56) stones. Pre-SWL auxiliary procedures (mainly insertion of a double-J stent) were used in 88% of the series, and the rate of post-SWL procedures for obstruction was 17%. The SWL retreatment rate was 57%. Monotherapy for large renal calculi by an occasional user of a lithotripter has the same stone-free rate as debulking percutaneous nephrostolithotomy and SWL without special post-SWL percutaneous measures. These results are unsatisfactory compared with the stone-free rate of percutaneous nephrostolithotomy and SWL for large renal calculi with special post-SWL percutaneous measures to remove residual fragments.

A controversy has arisen as to whether the initial form of therapy for lower pole nephrolithiasis should be extracorporeal shockwave lithotripsy (SWL) or percutaneous nephrolithotomy (PCNL). We reviewed our results with 968 single lower pole stones treated by SWL and reviewed publications comparing SWL and PCNL for lower pole nephrolithiasis. In our cases, the stone-free rate was 71.2%, the rate of repeat treatment and post-treatment secondary procedures was 6.4%, the complication rate was 0.5%, and the hospital stay was less than 24 hours in 99.3% of patients. In published series of PCNL for lower pole nephrolithiasis, the stone free rate was 70.5% to 100%, repeat treatment rates were 4% to 62.5%, the complication rates were 13% to 38%, and the hospital stay was 3.1 to 6.1 days. The rates of recurrent stone disease with PCNL were 11% to 22%, similar to the rates after SWL. The percentage of renal urolithiasis patients with lower pole calculi since we started our unit in late 1986 has remained essentially constant at 38%. Although the stone-free rate with PCNL is higher than with SWL, the lower complication rate, lower repeat treatment/secondary procedure rate, the shorter hospital stay, and the similar recurrent stone rate with SWL make SWL more clinically effective as the primary therapy for lower pole calculi less than 2 cm in diameter.

We studied renal function an average of 44 months after simultaneous bilateral renal SWL in 56 patients. No cases of clinically apparent acute renal failure occurred in the early postoperative period. The glomerular filtration rate (GFR) was calculated using an empiric formula having a significant correlation with measured creatinine clearance, and a change of 20% or greater was considered a clinically significant deterioration in renal function. Of the seven patients with a preoperative serum creatinine concentration of1.5 mg/dL, six had an average increase of 35% in postoperative GFR attributable to relief of obstruction, while one had a 30% reduction in GFR. Among 49 patients with a preoperative serum creatinine concentration of 1.5 mg/dL or less, there was an increase in postoperative GFR in 22 patients (45%), no change in 3 (6%), and a decrease in 24 (49%), who had a higher number of multiple renal stones (p0.05) and of repeat SWL (p = 0.08). Nine of them (18%) had a clinically significant decrease in GFR of20%. A review of the literature showed a long-term reduction of function in the individual human kidney after SWL in some cases of a solitary kidney and in some cases with an untreated contralateral kidney. Because there is no evidence that an untreated contralateral kidney aids the long-term recovery of the function of a treated kidney in all cases, simultaneous or separate bilateral renal SWL would not influence this long-term reduction in renal function, which was felt to occur with multiple renal stones and repeat SWL.

Studying renal function in patients with a solitary kidney undergoing SWL eliminates the compensatory effects of an untreated contralateral kidney and thus indicates any loss of function in the treated kidney. In 17 patients with a preoperative serum creatinine clearance of 1.5 mg/dl or less who underwent SWL to a solitary kidney, the glomerular filtration rate (GFR) was calculated by the formula of Cockcroft and Gault, which correlates significantly with measured creatinine clearance. A change ofor = 20% in the GFR was considered a clinically significant deterioration of renal function. In 12 patients with24 months' follow-up (mean 7.3 months) after SWL, there was no change in the estimated GFR, whereas 5 patients with24 months' follow-up (mean 36 months) had an average 22% reduction in the estimated GFR. This long-term effect is similar to the 29% long-term reduction in renal function recorded after percutaneous nephrolithotomy in solitary kidneys. Multiple stones, higher numbers of shock waves, and repeated SWL sessions correlated with decreases in GFR, but none of the differences was statistically significant. Like percutaneous nephrolithotomy, SWL results in a clinically significant long-term reduction in renal function.

