[Research on aging: biological perspectives].

Aging is a part of the continuous process from conception to death and is strongly modulated by environmental factors throughout the lifespan. Variability in functional capacity between different organs and between individuals therefore increases with aging. This review will discuss two tissues of importance for the fitness of the aging human being: connective tissue and bone. Connective tissues become stiffer with age, which can be mitigated by physical exercise. The physical-chemical stability of collagen is a precise measure for the functional age of the organism. While in the aged, the healing (formation of connective tissue scar) of uncomplicated incisional wounds is slightly impaired, the healing of ischemic wounds is endangered. The clinical observation that "simple" wounds also heal less well in the aged might be due to the presence of diseases with ischemia and other pathologies. During normal aging bone loses mass, structural continuity, and strength. When pronounced, these changes cause osteopenia and osteoporotic fractures. The age-adjusted incidence of osteoporotic fractures is increasing on account of changes in our lifestyle. Preventive efforts, with increased physical activity as the main feature, must be implemented to alter this trend. Our knowledge of the mechanisms of aging is not yet sufficient to formulate a policy containing preventive measures enabling man to achieve his maximum biological lifespan with good physical health and a high quality of life. Multidisciplinary efforts by biologists, clinicians and epidemiologists are warranted to achieve this goal.


[Research on aging: geriatric perspectives].

Geriatric efforts have prophylactic effects on further reduction of functional ability at every link in the therapeutic chain by means of interdisciplinary qualitative and quantitative assessment which establishes goal and plans which lead to coordinated action. This results in early diagnosis of multiple pathology, reduction of polypharmacy, confidence on account of good information, continuity on account of coordination between primary and secondary sectors, simultaneous efforts, early interruption of the cascade effect which results in production of helpless patients. By means of clinically controlled trials, effects have been obtained on a number of recently discovered diagnoses requiring treatment, unnecessary medication is withdrawn, conditions of rehabilitation, functional ability, quality of life, employment of bed-days, institutionalization and mortality. It is necessary to state that this is the only age group where the effect is obtained without further expense or where the effort has even resulted in economic savings. In Denmark, research is required as regards how prophylactic health visits to the elderly can best be carried out in all communities, the risk situations (death of a spouse, removal, illness) which require immediate increased efforts and research into how offensive geriatrics is to be established, how rehabilitation is ensured for healthy and sick elderly patients and research into the occurrence and treatment of the five geriatric giants (immobility, instability, incontinence, intellectual reduction and iatrogenesis). More Danish controlled trials are required of the individual components in and the total function of geriatric assessment and rehabilitation and the significance of personal choice when the functional ability is such that dependence on care by others is inevitable and, finally, the conduct and expenses of various arrangements.


[99mTc-HMPAO leukocyte scintigraphy in inflammatory intestinal disease].

Eighteen patients, suspected of active inflammatory bowel disease, were investigated. The 99mTc-HMPAO-leucocyte scintigraphy was evaluated using the results of the simultaneous clinical examinations, which included clinical and biochemical parameters, small intestinal series, colonoscopy and, in two patients, operation, as reference. In agreement with the clinical examinations, the leucocyte scintigraphy indicated active inflammatory bowel disease in 14 of the 18 patients. The leucocyte scintigraphy disclosed inflammation in all of the 19 bowel segments, in which the clinical examinations indicated active inflammation. In three patients with Crohn's disease the scintigraphy indicated more extensive inflammation. A correlation between the scintigraphic activity and the Crohn's Disease Activity Index was found. However, the leucocyte scintigraphy did not seem useful as a disease activity index. The 99mTc-HMPAO-leucocyte scintigraphy seemed especially useful in severely ill patients and in patients suspected of relapse.


[Encrusted ureteral endoprosthesis].

The case of a patient with a ureter endoprosthesis is presented. The endoprosthesis became encrusted after remaining in position for three years. Ureter endoprosthesis in connection with renal or ureteric calculi should only remain in position for 6-8 weeks.


[Captopril-induced toxic hepatitis].

Captopril, the competitive inhibitor of angiotensin-converting enzyme, has proved efficient in the treatment of arterial hypertension and heart failure. Its use is generally associated with low incidence of adverse reactions and hepatic injury has not been emphasized as an important adverse reaction in Denmark. However worldwide, several cases of hepatic injury have been reported. We report one case of Captopril-induced hepatic injury. Despite discontinuation of Captopril a hepatorenal syndrome developed and the patient died five weeks after admission. This report emphasizes the need to be aware of the possibility of hepatic injury in patients receiving Captopril.


Domain walls on graphite mimic DNA.

We show that domain walls on graphite are very likely to mimic features of extended macromolecules like DNA strands, when imaged with an STM. We explain with a simple model how different translational periods along a grain boundary originate from different relative orientations of the graphite lattice at the domain wall. We show how simple geometrical analysis of the images can be used to distinguish true macromolecular features from artifacts.


Electrostatic spraying of DNA molecules for investigation by scanning tunneling microscopy.

We have investigated electrostatic spraying of DNA onto gold surfaces as an alternative sample-preparation technique for STM studies. Preliminary results show that a higher distribution of isolated strands as well as well ordered aggregates can be obtained with this technique when compared with electrodeposition or drop evaporation. In many places, the well ordered aggregates were found to cleave in a direction perpendicular to their length after repeated scanning in the same direction.


Scanning tunneling microscopy of DNA: a novel technique using radiolabeled DNA to evaluate chemically mediated attachment of DNA to surfaces.

pBS+ plasmid deoxyribonucleic acid (DNA) was imaged by scanning tunneling microscopy (STM) after mounting microdroplets by aerosol deposition onto heated epitaxial gold surfaces. However, the instability of the adsorbate to forces exerted by the tunneling tip points out the need for more aggressive bonding of molecules to surfaces. We describe a sensitive assay for the qualitative and quantitative evaluation of chemical agents to influence binding of DNA to surfaces using 32P-labeled pBS+ plasmid DNA. We propose that such an assay can make an important contribution to immobilization techniques prior to STM imaging.


Tip-radius-induced artifacts in AFM images of protamine-complexed DNA fibers.

Isolated DNA fibers complexed with protamine (the chromosomal protein that packages DNA in mammalian sperm) have been produced by partially decondensing the highly compacted mouse sperm chromatin particle on a glass coverslip. These DNA fibers were then scanned with the atomic force microscope (AFM). While the smallest of the fibers appear in AFM images as ribbon-like structures 250-350 A wide and 10-25 A high, experiments indicate that these images are the result of a convolution of the imaging-tip's shape with the object's actual shape. In such convolutions the height of the object is affected only by the compressibility of the object, while the width is affected in addition by the sharpness of the tip. Images of polyamidoamine particles also appear to show this artifact. We have also deduced the tip's radius of curvature from images of sharp steps and attempt to demonstrate the artifacts associated with a relatively large imaging tip.


Imaging isolated strands of DNA molecules by atomic force microscopy.

We have employed an atomic force microscope (AFM) to image in air isolated strands of pBS+ plasmid DNA adsorbed onto freshly cleaved mica. At a DNA concentration below 0.3 micrograms/ml isolated strands of the plasmid DNA are usually seen, while for concentrations higher than 3 micrograms/ml a uniform coverage of interconnected DNA strands was observed. We found that the contrast and the width of DNA were dependent upon humidity. When the relative humidity exceeds 60%, negative contrast images with strand widths 20 times the width of DNA are found, while positive contrast images with 7 to 10 times the width of DNA are found when the humidity is below 30%. By placing the AFM in an environment where the humidity could be controlled, we were able to switch between positive and negative contrasts.


Visualization of the algal polysaccharide carrageenan by scanning tunnelling microscopy.

Scanning tunnelling microscopy has been used to obtain images in the constant-current mode in air and moist conditions at molecular resolution for the kappa- and iota-carrageenan algal polysaccharides. The molecules were deposited from an aqueous solution onto a graphite substrate. The samples formed aligned nematic-like arrays and were also found as individual molecules. The molecular dimensions of width, height and repeat distance along the molecule were found to be close to the values previously determined by X-ray diffraction. The results support a molecular model based on a double-helix structure for carrageenan.


Atomic force microscopy imaging of T4 bacteriophages on silicon substrates.

A new atomic force microscope incorporating microfabricated cantilevers and employing laser beam deflection for force detection has been constructed and is being applied to studies of biological material. In this study, T4 bacteriophage virus particles were deposited from solution onto electronic-grade flat silicon wafers and imaged in air with the microscope. Microliter droplets of the solution were deposited and either allowed to dry or removed with blotting paper. The images show both isolated viruses and aggregates of various sizes. The external structure as well as strands believed to be DNA streaming out of the virus could be observed. The construction of the microscope and its performance are also described.


Streptavidin binding observed with an atomic force microscope.

An atomic force microscope (AFM) was used to investigate a specific recognition reaction: the binding of streptavidin to a biotinylated lipid bilayer. Prior to the recognition reaction, the phase coexistence of the lipid bilayer was clearly observed: fluid domains were lower than the crystalline domains. After introducing to the bilayer a very dilute solution of streptavidin to give a final concentration of approximately 0.5 microM, the recognition reaction was imaged in real time. Several hours later, we observed a contrast reversal, i.e., the previously lower fluid domains grew so much in height that they became higher than the crystalline domains. We found that the streptavidin molecules bound almost exclusively to the biotin in the fluid domain (less than 0.25% coverage of the crystalline domains). The apparent structure of the few streptavidin molecules bound to the crystalline domain of the bilayer is shown to depend on the applied force. Finally, in a 2-dimensional quasi-crystal in which the streptavidin molecules were compressed at the air-water interface molecular resolution was achieved.


Molecular-resolution images of aspirin crystals with atomic force microscopy.

The atomic force microscope was developed in order to image arrays of molecules on the (001), (100) and (011) faces of aspirin crystals in water. Lattice spacings and symmetries of methyl groups and the part of the phenyl groups on the (001) face in water are consistent with X-ray diffraction data. Surfaces of the (100) face that show the best-developed cleavage, in general, are difficult to image. Although the lattice constant derived from (100) image is consistent with the X-ray diffraction data, the c-glide plane symmetry is lost and diffused spots are observed that are 1.8-3.1 times more elongated than (001) spots. It is not possible to image the (011) surface. This initial success in imaging the molecular crystal surfaces of drug compounds has clarified the different submolecular structures of the three different crystal faces, and the close relationship between the imaging difficulties and the differences in the dissolution process in water.


