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Thyroid Hormones in Patients With Chronic Renal Failure Undergoing Maintenance Hemodialysis
1140
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOV ASCULAR SURGERY
pounds that will lower androgen uptake or blood androgen binding, or inhibit the formation of 5a-dihydrotestosterone will, thus, have antiandrogenic properties. Three groups of antiandrogens are described: 1) pure antiandrogens, 2) antiandrogens with progestational effects and 3) progestins. A pure antiandrogen will block the hypothalamic feedback, and increase production and plasma testosterone. Flutamide is a strong and pure antiandrogen. The author notes that the most important antiandrogen that also possesses antigonadotropic effects is cyproterone acetate. Progestins are the most potent inhibitors of 5a-reductase enzyme activity and the effect of gestagens may be one of the most important for their antiandrogenic effects. E.D. W 8 figures, 24 references
CALCULUS Percutaneous Removal of Kidney Stones
W. R. CASTANEDA-ZUNIGA, R. P. MILLER AND K. AMPLATZ, Department of Radiology, University of Minnesota, College of Health Sciences, Minneapolis, Minnesota
cutaneous manipulation using the ultrasound lithotrite. Preliminary percutaneous nephrostomy was placed in 14 patients, while 3 already had a permanent operatively established nephrostomy. In the former patients the tract was dilated to 14F to 16F at the first session and gradually dilated up to 26F over the next several days, at which time a nephrostomy tube was placed and left indwelling for 4 to 5 days to establish a tract. The manipulation usually is performed in the operating room under general or peridural anesthesia, using an ultrasound lithotrite with suction. Procedural time for the disintegration averaged 86 minutes. Three patients required 2 sessions and 2 required 3. The average hospital stay for those requiring preliminary percutaneous nephrostomy was 25 days, while it was only 7 days for those who entered with a permanent nephrostomy tube in place. There was 1 residual stone among the former group of patients and 2 among the latter. Retroperitoneal extravasation of fluid occurred in 1 patient and bleeding occurred in another but both patients were treated conservatively. One patient with a ureteral stricture ultimately required an operation. T.D.A. 7 figures, 13 references
Urol. Clin. N. Amer., 9: 113-119 (Feb.) 1982 Percutaneous removal of renal calculi requires introduction of large tubes into the kidney by performing a percutaneous nephrostomy and then enlarging it with a system of gradually larger polyurethane dilators. Flushing aspiration techniques involve a single tube or an additional percutaneous or ureteral catheter either alone or combined with a blunt-tipped stone basket or one with a short floppy guidewire at the end. If a stone is too large to pull out through the tubing attempts can be made to crush it by forceful retraction or by a lithotriptor followed by flushing. A balloon catheter can be used to occlude the ureteropelvic junction and to prevent distal migration of stones. The authors have been able to extract stones percutaneously from 65 per cent of the patients in whom it was attempted. If the stones are free-floating and of appropriate size flushing usually is successful. The flushing techniques are safest and probably should be attempted before any instruments are used. Extraction of stones with rigid instruments and baskets is more hazardous and traumatic. Manipulation of these instruments within the renal pelvis commonly causes bleeding, which may make the procedure difficult as a result of confusing filling defects caused by blood clots. The limited experience with percutaneous removal of kidney stones prevents drawing firm conclusions regarding indications and results at this time. The authors believe that percutaneous visual endoscopic extraction of renal calculi may have great potential but at present, except perhaps for nonopaque stones, it does not offer a significant advantage over indirect radiologic techniques because of problems with instrument maneuverability, trauma and obscured vision from bleeding. M.G.F. 7 figures, 10 references
Percutaneous IDtrasonic Destruction of Renal Calculi P.