Objective . To compare the results of using Dornier HM3 and Medstone STS lithotriptors to treat a ureteral stone overlying the pelvic bone (mid third of ureter) requiring the patient to be in the prone position. Method . The ease of use with each lithotriptor was evaluated and a retrospective review of the results using a Dornier HM3 in 53 patients and a Medstone STS in 143 patients was performed. The chi-square test was used to determine statistical difference. Results . With single stones, the re-treatment rate, the post-ESWL secondary procedure rate, and the stone-free rate were 6 percent, 13 percent, and 75 percent, respectively, with the Dornier, and 6 percent, 8 percent, and 80 percent, respectively, with the Medstone. There was no statistically significant difference between these outcome results (p > 0.05). Conclusion . The prone position was difficult to achieve with the Dornier HM3, while the Medstone STS, a tubeless lithotriptor, allowed easy positioning of the patient in the prone position on its flat table. Satisfactory results were achieved using either machine.

Calcification of a ureteral stent has been an unusual complication of long-term stent use for bypassing ureteral obstruction or after surgical repair. Open or percutaneous procedures have usually been required to remove the calcification before the stent can be extracted. We report six cases of calcified ureteral stents successfully managed by extracorporeal shock wave lithotripsy (SWL) followed by cystoscopic extraction, thus avoiding open or percutaneous procedures.

A case report of an acute severe genital infection simulating Fournier's gangrene was subsequently found to be caused by chickenpox.

In situ (no instrumentation) extracorporeal shock wave lithotripsy (ESWL*) was used to treat 49 patients with obstructing ureteral stones causing acute renal colic. Ureteral obstruction was diagnosed on the delayed films of an excretory urogram and was classified as severe (dilatation above and no contrast medium seen below the stone) in 17 patients and partial (dilatation above and contrast medium seen below the stone) in 32. Upper third ureteral stones were present in 41 patients (obstruction severe in 15 and partial in 26) and lower third ureteral stones were present in 8 (obstruction severe in 2 and partial in 6). ESWL was performed within 14 days of the onset of the acute renal colic because of persistent pain with an unmodified Dornier HM3 lithotriptor in 17 patients and a Medstone STS device in 32. With single stones the stone-free rate at 3 months, the repeat ESWL rate and the secondary procedure (stone basketing) rate were 92%, 6% and 8%, respectively, with severe obstruction, and 78%, 6% and 6%, respectively, with partial obstruction. No urinary drainage procedures for sepsis were required after ESWL. Obstructing ureteral stones, which presented mainly in the upper third of the ureter, were successfully treated with in situ ESWL without the need for either bypassing the stone with a ureteral stent or for pushing the stone back into the kidney before treatment with ESWL.

A total of 12 patients with urinary diversions had calculi in 15 kidneys managed initially by extracorporeal shock wave lithotripsy (ESWL*) in 12 kidneys and percutaneous nephrolithotripsy in 3. After 15 treatments with ESWL only 3 of the 12 kidneys (25%) became stone-free. Endoscopic procedures were used in 5 kidneys with fragments remaining after ESWL, and comprised percutaneous ultrasound lithotripsy in 2 and transstomal retrograde manipulations in 3. The 3 initial and 5 subsequent endoscopic procedures resulted in 6 of the 8 kidneys (75%) being stone-free. The poor results with ESWL are due to preexisting dilated upper urinary tracts and to immobility in obese myelomeningocele patients. Endoscopic procedures are the preferred method of treatment in these patients.