Morphological difference between fibronectin sprayed on mica and on PMMA.

We have imaged with scanning force microscopy in air fibronectin (Fn) molecules sprayed on mica and on polymethylmetacrylate (PMMA), the latter being extensively used as biomaterial for implants. On mica we can observe small aggregates as well as individual molecules whose shape is influenced by the tip interaction during the scanning process, most of the isolated molecules showing a V-shape oriented in the scan direction. This indicates that the arms of the molecules are relatively free to move and the binding to the mica substrate is located near the disulfide bridge between the two subunits of the molecule. On the other side, when Fn molecules are sprayed on PMMA under the same conditions as for mica, we observe a thin network which we interpret as Fn molecules bound to each other. We relate our observation to the fact that mica is known to be strongly hydrophilic, which could reduce the Fn binding properties by interacting relatively strongly with molecules. On the other side, PMMA being hydrophobic, would interact less with molecules, leaving more binding sites for inter-molecular attachment.


In situ investigations of single living cells infected by viruses.

In this paper we report the direct observation of biological processes on living cells. The experiments were done in situ by scanning force microscopy on a scale inaccessible by other techniques under physiological conditions. Living monkey-kidney cultured cells were imaged under normal growth conditions and showed reproducible features on the 10 nm scale. Upon adding a suspension of pox viruses, characteristic changes of the cell membrane were repeatedly observed in different experiments on different cells. Almost immediately, a pronounced softening of the cell surface occurred which lasted only for a few minutes. More than two hours later very significant protrusions appeared to grow out of the cell membrane. These protrusions abruptly disappeared again. These events were only observed after infection and we interpret them as the exocytosis of proteins related to viral reproduction. After almost 20 h, a different type of event occurred which we interpret as the exocytosis of the progeny viruses themselves.


Scanning force microscopy and cryo-electron microscopy of tobacco mosaic virus as a test specimen.

In this study, tobacco mosaic virus (TMV) provides a resolution criterion for specimen preparation methods as well as for imaging parameters of the scanning force microscope (SFM). We present scanning force microscopic images of the virus embedded in 0.5% buffered phosphotungstic acid solution adsorbed on a freshly cleaved mica surface, and imaged under atmospheric conditions. Individual TMV particles were clearly identified with a characteristic shape of long rods of about 300 nm long and 60-70 nm in apparent width due to the geometric parameters of the tip. The structure of the virus was compared with cryo-electron microscopic data of vitrified suspensions observed to a resolution of 1.15 nm. Uncoated TMV particles were also deposited on evaporated titanium thin films and imaged by SFM.


Electrodeposition procedure of E. coli RNA polymerase onto gold and deposition of E. coli RNA polymerase onto mica for observation with scanning force microscopy.

Molecules of the transcriptional enzyme E. coli RNA polymerase (RNAP) have been deposited using three different deposition methods: (1) passive adsorption onto gold, (2) electrochemical adsorption onto gold and (3) adsorption onto mica. In all cases SFM imaging was straightforward and reliable, and surface coverage by the protein varied with deposition conditions as expected. To determine the nature of the electrochemical treatment on the gold substrate, cyclic voltammetry was performed with various chemical solutions. Finally, a comparison is made between the SFM images of RNAP obtained with these methods and STM images obtained earlier. Both STM and SFM show strikingly similar results; however, heights and widths of individual molecules differ.


Investigation of dialysis membranes with atomic force microscopy.

AFM was used to investigate dialysis membranes made of regenerated cellulose by the cuoxam process. The membranes were either Cuprophan or experimental samples, modified with different amounts of diethylaminoethylcellulose (DEAE). Atomic force microscopes with optical-lever detection systems were used to image the dry membranes in air as received from the manufacturer as well as wet membranes in a swollen state under water. Differences could be observed between modified and unmodified as well as between dry and wet membranes.


Is it possible to observe biological macromolecules by electrostatic force microscopy?

Biological macromolecules such as proteins are charged species in solution. The exact charge depends upon the pH, temperature and ionic strength of the medium in general. This suggests the possibility of employing electrostatic force microscopy as a useful tool for the observation of these macromolecules. Our calculations show that electrostatic forces could be used for this purpose, thus helping to remove ambiguities in the location and identification of proteins. The long-range nature of electrostatic forces could make them useful to locate these macromolecules on the appropriate substrate while, at the same time, overcoming important disturbing effects such as lateral displacement of the macromolecules or destructive contact with the sample.


Imaging of subunit complexes of thermophilic bacterium H(+)-ATPase with scanning tunneling microscopy.

Using a scanning tunneling microscope (STM), we observed reconstructed subunit complexes of H(+)-ATPase of a thermophilic bacterium. The measurement was carried out in air without conductive coating on the samples deposited on a highly oriented pyrolytic graphite (HOPG). The F1 subunit complex of the H(+)-ATPase, and an H(+)-ATPase whose F0 portion was embedded into liposomes prepared from soybean lecithin were imaged. Overall structural images of the subunit complex F1 were obtained: the structural dimensions of the STM images are in agreement with those deduced from conventional methods such as an transmission electron microscopy (TEM) and small-angle X-ray scattering (SAX) experimentation. Regarding the STM imaging of these samples, we discuss the advantages and disadvantages of the STM over those of conventional methods such as a TEM and SAX.


Imaging of proteins by scanning tunnelling microscopy.

Scanning tunnelling microscopy has been used to examine the structure of proteins deposited on a graphite surface. Three molecules have been studied; immunoglobulin G (IgG), Complement component 1q (C1q) and ATP-citrate lyase (ACL). The images show IgG as a tri-lobed molecule, consistent with the known 3D structure as determined by X-ray crystallography. The C1q images differ from the well known "tulip bunch" model derived by electron microscopy, but are consistent with the model if it is assumed that the six globular heads have aggregated. Molecules of ACL are visible as discrete units, with some hints of substructure. These results highlight the potential of STM in studying protein structures, but also illustrate the difficulties of interpreting micrographs of proteins whose structure is currently unknown.


Molecular images of cereal proteins by STM.

Scanning tunnelling microscopy (STM) has been used to study a seed storage protein of wheat known as gamma-gliadin. The protein was deposited onto highly oriented pyrolytic graphite (HOPG) from solutions of trifluoroethanol (TFE) and 1% acetic acid. Samples were dried down and then scanned in air. Transmission electron microscopy (TEM) was also used to visualise the distribution of protein on the substrate. Small-angle X-ray scattering (SAXS) was used to compare the molecular size and shape obtained with those from the STM images.


Scanning force microscopy studies of the S-layers from Bacillus coagulans E38-66, Bacillus sphaericus CCM2177 and of an antibody binding process.

In many prokaryotic cells (eubacteria and archaebacteria) the outermost cell envelope component is composed of a regularly structured protein surface layer (S-layer). The two-dimensional S-layer from Bacillus coagulans E38-66 and Bacillus sphaericus CCM2177 has been investigated by SFM at molecular resolution under physiological conditions (i.e., in buffer solution). We find the E38-66 S-layer lattice to be oblique with lattice parameters of a = 9-10 nm, b = 7-8 nm and gamma = 80 degrees -90 degrees (E38-66). The CCM2177 lattice is square with a = 12-14 nm, in good agreement with TEM data. We have used the unique possibility of the SFM to study the kinematics of biological processes and have performed experiments on the adhesion of polyclonal antibodies to the recrystallized E38-66 protein layer on a time scale of about two to ten seconds per image frame. This represents a first step in directly visualizing molecular recognition reactions.


Substrate preparation for reliable imaging of DNA molecules with the scanning force microscope.

A simple method of substrate preparation for imaging circular DNA molecules with the scanning force microscope (SFM) is presented. These biomolecules are adsorbed onto mica that has been soaked in magnesium acetate, sonicated and glow-discharged. The stylus-sample forces that may be endured before sample damage occurs depends on the ambient relative humidity. Images of circular DNA molecules have been obtained routinely using tips specially modified by an electron beam with a radius of curvature, Rc, of about 10 nm [D. Keller and C. Chih-Chung, Surf. Sci. 268 (1992) 333]. The resolution of these adsorbed biomolecules is determined by the Rc. At higher forces individual circular DNA molecules can be manipulated with the SFM stylus. Strategies to develop still sharper probes will be discussed.


Deposition and imaging of metal-coated biomolecules with the STM.

We have applied a simple and reliable procedure for imaging biomolecules with the scanning tunneling microscope (STM). The biomolecules are adsorbed on glow-discharged mica, then coated with a thin film of platinum-carbon. We have tested this method with linear and circular (plasmid) DNA molecules. The contrast and resolution of the STM images are comparable to electron micrographs of the same molecules when shadowed. Though the present lateral resolution (5-6 nm) is limited by the grain size of the conductive film, some details like supercoiled regions in the DNA are resolved. This method is interesting for two reasons. First, as an alternative technique for imaging biomolecules. Second, for use as a control in STM studies of bare biomolecules.


How useful are acceleration- and deceleration-based Doppler indices? A trial on patients with percutaneous transluminal angioplasty.

The usefulness of indices commonly used in Doppler sonography is limited; the aim of this study was to investigate if inclusion of systolic acceleration and deceleration patterns in Doppler indices will result in practical diagnostic advantages. Systolic delay time index (SDTI) and height-width index (HWI) are compared to Gosling's pulsatility index (PI) and to PI-based damping factors (DF) in patients with isolated lesions in the distal superficial femoral artery before and after percutaneous transluminal angioplasty (PTA). Before PTA, all indices distal to the lesion differ significantly from proximal indices. After successful PTA, none of the indices is able to detect the PTA outcome with sufficient sensitivity. The additionally defined curve broadening index (CBI) shows a 100% sensitivity for detecting PTA success in the examined patient population.


Modelling the feto-placental circulation: 1. A distributed network predicting umbilical haemodynamics throughout pregnancy.