Department of Urology, University of Mainz Medical School, Mainz, Federal Republic of Germany ALKEN,
Urol. Clin. N. Amer., 9: 145-151 (Feb.) 1982 Percutaneous manipulation of calculi in the upper urinary tract is becoming increasingly more common. In this respect 17 patients with stones in 18 kidneys and ureters underwent per-
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY Percutaneous Transluminal Angioplasty of the Renal Artery Z.
L. BARBARIC, Department of Diagnostic Radiology and Genitourinary Radiology, UCLA School of Medicine, Los Angeles, California
Urol. Clin. N. Amer., 9: 169-175 (Feb.) 1982 Percutaneous transluminal angioplasty for renal artery stenosis is now possible with a variety of catheters. Preparation of the patient with aspirin or dipyridamole and administration of heparin during the procedure are recommended by many angiographers, some of whom continue heparin or aspirin for a variable period thereafter. Fibromuscular lesions appear particularly amenable to these techniques and cure rates in excess of 89 per cent have been reported from a number of centers, although followup admittedly is short in most cases. Atherosclerotic lesions are more difficult and account for the majority of the 30 per cent technical failures reported for this procedure, particularly when the stenosis is >1 cm., but short-term cure rates of 40 to 70 per cent are encouraging. Any evaluation of percutaneous angioplasty must take into account alternative options and the procedure should be compared more appropriately in many cases with medical than with surgical results. T.D.A. 4 figures, 21 references
Thyroid Hormones in Patients With Chronic Renal Failure Undergoing Maintenance Hemodialysis TALBOT,DepartmentsofMedical Biology and Medicine, Hopital Saint-Francois d'Assise and Service of Medical Biochemistry, Hotel-Dieu de Quebec, Quebec, Canada
J.-C. FOREST,J. DUBE AND J.
Amer. J. Clin. Path., 77: 580-586 (May) 1982 The prevalence of goiter in patients with renal failure undergoing chronic hemodialysis was shown by some authors to
1141
DIVERSION
be high. In addition, several biochemical abnormalities of thyroid function also were noted in these patients. To characterize the effect of chronic dialysis on thyroid function the authors studied in detail the pituitary thyroid axis in 28 patients undergoing long-term hemodialysis before and after dialysis. Their results indicated a decrease in serum total T4, T3 and free T4 levels in patients on chronic hemodialysis. There is no correlation between the duration of dialysis and degree of abnormality of serum T4 and T3. The reason for the decrease of serum T3 is unclear. Some investigators suggested that there was an impaired conversion of T 4 to T3 in extra-thyroidal tissue, giving a greater reduction of T3 compared to T4. Simultaneous reduction of T4 and T3 could be explained in part by the reduction in protein binding capacity, which is evidenced as decreased thyroxin binding globulin in the present study. The study also suggests that abnormalities found in the diverse basal thyroid hormone tests can result at least partly from defects located at any level of the hypothalamic-pituitary-thyroid axis. Clinical significance of these changes remains to be established. N. V.R. 2 figures, 1 table, 19 references
Capoten-Induced Juxtaglomerular Hyperplasia in Rabbits
R. E. DRUILHET, s. A. SMITH Department of Internal Medicine, University of Texas Medical School and Department of Pathology, Baylor College of Medicine, Houston, Texas
M. L.
OVERTURF,
AND
W. M.
H.
D. SYBERS,
KIRKENDALL,
Res. Comm. Chem. Path. Pharm., 36: 169-172 (Apr.) 1982 Because recent Food and Drug Administration approval of captopril (Capoten; SQ 14, 225) for the treatment of hypertension has stimulated widespread interest the effects of this converting enzyme inhibitor on blood pressure, plasma aldosterone, plasma renin activity and kidney morphology were studied in 30 male New Zealand normotensive white rabbits. The findings of this study indicated that mean arterial pressure, converting enzyme activity and aldosterone levels were reduced significantly but that plasma and renal renin activities were increased. Microscopic examination of the kidney showed marked hyperplasia of the juxtaglomerular apparatus in all of the treated animals. The authors conclude that these results indicate that interrupting the normal feedback mechanism of the renin angiotensin system by captopril results in marked stimulation of the juxtaglomerular apparatus, which is manifested morphologically by pronounced hyperplasia and biochemically by increased renal renin content and hyperreninemia. They speculate that because of the fundamental nature of these responses to converting enzyme blockade they also would be expected to occur in humans treated with captopril. E.D. W. 1 figure, 3 references
Transvenous Embolization of the Internal Spermatic Veins for the Treatment of Varicocele Scroti
R.
