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Surgical treatment of horseshoe kidney
ACTA CHIRURGICA by F. P. Yuvienco,
tumor thrombus, is also reviewed.
SCANDINAVICA
fever, and anemia
with renal tumor
M.D
Funicular and Pedal Lymphography in Testicular Tumors, L. Hulten, L. G. Kindblom, J. Lindhagen, M. Rosencrantz, T. Seeman, and L. Wahlquist (139: 746, 1973) -The incidence of metastic involvement of lymph nodes and the relative value of funicular (testicular) and pedal lymphography in a diagnosis of lymphatic dissemination was investigated in 58 patients with malignant testicular tumors. A total of 63 consecutive patients with testicular neoplasma were examined and treated between 1965 and 1971. In 39 cases with nonseminomatous neoplasms, radiologic and histologic correlation could be made. At the time of surgery, funicular lymphography was performed. Pedal lymphography was performed one to six days later. Satisfactory studies were obtained in 58 patients. The technique suggested by Kinmonth for funicular lymphography was followed. The authors believe that lymphography is a valuable method to demonstrate the extent of retroperitoneal node metastases in testicular tumors. If funicular lymphography demonstrates evidence of metastases, the authors recommend pedal lymphography to demonstrate the full extent of retroperitoneal node disease. Bilateral lumbar lymph node involvement seems to be common and particularly so with tumors located on the right side.
ANGIOLOGY by Joel
Thurm,
M.D.
Angiographic Demonstration of Systemic Portal Collaterals in Renal Vein Occlusion, Y. Itzchak, R. Adar, M. Mozes, and V. Deutsch (2: 664,1974)-A case of a left renal vein occlusion secondary to carcinoma of the kidney is reported, and the selective renoangiogram demonstrated venous drainage from the affected kidney to the portal system. The reason for the development of renal portal rather than renal systemic collaterals was not evident. The shunt was established through collateral channels extending from the intrarenal veins via perforating and pararenal capsular veins through retroperitoneal veins and finally, by way of inferior mesenteric vein to superior mesenteric vein. It is important to use rapid selective injection of large quantities of contrast material in cases of renal carcinoma to best outline the venous drainage of the affected kidney.
JOURNAL OF BIOMECHANICS Unusual Manifestations of Renal Carcinoma, Kjell J. Tveter (139: 401, 1973)-The author emphasizes that renal tumor, in addition to the classic triad of hematuria, flank pain, and mass, manifests itself with a number of other symptoms and may masquerade as another disease. Among the endocrine manifestations are polycythemia or erythremia, hypercalcemia, and a Cushing-like syndrome. The hypotheses to explain the polycythemia are reviewed, and the incidence, according to the author, due to hypernephroma is 3 to 4 per cent. About 4 per cent of patients with polycythemia will be found to have renal tumor. Hypercalcemia is seen with renal tumors without evidence of the widespread bony metastases, and a number of hypotheses to explain these observations have been put forward. Whether the tumor produces a calcium-binding substance or a vitamin D-like material, or a factor which stimulates parathyroid production, or the tumor itself produces parathyroid-like material is not completely understood. The clinical picture in Cushing’s syndrome, due to neoplasia, develops rapidly, showing rapid progression in contradistinction to ordinary Gushing’s disease which has a more gradual onset. The diagnosis may be difficult because the syndrome is seen more frequently in men than women and because of the rapidity of onset, the classic clinical plethora, moon face and hirsutism, may be lacking. It appears that retention of sodium is responsible for the development of edema and hypertension. The association of amyloidosis, nephrogenic hepatopathy, neuromyopathy, arterial hypertension,
UROLOGY
/ AUGUST
1974
/ VOLUME
IV, NUMBER
2
by Joel Thurm,
M.D.
An Implantable Fluid Transfer System for Treatment of Impotence, D. R. Kothari, G. W. Timm, D. A. Frohrib, and W. E. Bradley (5: 567, 1972)-A hydraulic penile prosthesis to permit the volitionally controllable erectile state for the treatment of impotence is described. It is similar in design to the hydraulic system for the control of urinary incontinence designed by this same group. This article describes the preliminary experiences with a prototype of an implantable prosthesis superior to the rigid silicone rubber rods presently in use.