The modifications of the Doppler flow velocity parameters occurring in the feto-placental circulation throughout pregnancy have been reproduced on the basis of a mathematical model. Some simple assumptions were made, such as the progressive development of a dichotomous villous vessel network and the increase of the perfusion pressure and of the umbilical arteries dimensions throughout pregnancy. Moreover, both the viscous and capacitive characteristics of the vascular bed were taken into consideration in order to predict the mean values of blood volume, flow and velocity and the pulsatility index. Their value is shown to depend on few parameters, and mainly on the cross-sectional area ratio between the vessels belonging to two succeeding generations.


Modelling the feto-placental circulation: 2. A continuous approach to explain normal and abnormal flow velocity waveforms in the umbilical arteries.

A mathematical model of the feto-placental circulation which describes the development of the placental vasculature throughout pregnancy on the basis of simple assumptions is used to simulate some abnormalities of the villous vascular tree which may affect the values of Doppler indices. In normal cases, the model shows a decreasing trend of the pulsatility index (PI) throughout pregnancy which is comparable to that observed in vivo. When a pathological interruption of the villous growth is simulated, the PI does not decrease any further, unless the input pressure keeps increasing. When various degrees of obliteration of the villous tree are simulated, either through an occlusive process or a reduction of the lumen of the vessels, the PI values increase and the volume flow decreases to a greater extent. The data predicted by the model are compared to those obtained in clinical studies and in experimental animal models.


In vitro classification of gallstones by quantitative echography.

Gallstones (n = 20) were classified by dual energy Computer Tomography (CT) into three main classes: pure cholesterol stones (I), combination stones (II) and calcium stones (III). Further subclassification was possible by using morphological criteria. The acoustic measurements that were performed were measurements of the velocity of sound, the attenuation coefficient slope with frequency and intercept at 4.5 MHz, the attenuation coefficient slope per unit of time, the backscattering characteristics, and the appearance of B-mode echograms. The velocity of sound in calcium stones (c = 1695 +/- 107 m/s) was distinctly lower than in those containing some cholesterol (c > 2000 m/s). The attenuation coefficient slope ranged from 4.3 to 16.2 dB/cm MHz, the 4.5 MHz intercept from 21 to 66.2 dB/cm. The lowest values were found for the pure cholesterol stones (class IA), the highest values for subclass IIB (combination stones with shell). The attenuation coefficient slope per unit of time was distinctly lower (< 0.50 dB/microseconds MHz) for the cholesterol stones than for the combination and calcium stones (>0.64 dB/microseconds MHz). The backscattering spectrum was approximated by a straight line fit, and the slope for the cholesterol stones was lower than for the combination and calcium stones (<0.75 dB/MHz vs. >1.0 dB/MHz, respectively). The latter two parameters were assessed by in vivo applicable methods. The front echo level was found to be more than 5 dB higher for class IIB as compared to the other classes, while the spectral backscatter level at 4.5 MHz was considerably higher for both classes IIB and III. The B-mode echograms showed that a strong front echo in combination with a strong attenuation of the remaining echo signals was mainly found for stones of classes IIB and III. A significant difference between the group of stones that are suitable for lithotripsy and dissolution treatment (classes IA, IB and IIA) and the nontreatable calcium-containing stones (classes IIB and III) was found for the velocity of sound (p <0.01), the attenuation coefficient slope per time unit (p <0.10), the slope of the backscattering spectrum (p <0.05) and the 4.5 MHz intercept (p <0.01). B-mode classification yielded no complete distinction of these two groups of stones. It can be concluded that in vivo assessment of quantitative characteristics (front reflection, backscattering characteristics, attenuation coefficient slope per unit of time) in combination with the B-mode characteristics might be useful for in vivo gallstone classification.


An attempt to reconstruct the lithotriptor shock wave pulse in kidney: possible temperature effects.

Based on measurements carried out in water in two lithotriptor systems, the authors have made an attempt to reconstruct numerically amplitudes and shapes of shock wave pulses penetrating into kidney which differ from those in water. The difference between these pulses and those observed in water was analyzed and was also demonstrated experimentally. The amplitude and the steepness of the reconstructed pulse front were shown to be much lower than in water depending on the distance of the kidney stone from the patient's body surface. For a distance equal to 4 cm, the shock wave pulse amplitude of 40 MPa in water was estimated to decrease in the kidney by a factor of about two and the steepness of the positive shock pulse front to decrease several times. The analysis was carried out by considering the possible changes of absorption and attenuation in tissues which increase in an unknown way with the wave amplitude. It was shown that the temperature elevation caused by the increase of nonlinear high amplitude absorption is limited due to a corresponding increase in attenuation of the shock wave penetrating soft tissues. The temperature elevation was estimated on the basis of this work to be at most 1.8 times that one estimated in the case of two considered lithotripsy systems when assuming small amplitude absorption and attenuation coefficients.


Red cell aggregation and the echogenicity of whole blood.

To study the relationship between red cell aggregation and whole blood echogenicity, red cell aggregation was quantitated by a photometric method, whole blood echogenicity was quantitated by videodensitometry and sedimentation rate was quantitated by a modified Westergren method. Changes in red cell aggregation were produced by alterations in the hematocrit. The results showed that red cell aggregation increased in a linear fashion with increases in hematocrit. The sedimentation rate decreased in a linear manner with increases in hematocrit. Whole blood echogenicity showed a biphasic response, with an initial increase in echogenicity, peaking at hematocrits varying from 14-24% and decreasing thereafter. Over the physiologic range of hematocrits, an increase in the formation of red cell aggregates is associated with a decrease in the echogenicity of whole blood. Thus, red cell aggregates were not visible using our ultrasound equipment at physiologic hematocrits, and the echo contrast in blood under our experimental conditions at these hematocrits must represent either plasma spaces, platelet aggregates or possibly white cell aggregates. The association between spontaneous contrast and a propensity for thromboembolism imply that platelet aggregates are the most likely origin of in vivo echo contrast in flowing blood.


Identifying acoustic scattering sources in normal renal parenchyma in vivo by varying arterial and ureteral pressures.

Ultrasonic backscatter properties of normal dog kidney parenchyma are examined in vivo to determine sources of acoustic scattering. We systematically varied the renal perfusion and ureteral pressures to obtain detailed information about scattering sources that could not be seen under in vitro conditions. These data suggest that in normal parenchyma the principal sources of backscatter are Bowman's capsule at low frequencies (2.5-5.0 MHz) and glomerular arterioles at high frequencies (5.0-15.0 MHz). We found that the integrated backscatter coefficient (IBC) in normally perfused kidney cortex is approximately half that measured in the ischemic organ at all frequencies. Ischemia was found to reduce scatterer size estimates (D) by 10% at low frequencies and increase D54% at high frequencies. Acute obstruction of the kidney, under diuresis, produced an 11% increase in D at low frequencies, and no significant change in D at high frequencies. These variations in backscatter measurements are explained in terms of changes in the microscopic anatomy of the kidney.


Conservation of bactericidal activity in ultrasound-exposed murine peritoneal phagocytic cells.

Murine peritoneal exudate cells (PEC), predominantly macrophages, were insonated in vitro with burst-mode ultrasound and assayed for their ability to phagocytose and kill Staphylococcus aureus. PEC were exposed at 37 degrees C in rotating tubes to 1-MHz, burst-mode (10 ms on, 10 ms off) ultrasound at 3.7 +/- 0.2 W/cm2 ISPTA (7.4 +/- 0.4 W/cm2 ISPBA) for 150 s. Bactericidal activity was assayed at 1, 2, and 3 h after exposure and subsequent 37 degrees C incubation with the bacteria for 20 min. In these experiments, which comprised 17 treated and 7 sham-treated control samples, there was no significant difference in results between treated and control samples (p > 0.29).


Ultrasonic vibrational potentials in gels and preparations of biological tissue.

Measurements of the ultrasonic vibrational potentials (UVP) were performed at 815 kHz in agar and agarose gels as well as in several biological tissues from frog, rat and pig. The results for gels show that the magnitude of the UVP depends on the charge of the solid components of the gel, its mechanical strength and particularly on the concentration of free electrolytes present in the gel. The UVP decreases to less than 10 microV for a velocity amplitude of 1 cm/s if the salt concentrations exceed 10(-2) mol/L. The measurements in biological tissue in vitro demonstrate that the UVP are of the order of magnitude of a microV s cm-1 which is also explained by the presence of electrolytes of high concentrations in tissues. The measurements in biological tissue in vitro demonstrate that the UVP are of the order of magnitude of microV s cm-1 which is also explained by the presence of electrolytes of high concentrations in tissues. Based on these experiments, it can be concluded that the potential for harm to humans due to electrical effects of ultrasound as used in medical diagnostics is very low.


Influence of dissolved and free gases on iodine release and cell killing by shock waves in vitro.

Exposure of a potassium iodide solution to lithotripter shock waves resulted in formation of iodine with the amount of iodine depending on the gas dissolved in the solution. Iodine yield was higher with O2 and Ar, as compared to CO2 and N2O; degassed solution revealed the lowest iodine yield. Exposure of L1210 mouse leukemia cells to shock waves reduced the number of viable cells with no difference between O2-, Ar-, or N2O-equilibrated and degassed conditions. CO2 equilibration resulted in a more pronounced reduction. The difference between chemical and biological effects argues against the involvement of free radicals in cell killing by shock waves. In additional experiments, gas bubbles of various sizes were introduced into the test vials. Addition of a 10 microL gas bubble revealed an over 10-fold increase in iodine yield from degassed potassium iodide solution with all gases. Addition of a gas bubble also reduced the number of viable cells again with no difference between the gases. It is suggested that shock wave-gas bubble interaction is an important mediator of iodine release and cell killing by shock waves.


The influence of spatial polarization distribution on spot poled PVDF membrane hydrophone performance.

The influence of spatial polarization distribution on spot poled PVDF membrane hydrophone performance was calculated and then experimentally verified using a one-dimensional model based on acoustic wave propagation through a layered medium. It is shown that the sensitivity of the hydrophone is markedly dependent on the spatial polarization distribution. It is also shown that there can be a significant difference between the voltage sensitivities measured in the same hydrophone probe depending on which electrode is actually facing the acoustic source. The measurements carried out in the frequency range 1-20 MHz indicate that this difference, while negligible below 2 MHz, may exceed 1.6 dB at higher frequencies. The model developed can also be used to determine the "effective" piezoelectric constant d33 of the PVDF material as a continuous function of frequency. Moreover, the model predicts the existence of a negative slope in the frequency response of the spot poled membrane hydrophone. The experimental confirmation of this prediction underscores the importance of using swept frequency methods during calibration measurements.