believe that it is caused by defective cooling and that the finding of infertility in association with a unilateral varicocele is caused by a subclinical varicocele contralaterally. Using sophisticated diagnostic techniques, such as retrograde spermatic venography, some investigators have identified varicoceles in as many as 81 per cent of the infertile patients. In this report 24 infertile patients exhibiting oligoasthenospermia were subjected to transjugular attempts at bilateral spermatic vein catheterization. Bilateral catheterization was accomplished successfully in 19 and in only 1 patient was catheterization unsuccessful on either side. Reflux was identified on at least 1 side in 21 patients and bilateral reflux was documented in 10 of 15 patients with varicoceles on the left side. Embolization then was attempted in 22 patients, using coils passed through BF thin-walled catheters. Success was achieved bilaterally in 15 cases and unilaterally in 6. Followup evaluation of 16 patients revealed disappearance of all palpable signs of the varicocele and improvement of the sperm count or motility in all but 2 patients. There were no serious complications encountered in the study, although the spermatic vein was avulsed in 1 patient and a catheter tip embolized to the lung in another. Neither had adverse clinical effects. T.D.A. 4 figures, 2 tables, 33 references
P. NARAYAN, W.R. CASTANEDA-ZUNIGA AND K. Departments of Urologic Surgery and Radiology, University of Minnesota College of Health Sciences, Minneapolis, Minnesota GONZALEZ,
AMPLATZ,
Urol. Clin. N. Amer., 9: 177-184 (Feb.) 1982 Varicoceles may be associated with testicular atrophy and infertility, although the mechanism is uncertain. The authors
DIVERSION Percutaneous Nephrostomy: Techniques, Indications, and Results
P. STABLES, Department of Radiology, Salem Memorial Hospital, Salem, Oregon
D.
Urol. Clin. N. Amer., 9: 15-29 (Feb.) 1982 Percutaneous nephrostomy has become a significant therapeutic modality, almost replacing surgical nephrostomy as an isolated procedure. In addition to providing direct renal drainage and relief of obstruction it provides convenient access to the upper urinary tract for insertion of ureteral stents, dissolution or extraction of calculi, closure of fistulas, administration of drugs, insertion of brush biopsy instruments and nephroscopes, and the performance of ureteral meatotomy. Technical aspects are emphasized, including preparation of the patient, localization procedures, definitive puncture of the pyelocaliceal system, and insertion, positioning and fixation of the catheter. Local anesthesia with mild sedation usually is adequate. Fluoroscopy, ultrasonography and, to a lesser extent, computerized tomography alone or in combination are essential for precise technique. Final optimal positioning of the catheter requires fluoroscopy. Aspiration and a small test injection of contrast medium should be performed to ensure proper positioning for drainage but full diagnostic antegrade pyeloureterography is best deferred until the patient is more comfortable, especially if the urine is infected. In a recent survey mortality of percutaneous nephrostomy was 0.2 per cent compared to 6 per cent for surgical nephrostomy in 2 other recently published series. All of the published deaths of percutaneous nephrostomy resulted from hemorrhage and each of these had either a specific coagulation disorder or a coagulopathy associated with advanced uremia from malignant disease. Significant complications occurred in 4 per cent, with infection in 1.9 per cent and hemorrhage in 1.3 per cent. Obstruction of the catheter usually can be managed by irrigation or removal, using the old catheter as a guide for the new
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOV ASCULAR SURGERY