SCANDINAVIAN JOURNAL OF UROLOGYANDNEPHROLOGY by M. Josem,
M.D.
Surgical Treatment of Horseshoe Kidney, B.Kvarstein, and W. Mathien (8: 10, 1974)-This publication reviews the authors’ experience with 14 patients operated on for horseshoe kidney. The usual preoperative indications for surgery were hydronephrosis and urinary tract calculi. The 14 patients had a total of 23 operations; division or resection of the isthmus or kidney accounted for 11 of the procedures, and 8 procedures for removal of calculi were performed. From the review of the literature and the patients’ they recommended the surgical own experience, treatment of horseshoe kidneys with complications
231
of hydronephrosis, calculi, and urinary tract infection, as early as possible to avoid irreversible damage to the kidney.
Surgical Treatment of Cushing’s Syndrome in 72 Patients, 0. K. Mjolerophn, H. A. Haugen, B. Fretheim, B. Otnes, and W. Mathiesen (8: 13, 1974)-During a sixteen-year period, 72 patients with Cushing’s syndrome were treated by the authors. In 58, adrenal hyperplasia was present, in 9 an adrenal adenoma was present, in 2 adrenal carcinoma was found, and in the last 3 cases a pituitary tumor was diagnosed. Seventy-one patients were treated by adrenal surgery, including 12 who had previously been subjected to pituitary irradiation. Unilateral adrenalectomy was performed in the adrenal adenoma and carcinoma cases. In cases of adrenal hyperplasia, subtotal adrenalectomy was performed in the early years of this study, but this policy was abandoned and 52 of the 58 patients were subjected to a total adrenalectomy. A number of surgical approaches were used, including the transthoracic approach; but in the majority of cases, either a two-stage flank approach or a transabdominal exposure was adapted, permitting simultaneous access to both the adrenal glands and possible ectopic adrenal tissue. The early postoperative mortality rate was 15.5 per cent and in most cases was due to thromboembolic complications in poor risk patients. The postoperative endocrine management of these patients is not covered by the authors in this article.
JOURNAL by Michael
OF PEDIATRIC Berson,
SURGERY
M.D.
Carcinoma of the Adrenal Gland in Children, David R. Stewart, Patricia H. Morris Jones, and Ambrose Jolleys (9: 59, 1974)-Five cases of functioning, malignant adrenocortical tumors in children are presented. Their ages ranged from eight months to eleven years with signs and symptoms for two to eighteen months prior to presentation. Four of the 5 children were girls. The predominant endocrine disturbances consisted of virilization in 3 children and Cushing’s syndrome in 2, of which 1 also demonstrated virilization. The earliest manifestation was either facial acne or a rapid increase in height and weight, usually associated with secondary sexual changes. While an abdominal mass was palpable in 2 cases, this was not the initial complaint. Four children were hypertensive, while none exhibited the hemihypertrophy urinary tract anomalies or astrocytomas previously described as associated with adrenocortical neoplasms. Diagnostically, urinary 17 keto- and 17 hydroxycorticosteroids were elevated in all cases and not suppressed following dexamethasone administration. Other useful measures in the diagnosis of adrenocortical carcinoma included markedly elevated I7 ketosteroid levels, absence of effect on urinary steroid production after ACTH infusion, lack of
232
diurnal variation in serum cortisol, and elevated levels of tetrahydrosubstance (THS) in the urine. Intravenous pyelography revealed a suprarenal mass in 4 of the 5 cases, and angiography was performed in 2 children to aid in the differentiation of hyperplasia from solid neoplasm. All patients underwent attempted surgical excision using a transabdominal approach to assess the state of the contralateral adrenal gland as well as the extent of metastatic disease within the abdomen. In most cases of unilateral functioning adrenocortical tumors, the contralateral adrenal is atrophic secondary to chronic suppression. One child was found to have metastatic liver involvement at the time of exploration, while another was left with tumor extending into the vena cava. Pathologically, the tumors are tan or yellow in color and may exhibit focal areas of hemorrhage, necrosis, or calcification. The microscopic picture ranges from resemblance to normal adrenal tissue to an undifferentiated sarcomatous pattern with marked pleomorphism. Metastases occur most often in lung, liver, and regional nodes, while spread to bone and brain is unusual. Local invasion of kidney, omentum, or mesentary may occur. Postoperatively, supplemental steroid therapy is necessary for several months until the remaining suppressed normal adrenal gland recovers its function. Marked increase in twenty-four-hour urinary steroid production determined at frequent intervals may indicate residual tumor recurrence. Four of the 5 children in this study received 2500 r of radiotherapy postoperatively; while chemotherapy, including the use of o, p-DDD, was not used. Four of the 5 children are alive without evidence of disease for from one to twelve years after surgery.