Continuous and simultaneous ultrasound Doppler velocimetry of the internal carotid and vertebral arteries: preliminary observations of cerebral blood flow changes with common carotid compression.

We have developed a new technique for simultaneous assessment of the four cervical cerebral arteries. Using a cervical brace with four freely adjustable Doppler probes attached, we studied four healthy young males and observed their cerebral blood flow changes during common carotid compression. The results indicated various reactivity in these subjects. We observed that carotid compression sometimes affects or stops the ipsilateral vertebral flow according to the intensity and location of compression. Also, the flow of the contralateral internal carotid artery (ICA) and vertebral artery (VA) showed remarkable increases greater than those due to ICA obliteration alone. This indicates the possibility that using only one probe during compression may often result in unknown obliteration of the ipsilateral VAs flow and could also produce other incomplete data. Moreover, with our technique, we would be able to assess the cerebral reserve more precisely and clearly in patients with carotid or vertebral occlusive diseases.


The assessment of benign uterine tumor vascularization by transvaginal color Doppler.

Transvaginal color flow Doppler was used to study uterine flow and fibroid arterial supply. These studies were carried out in 101 patients with palpable uterine fibroids and 60 women attending the clinic for annual checkups. Blood flow impedance expressed as resistance index (RI), pulsatility index (PI), and blood velocity are calculated from the 5th to the 8th day of the menstrual calendar. Increased blood velocity and decreased RI and PI in both uterine arteries occurred in patients with uterine fibroids. The same technique was also used to study blood flow in the main arteries supplying identifiable fibroid. Diastolic flow in these arteries was always present and increased in comparison with uterine artery blood flow. The difference in uterine artery blood flow between patients with fibroids and healthy volunteers is statistically significant and may have predictable value in growth rate evaluation of the benign uterine mass.


Colour Doppler velocity imaging of the myocardium.

A technique has been developed for producing images of the velocity of tissue motion within the myocardium. It has been demonstrated that Colour Flow Doppler imagers can be operated to depict the velocities within the myocardium rather than moving blood in the cardiac chambers. The technique exhibits the normal advantages of diagnostic ultrasound, i.e., real-time imaging with relatively inexpensive equipment and no hazard to the patient. Further work requires to be done to determine the optimum signal processing algorithms for moving tissue echoes and to ascertain whether the technique is of value in clinical applications.


[Penetrating thoracic injuries].

In a period of peace in Germany and other westeuropean countries, penetrating trauma of the thorax (PTT) is much more rarer than blunt trauma. An analysis of 103 patients with PTT, treated in the Surgical Department of the University of Cologne from 1980 to 1990, showed, that these are usually isolated injuries in young patients. These occur usually following violence as stab wounds and less commonly gunshot wounds. Two thirds of the patients could be treated adequately with intensive care therapy and the use of thoracic drains. One third of the patients underwent thoracotomy, which was carried out in two thirds within one hour after hospital admission and in the remaining one third within the first 24 hours. The mortality for all PTT was 13%, being 10% for isolated thoracic injuries and 19% for patients with multiple trauma.


[Clinical criteria of acute epidural hematoma].

In a retrospective study 368 epidural hematomas are presented, treated from 1970 until August 1991. The clinical course and manifestation of acute epidural hematomas is commented on by means of own cases. Assessing the success of treatment, it could be demonstrated that the prompter diagnosis reduced the lethal outcome of epidural hematoma to 6.6%.


[MR and ultrasound study of Achilles tendon injury].

In 24 patients with lesions of the achilles tendon MRI and ultrasound was performed to compare the results with clinical examination. MRI had an accuracy of 100%, ultrasound of 90%. Especially partial rupture with chronic degenerative lesions of the tendon can be diagnosed more accurate by MRI which enables easier indication for treatment. By MRI diagnostic differentiation of our patients in four groups was possible.


[Damage to the knee ligament as a concomitant injury in femoral shaft fractures].

Knee ligament injuries associated with femoral shaft fractures can severely influence the functional results of treatment. In a follow-up of 59 operatively treated femoral shaft fractures 18.6% of the patients revealed ligamentous damages. In all cases one or both of the cruciate ligaments were injured. Especially polytraumatized car front-seat passengers are at higher risk with 30.8% ligament ruptures. While only 61.6% of the ligament injuries were primarily diagnosed, the testing of knee joint stability after osteosynthesis of a femoral fracture is essential. Furthermore arthroscopy should be performed if there is any hint of ligamentous damage. The ruptures of the anterior cruciate ligament and the ligamentous avulsion fractures can be successfully treated on by operative means.


[The value of sonographic diagnosis of the injured knee joint in trauma-surgical practice].

In a period of two years (January 1990 to December 1991) 136 knee joints were examined by ultrasound and arthroscopy. 40 out of 42 arthroscopically proven lesions of the anterior cruciate ligament were detected by ultrasound. The sensitivity therefore was 95.24%. We found three cases of ruptures of the posterior cruciate ligament, which were not detected clinically. 16 cases of ruptured medial collateral ligaments and 27 cases of elongations of the same ligament were diagnosed. Ultrasound examination of the knee and especially of the cruciate ligaments showed to be an accurate tool in order to obtain additional information on an injured knee even if clinical examination is difficult or impossible. Sonography is able to exclude lesions of the cruciate ligaments precisely. Therefore it helps to restrict the necessity of acute or early arthroscopy of knee joints.


[Bilateral tibial head epiphysiolysis in somersault jumping].

We are reporting about a rare case of a bilateral epiphyseal separation of the proximal tibial epiphysis which occurred to a 16 year old male at the time of bileged take-off when somersault diving. The X-rays at admission showed a bilateral proximal tibial epiphyseal separation of Salter-Harris type I on the right side and Salter-Harris type II on the left side. Both epiphyses showed a posterior dislocation. Stable, anatomical position on both sides was achieved by closed reduction under general anaesthesia and fixed by a plaster cast for five weeks. Healing occurred in anatomical position and no redislocation or growth disturbance was observed. The treatment for such separations is usually conservative; the prognosis is very good, provided that an optimal reposition with restoration of the anatomical situation has been achieved.


[Initial experiences with the humerus interlocking nail].

A preliminary report is given on the good results of eleven patients, who had been treated with a locking nail for a fracture of the humerus at three different trauma departments. No non-union, infection or radial palsy has been seen nor was there any neurovascular complication intraoperatively. Four patients had misalignments of up to 15 degrees, whereof three of them had combined varus-recurvation-angulations without functional or cosmetic sequelae. All but one had excellent functional results six months postoperatively. Bone healing could be confirmed three months postoperatively. Only transverse and spiral fractures of the second to fifth sixth had been treated until now, though open fractures up to the second degree can be managed too. Finally, some technical issues are considered, which include a better guiding device, the use of cancellous screws for proximal looking, a more oblique position of one of the proximal screwholes to obtain some kind of interfragmentary compression for appropriate fractures, and the use of a Williams-screwdriver.


[PC-assisted planning and documentation of the surgical schedule].

A computer program for personal computers was developed to support and control the schedule in the operation theatre. With this program a great amount of operational and medical data will be recorded (e.g. the duration of operation and anesthesia, the number of operating rooms occupied, the personnel involved, the diagnosis and surgical therapy). The screen shows up-to-date information about the ongoing events. All data can be easily evaluated for different criteria. In a four years period the program presented has proved valuable for daily routine planning and documentation in a great operation unit.


Cytogenetic evidence of intratumoral focal heterogeneity in prostatic carcinomas.

Although prostatic cancer is the most common malignant disease in men in western countries, only limited data on chromosomal changes are available. We report on our cytogenetic findings in cell cultures from four primary prostatic carcinomas indicating the existence of intratumoral focal heterogeneity concerning chromosomal anomalies in prostatic cancer.


Tumor size of renal cell carcinoma: its clinical implication.

We studied the clinical implication of tumor size in renal cell carcinoma, by revealing its relation with the other histopathological and clinical features. The tumor size was well correlated with histopathological findings and metastatic status of the carcinoma. Smaller carcinomas (usually less than 60 mm) generally had a higher disease-specific survival than those of 60 mm or greater. The results indicated that the size reflected the biological character of the carcinoma. However, 10% of patients with the smaller carcinoma had lymph node metastasis or distant metastasis at the time of diagnosis, each of which contributed to a renal cell carcinoma-related death in the early follow-up period.


[Mammography].

Mammography is the most important method for the diagnosis and the screening of breast diseases. Sensitivity and accuracy of mammography are very high in the detection of breast cancer. The use of the stereotaxic localization and fine-needle aspiration of nonpalpable breast lesions improve its effectiveness. The American Breast Cancer Detection Demonstration Project (BCDDP) has demonstrated the benefits of breast screening for women over 40 years of age. Many American medical associations and societies have adopted the guidelines based on the BCDDP results, promoting breast cancer screening for these women. However, recently released results of some randomized breast screening studies demonstrated only a 5% reduction in mortality from breast cancer in women 40-49 years of age, and a 40% reduction for women aged over 50 years. There is no explanation for this dilemma at the present time. However, screening mammography should stay available for women over 40 years of age.


[An effective intervention project for arterial hypertension screening in family medicine].

This study was carried out to assess the effectiveness of a preventive protocol in improving hypertension detection in a hospital-based family medicine unit. This protocol was planned and implemented by local practitioners and did not need any additional budgeting. Two distinct groups, each of 850 adults, were randomly selected from patients having consulted before and after the introduction of the protocol. Medical records were audited. Hypertension screening rate improved of 17.7% (p less than 0.00001) after the application of the preventive intervention. Furthermore, a 20.5% increase of the screening rate was estimated after adjustment by the logistic regression method, for characteristics related to patients and to practitioners. In conclusion, these findings support the hypothesis that this preventive protocol contributes to improve in family physicians their hypertension screening performance and they justify further assessment with a control group.


