Pseudoangiosarcomatous carcinoma of the genitourinary tract

Two cases of pseudoangiosarcomatous carcinoma of the genitourinary tract, arising in the vulva in one and the bladder in the other, are presented. In case 1, an 84 year old woman, the vulvectomy specimen contained an irregular ulcerated tumour, infiltrating the left labia and extending into the clitoris. In case 2, a 59 year old woman, the excised bladder showed diffuse thickening of its wall by infiltrating haemorrhagic tumour. Both tumours showed focal keratinisation. This, in association with the presence of atypical squamous epithelium, immunohistochemistry and ultrastructural analysis, led to a diagnosis of pseudosarcomatous carcinoma in both cases. Pseudoangiosarcomatous carcinoma should be considered in the differential diagnosis of malignant angiomatoid tumours, particularly those that arise at sites, like the genitourinary tract, where angiosarcoma is rare.     

Ofloxacin. A reappraisal of its use in the management of genitourinary tract infections

Ofloxacin is an established fluoroquinolone agent which achieves good concentrations in genitourinary tract tissues and fluids. It has good in vitro activity against most Enterobacteriaceae, Staphylococcus saprophyticus, methicillin-susceptible S. aureus, Neisseria gonorrhoeae, Chlamydia trachomatis and Haemophilus ducreyi, intermediate activity against Ureaplasma urealyticum and most enterococci, but limited or no in vitro activity against enterococci, Serratia marcescens, Pseudomonas aeruginosa and many anaerobes. However, high concentrations achieved in the urine ensure its activity against most urinary tract pathogens. Ofloxacin demonstrates consistent efficacy in a broad range of urinary tract infections, achieving bacteriological response rates in excess of 80% in uncomplicated and 70% in complicated infections. The efficacy of ofloxacin was similar to that of all comparators tested including other fluoroquinolones, cephalosporins and cotrimoxazole (trimethoprim/sulfamethoxazole). Ofloxacin is also effective as a single-dose regimen in the treatment of uncomplicated gonorrhoea, as a 7-day regimen in uncomplicated C. trachomatis infections, and as monotherapy in uncomplicated pelvic inflammatory disease (PID). Again, ofloxacin demonstrated similar efficacy to alternative treatments in each type of infection. The availability of an intravenous formulation and near-complete oral bioavailability allow ofloxacin to be administered as a sequential regimen without loss of activity. The tolerability and drug interaction profile of ofloxacin is consistent with that of other fluoroquinolones. The most commonly reported adverse events with ofloxacin are gastrointestinal, neurological and dermatological. It was associated with a lower incidence of photosensitivity and tendinitis and higher incidence of some neurological events than some other fluoroquinolones. Ofloxacin seems to have a lower propensity to interact with xanthines than other fluoroquinolones. Conclusion: ofloxacin has established efficacy in the treatment of a wide variety of urinary tract infections, although, like other fluoroquinolones, it should be used rationally to preserve its activity. Currently, ofloxacin also holds an important place among fluoroquinolones in the treatment of C. trachomatis infections and uncomplicated PID, although its acceptance as monotherapy in PID is likely to depend on clarification of the causative role of anaerobic pathogens in this infection.     

Pediatric genitourinary tumors

During the past two decades, highly effective multimodality therapy involving surgery, chemotherapy, and radiation has been developed through consecutive national and international study protocols for childhood genitourinary cancers with the model being Wilms' tumor. These studies represent a landmark achievement in the history of pediatric oncology and mark the success of multi-institutional studies. With the excellent survival rates that have been established, current interest is now directed toward examining survivors for long-term treatment complications and minimizing the side effects while preserving treatment efficacy. In addition, new developments in the molecular biology of Wilms' tumor have made this neoplasm a model for understanding the molecular and genetic aspects of tumorigenesis. This article reviews some of the publications from 1992 on pediatric genitourinary tumors.     

Pediatric genitourinary trauma

Trauma is the leading cause of death in children in the United States, and blunt trauma is responsible in most cases. The kidney is the urogenital organ most frequently injured. Renal injuries are classified on a scale of I to V. Only grades IV and V injuries need operative intervention. CT is the preferred diagnostic imaging modality in most instances. Cystography and urethrography are necessary to diagnose bladder and ureteral injuries. Genital injuries sometimes are produced by sexual abuse, and the clinician must be alert to this possibility.     

Anaerobes in genitourinary infections in men

Urethral and sub-preputial swabs from 150 men were examined. There was a strong association between the isolation of anaerobic bacteria, particularly Bacteroides spp, and a clinical diagnosis of balanoposthitis, non-specific urethritis (NSU), or both. Aerobic bacteria formed the predominant flora in 28 healthy controls whereas anaerobes were predominant in specimens from 79 patients with balanoposthitis, from 24 with NSU, and from 19 with both. Bacteroides spp were the commonest isolates in all patient groups; B asaccharolyticus, B melaninogenicus ss intermedius, B ureolyticus, and B bivius were the most common species. The results obtained with the two swabs were identical except that Gardnerella vaginalis was isolated from the urethral swab only in five patients.     