The Occult Neuropathic Bladder, D. Innes Williams, G. Hirst, and D. Doyle (9: 35, 1974)-The clinical and radiologic presentation of neuropathic bladder dysfunction in the absence of neurologic and pathologic findings has been variously termed “subclinical or occult neurogenic bladder,” “isolated neurogenic dysfunction,” and now “occult neuropathic bladder.” Fourteen children with this syndrome are discussed in terms of their clinical course, diagnostic studies, and treatment. All patients, ranging in age from four to thirteen years, complained of incontinence, the majority both diurnal and nightly, since birth. In addition, micturition was at times slow, difficult, and urgent; almost all children exhibited intermittent or continuous urinary tract infections. Bowel dysfunction was evident as well as manifested by complaints of persistent constipation and/or fecal soiling. Positive findings on physical examination were limited to a palpably distended bladder and full colon. The anal sphincter appeared to be intact with good contraction and results of electromyogram studies performed on 3 children were normal. Standard clinical neurologic examination of superficial sensation, tendon reflexes, and the voluntary muscle system was unremarkable. The bulbocavernosus reflex was difficult to assess in young children.
UROLOGY
/ AUGUST
1974
I
VOLUME
IV, NUMBER
2
tumor thrombus, is also reviewed.
SCANDINAVICA
fever, and anemia
with renal tumor
M.D
Funicular and Pedal Lymphography in Testicular Tumors, L. Hulten, L. G. Kindblom, J. Lindhagen, M. Rosencrantz, T. Seeman, and L. Wahlquist (139: 746, 1973) -The incidence of metastic involvement of lymph nodes and the relative value of funicular (testicular) and pedal lymphography in a diagnosis of lymphatic dissemination was investigated in 58 patients with malignant testicular tumors. A total of 63 consecutive patients with testicular neoplasma were examined and treated between 1965 and 1971. In 39 cases with nonseminomatous neoplasms, radiologic and histologic correlation could be made. At the time of surgery, funicular lymphography was performed. Pedal lymphography was performed one to six days later. Satisfactory studies were obtained in 58 patients. The technique suggested by Kinmonth for funicular lymphography was followed. The authors believe that lymphography is a valuable method to demonstrate the extent of retroperitoneal node metastases in testicular tumors. If funicular lymphography demonstrates evidence of metastases, the authors recommend pedal lymphography to demonstrate the full extent of retroperitoneal node disease. Bilateral lumbar lymph node involvement seems to be common and particularly so with tumors located on the right side.
ANGIOLOGY by Joel
Thurm,
M.D.
Angiographic Demonstration of Systemic Portal Collaterals in Renal Vein Occlusion, Y. Itzchak, R. Adar, M. Mozes, and V. Deutsch (2: 664,1974)-A case of a left renal vein occlusion secondary to carcinoma of the kidney is reported, and the selective renoangiogram demonstrated venous drainage from the affected kidney to the portal system. The reason for the development of renal portal rather than renal systemic collaterals was not evident. The shunt was established through collateral channels extending from the intrarenal veins via perforating and pararenal capsular veins through retroperitoneal veins and finally, by way of inferior mesenteric vein to superior mesenteric vein. It is important to use rapid selective injection of large quantities of contrast material in cases of renal carcinoma to best outline the venous drainage of the affected kidney.