Partial ureteric obstruction in weanling rats. II. Long-term effects on renal function and arterial blood pressure.

A partial obstruction of the left ureter was created in weanling (3-week-old) rats. Renal function was studied after 7-9 weeks and compared to that in age-matched controls. Arterial blood pressure was found substantially increased. During normal hydration, the hydronephrotic kidney had low excretions of urine, potassium, osmoles and, especially, sodium. The contralateral, intact side showed no compensatory traits. On volume expansion, the hydronephrotic kidney demonstrated an unimpaired reacting capacity, leading to normalization of urine, sodium and osmole excretions and even to supernormal renal blood flow, glomerular filtration and potassium excretion. On the intact side, the excretion of potassium was increased like that on the hydronephrotic one, while excretions of urine, sodium and osmoles were increased even more. The fact that the intact kidney handled most of the urine excretion was interpreted as the result of a mechanism protecting the obstructed kidney from additional pressure insults while homeostasis was maintained. The arterial hypertension may result from the combination of retention of fluid and sodium by the hydronephrotic kidney and the absence of compensation by the intact kidney during normal hydration--like that in everyday life. The functional changes during normal hydration were generally more severe than those we found after obstruction in neonatal and adult rats, in which arterial hypertension was never observed. The clinical implication would be that the kidney may be less tolerant to pressure rises during the infant year. Changes due to obstruction are known to occur rapidly, but after that neither progress nor reverse.(ABSTRACT TRUNCATED AT 250 WORDS)


Adenosine triphosphate and adenosine diphosphate in human semen: correlation with sperm count and motility.

Adenosine triphosphate (ATP) and adenosine diphosphate (ADP) have been correlated with traditional semen parameters such as forward motility and sperm count. ATP and ADP were determined by a bioluminescence assay using the luciferin-luciferase reaction. Short boiling of the ejaculate was performed to inactivate phosphatases (ATPases) in the seminal plasma and the sperm tails. Fresh and deep-frozen semen samples from 45 men with oligozoospermia (n = 22) and normal sperm count (n = 23) were evaluated. Freezing of the sperm for 12 weeks did not effect the ATP or ADP content in the spermatozoa as compared to fresh semen. ATP and ADP concentration was in the range of picomoles/microliter and showed a significant correlation with the number of normal sperm per milliliter and a less marked correlation with the sperm motility. ATP and ADP concentration in the spermatozoa can be measured relatively easy and is reproducible. Unlike the monotonous evaluation of sperm motility by a technician, this biochemical method provides an objective parameter for semen quality. These qualities suggest that this method could be a way to determine the fertilizing potential of semen and to relate this to actual pregnancy rates.


Urinary tract infection caused by nontyphoidal Salmonella: report of 30 cases.

Thirty cases of nontyphoidal Salmonella bacteriuria were identified by review of cultures performed at the Mayo Clinic (Minn.) from 1985 to 1989 and at the Federal Public Health Laboratory Innsbruck (Austria) from 1979 to 1989. All patients had symptoms of an acute urinary tract infection (UTI). In 24 cases nontyphoidal Salmonella was the sole pathogen isolated. Only 1 patient presented with concomitant gastroenteritis and 2 had experienced episodes of diarrhea during the weeks before the UTI, but 15 patients had positive stool cultures in the absence of a gastrointestinal illness. Among all positive urine cultures at the Mayo Microbiology Laboratory, 0.015% were positive for nontyphoidal Salmonella; at the Federal Public Health Laboratory Innsbruck, 0.024% of organisms cultured from urine were nontyphoidal salmonellae. In the majority of our patients, Salmonella UTI did not differ clinically from UTI caused by other members of the Enterobacteriaceae; only in renal transplant recipients was the course of genitourinary salmonellosis more serious. While some urinary isolates of nontyphoidal Salmonella may be fecal contaminants, all 30 isolates recovered from urine during this study were considered to be the cause of symptomatic UTI.


Efficacy of prophylactic gentamicin use in postoperative urinary tract infections after endoscopic procedures of the urinary tract.

In this study, the efficacy of prophylactic antibiotic use was investigated. A total of 110 patients undergoing endoscopic procedures of the urinary tract were enrolled in the study. Fifty-five of the patients were treated with 8-hourly, 80 mg gentamicin sulfate of total three doses. The drug administration began just prior to the operation. Seven postoperative infections (12.7%) were detected, the same number as in the control group of 55 patients. The results confirm that there is no place for gentamicin prophylaxis in endoscopic procedures of the urinary tract.


Inhibitors of calcium oxalate crystallization and urolithiasis.

In urolithogenic processes both, promoters and deficit of inhibitors, play an important role. The inhibitory action of added inhibitors (magnesium, citrate, pyrophosphate and chondroitin sulphate) was investigated using the urine of 72 patients with calcium urolithiasis. It was concluded that the deficit of inhibitors seems to be an important cause of stone formation in idiopathic oxalocalcic urolithiasis. Nevertheless, when that specific heterogeneous nucleation takes place it becomes an important factor and the inhibitor plays a complementary role in calcium oxalate urolithiasis.


Renal damages after extracorporeal shock wave lithotripsy evaluated by Gd-DTPA-enhanced dynamic magnetic resonance imaging.

Renal damages after extracorporeal shock wave lithotripsy (ESWL) were evaluated by magnetic resonance imaging (MRI) including Gd-DTPA-enhanced dynamic MRI in 37 patients with renal stone by spin echo methods (T1 and T2-weighted scan) and small tip angle gradient echo method (T2-weighted scan). Sixty-eight percent of the patients had changes in the MRI findings after ESWL. The frequently observed findings were perirenal fluid collection (38%), loss of corticomedullary junction (35%), and increased signal intensity of muscle and other adjacent tissue (34%). Preoperative Gd-DTPA-enhanced dynamic MRI showed low intensity band which suggests Gd-DTPA secretion from the glomerulus into the renal tubulus. In all cases the low intensity band became unclear after ESWL because of renal contusion due to ESWL. MRI, including Gd-DTPA-enhanced dynamic MRI, is considered to be a good procedure for evaluation of renal damages due to ESWL.


An azoospermic male with reciprocal translocation t(3;4)(p12;q21).

We report a case of autosomal translocation associated with azoospermia. The literature is reviewed, and hormone condition and testicular histology are discussed.


Effect of extracorporeal shockwave lithotripsy for urolithiasis on concentrations of creatine kinase isozymes in patient serum and urine.

To determine whether extracorporeal shockwave lithotripsy (ESWL) for urolithiasis causes renal injury, we immunoassayed creatine kinase isozymes (CK-B and CK-M) in serum and urine from patients with renal stone (n = 21) and ureteral stone (n = 18) before and after (0, 2, and 24 h) ESWL. CK-B is generally present in renal tissue at relatively high concentrations, whereas CK-M is found at low concentrations. CK-B and CK-M levels were enhanced both in the serum and urine samples after ESWL in both groups of patients but CK-B levels return to almost normal very rapidly. Because CK-M, which is mainly localized in muscle tissue, also increased in both groups, the increased CK-B in serum after ESWL might be derived not only from kidney but also from muscle tissues which also contain a significant level of CK-B. These results suggest that significant tissue injury, including kidney and muscles, might be caused by ESWL treatment for urolithiasis but there is no long-term renal adverse effect, and that creatine kinase isozymes in serum and urine might be useful markers of tissue injury by such treatment.


Surgical reinforcement of gender identity in adolescent intersex patients.

The presentation of phenotypic gender ambiguity at the time of adolescence is uncommon. Surgical reinforcement of gender, or reassignment is often complex and multistage. We present 2 cases of children who developed secondary sexual characteristics contrary to their chromosome status who, because of their late presentation, required significant surgical intervention to reinforce the gender assigned to them. We review some of the surgical techniques involved.


Urethral narrowing due to ectopic prostatic tissue in the bulbar urethra.

Ectopic prostatic tissue in the bulbar urethra is a rare disorder. A case of urethral narrowing due to such tissue is presented. The tissue specimen from the urethral narrowing was positively stained immunohistochemically by the prostatic specific antigen. Urethrocystographic findings are also discussed.


Urethral tuberculosis.

Tuberculous affection of the urethra is very rare. Herein we report 2 cases of urethral tuberculosis. One in a young married female who had isolated urethral involvement presenting as urethral caruncle and the second in a young male with urethral stricture complicated by fistulae and abscess in association with renal tuberculosis. The relevant literature is briefly reviewed.


Abscess of corpus cavernosum.

A rare case of abscess of the corpus cavernosum is described. Culture of the abscess yielded beta-hemolytic streptococcus. Ultrasound scan and cavernosography confirmed the physical examination findings of involvement of the corpus cavernosum. The patient was treated successfully by percutaneous ultrasound-guided aspiration drainage and systemic antibiotic therapy.


Spontaneous thrombosis of the renal vessels. Rare entities to be considered in differential diagnosis of patients presenting with lumbar flank pain and hematuria.

We report 2 cases of spontaneous thrombotic occlusion of the main renal vessels presenting with acute lumbar flank pain and hematuria suspect of nephrolithiasis. Clinical and laboratory signs of blood hypercoagulability, generalized arterial embolism, nephrotic syndrome or glomerulonephritis were absent. Excretory urography, nephrosonography and retrograde ureteropyelography showed no evidence of upper urinary tract calculi or other causes of obstruction. Renal angiography and cavography demonstrated an acute renal vein thrombosis in 1 patient and a thrombotic occlusion of all but one of the segmental renal arteries in the other patient. These 2 cases demonstrate that thrombotic occlusion of the renal artery or renal vein has to be considered in patients who are presenting with lumbar flank pain and hematuria, in whom the excretory urogram shows severe malfunction of one of the kidneys, and stone disease can be excluded. Renal angiography and cavography as well as CT scan should be carried out in these patients. When the disease is diagnosed at an early stage, an intra-arterial thrombolysis can be attempted.


Renal cell carcinoma with unusual metastatic lesions detected by angiography.