Second generation tubless lithotriptors allow for easy prone positioning of patients, resulting in increased use of extracorporeal shock wave lithotripsy (ESWL) for calculi in the ureter, especially in the mid and lower third portions. The 3-month stone-free rate with single stones using a Dornier HM3 and a Medstone STS lithotriptor in the upper ureter was 79% (316 patients) and 81% (188), respectively, while in the mid ureter it was 60% (20 patients) and 81% (32), respectively, and in the lower ureter it was 80% (5 patients) and 85% (26), respectively. The retreatment rate with single stones using the Dornier HM3 and the Medstone STS devices was 5% and 4%, respectively, in the upper ureter, 13% and 12%, respectively, in the mid ureter, and 0% and 5%, respectively, in the lower ureter. The second procedure rate after ESWL with single stones using the Dornier HM3 and the Medstone STS units was 6% and 6%, respectively, in the upper ureter, 15% and 16%, respectively, in the mid ureter, and 0% and 17%, respectively, in the lower ureter. Expectant management is still an acceptable method to treat small ureteral stones, and it is questionable whether ESWL is the appropriate treatment for lower third ureteral stones compared to equally effective and less expensive ureteroscopy.

We report spontaneous bladder and uterine rupture in a patient undergoing oxytocin augmented labor while under epidural anesthesia after a previous cesarean section. The presenting signs were gross hematuria at placement of an indwelling catheter and fetal distress. Cesarean section produced a healthy newborn. The patient recovered satisfactorily after subtotal hysterectomy, bladder repair and transfusion.

The current practice for the management of upper ureteral stones is to push the stone back into the renal pelvis before extracorporeal shock wave lithotripsy (ESWL**Dornier Medical Systems, Inc., Marietta, Georgia.). The results in 903 patients with an upper third ureteral stone pushed back before ESWL were compared to those of 815 with an upper third ureteral stone treated by ESWL in situ with a ureteral stent bypassing the stone. The stone size in the in situ group was larger than in the push back group. More shocks at a higher kilovoltage were required to treat the in situ group. The retreatment rate and post-ESWL secondary procedure rate for the push back group with single stones were 4% and 1.5%, respectively, compared to 5% and 7.5%, respectively, for the in situ group. The stone-free rate with single stones at 3 months was 73% in the push back group and 79% in the in situ group. There appears to be little advantage in manipulating a ureteral stone into the kidney (push back) before treatmen...

We reviewed 91 testicular injuries in 86 patients (5 bilateral) as a result of blunt trauma in 72 patients and gunshot wounds in 14 patients. In 90 percent of the patients the injury was solitary. With blunt trauma initially conservative management led to the loss of the entire testis in 21 percent in comparison with only 6 percent of those explored promptly. The recent use of testicular ultrasonography has not differentiated intratesticular hematoma from rupture in the majority of cases of blunt trauma. Bilateral testicular injury occurred in 1 of 72 patients (1.4%) with blunt trauma versus 4 of 14 (29%) with penetrating trauma and affected the fertility in 3 of 4 patients on follow-up.

In 6 patients who underwent ultrasound scanning and operation after blunt testiculartrauma, the scan suggested the correct diagnosis in only 2 patients. There was one false-positive and three false-negative diagnoses of rupture. Absence of firm diagnostic criteria for rupture and high error rates with various criteria now in use make reliance on ultrasound in the diagnosis of testicular rupture inappropriate at this time.

A fistula developed between the left common iliac artery and the distal left ureter of an 83-year-old woman who had undergone aortofemoral bypass grafting many years previously and in whom a Double-J**Medical Engineering Corp., New York, New York. stent was in place for 3 weeks while she was awaiting extracorporeal shock wave lithotripsy. Exsanguinating hemorrhage into the urinary tract necessitated emergency nephrectomy and vascular repair. Although these measures were successful temporarily, the patient died 6 weeks later of repeat myocardial infarction and acute renal failure. The increasing frequency of ureteral stent use and of an operation on the iliac arteries is expected to increase the frequency of these potentially catastrophic fistulas.

When pull on a stone basket enclosing a distal ureteral stone met marked resistance and endoscopic lithotripsy failed, extracorporeal shock wave lithotripsy was used to fragment the entrapped stone in the ureter and allowed successful removal of the basket with the enclosed fragments.

