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Kidney transplantation: improvement in patient and graft survival
by D. Howard,
M.D.
Late Results of Intubated Ureterotomy, S. Wesolowski and A. Vorkowsky (139: 578, 1974) - Intubated ureterotomy was performed 193 times on 179 patients during an eleven-year period, and results of follow-up examinations on 100 patients are reported. The technique used is essentially that described by Davis in 1943. In this series of cases, however, a Cummings-Malecot catheter was substituted for the originally described T-tube drainage. Three groups of patients are included in this study. The first group consists of 8 patients in which this was a primary operation for hydronephrosis secondary to ureteropelvic obstruction. The second group consisted of 17 patients in which the procedure was used as a secondary operation for hydronephrosis following one or more unsuccessful plastic operations at the ureteropelvic junction and, in the third group, 75 patients with ureteropelvic obstruction associated with renal calculi. According to the authors, the results were good in 76 patients, satisfactory in 16 patients, and poor in 8 of the patients followed. A majority of the satisfactory results were obvious in the immediate postoperative period and, generally, persisted over a long period of time. A defective diversion of the urine and leakage through the wound was associated with poor results. Editc~‘s Comment: Unfortunately, the authors fail to describe what selectivity was used in presenting the 100 patients reported. The success or failure of the other 93 operations is essential if one is to evaluate this series fairly and draw conclusions on the results of intubated ureterotomy in the therapy of ureteral strictures. (A.N.T.)
AMERICAN OBSTETRICS
JOURNAL OF AND GYNECOLOGY
by S. Kallet,
M.D.
Gynecologic Complications of Epispadias and Bladder Extrophy, S. L. Stanton (119: 749, 1974) Fifteen female patients with epispadias and 59 with extrophy are presented with regard to gynecologic sequelae. In the patients with epispadias alone there was less associated genital abnormalities and 2 of the 15 have conceived. This is in agreement with the literature. On the other hand, 30 per cent of the female patients with extrophy had reproductive tract abnormalities including narrowed vagina (10 patients), genital prolapse (3), septate vagina (4), bicornuate uterus (4), and rectovaginal fistula (2). There was also a high incidence of renal and gastrointestinal abnormalities, including rectal prolapse, ectopic anus, imperforate anus, vesicointestinal fistulas, and renal agenesis. Required gynecologic procedures included ventrofixation, perineotomy, vaginoplasty, and
774
plastic surgery to the mons. The author believes that in patients who have had successful reconstructions with urinary continence or a competent anal sphincter, cesarean section should be done to prevent damage to these structures. Bladder or Rectal Injury Following Radiation Therapy for Cervical Cancer, J. R. van Nagell, Jr., J. C. Parker, Jr., Y. Maruyama, J. Utley, and P. Luckett (119: 727, 1974) - Rectovaginal or vesicovaginal fistulas developed in eleven of271 patients (4.1 per cent) with invasive cervical cancer who received radiation therapy eleven to sixty months after radiation. Six of these 11 had no evidence of recurrent tumor in the fistula and were studied for possible predisposing factors. Only diabetes and hypertension significantly predisposed to bladder or rectal injury. There was also noted to be a high incidence of severe bowel or bladder radiation reaction immediately after therapy in those patients in whom fistulas later developed. Bladder and rectal specimens from 15 patients undergoing pelvic exenteration (without previous radiation) were examined. Six of the 15 were hypertensive or diabetic. Four of these 6 had significant arteriolar narrowing, while this was not found in any of the 9 normotensive, nondiabetic patients. The authors believe this to be the underlying factor involved in the higher incidence of fistulas noted in diabetic and hypertensive patients.
ANNALS
OF SURGERY
by J. Thurm,
M.D.
Kidney Transplantation: Improvement in Patient and Graft Survival, K. H. Stenzel, et al. (180: 29, 1974) - This review of 249 kidney transplantations performed over a ten-year period reveals a significant improvement in patient survival during the past few years. Comparisons of kidney survival between living related donors and cadaver kidneys revealed an increased kidney survival in the cadaver kidneys, but this was the result of prolonged patient survival to a greater extent than kidney rejection. As in most series, the major cause of death was infection. Again, as might be expected, kidney survival in both groups was improved when immunologically closer matched. It was noted that none of HL-A identical donors had a similar kidney survival to cadaver donors when two or more antigens matched. The authors conclude that improved results can be achieved when careful attention is paid to antigenetic strength and immune responsiveness are tested. They further conclude that patient mortality rate can be expected at 10 per cent or less if there is ready availability of dialysis, prompt removal of marginally functioning kidneys, limited dosages of cortical steroids, and continuity of patient care.
UROLOGY
i
DECEMBER
1974
/ VOLUWE
IV, NUMBER
6
M.D.