The case of a patient with left renal cell carcinoma with two small metastatic lesions in the mesenterium and retroperitoneal fatty tissue is reported. These metastatic lesions were incidentally detected by preoperative routine angiographic examinations. The patient underwent left radical nephrectomy and resection of the metastatic nodules. The usefulness of angiography for detecting metastatic lesions and the possible metastatic pathways of these uncommon lesions are discussed.


Coexisting renal cell carcinoma and xanthogranulomatous pyelonephritis in a chronic calculous disease.

Association of renal cell carcinoma (RCC) with renal calculi is very rare. Herein we report a case of RCC developing in a non-functioning kidney containing multiple renal and ureteric calculi. Histologically, the kidney, in addition, revealed changes of xanthogranulomatous pyelonephritis (XGP). XGP can be confused clinically, grossly and microscopically with RCC. In the present case both were coexistent and thus make it interesting.


Focal xanthogranulomatous pyelonephritis: diagnostic and therapeutic aspects.

The authors report 2 cases of localized xanthogranulomatous pyelonephritis (XGP) in which computed tomography (CT) permitted to raise a motivated clinical suspicion of inflammatory disease: the surgical exploration documented absence of neoplasm and allowed a conservative therapy implying only the removal of the mass. A literature review confirms that some CT signs in XGP permit differentiation from carcinoma. If they are present, in unifocal cases of disease, the authors suggest a limited surgical approach and a therapeutic strategy as conservative as possible.


Bellini duct carcinoma of the kidney.

We report a very rare case of Bellini duct carcinoma originating from the collecting tubules of the kidney. A left renal tumor was detected during a health examination and radical nephrectomy was performed. Histological examination showed papillary adenocarcinoma. By means of immunohistochemical methods, we felt that the tumor was a renal carcinoma of Bellini duct origin.


Gynecomastia and ectopic human chorionic gonadotropin production by transitional cell carcinoma of the bladder.

We report a patient with gynecomastia and ectopic production of human chorionic gonadotropin (HCG) by a transitional cell carcinoma of the bladder. In the present case, serum HCG levels and gynecomastia paralleled the clinical course. On admission, the patient was suffering from invasive transitional cell carcinoma (grade 3) of the bladder with metastasis to the left inguinal lymph nodes, together with gynecomastia. The serum HCG level was also elevated. After anticancer chemotherapy, the apparent bladder lesion and gynecomastia disappeared, and the serum HCG level declined to within normal limits. About 2 months after discharge, when the patient suffered from recurrent invasive tumors of the bladder, gynecomastia reappeared and the serum HCG level again became elevated. beta-HCG was demonstrated in biopsy tissue using the immunoperoxidase technique. The presence of beta-HCG was always focally demonstrated and was shown to be localized in the cytoplasm of the tumor cells.


Flap valve ureteral stent with an antireflux function: a review of 46 cases.

During a 2-year period, 46 patients with upper urinary obstructions (intrinsic obstruction and extrinsic compression) underwent treatment with a flap valve indwelling double-pigtail stent. Our subsequent analysis suggests that a flap valve at the lower end of a conventional ureteral stent can effectively prevent reflux in the upper urinary tract, and reduce discomfort and pain in the flank region during micturition.


Secondary tumors of testis: two rare cases and review of the literature.

Secondary testicular tumor is a rare event. Approximately 200 cases have been documented in the international literature since 1935. The most common primary tumor sites have been the prostate, lung and kidney with other sites being reported less frequently. Our literature review discovered only 7 cases originating from primary tumors of the stomach and 14 cases from primary tumors of the colon. We want to add 2 more cases and discuss the possible mechanism of this neoplastic dissemination.


Significance of cavernosography in standardized cavernosometry.

Ninety-five patients with erectile dysfunction underwent standardized cavernosometry and cavernosography. In a first stage, the investigation was performed in each patient without and in a second stage with 60 mg papaverine injected intracavernously. A pathological maintenance flow rate between 20 and 120 ml/min decreased by 55% on average. The induction flow is of considerable variability and of poor diagnostic value. For quantification of venous leakage, the maintenance flow rate is of great importance and in correlation with the time of pressure decrease. Our results with a sensitivity of 59% suggest that cavernosography as the only screening method for venous leakage is not sufficient. In most of the cases, cavernosography is indicated only in consideration of venous leakage surgery.


Surgical approach of venous leakage.

Venous leakage is a cause of impotence easily demonstrated by dynamic cavernosography. It revealed dorsal venous leakage in 41 patients, perineal leakage in 15 patients and dorsal plus perineal leakage in 42 patients. Dorsal vein ligation was performed in 38 cases. Fourteen patients underwent ligation of crura penis. Combined procedure was done in 36 patients. Immediate results of the surgical approach are quite encouraging, but finally, they are satisfactory in only 20% of the cases. Nevertheless, surgical treatment of venous leakage can further be taken into consideration to reduce blood outflow and strengthen vasoactive drug effects.


Venous surgery in veno-occlusive dysfunction: long-time results after deep dorsal vein resection.

Follow-up of patients 1 year after deep dorsal vein resection gives evidence of an approximate 50-60% success rate. A careful selection of only this small percentage of patients, in whom abnormal drainage through the penile dorsum is obvious, is mandatory. Men with an arterial cofactor have to be excluded or to be subsequently treated by intracavernosal autoinjection of vasoactive substances. Late results from our study demonstrate a further loss of sufficient erection, also in men considered as persistent success by us, in the subjective view of the patient and/or his sexual partner.


Venous surgery in erectile dysfunction.

According to the physiopathological process beyond it, veno-occlusive dysfunction (VOD) may be classified in organic or functional VOD. The former is caused by lack of control of smooth muscle relaxation, while the later is related with morphological alterations of the corporeal tissue. The differential diagnosis of those two types is fundamental when venous surgery is to be discussed. Functional VOD may be treated with sex therapy, while in organic VOD, surgical treatment may be considered. The experience with venous surgery for impotence at the H. Ellis Institute was not encouraging. Although a few patients were cured, the long-term follow-up showed that only 9 out of 57 patients were able to have a normal sexual life. New diagnostic tools, as well as a better understanding of the erectile mechanism, may lead to a better selection of cases with an improvement of the results in the future. Today, venous surgery remains as an option to patients with organic VOD, who are willing to accept a 45% probability of improvement for a few months, having been informed about all the other options in the treatment of erectile disorders.


Penile venous ligation surgery for the management of cavernosal venous leakage.

Forty-one patients underwent penile venous ligation surgery for pure cavernosal venous leakage diagnosed by infusion cavernosometry and cavernosography. Before surgery, arterial integrity was assessed by pelvic angiography, and all patients were found to have a normal penile arterial system. The patients were divided into two groups on the basis of the type of venous operation performed. The overall complete-potency success rate was 46% (19 of 41 patients). Postoperative complications were minimal. Our experience shows that penile venous surgery remains an acceptable option for treatment of carefully selected patients with documented pure cavernosal venous leakage of a mild degree who have no evidence of arterial insufficiency and who do not prefer, or are not suitable for, other medical or surgical treatment options. Patients who had more severe degrees of cavernosal venous leakage had a poor result from this procedure. For patients with moderate to severe venous leakage, we now perform a combined surgical procedure, deep dorsal vein arterialization and venous ligation.


Venous surgery in erectile dysfunction. The role of dorsal-penile-vein ligation and spongiosolysis for impotence.

We report here on our surgical experience with venous leakage of the cavernous bodies. Out of 159 patients operated on, 134 were available for long-term follow-up. Depending on the cavernosographic findings, one of three different surgical procedures was carried out: ligation of the deep dorsal vein of the penis, spongiosolysis, or ligation of the crura. 18% of the patients undergoing ligation of the deep dorsal vein, postoperatively attained spontaneous erections, while 35% needed adjuvant corpus cavernosum autoinjection therapy. Spongiosolysis gave a more favourable result: spontaneous erections in 30% and vasoactive drug-dependent erections in 35%. Crural ligation did not prove successful. No serious complications were encountered postoperatively. Our data suggest that venous surgery should only be offered to a selected group of patients comprising young impotent men with venous leakage, maybe in combination with arterial disease, and patients suffering from distal venous leakage. Old age, neurogenic disorders causing erectile dysfunction, and diabetes mellitus should represent exclusion criteria for venous surgery.


Management of corporal veno-occlusive dysfunction.

Veno-occlusive dysfunction has become a recognized cause of organic impotence. The existence of concomitant arterial and sinus smooth-muscle disease makes this disorder often difficult to diagnose. It rarely can be the sole etiology for impotence. The authors' experience in the treatment of this disorder in over 100 patients is presented. The authors rely on cavernosometry/pharmacocavernosometry/pharmacocavernosogr  aphy and the color duplex Doppler screening test (to eliminate concomitant arterial disease) as the primary diagnostic tools. Twenty-two patients of 58 (38%) have achieved long-lasting success from the surgery so that they are able to have vaginal intercourse. Another 12 patients (21%) have been improved but must depend upon pharmacological injection therapy to obtain a sufficient erection for intercourse. There has been a 41% failure rate, and these are discussed.


Venous leakage--a new therapeutical concept.

According to our opinion, so-called venous leakage is no venous disease but a result of impaired cavernous tissue. Since in over 90% of all patients with venous leakage also arterial disease was discovered and since ultrastructural degenerative processes in the cavernous bodies were detected, we consider traditional corrective venous surgery as unphysiological and illogical. We suggest arterial revascularization combined with a mechanical penis banding as a new therapeutical concept.


Venous surgery in erectile dysfunction: therapeutic strategy and results.

The therapeutic rationale of venous surgery is to create an effective obstacle to the pathologically increased venous outflow, determined by an intrinsic pathology of the cavernous bodies. In the last 15 years, many techniques have been proposed, and our therapeutic approach has evolved with our knowledge of penile haemodynamics. Up to October 1990, we performed 316 operations for the relief of impotence. In a 2-year follow-up our recurrence rates were as follows: DDV plus corporpexy (n = 50): 26% (n = 13); DDV plus crura plication (n = 34): 47% (n = 16); DDV plus collateral vein ligation (n = 48): 62.5% (n = 30).


Present state of diagnostic management in veno-occlusive dysfunction.