Extracorporeal shock wave lithotripsy to a left lower third ureteral calculus, 1.4 × 0.9cm. large, using an unmodified Dornier HM3⁎⁎Dornier Medical Systems, Inc., Marietta, Georgia. lithotriptor with the patient in the sitting position produced thigh adductor movement with each shock. The procedure was terminated. Extracorporeal shock wave lithotripsy was performed uneventfully 1 week later using a Medstone STS lithotriptor with the patient in the supine position. We believe that the sitting position caused increased intraabdominal pressure in the pelvis resulting in apposition of the ureteral segment containing the calculus to the obturator nerve, which was included either in the second focal point or in the extended shock path of the Dornier HM3 unit.

Multiple large cystine stones formed on an indwelling ureteral stent used in the medical management of a 12-year-old boy with obstructing renal stones and cystinuria. Extracorporeal shock wave lithotripsy fragmented the cystine stones and allowed for extraction of the stent by cystoscopy.

We found simultaneous upper and lower urinary tract injury to be rare, beingpresent in 10 of 2,310 patients (0.4 %). Multiple associated injuries were present in all patients (average 4.4 per patient). In 3 patients both upper and lower urinary tract injuries were minor, and 1 patient died of associated injuries. In 4 patients one of the urinary injuries was significant and the other minor, and 2 of these patients died. In 3 patients both urinary injuries were significant, and all 3 died of associated injuries. A comprehensive urologic evaluation was required in all 10 patients because of their severe associated multiple injuries.

We reviewed 105 cases of extraperitoneal bladder rupture admitted to our hospitals from 1959 to 1985. Primary suturing of the rupture was performed in 65 patients, and catheter drainage alone without suturing of the rupture was performed in 34. The incidence of blunt trauma causing the rupture of gross hematuria on admission, and of associated injuries was similar in both groups. There was a higher incidence of women older than sixty years in the group managed by catheter drainage alone, and a higher incidence of laparotomy for associated intra-abdominal injuries and a higher mortality rate in the group treated by primary suturing. There were three early complications in the group treated by suturing (hematuria with clot retention 2, sepsis contributing to death 1) and four early complications in the conservatively treated group (hematuria with clot retention 1, pseudodiverticulum with bone spike in its floor 1, persistent urinary fistula 1, and sepsis contributing to death 1). There were two late complications in 42 patients followed in the group treated by suturing (urethral stricture 1, frequency and dysuria 1), and three late complications in 14 patients followed in the conservatively treated group (hyperreflexic bladder 2, urethral stricture and vesical calculi 1). Catheter drainage alone for extraperitoneal rupture from external trauma was simple, quick to perform, and appealing in the multiple-injured patient. Although the early and late complication rates were higher in the conservatively managed group, there was no statistically significant difference from the group treated by primary suturing.

Excretory urography (IVP) is the primary diagnostic tool for renal injury but has been indeterminate in diagnosing severe renal injuries in most cases. Computed tomography (CT) provides precise anatomic detail of renal injuries. The IVP and CT findings were compared in 22 patients with suspected severe renal injuries suggested by clinical examination and initial screening IVP. CT provided determinate diagnoses in all the cases of severe renal injury, while the IVP diagnoses were indeterminate in 82 per cent of these cases. Although clarification is needed on the accuracy of CT in diagnosing renal vascular injury, the CT diagnoses were accurate in all other types of severe renal injury (as well as minor renal injuries).

Fifty-six patients with urethral injuries comprised 35 involving the posterior urethra and 21 involving the anterior urethra. Immediate retrograde urethrography confirmed the clinical diagnosis made when blood was found at the external urinary meatus after external trauma. Traffic accidents caused most of the posterior urethral injuries and were associated with severe injuries to multiple systems and a significant mortality rate (34 per cent). Primary realignment of the urethral injury by a urethral catheter in all cases of urethral rupture (plus a suprapubic cystostomy in most of these cases) resulted in a stricture rate of 62 per cent on follow-up. However, only half of these strictures required surgical correction. The incidence of incontinence was 10 per cent and of impotence 38 per cent.

