The effect of pulse therapy on severe secondary hyperparathyroidism related to chronic renal failure has been examined in 11 patients on maintenance hemodialysis by using an oral administration of 8 micrograms of 1 alpha(OH)D maximum per week. Throughout the 10 months of this treatment, the serum levels of intact-PTH, HS-PTH, and C-PTH were followed up. Additionally, to estimate the peak level of 1,25(OH)2D, its serum concentration at 10 hours after the 1 alpha (OH)D ingestion was measured. Results have shown that the serum levels of the intact-PTH, HS-PTH, and C-PTH were lowered in 9 of these 11 patients, two of this number especially showing a marked suppression of the serum intact-PTH to a low that was near to the normal upper limit level. In the two other cases of these 11 patients, no suppression was seen in any of serum PTH levels throughout the 10 months. In the cases that showed a good response, the 1,25(OH)2D serum concentration elevated significantly, to more than 100 pg/ml at 10 hours after the 1 alpha (OH)D intake. In contrast, in the 2 cases that showed no response, no appreciable elevation in the serum concentrations was noted. Thus, since the pulse therapy using 1 alpha (OH)D decreased the serum levels of the intact-PTH, HS-PTH, and C-PTH in 9 out of the 11 cases, we have concluded that pulse therapy using 1 alpha(OH)D is a valid therapy for secondary hyperparathyroidism in patients on maintenance hemodialysis.
We discuss the transurethral resection of the prostate (TUR-P) on 40 patients in the chronic stage of stroke, all of whom were refractory to conservative managements of urinary disturbance. All patients, between 35 and 89 years old (mean: 52.6 years), had only one episode of stroke and were diagnosed as benign prostatic hypertrophy or bladder neck contracture that appeared to cause urinary disturbance in these patients. At six months after TUR-P, all except for one patient, who needed an indwelling catheter due to a reinfarction, were catheter free. Of these cases 36 (92%) obtained independent micturition and did not develop urinary incontinence except transiently postoperatively. Two cases with impaired mobility and one case with progressive senile dementia required helpmates and/or a commode and so forth postoperatively. It is concluded that in chronic stroke patients TUR-P is recommended for those with benign prostatic hypertrophy or bladder neck contracture.
Urinary managements of 332 stroke patients in the chronic phase were performed at Bobath hospital. Cerebrovascular accidents (CVA) were caused by cerebral infarction in 178 (53.6%), intracerebral hemorrhage in 123 (37.1%) and subarachnoid hemorrhage in 31 (9.3%). Voluntary urination appeared in 124 patients before treatment, however in 29 of them occasional incontinence were observed. One hundred forty-three patients used diapers and 64 were controlled by indwelling catheters. The remaining one patient was treated by intermittent catheterization. Sixty-two patients who seemed to have communicative abilities in daily living were assessed with regard to their cerebrovascular dementia by Hasegawa's Dementia Rating Scale. After treatment 235 patients (70.8%) were able to urinate voluntarily, and only 15 of them remained incontinent and could use small pads successfully. TURP was effective for the stroke patients with benign prostatic hypertrophy (BPH) or bladder neck scleosis (BNS). Fifty-three patients (16.0%) with persistent urinary incontinence were managed by diapers or a system of condom drainage. Thirty-nine patients (11.7%) were kept dry with intermittent catheterization at home, and long-standing use of indwelling catheters were required in the remaining 5 patients (1.5%). These results indicate that the lower level of activity, mobility and mental state tended to prevent the stroke patients from improvement of urinary disorders.
A series of 32 patients with spina bifida, representing 50 renal units with vesicoureteral reflux (VUR), was treated with antireflux operation. All but one patient underwent ureteral reimplantation with Cohen's technique. Another patient was treated with bilateral Politano-Leadbetter's technique. The overall success rates were 92.0% by renal unit and 87.5% by case, with a mean follow-up period of 42.5 months. These results were comparable to those in the recent literature. Failure included recurrence of VUR in 3 patients. Another patient who had undergone unilateral reimplantation developed new occurrence of reflux in the contralateral ureter. Possible masking of contralateral VUR should be taken into consideration in patients with unilateral high grade VUR. We also emphasize the importance of continuing clean intermittent catheterization in a proper manner to be free of VUR postoperatively.