Tissue repair in the fetal intestinal tract occurs with adhesions, fibrosis, and neovascularization

Cutaneous wound healing in the fetus can occur in a nonfibrotic, regenerative manner. However, other fetal tissues such as bone and stomach heal with scar formation. In light of potential ramifications for adult hollow visceral scarring (biliary and intestinal strictures), this study was undertaken to determine if tubular visceral tissue repair in the fetus is regenerative or fibrotic. Fetal rabbits underwent laparotomy on day 24 of gestation, during which a controlled intestinal enterotomy was created and suture repaired immediately using microsurgical techniques. Maternal rabbits and adult male rabbits also underwent enterotomy and repair. After 5 days all animals were sacrificed and the wounds analyzed histologically by a pathologist in a blinded fashion. All animals demonstrated a similar degree of peri-intestinal adhesion formation. Fetal and maternal wounds contained fibroblastic and smooth muscle cell proliferation, mild inflammatory infiltration, and new blood vessel formation. The male adult wounds demonstrated a more pronounced fibrovascular healing response. Immunohistochemical staining for CD31 (endothelial cell marker) was quantitated on a scale of 0 to 4+, indicating degree of neovascularization. The mean scores for the fetal and maternal groups were similar (1.70 +/- 0.68 and 1.23 +/- 1.07 respectively), but were significantly greater for male adults (2.93 +/- 0.12; p = 0.001 by analysis of variance). The results of this study indicate that hollow visceral tissue repair in the fetal rabbit intestine occurs in a similar fibrotic manner as adult healing. This provides further evidence that regenerative healing in the fetus is not ubiquitous. Differences in the degrees of fibrosis and neovascularization between adult male and pregnant female wounds deserve further investigation.     

The provision of psychosexual services by genitourinary medicine physicians in the United Kingdom

A postal questionnaire survey, enquiring about the provision of psychosexual services, was sent to each GUM clinic in the UK. Of the 246 questionnaires distributed, replies were received from 166 directors responsible for 171 (69.5%) clinics. Of the 140 (84%) who supported the provision of a sexual dysfunction service, 59 (42%) currently provided such a service. Doctors and psychologists were the health care professionals most commonly involved in sexual dysfunction services for patients who were referred both internally and from external sources such as general practice and diabetic clinics. Patients with a variety of dysfunctions were being treated with a broad range of therapies, a reflection probably of the multidisciplinary nature of the team providing the service. However, it appears that junior doctors are not being trained in this field at present.     

The epidemiology of genitourinary fistulae in Kumasi, Ghana, 1977-1992

The aim of the study was to determine the clinical epidemiology of genitourinary fistulae as seen at Komfo Anokye Teaching Hospital in Kumasi, Ghana. A retrospective study was carried out from the hospital records and operative reports of all patients with genitourinary fistulae seen at Komfo Anokye Teaching Hospital between January 1977 and December 1992. Patient age, parity, type of fistula and cause of fistula were abstracted from the medical records. There were 164 cases of genitourinary fistula managed during the study period. There were 150 fistulae due to obstetric causes (91, 5%), the vast majority of which were due to prolonged obstructed labor (121 cases, 73.8% of all fistulae), with a minority related to complications of lower-segment cesarean section (14 cases, 8.5% of all fistulae). In 5 cases (3.1%) patients developed a rectovaginal fistula owing to perineal tears and prolonged obstructed labor. During this time period there were 157,449 deliveries, giving an obstetric fistula rate of 1 fistula per 1000 deliveries. Obstetric fistulae were most common at the extremes of reproductive age and parity Fourteen additional fistulae (8.5% of all cases) were due to gynecologic causes, most commonly from surgical injury occurring at the time of abdominal hysterectomy for leiomyomata uteri (12 cases, 7.3% of all fistulae). It was concluded that in Kumasi, Ghana, obstetric trauma from prolonged obstructed labor is the most common cause of genitourinary fistula formation. Such fistulae occur in older multiparous women as well in young primigravidae. Obstructed labour can, and does, occur in women who have previously undergone uneventful vaginal delivery. Birth attendants should be aware of that fact. Prompt referral for obstetric intervention should be made in obstructed labor, irrespective of the age and parity of the patient.     

The fetal inflammatory response syndrome

A mathematical model of the ARDS lung, with simulated gravitational superimposed pressure, evaluated the effect of varying alveolar threshold opening pressures (TOP), PEEP and peak inspiratory pressure (PIP) on the static pressure-volume (PV) curve. The lower inflection point (Pflex) was affected by SP and TOP, and did not accurately indicate PEEP required to prevent end-expiratory collapse. Reinflation of collapsed lung units (recruitment) continued on the linear portion of the PV curve, which had a slope at any volume greater than the total compliance of aerated alveoli. As recruitment diminished, the reduced PV slope could produce an upper Pflex at 20 to 30 cm H2O pressure. An upper Pflex caused by alveolar overdistension could be modified or eliminated by recruitment with high TOP. With constant PIP as PEEP increased, and TOP range of 5 to 60 cm H2O, PEEP to prevent end-expiratory collapse was indicated by minimum PV slope above 20 cm H2O, minimum hysteresis, and maximum volume at a pressure of 20 cm H2O. With constant inflation volume as PEEP increased, the effect on PV slope was unpredictable. Although increased PV slope indicated recruitment, maximum PV slope usually underestimated PEEP required to prevent end-expiratory collapse. Therefore, with this model the PV curve did not reliably predict optimal ventilator settings.     

The therapeutic reactivation of fetal haemoglobin

Unusually high levels of fetal haemoglobin production can ameliorate sickle cell disease and beta thalassaemia. Although efforts directed at the pharmacological stimulation of fetal haemoglobin as an approach to managing these conditions have met with limited success, there is wide variation in individual responses. Whether this reflects the particular mutations that underlie these conditions or other genetic factors remains to be determined, as does the ideal combination of agents to achieve this end. These results are encouraging, however, in particular in view of the recent demonstration that other monogenic diseases, Duchenne muscular dystrophy, for example, might be amenable to the same therapeutic strategy.