Renal dysplasia and atrophy are associated with congenital urinary tract obstruction, such as posterior urethral valves, and are thought to result from the increased pressure in the developing obstructed urinary system. This increased pressure is likely to be alleviated by perirenal urinary extravasation and urinary ascites. Whether this relief of pressure in the obstructed developing kidney results in a lessened degree of renal abnormality is likely to depend on the time during the period of gestation when the urinary leak occurs and the degree of renal dysplasia and atrophy at the time of the urinary leak.

Physical exertion, sexual activity or trauma can precipitate cremasteric contraction and result in torsion of a testicle with an underlying congenital anomaly. A high index of suspicion is required by the primary care doctor if acute torsion is to be diagnosed early for immediate reduction. The duration of torsion and the degree of twisting determine the long-term salvage rate of testicular tissue. An aggressive policy of immediate exploration of the unilateral acute scrotum in young men resulted in exploration of twice as many cases of acute epididymitis as torsion of the testis or its appendages but also resulted in an immediate orchiopexy (salvage) rate of 90 per cent and a long-xsterm salvage rate of 73 per cent of patients with acute torsion of the testis.

Results of a study that began at Stanford in 1956 demonstrate that long-term, disease-free survival can be achieved following appropriate irradiation in patients with prostatic carcinoma. However, the investigation has also uncovered several powerful prognostic indicators, such as the extent of anatomic involvement, histologic pattern, particularly as described by Gleason; and presence or absence of lymphnode metastases. To illustrate the importance of these parameters, the author presents data that correlate survival with the anatomic extent of the primary tumor and the Gleason pattern scores. Of the staged patients, 64 have been subjected to post-therapeutic biopsy of the prostate 18 months or more following therapy. A correlation also seems to exist among clinical stage, lymph node involvement, and subsequent biopsy status. The implication of this finding in the development of more aggressive therapeutic approaches will be discussed.

During the last 10 years the management of the neurogenic bladder in children has changed from indwelling urethral catheterization or urinary diversion to intermittent catheterization or artificial sphincter implantation. Neurogenic bladder dysfunction in 413 children was caused by myelomeningocele in 323, traumatic paraplegia in 47, spastic quadriplegia in 11, sacral agenesis in 18 and spinal cord disease in 14. Management included indwelling urethral catheterization in 27 children, urinary diversion in 193, intermittent catheterization in 84, an artificial sphincter in 11 and undiversion in 6. No single treatment was completely effective or without significant complications.

Surgical exploration of a testicular mass should follow the basic principles of cancer surgery, including an inguinal approach, occlusion of the spermatic vessels, opening of the tunica vaginalis, and careful exploration of the testicle, epididymis, paratesticular structures, and spermatic cord. In a very few patients, when intratesticular lesion is small and moveable and can be seen through the tunica albuginea, and if there is a long history of scrotal mass, then the tunica albuginea should be opened and intratesticular exploration performed. The opening of the tunica albuginea should be opened and intratesticular exploration performed. The opening of the tunica albuginea does not violate the principles of cancer surgery, and for a few selected cases can prevent unnecessary orchiectomy. The incision of the tunica albuginea should no longer represent a surgical taboo to the urologist. Six cases of rare, benign intratesticular tumors are presented along with a rare indication for intratesticular exploration and testicle-preserving surgery.

Spastic or hyperreflex bladder dysfunction can cause frequency, urgency, and incontinence. Detrusor activity was inhibited by FES (functional electrical stimulation) applied to the anal sphincter causing decreased bladder spasticity and increased bladder capacity. FES is indicated for incontinence not only because of weakness of the pelvic floor but also because of hyperreflex bladder.