Late Results of Intubated Ureterotomy, S. Wesolowski and A. Vorkowsky (139: 578, 1974) - Intubated ureterotomy was performed 193 times on 179 patients during an eleven-year period, and results of follow-up examinations on 100 patients are reported. The technique used is essentially that described by Davis in 1943. In this series of cases, however, a Cummings-Malecot catheter was substituted for the originally described T-tube drainage. Three groups of patients are included in this study. The first group consists of 8 patients in which this was a primary operation for hydronephrosis secondary to ureteropelvic obstruction. The second group consisted of 17 patients in which the procedure was used as a secondary operation for hydronephrosis following one or more unsuccessful plastic operations at the ureteropelvic junction and, in the third group, 75 patients with ureteropelvic obstruction associated with renal calculi. According to the authors, the results were good in 76 patients, satisfactory in 16 patients, and poor in 8 of the patients followed. A majority of the satisfactory results were obvious in the immediate postoperative period and, generally, persisted over a long period of time. A defective diversion of the urine and leakage through the wound was associated with poor results. Editc~‘s Comment: Unfortunately, the authors fail to describe what selectivity was used in presenting the 100 patients reported. The success or failure of the other 93 operations is essential if one is to evaluate this series fairly and draw conclusions on the results of intubated ureterotomy in the therapy of ureteral strictures. (A.N.T.)
AMERICAN OBSTETRICS
JOURNAL OF AND GYNECOLOGY
by S. Kallet,
M.D.
Gynecologic Complications of Epispadias and Bladder Extrophy, S. L. Stanton (119: 749, 1974) Fifteen female patients with epispadias and 59 with extrophy are presented with regard to gynecologic sequelae. In the patients with epispadias alone there was less associated genital abnormalities and 2 of the 15 have conceived. This is in agreement with the literature. On the other hand, 30 per cent of the female patients with extrophy had reproductive tract abnormalities including narrowed vagina (10 patients), genital prolapse (3), septate vagina (4), bicornuate uterus (4), and rectovaginal fistula (2). There was also a high incidence of renal and gastrointestinal abnormalities, including rectal prolapse, ectopic anus, imperforate anus, vesicointestinal fistulas, and renal agenesis. Required gynecologic procedures included ventrofixation, perineotomy, vaginoplasty, and
774
plastic surgery to the mons. The author believes that in patients who have had successful reconstructions with urinary continence or a competent anal sphincter, cesarean section should be done to prevent damage to these structures. Bladder or Rectal Injury Following Radiation Therapy for Cervical Cancer, J. R. van Nagell, Jr., J. C. Parker, Jr., Y. Maruyama, J. Utley, and P. Luckett (119: 727, 1974) - Rectovaginal or vesicovaginal fistulas developed in eleven of271 patients (4.1 per cent) with invasive cervical cancer who received radiation therapy eleven to sixty months after radiation. Six of these 11 had no evidence of recurrent tumor in the fistula and were studied for possible predisposing factors. Only diabetes and hypertension significantly predisposed to bladder or rectal injury. There was also noted to be a high incidence of severe bowel or bladder radiation reaction immediately after therapy in those patients in whom fistulas later developed. Bladder and rectal specimens from 15 patients undergoing pelvic exenteration (without previous radiation) were examined. Six of the 15 were hypertensive or diabetic. Four of these 6 had significant arteriolar narrowing, while this was not found in any of the 9 normotensive, nondiabetic patients. The authors believe this to be the underlying factor involved in the higher incidence of fistulas noted in diabetic and hypertensive patients.
ANNALS
OF SURGERY
by J. Thurm,
M.D.
Kidney Transplantation: Improvement in Patient and Graft Survival, K. H. Stenzel, et al. (180: 29, 1974) - This review of 249 kidney transplantations performed over a ten-year period reveals a significant improvement in patient survival during the past few years. Comparisons of kidney survival between living related donors and cadaver kidneys revealed an increased kidney survival in the cadaver kidneys, but this was the result of prolonged patient survival to a greater extent than kidney rejection. As in most series, the major cause of death was infection. Again, as might be expected, kidney survival in both groups was improved when immunologically closer matched. It was noted that none of HL-A identical donors had a similar kidney survival to cadaver donors when two or more antigens matched. The authors conclude that improved results can be achieved when careful attention is paid to antigenetic strength and immune responsiveness are tested. They further conclude that patient mortality rate can be expected at 10 per cent or less if there is ready availability of dialysis, prompt removal of marginally functioning kidneys, limited dosages of cortical steroids, and continuity of patient care.
UROLOGY
i
DECEMBER
1974
/ VOLUWE
IV, NUMBER
6