JOURNAL OF BIOMECHANICS Unusual Manifestations of Renal Carcinoma, Kjell J. Tveter (139: 401, 1973)-The author emphasizes that renal tumor, in addition to the classic triad of hematuria, flank pain, and mass, manifests itself with a number of other symptoms and may masquerade as another disease. Among the endocrine manifestations are polycythemia or erythremia, hypercalcemia, and a Cushing-like syndrome. The hypotheses to explain the polycythemia are reviewed, and the incidence, according to the author, due to hypernephroma is 3 to 4 per cent. About 4 per cent of patients with polycythemia will be found to have renal tumor. Hypercalcemia is seen with renal tumors without evidence of the widespread bony metastases, and a number of hypotheses to explain these observations have been put forward. Whether the tumor produces a calcium-binding substance or a vitamin D-like material, or a factor which stimulates parathyroid production, or the tumor itself produces parathyroid-like material is not completely understood. The clinical picture in Cushing’s syndrome, due to neoplasia, develops rapidly, showing rapid progression in contradistinction to ordinary Gushing’s disease which has a more gradual onset. The diagnosis may be difficult because the syndrome is seen more frequently in men than women and because of the rapidity of onset, the classic clinical plethora, moon face and hirsutism, may be lacking. It appears that retention of sodium is responsible for the development of edema and hypertension. The association of amyloidosis, nephrogenic hepatopathy, neuromyopathy, arterial hypertension,
UROLOGY
/ AUGUST
1974
/ VOLUME
IV, NUMBER
2
by Joel Thurm,
M.D.
An Implantable Fluid Transfer System for Treatment of Impotence, D. R. Kothari, G. W. Timm, D. A. Frohrib, and W. E. Bradley (5: 567, 1972)-A hydraulic penile prosthesis to permit the volitionally controllable erectile state for the treatment of impotence is described. It is similar in design to the hydraulic system for the control of urinary incontinence designed by this same group. This article describes the preliminary experiences with a prototype of an implantable prosthesis superior to the rigid silicone rubber rods presently in use.
SCANDINAVIAN JOURNAL OF UROLOGYANDNEPHROLOGY by M. Josem,
M.D.
Surgical Treatment of Horseshoe Kidney, B.Kvarstein, and W. Mathien (8: 10, 1974)-This publication reviews the authors’ experience with 14 patients operated on for horseshoe kidney. The usual preoperative indications for surgery were hydronephrosis and urinary tract calculi. The 14 patients had a total of 23 operations; division or resection of the isthmus or kidney accounted for 11 of the procedures, and 8 procedures for removal of calculi were performed. From the review of the literature and the patients’ they recommended the surgical own experience, treatment of horseshoe kidneys with complications
231
of hydronephrosis, calculi, and urinary tract infection, as early as possible to avoid irreversible damage to the kidney.
Surgical Treatment of Cushing’s Syndrome in 72 Patients, 0. K. Mjolerophn, H. A. Haugen, B. Fretheim, B. Otnes, and W. Mathiesen (8: 13, 1974)-During a sixteen-year period, 72 patients with Cushing’s syndrome were treated by the authors. In 58, adrenal hyperplasia was present, in 9 an adrenal adenoma was present, in 2 adrenal carcinoma was found, and in the last 3 cases a pituitary tumor was diagnosed. Seventy-one patients were treated by adrenal surgery, including 12 who had previously been subjected to pituitary irradiation. Unilateral adrenalectomy was performed in the adrenal adenoma and carcinoma cases. In cases of adrenal hyperplasia, subtotal adrenalectomy was performed in the early years of this study, but this policy was abandoned and 52 of the 58 patients were subjected to a total adrenalectomy. A number of surgical approaches were used, including the transthoracic approach; but in the majority of cases, either a two-stage flank approach or a transabdominal exposure was adapted, permitting simultaneous access to both the adrenal glands and possible ectopic adrenal tissue. The early postoperative mortality rate was 15.5 per cent and in most cases was due to thromboembolic complications in poor risk patients. The postoperative endocrine management of these patients is not covered by the authors in this article.