pounds that will lower androgen uptake or blood androgen binding, or inhibit the formation of 5a-dihydrotestosterone will, thus, have antiandrogenic properties. Three groups of antiandrogens are described: 1) pure antiandrogens, 2) antiandrogens with progestational effects and 3) progestins. A pure antiandrogen will block the hypothalamic feedback, and increase production and plasma testosterone. Flutamide is a strong and pure antiandrogen. The author notes that the most important antiandrogen that also possesses antigonadotropic effects is cyproterone acetate. Progestins are the most potent inhibitors of 5a-reductase enzyme activity and the effect of gestagens may be one of the most important for their antiandrogenic effects. E.D. W 8 figures, 24 references
CALCULUS Percutaneous Removal of Kidney Stones
W. R. CASTANEDA-ZUNIGA, R. P. MILLER AND K. AMPLATZ, Department of Radiology, University of Minnesota, College of Health Sciences, Minneapolis, Minnesota
cutaneous manipulation using the ultrasound lithotrite. Preliminary percutaneous nephrostomy was placed in 14 patients, while 3 already had a permanent operatively established nephrostomy. In the former patients the tract was dilated to 14F to 16F at the first session and gradually dilated up to 26F over the next several days, at which time a nephrostomy tube was placed and left indwelling for 4 to 5 days to establish a tract. The manipulation usually is performed in the operating room under general or peridural anesthesia, using an ultrasound lithotrite with suction. Procedural time for the disintegration averaged 86 minutes. Three patients required 2 sessions and 2 required 3. The average hospital stay for those requiring preliminary percutaneous nephrostomy was 25 days, while it was only 7 days for those who entered with a permanent nephrostomy tube in place. There was 1 residual stone among the former group of patients and 2 among the latter. Retroperitoneal extravasation of fluid occurred in 1 patient and bleeding occurred in another but both patients were treated conservatively. One patient with a ureteral stricture ultimately required an operation. T.D.A. 7 figures, 13 references
Urol. Clin. N. Amer., 9: 113-119 (Feb.) 1982 Percutaneous removal of renal calculi requires introduction of large tubes into the kidney by performing a percutaneous nephrostomy and then enlarging it with a system of gradually larger polyurethane dilators. Flushing aspiration techniques involve a single tube or an additional percutaneous or ureteral catheter either alone or combined with a blunt-tipped stone basket or one with a short floppy guidewire at the end. If a stone is too large to pull out through the tubing attempts can be made to crush it by forceful retraction or by a lithotriptor followed by flushing. A balloon catheter can be used to occlude the ureteropelvic junction and to prevent distal migration of stones. The authors have been able to extract stones percutaneously from 65 per cent of the patients in whom it was attempted. If the stones are free-floating and of appropriate size flushing usually is successful. The flushing techniques are safest and probably should be attempted before any instruments are used. Extraction of stones with rigid instruments and baskets is more hazardous and traumatic. Manipulation of these instruments within the renal pelvis commonly causes bleeding, which may make the procedure difficult as a result of confusing filling defects caused by blood clots. The limited experience with percutaneous removal of kidney stones prevents drawing firm conclusions regarding indications and results at this time. The authors believe that percutaneous visual endoscopic extraction of renal calculi may have great potential but at present, except perhaps for nonopaque stones, it does not offer a significant advantage over indirect radiologic techniques because of problems with instrument maneuverability, trauma and obscured vision from bleeding. M.G.F. 7 figures, 10 references
Percutaneous IDtrasonic Destruction of Renal Calculi P.
Department of Urology, University of Mainz Medical School, Mainz, Federal Republic of Germany ALKEN,
Urol. Clin. N. Amer., 9: 145-151 (Feb.) 1982 Percutaneous manipulation of calculi in the upper urinary tract is becoming increasingly more common. In this respect 17 patients with stones in 18 kidneys and ureters underwent per-
DISEASES OF BLOOD VESSELS, HYPERTENSION AND RENOVASCULAR SURGERY Percutaneous Transluminal Angioplasty of the Renal Artery Z.