An ampullometrogram (AMG) was done in 20 patients to evaluate the rectal ampulla as a functional unit. Results were compared to a cystometrogram (CMG). The AMG displayed a normal curve (capacity 230 to 330 ml; pressure 47 to 80 cmH2O) in 14 of 16 patients having a normal CMG. The AMG was hyporeflexic (variable capacity; no increase in pressure at capacity) in 3 of 5 patients having a hyporeflexic CMG and hyperreflexic (capacity less than 175 ml, pressure over 80 cmH2O) in one patient having a hyperreflexic CMG. This technique might represent a useful clinical adjunct in the evaluation of bladder dysfunction, the evaluation of neurogenic type bowel dysfunction, and in the possible use of functional electrical stimulation for treatment of faecal incontinence or constipation.

Incontinence due to hyperreflexic bladder and/or pelvic floor weakness can be corrected by chronic functional electrical stimulation (FES). Cystometry, electromyography of pelvic floor muscles, and anal sphincter pressure measurements with and without electrical stimulation determines if chronic FES will be successful. Post-acute stimulation improvement occurred in patients with incontinence due to hyperreflexic bladder and/or pelvic floor weakness. A success rate of 92 per cent was achieved with chronic FES in incontinent patients with this method of selection.

From 1969 to 1981, 1,176 blunt renal injuries were recorded in 1,166 patients (10 patients had bilateral injuries). Conservative management of 27 patients with severe renal injuries resulted in a delayed renal operation in 30 per cent and total renal loss in 22 per cent. A review of the published series of the conservative management of patients with severe renal injuries (laceration, rupture and pedicle injury) shows a renal surgery rate of 13 to 68 per cent, a renal loss rate of 3 to 33 per cent and a significant complication/renal surgery rate of 13 to 76 per cent. In our patients 88 per cent with severe renal injuries had associated injuries and 73 per cent of these underwent immediate laparotomy for intra-abdominal injury. Immediate renal surgery in 59 patients with severe renal injuries resulted in a nephrectomy rate of 6.5 per cent of 31 renal lacerations, 100 per cent of 14 renal ruptures and 50 per cent of 14 pedicle injuries. Of the 14 patients with pedicle injuries 6 (43 per cent) had immediate vascular repair, with salvage of the kidney. Immediate surgical management of the patients with severe renal injuries obviated the need for a second exploration in a severely injured patient, reduced morbidity and resulted in increased renal salvage.

Postural changes did not affect the cystometric curves of bladder function that were hyperreflexic, flaccid or secondary to bladder wall changes (fibrosis and inflammation). However, postural changes did affect normal curves in some patients with a history of micsturition disorders and resulted in detrusor instability when the patient was standing or walking. Functional electrical stimulation of the pelvic floor muscles during the cystometrogram inhibited detrusor instability of these patients in all positions. Use of postural changes and functional electrical stimulation of the pelvic floor muscles during the cystometrogram inhibited detrusor instability of these patients in all positions. Use of postural changes and functional electrical stimulation of the pelvic floor muscles is suggested to determine actual bladder function and to exclude possible artifacts in the curve.

Acute urinary retention in middle-aged females is an infrequent occurrence; therefore,when such a patient presents to the urologist, an aggressive diagnostic evaluation is warranted. Carcinoma of the urethra might be the underlying pathologic process causing urinary retention. Herein, we present 2 cases of acute urinary retention triggered by adenocarcinoma of theurethra. In 1 patient the diagnosis was delayed due to severe superimposed infection which responded poorly to medication. Anterior exenteration and radiotherapy were used in the management of both patients.

We herein evaluate the correlation among cystometry, urethral pressure profilometry and pelvic floor electromyography in 137 female patients. The predominant symptom was frequency in 40 patients, urge incontinence in 31 and stress incontinence in 66. There appeared to be a correlation between urge incontinence and a hyperreflexic cystometrogram but no correlation was noted between either frequency or stress incontinence and the cystometrogram profile. The urethral pressure profile showed a correlation between stress incontinence and the lowest profile measurements. Frequency and urge incontinence had similar profile measurements except for maximum urethral planimetry. Electromyography showed that the external urethral sphincter had a different finding than the levator ani or the external anal sphincters in all 3 groups of female patients. The external urethral sphincter had a higher percentage of denervation than the other 2 muscles, especially in the stress incontinence group.