JOURNAL by Michael
OF PEDIATRIC Berson,
SURGERY
M.D.
Carcinoma of the Adrenal Gland in Children, David R. Stewart, Patricia H. Morris Jones, and Ambrose Jolleys (9: 59, 1974)-Five cases of functioning, malignant adrenocortical tumors in children are presented. Their ages ranged from eight months to eleven years with signs and symptoms for two to eighteen months prior to presentation. Four of the 5 children were girls. The predominant endocrine disturbances consisted of virilization in 3 children and Cushing’s syndrome in 2, of which 1 also demonstrated virilization. The earliest manifestation was either facial acne or a rapid increase in height and weight, usually associated with secondary sexual changes. While an abdominal mass was palpable in 2 cases, this was not the initial complaint. Four children were hypertensive, while none exhibited the hemihypertrophy urinary tract anomalies or astrocytomas previously described as associated with adrenocortical neoplasms. Diagnostically, urinary 17 keto- and 17 hydroxycorticosteroids were elevated in all cases and not suppressed following dexamethasone administration. Other useful measures in the diagnosis of adrenocortical carcinoma included markedly elevated I7 ketosteroid levels, absence of effect on urinary steroid production after ACTH infusion, lack of
232
diurnal variation in serum cortisol, and elevated levels of tetrahydrosubstance (THS) in the urine. Intravenous pyelography revealed a suprarenal mass in 4 of the 5 cases, and angiography was performed in 2 children to aid in the differentiation of hyperplasia from solid neoplasm. All patients underwent attempted surgical excision using a transabdominal approach to assess the state of the contralateral adrenal gland as well as the extent of metastatic disease within the abdomen. In most cases of unilateral functioning adrenocortical tumors, the contralateral adrenal is atrophic secondary to chronic suppression. One child was found to have metastatic liver involvement at the time of exploration, while another was left with tumor extending into the vena cava. Pathologically, the tumors are tan or yellow in color and may exhibit focal areas of hemorrhage, necrosis, or calcification. The microscopic picture ranges from resemblance to normal adrenal tissue to an undifferentiated sarcomatous pattern with marked pleomorphism. Metastases occur most often in lung, liver, and regional nodes, while spread to bone and brain is unusual. Local invasion of kidney, omentum, or mesentary may occur. Postoperatively, supplemental steroid therapy is necessary for several months until the remaining suppressed normal adrenal gland recovers its function. Marked increase in twenty-four-hour urinary steroid production determined at frequent intervals may indicate residual tumor recurrence. Four of the 5 children in this study received 2500 r of radiotherapy postoperatively; while chemotherapy, including the use of o, p-DDD, was not used. Four of the 5 children are alive without evidence of disease for from one to twelve years after surgery.
The Occult Neuropathic Bladder, D. Innes Williams, G. Hirst, and D. Doyle (9: 35, 1974)-The clinical and radiologic presentation of neuropathic bladder dysfunction in the absence of neurologic and pathologic findings has been variously termed “subclinical or occult neurogenic bladder,” “isolated neurogenic dysfunction,” and now “occult neuropathic bladder.” Fourteen children with this syndrome are discussed in terms of their clinical course, diagnostic studies, and treatment. All patients, ranging in age from four to thirteen years, complained of incontinence, the majority both diurnal and nightly, since birth. In addition, micturition was at times slow, difficult, and urgent; almost all children exhibited intermittent or continuous urinary tract infections. Bowel dysfunction was evident as well as manifested by complaints of persistent constipation and/or fecal soiling. Positive findings on physical examination were limited to a palpably distended bladder and full colon. The anal sphincter appeared to be intact with good contraction and results of electromyogram studies performed on 3 children were normal. Standard clinical neurologic examination of superficial sensation, tendon reflexes, and the voluntary muscle system was unremarkable. The bulbocavernosus reflex was difficult to assess in young children.
UROLOGY
/ AUGUST
1974
I
VOLUME
IV, NUMBER
2