L. BARBARIC, Department of Diagnostic Radiology and Genitourinary Radiology, UCLA School of Medicine, Los Angeles, California
Urol. Clin. N. Amer., 9: 169-175 (Feb.) 1982 Percutaneous transluminal angioplasty for renal artery stenosis is now possible with a variety of catheters. Preparation of the patient with aspirin or dipyridamole and administration of heparin during the procedure are recommended by many angiographers, some of whom continue heparin or aspirin for a variable period thereafter. Fibromuscular lesions appear particularly amenable to these techniques and cure rates in excess of 89 per cent have been reported from a number of centers, although followup admittedly is short in most cases. Atherosclerotic lesions are more difficult and account for the majority of the 30 per cent technical failures reported for this procedure, particularly when the stenosis is >1 cm., but short-term cure rates of 40 to 70 per cent are encouraging. Any evaluation of percutaneous angioplasty must take into account alternative options and the procedure should be compared more appropriately in many cases with medical than with surgical results. T.D.A. 4 figures, 21 references
Thyroid Hormones in Patients With Chronic Renal Failure Undergoing Maintenance Hemodialysis TALBOT,DepartmentsofMedical Biology and Medicine, Hopital Saint-Francois d'Assise and Service of Medical Biochemistry, Hotel-Dieu de Quebec, Quebec, Canada
J.-C. FOREST,J. DUBE AND J.
Amer. J. Clin. Path., 77: 580-586 (May) 1982 The prevalence of goiter in patients with renal failure undergoing chronic hemodialysis was shown by some authors to
1141
DIVERSION
be high. In addition, several biochemical abnormalities of thyroid function also were noted in these patients. To characterize the effect of chronic dialysis on thyroid function the authors studied in detail the pituitary thyroid axis in 28 patients undergoing long-term hemodialysis before and after dialysis. Their results indicated a decrease in serum total T4, T3 and free T4 levels in patients on chronic hemodialysis. There is no correlation between the duration of dialysis and degree of abnormality of serum T4 and T3. The reason for the decrease of serum T3 is unclear. Some investigators suggested that there was an impaired conversion of T 4 to T3 in extra-thyroidal tissue, giving a greater reduction of T3 compared to T4. Simultaneous reduction of T4 and T3 could be explained in part by the reduction in protein binding capacity, which is evidenced as decreased thyroxin binding globulin in the present study. The study also suggests that abnormalities found in the diverse basal thyroid hormone tests can result at least partly from defects located at any level of the hypothalamic-pituitary-thyroid axis. Clinical significance of these changes remains to be established. N. V.R. 2 figures, 1 table, 19 references
Capoten-Induced Juxtaglomerular Hyperplasia in Rabbits
R. E. DRUILHET, s. A. SMITH Department of Internal Medicine, University of Texas Medical School and Department of Pathology, Baylor College of Medicine, Houston, Texas
M. L.
OVERTURF,
AND
W. M.
H.
D. SYBERS,
KIRKENDALL,
Res. Comm. Chem. Path. Pharm., 36: 169-172 (Apr.) 1982 Because recent Food and Drug Administration approval of captopril (Capoten; SQ 14, 225) for the treatment of hypertension has stimulated widespread interest the effects of this converting enzyme inhibitor on blood pressure, plasma aldosterone, plasma renin activity and kidney morphology were studied in 30 male New Zealand normotensive white rabbits. The findings of this study indicated that mean arterial pressure, converting enzyme activity and aldosterone levels were reduced significantly but that plasma and renal renin activities were increased. Microscopic examination of the kidney showed marked hyperplasia of the juxtaglomerular apparatus in all of the treated animals. The authors conclude that these results indicate that interrupting the normal feedback mechanism of the renin angiotensin system by captopril results in marked stimulation of the juxtaglomerular apparatus, which is manifested morphologically by pronounced hyperplasia and biochemically by increased renal renin content and hyperreninemia. They speculate that because of the fundamental nature of these responses to converting enzyme blockade they also would be expected to occur in humans treated with captopril. E.D. W. 1 figure, 3 references
Transvenous Embolization of the Internal Spermatic Veins for the Treatment of Varicocele Scroti
R.
