Although Benign enlargement of the prostate occurs in every man after 40 years of age to a different degree, in only 10 per cent does it cause trouble. It is sometimes extremely difficult to decide whether a person with mild symptoms of prostatism will be one of the luckier 90 per cent or one of the 10 per cent who must undergo operation. An excellent discussion of the symptoms, signs and findings as indications for prostatectomy is presented. Among symptoms, acute retention of urine, residual urine and diverticuli are regarded as absolute indications for prostatectomy. Chronic retention of urine and upper tract obstruction also indicate the need for prostatectomy and, to avoid the higher mortality associated with uremia, infection and retention, early operation for the relief of obstruction of outflow is advised. These and other symptoms correlate poorly with the size of the prostate and the obstruction it causes to the outflow of urine. Hence, a large prostate seen on examination of the rectum has little significance. The urine flow, measured by a flow meter and the residual urine, measured by ultrasonic toms of prostatism at the time of routine annual check-up. These methods are ideals, but a method which would be useful in practice would be to ask the patient about the force of the urinary stream and if he has frequency which disturbs routine activities during the day and sleep at night.
Urographic indications for prostatectomy include a thick bladder wall, often with a diverticulum or two, a large volume of residual urine and evidence of dilatation of the ureter and hydronephrosis. Cystourethroscopy must precede operation. Before deciding upon prostatectomy, other conditions that mimic the symptoms and signs of prostatism must not be forgotten, including early or small carcinoma of the bladder, psychosomatic disorder including depression and neuropathic bladder from occult low disc protrusion, diabetes, pernicious anemia and infection of the bladder, including tuberculosis. Lastly, the choice of technique of prostatectomy was discussed. Methods of treating prostatism other than prostatectomy either by transurethral or open method, including both transvesical and retropubic methods, should not be considered an adequate transurethral resecitious has advantages over any of the open methods.
Testicular Biopsies in 101 Cases of Varicocele. Michael R. McFadden and Donald J. Mehan. J. Urol., 1978, 119:372.
To Explain the effects of varicocele on semenograms, biopsies of the testes were per- formed in 101 patients during operation for ligation of the internal spermatic vein. Serum levels of follicle-stimulating hormone, luteinizing hormone, testosterone and Cortisol also were estimated. The changes noted were premature solughing, tubular thickening hyperplasis of Leydig\'s cells, arrest of maturation, few Sertoli\'s cells and decreased spermatogenesis, either singly or in combination. These changes were compared with subsequent sperm counts and pregnancies to determine the prognostic value of results of biopsy of the testes in subfertile men.
Arrest of maturation could not be correlated with prognosis because of the small number of instances. Other changes were associated with a poor prognosis as far as pregnancy was concerned, with one exception being decreased spermatogenesis, which was associated with favorable response to ligation of the internal spermatic vein. Though biopsy of the testes has a research potential it is of limited value and benefit as far as the patient is concerned.
Anterior Transperitoneal Approach for Treatment of Urolithiasis. Charles A. Linke, Clara L. Linke, Robert S. Davis and others. J. Urol., 1978, 119:453.
The Anterior transperitoneal approach for treatment of urolithiasis has long been utilized in patients with severe pulmonary and cardiac disease who are unable to tolerate the lateral flexed position more often used. Advantages include ease with which roentgenograms can be made pre-operatively and intraoperatively; good access to the anterior portion of renal pelvis unilaterally and, if need be, operated upon for diseases of the kidneys, and ease in performance of intra-abdominal procedures such as ureterolithotomy and appendectomy.
No difficulty was encountered with intraperitoneal irritation resulting from the operation. It is believed that the anterior transperitoneal approach is of great advantage in selected patients and its use should be continued.
Surgical Treatment of Clavicular Fractures with Kirschner Wires; a Comparative Study. P.J. Paffen and E.W.L. Jansen. Arch. Chir. Neerl., 1978, 30:43.
Between 1968 and 1976, 1,400 patients with fractures of the clavicle were conservative; in 76 patients, 5 per cent, it was surgical. Excellent results were obtained in 53 patients treated operatively, in whom healing of the fracture was uncomplicated, who had normal anatomic and functional findings and no symptoms at final discharge.
After hospitalization for an average of 4.2 days, the patients were completely fit for work at an average of 7 5 weeks after operation, provided the course postoperatively was uncomplicated. If the results at final discharge are considered for the 71 patients treated with Kirschner wires only, the results of coadaptation osteosynthesis for fractures of the clavicle were subjectively good in 66, 93 per cent, and functionally good in 71, 100 per cent. From the literature it appears that with conservative treatment an anatomically poor result is obtained in 16 per cent of patients, with healing in poor position or with development of pseudarthrosis. These patients have few or no symptoms. In children, correction of this malposition occurs later during growth. The functional and subjective results of conservative treatment were good in 97 per cent of patients. Overemphasis on the roentgenographic findings as an indication for surgical treatment of fractures of the clavicle appears incorrect.