Augmentation cystoplasty is evolving into a common method of surgical treatment for a low capacity and/or low compliance neurogenic bladder. Although an increasing number of successful results have been recently reported, the operative indication of augmentation cystoplasty is yet to be established. Herein, we report two cases of neurogenic bladder due to spina bifida which required abandonment of augmentation cystoplasty. The first case was in a 23-year-old female with a severely deformed bladder and right vesicoureteral reflux (VUR). She refused to undergo ileocystoplasty because we could not assure her of postoperative conception which she eagerly anticipated. The second case was in a 19-year-old male with a severely deformed bladder and right VUR. He experienced recurrent episodes of ventriculoperitoneal shunt (V-P shunt) difficulty which required exchanging the shunt tube each time, and each exchange proved to be very difficult or nearly impossible. Based on lengthy neurosurgical consultation, we came to the conclusion that ileocystoplasty was not a preferable treatment of choice for the correction of his disease due to the possibility of V-P shunt infection, which could be fatal. Alternatively, both cases were treated with Cohen's ureteral reimplantation, which resulted in the recurrence of VUR. These cases presented still unresolved issues concerning the operative indication of augmentation cystoplasty in spina bifida patients.
In a patient with a patent RITA-LAD (right internal thoracic artery-left anterior descending artery) graft, re-CABG (re-coronary artery bypass grafting) with re-median sternotomy has been a high risk procedure. A 56-year-old male underwent 4-CABG (RITA-LAD, LITA-Dx, SVG-PL, and SVG-RCA) nine years ago. Coronary angiography showed that the RITA-LAD graft was well patent, but there was 95% stenosis distal to RITA-LAD anastomosis site. We performed re-CABG (right gastroepiploic artery-LAD; RGEA-LAD), using MIDCAB (minimally invasive direct coronary artery bypass) technique with neither re-median sternotomy nor cardiopulmonary bypass. The right gastroepiploic artery was harvested through a small upper median laparotomy and anastomosed to LAD through a small left anterior thoracotomy. The postoperative course was uneventful. This technique seems to be useful for re-revascularization of the LAD in a patient with a patent RITA-LAD graft.
To introduce the proper voiding modality to patients with myelodysplasty, urethral opening pressure (UOP), an intravesical pressure just at the beginning urine flows out beyond the external urethral sphincter, was measured in 63 myelodysplastic patients.Among 45 renal units with any morphological or functional changes at the first UOP measurement, 37 units (82.2%) were included in the high UOP group (≥35cmH2O). And among 41 ureters with VUR of more than grade 2, 32 (78.0%) were in the high UOP group. In addition, deformity of the urinary bladder was observed in 36 patients, and 26 (72.2%) of these bladders showed high UOP values. Therefore, all the patients could be divided into two groups: high UOP group (≥35cmH2O, 28 cases) and low UOP group (<35cmH2O, 35 cases). Twenty-three patients (82.1%) with high UOP values had been mainly treated with clean intermittent catheterization (CC). In contrast, 24 patients (68.6%) with low UOP values had been allowed to urinate by Credè' or Valsalva's method. In the followup study for 40 to 44 months, patients in the CIC group obtained good prognosis as for morphological or functional changes of the urinary tract. On the other hand, patients in the Credè' or Valsalva's method group showed a significantly higher deterioration rate in the high UOP group (80.0%) than that in the low UOP group (9.1%) (p<0.005).From these results, hopely that in myelodysplastic patients with the underactive detrusor, CIC may be introduced for low pressure voiding to those who show high UOP values as early as possible. On the other hand, those who show low UOP values may be managed with Credè' or Valsalva's method as well as CIC. Thus, UOP is considered a possible prognostic factor for the morphological and functional changes of the urinary tract, which may be a useful parameter in decision of voiding modalities in myelodysplastic patients.