Pharmacocavernosometry and pharmacocavernosography are essential for the diagnosis of veno-occlusive dysfunction. Pressure fading obtained by cavernosometry correlates excellently with results of intracavernosal pharmacon testing. Venous drainage as visualized by pharmacocavernosography is essential for localization of the venous channels especially if venocorrective surgery is planned.


[The cardiovascular and thromboembolic complications of intravital estrogen therapy in middle-aged and elderly patients with prostatic cancer].

Cardiovascular and thromboembolic complications arising as a result of 1-16-year estrogen therapy were evaluated in 105 prostatic cancer patients. The incidence of the complications was higher in those who had pretreatment cardiological or vascular load. The latter caused death in half of the patients. Preventive and therapeutic measures to control the complications, prognosis signs are indicated.


[The role of transperitoneal fine-needle aspiration biopsy in the diagnosis of obstructive uropathy in patients with cervix uteri cancer].

Upon the exposure to remote or combined radiotherapy, the patients with uterine cervical cancer often develop ureterostenosis due to recurrence or postradiation alterations in the walls and adjacent tissues of the ureter. Etiology of the urodynamic defect is essential for the treatment policy choice. Therefore, in attempt to find out effective means of differential diagnosis between ureteral obstruction due to cervical cancer relapse and due to postradiation lesion, the authors tried transperitoneal aspiration biopsy with thin needle as a tool of such diagnosis. The biopsy was obtained from 19 females. In 14 of them the obstruction was attributed to recurrent cancer, in 5 to radiotherapy. No errors in the diagnosis were made. Thus, the accuracy of the method reached 100%.


[The prognosis of the treatment results in patients with operable kidney cancer].

Computer processing by 73 characteristics in the system "host-tumor" was performed for 322 patients operated on for renal carcinoma from 1976 to 1986. The automatic classification method or cluster-analysis allowed distribution of the patients into homogeneous preoperative and postoperative groups (classes) which differed by the mean of the signs in the classes, survival and response to treatment. The formulas have been derived that enable the clinicians to refer the patients to a certain prognostic group without using a computer. This suggests more grounded examinations and treatment policy.


[The functional assessment of the renal parenchyma and perirenal fatty tissue during electropiezolithotripsy by x-ray computed tomography].

Computed tomography was performed before and after telelithotripsy to evaluate changes in renal parenchyma induced by the procedure in 34 patients with nephroliths. Piezolith-2300 lithotriptor ("Wolf", FRG) was employed. The images showed no serious parenchymal injuries or paranephric hematomas, on the one hand, but density changes in the parenchyma, on the other hand. These were of 3 types: focal reduction in 3, diffuse reduction in 4 and diffuse increase of the density in 2 patients. As shown by comparison with literature data, telelithotripsy on "Piezolith-2300" causes minimal changes in renal parenchyma and perirenal fat. In view of this, the procedure is recommended for wide clinical and outpatient practice.


[Telelithotripsy in the treatment of staghorn nephrolithiasis in children using the URAT-P lithotriptor].

The paper presents the results of telelithotripsy monotherapy for 34 staghorn stones in 32 nephrolithiasis children carried out at the RSFSR Research Institute of Urology, Moscow. Commonest manifestations of the disease were leukocyturia (87.5% of cases) and Proteus bacteriuria (31.8% of cases). Basing on roentgenological findings, the stones were classified into 3 groups: initial (K1), incomplete (K2) and complete (K3). All the children underwent treatment on Soviet lithotriptor "URAT-P" under a delicate regime using different techniques of disintegration which started from the periphery and advanced to the pelvic part of the calculus. No pretreatment drainage of the pelvicaliceal system was performed. The intended staged disintegration of the stones was achieved in 94.2% of cases at 2.4 sessions, on the average, and overall number of impulses 1973.1 per each stone. At discharge 76.4% of the children were free of the main mass of the stone dust. Acute pyelonephritis which appeared the most frequent postoperative complication developed in 7.8% of the patients one of which required open nephrostomy and one percutaneous puncture nephrostomy. Other cases were treated by specific antimicrobial therapy. Complete series of investigations in the postoperative period did not reveal any intra- or pararenal hematomas. Radioisotopic renography revealed improvement in renal function in 62% of cases in early postoperative follow-up. Thus, 93.8% of children with stag-horn stones were spared of traumatic operative intervention or invasive manipulations. This makes the method of telelithotripsy a valuable therapeutic tool in childhood staghorn nephrolithiasis.


[Extensive operations in kidney cancer complicated by tumor thrombus invasion of the inferior vena cava].

Invasion of renal tumor into retroperitoneal major vessels with thrombosis should be characterized as local spread of renal carcinoma and a serious complication. Extensive interventions were conducted in 30 subjects out of 196 nephrectomy cases. Nephrectomy was attended by colectomy (3 cases), pancreatic resection and adrenalectomy (3 cases), resection of the liver (2 cases), one-stage lobectomy (2 cases), adrenalectomy (9 cases), resection of the uterine appendages (1 case), resection of the colon, splenectomy, opening of an intraorganic abscess. 12 patients underwent thrombectomy from the major vein via the thoracophrenoabdominal approach. Cavathrombectomy was carried out in 7 (3.6%) patients, in 3 of which vena cava inferior was resected. Removal of the thrombus from the renal vein with resection of the opening and suturing of the vena cava inferior was performed in 5 patients. The thrombus originated from the right kidney in 9, while from the left one in 3 patients treated surgically. The thrombi occupied 4-10 cm along the renal vein from its opening. The removed kidney weighted from 400 to 3200 g. One death occurred due to pulmonary embolism during the operation, one on day 5 due to cardiopulmonary insufficiency. Histological examinations of the thrombi showed them to consist of fibrin, blood elements and tumor cells within the thrombus. The thrombi grow slowly, undergo organization and vascularization. Tumor cells multiply in the thrombus. Fibrin coating restricts cancer cell free dissemination via the venous system. Cavathrombectomy is considered the only way to prolong survival for the above patients.


[The removal of calculi from the pelvic ureter by extracorporeal lithotripsy].

Using high-energy impulses from Dornier HM-3 lithotriptor, iliac ureteroliths were crushed in 18 patients for the period of 2.5 years. The mean age of the patients was 38 years. The lithotripsy was in all cases preceded by retrograde catheterization. Reposition of the stones was achieved in 6 patients. Prone-position lithotripsy was conducted in 12 patients. Specially designed support cushions helped to keep the patient in a steady position, speeded up the stones excretion, relaxed knee joints and reduced the exposure to the impulses. All the patients underwent antiinflammatory and spasmolytic therapy. The mean hospital stay reached 3.2 days. Good results were reported in 94.1% of those treated. Neither early nor long-term complications arose.


[The rehabilitation of patients with urethral injuries and their sequelae].

The treatment was conducted for 154 patients aged 3-69 with traumatic rupture of the urethra. Eighteen patients underwent primary suturing, five patients primary delayed repair of the urethra. Urethral patency was achieved in all the cases. In 127 cases urethral rupture was associated with visceral and skeletal injuries managed by epicystostomy with good results. 16 patients without extended diastasis of the urethral fragments got circular tubes. 24 patients out of 111 developed restenosis (7 due to urethrotomy and 17 after tunneling). Later on 14 of these and the rest 87 patients were subjected to plastic reconstruction. Out of 101 patients operated on 3 needed bougienage, 1 patients retained urethrorectal fistula. 8 patients had postoperative dynamic urethral obstruction removed upon augmentation of detrusor tonicity by means of intravenous administration of calcium chloride and strofantina. Copulative dysfunction occurred in 70% of the patients over 22 years of age. Extracavernous prosthetic implantations performed in 33 of them corrected erectile impotence [correction of importance].


[The characteristics of the membranous part of the urethra].

The membranous part of the urethra has anatomic specificity influencing its trauma mechanism and allowed for in the trauma treatment policy. In 239 patients with an injured membranous part of the urethra described in the paper, the rupture was mainly due to the hip fracture. 85% of the patients developed a complete rupture with subsequent obliteration, 15% had strictures. Cicatrization involved the whole membranous part in 74% of the cases. In relevant traumas common are severe rectourethral and peritoneal fistulas surgical treatment of which as well as obliterations involves great technical difficulties. There is a variety of operative approaches and techniques (perineal, original anteropubic and anorectal). Urethral reconstruction should not be followed by bougienage. Typical are also frequent renal and genital complications (phlegmons, nephroliths, ureteroliths, epididymitis, orchitis, prostatitis, pyelonephritis). The number of complications depends on the choice of the adequate operative technique and due consideration of anatomical characteristics of the membranous part of the urethra.


Technique of external sphincter balloon dilatation.

We report on our technique and early experience with balloon dilatation of the external sphincter in 7 spinal cord-injured men with detrusor external sphincter dyssynergia and elevated voiding pressure. Following dilatation, bladder emptying into condom catheters was achieved in all patients without dribbling incontinence.


[Treatment results in urethral strictures].

A total of 231 patients with urethral strictures were treated. The disease resulted from trauma, adenomectomy, chronic urethritis, prostatic sclerosis in 92, 72, 51 and 16 patients, respectively. Fifty-one patients underwent conservative treatment which involved bougienage, resolving and anti-inflammatory agents. 38 of them responded, 13 nonresponders were operated on. 72 patients were subjected to partial urethral tunneling according to an original technique which brought success in 90% of the cases. Out of 92 traumatic urethral strictures 88 were cured after end-to-end plastic reconstruction. It is believed that urethral strictures should be managed individually basing on the stricture cause, location, length, severity, complications.


[An improved guide for urethral bougies].

A routine-technique urethral bougienage using an elastic guide in marked urethral strictures is performed practically at random in view of great difficulties of the guide advance through the narrow part of the urethra which is not safe for urethral tissues. An atraumatic guide developed by the authors is radio-opaque. This makes it possible to bring it along the urethra to the bladder under the control of x-ray television and to avoid damage to the tissues. The guide was used in 9 patients with urethral strictures who failed bougienage attempted by conventional methods. Not only the results were positive, but also there were no complications such as urethrorrhagia, false urethral passages and urethral fever.


Technical aids in investigation and management of urethral diverticula in the female.

