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Thirty-seven patients with intractable bladder hemorrhage were treated with intravesical epsilon aminocaproic acid (EACA). Radiation cystitis and cyclophosphamide-induced cystitis were the two most common causes of intractable bladder hemorrhage. Thirty-four patients responded to treatment. No side effects were noted. Intravesical EACA appears to be a safe and effective method to control intractable bladder hemorrhage.

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Piezoelectric shock wave lithotripsy has been shown to offer a low-cost, safe, anesthesia-free yet effective means of disintegrating urinary calculi. The Therasonic lithotriptor combines proprietary piezoelectric shock wave technology for effective stone fragmentation with a multi-purpose urologic table and both fluoroscopic and ultrasound imaging for accurate stone localization and real-time treatment monitoring. From December 1, 1988 to November 15, 1989, 138 patients with 172 calculi were treated (94.2% were intrarenal, 5.8% were in ureter). All stones greater than or equal to 4 mm were considered suitable for treatment. Lithotripsy was performed under intravenous sedation except when ancillary procedures were necessary. For evaluation of device effectiveness, 94 patients were available with follow-up greater than or equal to thirty days. Successful fragmentation (stone free or residual debris less than or equal to 4 mm) was achieved in 97 percent of patients. The retreatment rate for stones 0.5-2.0 cm was 11 percent, and the overall retreatment rate was 21.2 percent regardless of stone size. Complications were minimal, transient, and resolved spontaneously.

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Twenty patients with advanced transitional cell carcinoma of the bladder were treated with radiation and concomitant continuous infusion of 5-fluorouracil with or without Mitomycin. Nineteen of 20 patients were assessed for response. Fourteen of 19 patients (74%) obtained a complete response within 3 to 6 months. An additional three patients (15%) acquired and maintained a complete response after local transurethral resection of the tumor and intravesical chemotherapy, raising the overall complete response (CR) rate to 17/19 (89%). Of the two patients with persistent disease, one is alive and well after salvage cystectomy. Eighteen of 20 patients were evaluated for survival with a median follow-up of 38 months. Seven patients remain alive and well 51 to 78 months, whereas three patients died from intercurrent disease. Eight patients died of either distant metastatic disease (7 patients) or regional disease (1 patient). An adjusted survival calculated by the Life Table Method was 53.6% at 5 years, whereas the overall survival was 39%. The combined modality therapy was well tolerated with no need for treatment interruption or reduction in dose. Late bladder complications include one patient with hemorrhagic cystitis, two patients with dysuria, and two with symptoms of irritable bladder. One patient required a colostomy for a chronic hemorrhagic proctitis. Bladder preservation was achieved in 19/20 patients.

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Eighteen girls with major uterovaginal malformations were admitted to the Pediatric Surgical Service over a 17-year period. The diagnosis was not suspected or delayed in more than one half of the patients. The encountered anomalies were divided into four groups: I, isolated uterovaginal malformations (UVM) (4); II, UVM with anorectal anomalies (8); III, UVM with cloacal (urogenital sinus) abnormalities (5); and IV, caudal twinning (1). Imperforate hymen, vaginal web, low vaginal obstruction, or disorders of gonadal or chromosomal development were excluded. Patients presented with an abdominal mass or distension (5), abdominal pain (4), "sciatic"-like pain (1), purulent vaginal discharge with perineal pain (1), amenorrhea (2), and a pelvic and prerectal mass (1). The introitus was reported as normal in 11 patients with vaginal atresia or agenesis by the primary physician. Diagnostic studies, in addition to clinical and endoscopic examination, included routine radiological workup, genitourinary contrast studies, pelvic and perineal sonography, computerized tomography (CT) scanning, and more recently, magnetic resonance imaging. In complicated UVM, especially vaginal duplications with unilateral atresia, the CT scan was the most helpful diagnostic tool. Laparotomy was necessary, not only for therapeutic, but diagnostic reasons; even so, complex anomalies, such as vaginal duplication with unilateral atresia and a septate uterus, could not be suspected. Treatment was directed toward the restoration of a functional uterovaginal tract and the frequently associated anorectal anomalies. A review indicated that contrary to our expectations, the major UVM occurred in children with a low imperforate anus rather than the high variety.

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The survival of 117 black and white patients treated by radiation for carcinoma of the prostate at SUNY Health Science Center at Brooklyn (SUNY/HSCB) and Kings County Hospital Center (KCHC) was analyzed according to Gleason's grading system. The effect of total pattern score and its relationship to stage and survival and to race were intercompared. In both black and white racial groups, there was strong correlation between high pattern score and high stage p = less than 001. The percentage of black patients presenting with high pattern score (7-10) was significantly greater, 43 versus 27%; this adversely affected stage and survival. The median survival for white and black patients was 4.8 and 3.2 years, respectively; p = 0.007. Stage for stage and grade for grade, survival was similar in both racial groups.

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Retroperitoneal abscesses have been a difficult diagnostic and therapeutic challenge in the past. With the advent of precise noninvasive imaging modalities, they now are defined more easily. Percutaneous guided catheter drainage has changed our therapeutic approach to this disease and enabled rapid and complete drainage to be performed in the majority of cases. Although the literature is replete with documentation of the percutaneous management of intra-abdominal abscesses, series dealing with retroperitoneal abscesses exclusively are surprisingly infrequent. We report on the percutaneous treatment of 31 retroperitoneal abscesses and the combined percutaneous and surgical management of 4 additional cases.