Conservative treatment of fractures of the middle third consisted of immobilization by means of a figure of eight bandage for four weeks. Lateral fractures were treated with a corrective Robert Jones. During this period, 81 osteosyntheses were carried out in 79 patients, 76 times for a recent fracture and five times for nonunion. For recent fractures, intramedullary fixation with a 2 mm. Kirschner wire was routinely performed. The fracture ends were exposed through a slightly curved incision in the skin crease just below the clavicle as far as possible without removing periosteum and without detachment of muscle. The Kirschner wire was drilled dorsolaterally through the medullary cavity of the lateral fragment, piercing the cortex and skin. Anatomic reduction of the fracture was then carried out and provisionally secured with a clamp, after which the Kirschner wire was driven back through the medullary cavity anteromedially into the cortex of the middle fragment. Indications for operation were imminent perforation of the dications for operation were imminent perforation of the skin if reduction could not be obtained, with lateral displacement of more than the width of the shaft and shortening of more than 1 cm.; patients with multiple lesions, especially those with cranial lesions who were restless; patients with multiple lesions of the same arm; occasionally, patients in whom protracted bedrest was indicated for nursing reasons, and patients in whom compression by a bone fragment caused irritation of the brachial plexus.
Perioperative Antibiotics in Major Elective Gynecologic Surgery. James F. Holman, John E. McGowan and John D. Thompson. South. Med. J., 1978, 71:417.
The Efficacy of a three dose, perioperative regimen of cerfazolin in reducing infection posto- peratively was evaluated in a double blind study of 206 patients who underwent elective vaginal or abdominal hysterectomy. It was obvious that the patients treated with placebo had a measurable risk of infection postoperatively in the institution in which these patients were studied. The greater risk of infection in patients who underwent abdominal operations as compared with vaginal operations has not been the finding of most investigators; however, in the group treated with cefazolin who underwent abdominal hysterectomy there was evidence of infection in 19 per cent as compared with 71 per cent in the group given the placebo. In the group treated with cefazolin who had vaginal hysterectomies, 10 per cent had infectious complications, compared with 37 per cent in the placebo group.
Studies of hepatic and renal function postoperatively were not a part of this investigation because cefazolin was believed to be safe, particularly in the short term, low dose regimen. There is no clinical evidence from results of the study that any patient had nephrotoxicity or hepatotoxicity develop. Results of previous work stating that there is no advantage to a long course of antibiotics but there is a definite advantage in short term antibiotic regimens periopera-tively were confirmed.
Wound Infection in Emergency Appendicec-tomy; a prospective Trial with Topical Ampicillin and Antiseptic Solution Irrigation. Chanvit Tanphiphat, Chesads Sang-subhan, Viroj Vongvaravipatr and others. Br. J. Surg., 1978,65:89.
Three hundred and Seventy-four patients with acute appendicitis who required emergency surgical procedures were randomized to one of three groups of topical wound treatments. In patients in group 1, a total of 1 gm. of ampicillin was sprinkled on each layer of the incision; group 2 was a control group and patients were given no treatment, and group 3 patients had each layer irrigated with a 1 per cent solution of acetyl trimethyl ammonium bromide, Savlon. In instances of perforated appendicitis, ampicillin significantly reduced the rate of wound infection, P/0 01, statistical difference between regimens and the rates of wound infection was extremely low. It was concluded that, when perforated appendicitis is encountered, topical ampicillin should be used to reduce the rate of wound infection. It was warned that the statistics could differ with predominant bacterial flora in each community.
Renal Transplantation in Children Ages 1 to 5 years. Elisabeth M. Hodson, John S. Najarian, Carl M. Kjellstrand and others. Pediatrics, 1978,61:458.
Twenty-one Children between one and five years of age received 23 intraperitoneally placed renal allografts; 18 received primary grafts from a living related donor. Sulfisoxazole was administered prophylactically to prevent infections of the urinary tract, and pencillin was given to children who underwent splenectomy. Five grafts from live relations and one cadaver graft were lost to rejection. Cumulative patient survival rates two and four years after transplantation from a live related donor were 94 per cent and 76 per cent, respectively.
There were 12 episodes of serious infection in ten children and two resultant deaths. Six children had primary varicells infections, four had clinical cytomegalovirus infection, one had pneumococcal sepsis and one had pneumococcal meningitis.
All children with normal renal function grew after transplantation. Many showed catch-up growth in the first year but catch-up growth stopped thereafter despite continued normal renal function and small doses of prednisone administered daily or on alternate days.