believe that it is caused by defective cooling and that the finding of infertility in association with a unilateral varicocele is caused by a subclinical varicocele contralaterally. Using sophisticated diagnostic techniques, such as retrograde spermatic venography, some investigators have identified varicoceles in as many as 81 per cent of the infertile patients. In this report 24 infertile patients exhibiting oligoasthenospermia were subjected to transjugular attempts at bilateral spermatic vein catheterization. Bilateral catheterization was accomplished successfully in 19 and in only 1 patient was catheterization unsuccessful on either side. Reflux was identified on at least 1 side in 21 patients and bilateral reflux was documented in 10 of 15 patients with varicoceles on the left side. Embolization then was attempted in 22 patients, using coils passed through BF thin-walled catheters. Success was achieved bilaterally in 15 cases and unilaterally in 6. Followup evaluation of 16 patients revealed disappearance of all palpable signs of the varicocele and improvement of the sperm count or motility in all but 2 patients. There were no serious complications encountered in the study, although the spermatic vein was avulsed in 1 patient and a catheter tip embolized to the lung in another. Neither had adverse clinical effects. T.D.A. 4 figures, 2 tables, 33 references
P. NARAYAN, W.R. CASTANEDA-ZUNIGA AND K. Departments of Urologic Surgery and Radiology, University of Minnesota College of Health Sciences, Minneapolis, Minnesota GONZALEZ,
AMPLATZ,
Urol. Clin. N. Amer., 9: 177-184 (Feb.) 1982 Varicoceles may be associated with testicular atrophy and infertility, although the mechanism is uncertain. The authors
DIVERSION Percutaneous Nephrostomy: Techniques, Indications, and Results
P. STABLES, Department of Radiology, Salem Memorial Hospital, Salem, Oregon
D.
Urol. Clin. N. Amer., 9: 15-29 (Feb.) 1982 Percutaneous nephrostomy has become a significant therapeutic modality, almost replacing surgical nephrostomy as an isolated procedure. In addition to providing direct renal drainage and relief of obstruction it provides convenient access to the upper urinary tract for insertion of ureteral stents, dissolution or extraction of calculi, closure of fistulas, administration of drugs, insertion of brush biopsy instruments and nephroscopes, and the performance of ureteral meatotomy. Technical aspects are emphasized, including preparation of the patient, localization procedures, definitive puncture of the pyelocaliceal system, and insertion, positioning and fixation of the catheter. Local anesthesia with mild sedation usually is adequate. Fluoroscopy, ultrasonography and, to a lesser extent, computerized tomography alone or in combination are essential for precise technique. Final optimal positioning of the catheter requires fluoroscopy. Aspiration and a small test injection of contrast medium should be performed to ensure proper positioning for drainage but full diagnostic antegrade pyeloureterography is best deferred until the patient is more comfortable, especially if the urine is infected. In a recent survey mortality of percutaneous nephrostomy was 0.2 per cent compared to 6 per cent for surgical nephrostomy in 2 other recently published series. All of the published deaths of percutaneous nephrostomy resulted from hemorrhage and each of these had either a specific coagulation disorder or a coagulopathy associated with advanced uremia from malignant disease. Significant complications occurred in 4 per cent, with infection in 1.9 per cent and hemorrhage in 1.3 per cent. Obstruction of the catheter usually can be managed by irrigation or removal, using the old catheter as a guide for the new