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Nineteen patients with locally advanced bladder cancer were treated with irradiation and concomitant 5-fluorouracil intravenous infusion with or without bolus mitomycin. Eighteen of the 19 patients were evaluated for local response. Eleven of the 18 patients (61%) obtained a complete local response within 3 to 6 months. An additional five patients (28%) showed tumor regression to a superficial state controlled by local transurethral resection and intravesical chemotherapy making the overall local clearance rate 16/18 (89%). The remaining two patients (11%) required salvage cystectomy for persistent disease and presently show no evidence of disease. Nine patients have died. Two patients died of intercurrent disease, six patients died of metastatic disease, and one patient who died from regional disease showed no evidence of local bladder tumor at the time of death. Berkson-Gage life-table analysis yields an adjusted survival of 62.5% at 5 years. Late complications included five patients with hemorrhagic cystitis, two patients with a contracted bladder, and one patient with a hemorrhagic radiation proctitis.

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The efficacy and merit of testicular imaging, utilizing Tc-99m pertechnetate, were studied prospectively in a group of patients who presented with acute onset of scrotal pain. Consecutive admissions were studied. All were managed according to the likelihood of the problem being testicular torsion, which was determined from the clinical history, physical examination and the routine laboratory data. The final diagnostic outcome, whether by surgical exploration or clinical progress with conservative treatment, is collated with the preoperative scintigraphic interpretations, made with respect to predefined criteria. Analysis of the pretreatment images obtained in 57 patients shows that the radionuclide study is highly reliable in cases of testicular torsion and epididymo-orchitis. It appears to be much less dependable, however, in the other acute scrotal conditions. Torsions that are intermittent in nature or corrected manually apparently can have variable presentations. Certain difficulties and potential pitfalls encountered in interpreting the scintigraphic studies are discussed.

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An alternative method is presented for the removal of caliceal calculi refractory to standard techniques. The involved calyx is punctured directly and dilatation performed to the stone without negotiating a wire into the renal pelvis. The stone is then removed under direct vision. This technique has been successfully used in 3 patients without complication.

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We reimplanted 121 ureters by the Cohen technique. A modification is introduced for difficult cases, making the Cohen technique more adaptable for dilated ureters and small bladders. Radiographic studies obtained at least 6 months after reimplantation revealed only 1 case of persistent reflux (grade I), no case of contralateral reflux and no obstruction. Even though the series included 35 ureters with grade V primary reflux and 7 primary obstructive megaureters, only 7 ureters were tapered. This finding suggests that the Cohen method might require tapering in a smaller percentage of cases compared to other reimplantation techniques.

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Nesbit's technique of excising ellipses of tunica albuginea has been effective in correcting chordee in children. We have used this technique successfully in adults for the correction of 19 congenital and traumatic curvatures, as well as those resulting from stable Peyronie's disease. All patients retained potency and reported excellent correction of the deformities. We believe that Nesbit's operation is the procedure of choice for the correction of disabling adult penile curvature.

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A case of penile amputation and replantation is presented. Partial amputation may be repaired without microsurgical technique with good results. For complete amputation, specific microneurovascular repair is recommended.

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We evaluated the anterior extravesical ureteroneocystostomy technique in 184 consecutive renal transplants done in 2 consecutive calendar years. Complications included 5 cases of ureteral and 1 of pelvic necrosis, and 2 of ureteral obstruction, with a ureteral complication rate of less than 4 per cent. All cases of pelvic or ureteral necrosis except 1 were seen in cadaver donor kidneys that were imported from other centers. No bladder complications were seen. Pelvioureteral obstruction, presumably of congenital origin in the cadaver donor, was discovered in the kidney after transplantation in 2 cases and was corrected successfully by pyeloureterostomy to the native ureter. The extraordinary simplicity of this technique, coupled with improvement in the complication rate, makes it our procedure of choice.

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A case of bilateral kidney herniation through cutaneous pyelostomy stomas is reported. The child is doing well after successful closure of the pyelostomies and repair of both ureteropelvic junctions obstructions.

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Our experience in the management of difficult vesicovaginal and urethrovaginal fistulas is presented. The fistulas were secondary to radiation damage and extensive local fibrosis owing to previous attempts to repair surgically. Satisfactory surgical repair of the fistulas was obtained by interposition of viable gracilis muscle and labial fibrofatty tissue at the repair site. The patients have been followed for 1 to 2 years postoperatively.

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We reviewed 105 patients with rupture of the membranous urethra in whom impassable strictures developed. With 16 years being the division between children and adults there were 73 adults and 32 children. We prefer to repair these strictures with the mobilized anterior urethra if this can be accomplished satisfactorily, rather, than using skin substitution urethroplasties. The mobilized anterior urethra was used in 90 patients: 63 adults and 27 children. The anterior urethra in the remaining 15 patients had been damaged either by a previous operation or by previous disease and needed skin substitution urethroplasty. Techniques, complications and results in the 3 types of repair are presented.

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Epsilon-aminocaproic acid (EACA) was intravenously administered to rabbits subjected to bilateral renal crushing trauma. Posttraumatic hematuria in 10 control rabbits lasted a mean of 5.5 days (range 5 to 7 days). Rabbits treated with 1250 mg 5 min before renal trauma and with repeat EACA injections 1 hr (500 mg) and 24 hr (500 mg) after the injury had significantly less hematuria. Only eight of 20 EACA-treated rabbits had any hematuria, and this bleeding terminated by the 2nd posttrauma day in all. EACA may have an important role in the management of trauma-induced renal bleeding.

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