Three aids in the diagnosis and management of urethral diverticula are described. First, the technique of double-balloon urethrography has been modified. Diluted contrast medium is used to inflate the intravesical and external balloons so that improved delineation of the anatomy of the diverticular pouches is obtained with undiluted contrast medium. Second, for identification and irrigation with antibiotic solution of the nondraining pouches of compound diverticula, an angiographic catheter is placed in the most distal pouch using fluoroscopically guided manipulation, and then this catheter is replaced with a pigtail-shaped nephrostomy drainage catheter. Third, a 7 F Foley catheter balloon is placed in thin-walled and friable diverticular pouches to facilitate dissection.


Prototype of a reflux-preventing ureteral stent and its clinical use.

We have experimentally produced a ureteral stent which prevents vesicorenal reflux. This stent has a thin silicon sleeve at its distal end (intravesical portion). In a model experiment the sleeve demonstrated an excellent capability to prevent reflux. The sleeve allowed flow of fluid with minimal pressure rise. A patient with bilateral ureteral obstruction was managed with endoscopic insertion of a sleeved stent in the right ureter and a usual pigtail stent in left ureter. During cystography vesicorenal reflux was not observed on the right side while reflux occurred on the left side. Excretory urography forty days after stent placement demonstrated recovery of renal function and maintenance of drainage in both renal units. Thus, the drainage characteristic of this stent appears to be approximately the same as that of usual stent.


[A way to improve the quality of compression anastomoses of the urethra in children].

The paper presents the analysis of compression anastomosis establishment in surgical treatment of children with posttraumatic strictures of the posterior urethra. It is noticed that quality of the anastomoses deteriorates with enlargement of the interpolated tissues layer. Anastomosis is suggested to be formed between submucous layers. The new variant was tried in experiment on 9 dogs and in 5 patients with posttraumatic urethral strictures. As a result of more advanced anastomoses the thickness of the interpolated tissues reduced 2-3-fold. The techniques of the above surgery are discussed as well as the advantages of the proposed submucous compression anastomosis in posttraumatic strictures of the posterior urethra.


KTP-532 laser ablation of urethral strictures.

In 1988 the KTP-532 laser was used to ablate a series of benign urethral strictures. Rather than using a single incision as in urethrotomy, strictures were treated with 360-degree contact photoradiation. Thirty-one male patients, average age 53.2 years, received thirty-seven treatments; 6 patients underwent a second laser treatment. Stricture etiology was commonly iatrogenic (32%), traumatic (16%), and postgonococcal (10%). Stricture location included mainly bulbar (49%), membranous (20%), and penile (12%) areas. The surgical technique consisted of circumferential ablation, followed by Foley catheter placement (mean, 10 days). Follow-up on 29 of 31 patients ranged from one to sixteen months (mean 9.7). Complete success occurred in 17 patients (59%) who had no further symptoms or instrumentation. Partial success was seen in 6 patients (20.5%) with symptom, but not stricture, recurrence. Six patients (20.5%) failed therapy, requiring additional surgery or regular dilations. No complications were seen. Although longer assessment is required, KTP-532 laser ablation of urethral strictures appears efficacious.


[The assessment of the state of the blood lipid spectrum, hemostasis, hormonal homeostasis and hemodynamics in the early diagnosis and drug correction of the cardiovascular changes in prostatic cancer patients undergoing estrogen therapy].

A complex of investigation was performed in 30 males with newly diagnosed prostatic cancer (stages T2NOMO-T3NO-1MO) before treatment with estrogens, 2-3 months and 1 year after its start. The complex included evaluation of blood lipid spectrum (HDL, LDL, VLDL, triglycerides), hemostasis (coagulation, platelet aggregation, fibrinolysis), hormonal profile (blood hydrocortisone, aldosterone, testosterone, estradiol, STH, FSH, LH, prolactin, plasma renin activity), central and intracardiac hemodynamics, ECG. 66 healthy men of advanced age served control. It was found that estrogen therapy affected blood lipid metabolism, leading to impairment of physiological correlation between HDL and triglycerides, increased blood levels of VLDL and triglycerides. Long-term estrogen treatment brought about enhancement of hemocoagulation and platelet aggregation. Hormonal shifts involved hyperprolactinemia, hypersomatotropism, hypercorticism, aldosterone hypersecretion, proportional androgens-estrogens alterations. Hormonal abnormalities produce side effects in estrogen-treated CHD and hypertonic patients: negative ECG readings indicative of deteriorated coronary circulation and hypertensive episodes, central hemodynamic disorders, respectively. In view of possible cardiovascular damage related to estrogen therapy, a differentiated approach is proposed which would allow a long-term estrogen treatment free of relevant complications.


Identification of motile sperm in caput epididymis. Intraoperative observations and clinical correlations.

This retrospective review of patients who underwent vasoepididymostomy demonstrates that motile sperm may be identified in the most proximal portion of the epididymis, and implies that induction of sperm motility may be independent of transit through the epididymis. Although further studies are needed, the data imply that it may not be necessary to identify motile sperm in the epididymal fluid to achieve a successful vasoepididymostomy.


Vesicoureteral reflux in children with and without a history of urinary tract infection: a comparative analysis.

Eighty-eight children who were discovered to have vesicoureteral reflux were prospectively studied over a two-year period. Two groups were compared: 49 who presented with a urinary tract infection and 39 who were identified through prospective screening. Based on the distribution of grade and the presence of parenchymal scarring, the severity of vesicoureteral reflux was comparable in the two groups. Of note, more males with reflux were identified in the noninfected group, whereas sex distribution was almost equal in the infected group. Ultrasound alone was found to be highly inaccurate in identifying reflux or parenchymal changes. In conclusion, screening of at-risk groups of children without a history of urinary tract infection may identify patients with clinically significant vesicoureteral reflux.


Accessory and ectopic scrotum with VATER association.

Scrotal ectopia or accessory scrotum are both rare conditions. This report describes a neonate with both abnormalities, who also has elements of the VATER association. This constellation of anomalies has not been previously described.


Preoperative assessment of prostatic carcinoma by computerized tomography. Weaknesses and new perspectives.

A retrospective study of five years' experience with fourth-generation computerized tomography (CT) scan was undertaken to assess the frequency of understaging in prostate cancer. A total of 160 patients with preoperative scans were surgically staged. In 10 patients, the operation was aborted after pelvic node dissection had revealed unsuspected metastatic involvement. Based on the histopathologic evidence of local tumor invasion, extension into seminal vesicles or pelvic lymph nodes, restaging was required in 78 percent of cases. Accuracy was 24 percent for capsular extension, 69 percent for seminal vesicle invasion, and 72 percent for lymphadenopathy. The poor yield of CT scan as a preoperative staging modality is demonstrated. Recent advances in the understanding and management of prostatic cancer require reassessing patient benefit and cost effectiveness of available imaging techniques, focusing on the problem of detecting nodal metastases, and predicting tumor spread to regional lymph nodes by accurately evaluating the primary neoplasm. We conclude that CT scan fails to demonstrate the required precision needed to evaluate local tumor spread; therefore, this goal must be pursued with newer imaging modalities.


Is magnetic resonance imaging alone accurate enough in staging renal cell carcinoma?

A patient with renal cell carcinoma extending into the inferior vena cava presented to our institution. Magnetic resonance imaging demonstrated the superior extent of the thrombus to be at the level of the hepatic veins. Preoperative venacavography showed extension into the right atrium. The need for both studies in evaluating patients with Stage 3A disease is reviewed.


Adenomatoid tumor of testicle.

A rare case of intratesticular adenomatoid tumor is described. Pathologically and clinically this tumor is associated with the seminiferous tubules and the rete testis. The patient underwent left inguinal exploration to confirm the testicular tumor. A radical orchiectomy was performed. We believe this is the first case of documented intratesticular adenomatoid tumor that did not arise from either tunica albuginea or epididymis. The cytologic origin of adenomatoid tumors and an unusual finding of decreased spermatogenesis with marked atrophy of the testes are also presented.


Ureteropelvic junction obstruction caused by accessory renal vessels in association with preureteral vena cava and vena caval duplication.

An apparent ureteropelvic junction obstruction on the right side may herald an array of anomalous conditions for which the surgeon should be prepared. A case is presented in which ureteropelvic junction obstruction caused by accessory renal vessels was found in association with a preureteral vena cava and a vena caval duplication on the right side. The embryology of caval anomalies associated with preureteric vena cava is reviewed.


Testicular teratocarcinoma with intracaval metastases to the heart.

We report a case of testicular teratocarcinoma involving the inferior vena cava with extension to the right atrium and metastases to the tricuspid valve. We believe this to be the first such reported case.


Priapism associated with asplenic state.

Priapism may be primary (idiopathic) or secondary to sickle cell anemia, trauma, leukemia, drugs, venous thromboembolic diseases, and other less common disorders. This study concerns 21 patients with priapism treated during a period of ten years. Nine patients (43%) had sickle cell anemia. Of the 12 individuals (57%) classified as idiopathic, 3 (25%) had previously undergone surgical splenectomy for benign conditions. Considering the propensity for this unusual condition to develop in patients with hemoglobinopathy-induced hyposplenism, the possibility of a relationship between the asplenic state and priapism is considered.


Use of tunica vaginalis patch graft for repair of traumatic testicular rupture.

Early exploration of patients with testicular rupture has become the standard of care in traumatic testicular injuries. We report on a case of traumatic rupture of the testicle diagnosed by ultrasonography, with a large testicular defect that could not be closed primarily. This was managed successfully with a free graft of tunica vaginalis. The affected testicle is palpably normal three months postoperatively. This technique may represent a valuable adjunct in managing major testicular ruptures.


Sarcomatoid renal carcinoma with angiosarcomatoid component. Light microscopic and immunohistochemical study.

We describe a case of primary renal pelvic carcinoma which showed an unusual histologic pattern of anastomosing blood-filled channels lined by atypical cells. This angiosarcomatoid pattern merged with solid areas typical of renal carcinoma. Immunoperoxidase stains for cytokeratin and epithelial membrane antigen were positive in both the angiosarcomatoid and typical carcinomatous areas, while stains for factor VIII-related antigen and desmin were negative. Since primary renal angiosarcomas are rare neoplasms, the diagnosis of sarcomatoid renal carcinoma should be considered in primary renal neoplasms which show this angiosarcomatoid pattern.