International Urology and Nephrology 7 (2), pp. 95--101 (1975)
Current Scientific Interests of Division of Urology, U. C. L. A. J. J. KAUFMAN
Division of Urology School of Medicine, University of California, Los Angeles, California (Received August 26, 1974)
The purpose of this communication is to acquaint the urological community at large with my personal interests ("hobbies") and with activities of the Division of Urology at University of California, Los Angeles (U. C. L. A.).
Upon the retirement of W. E. Goodwin in 1970, I assumed direction of the Division of Urology at U. C. L. A. Dr. Goodwin, having spent a zealous nineteen years of intense activity, developed a department that was truly outstanding. Under his inspiring leadership, we became pioneers in the field of kidney transplantation. He was the first to describe the use of large doses of corticosteroids to prevent the rejection reaction. And the first to use ureteropyelostomy in kidney transplantation as well as fetal transplants. Prior to his voluntary retirement to become more active in Pediatric Urology, we had performed over 250 kidney transplants at U. C. L.A. Together with colleagues in the division, we have reported our experience in the technique, medical management and complications of the kidney transplantation. Professor Goodwin made an excellent motion picture in 1962 on "The Technique of Kidney Transplantation in the Dog", and this became a prototype for experimental work in canine models. Under Dr. Goodwin's direction and inspiration, the use of the intestine for urinary tract replacement and augmentation flourished, and ours continues to be one of the largest experiences in the world. Dr. Goodwin and I did extensive laboratory studies on renal lymphatics. We published our review of the subject in Urologic Survey, 6, 305-329, 1956. We also reported the clinical implications of our renal lymphatic work in the Annals of Internal Medicine, 49, 109-119, 1958. Dr. A. T. K. Cockett was formerly associated with our group and he has followed-up on the renal lymphatic work with respect to its role in renal infection and antibiotic therapy, transplantation, etc. Dr. Goodwin's main interest since 1969 has been in the field of Pediatric Urology and he devotes the major portion of his time and effort in this specialty. He is editing a book on Pediatric Urology with Mr. H. Johnston and he has inspired a number of young urologists to enter a career in Pediatric Urology. He continues to use innovative reconstructive techniques and has a major interest in pediatric urological oncology. 1"
International Urology and Nephrology 7, 1975
96
Kaufman: Current scientific interests
I, personally, had worked with Dr. Goodwin as one of his first residents at U. C. L. A. in 1951. After a period of private practice, I resumed full-time academic pursuits in 1960. My own major interests have been in the field of urological oncology, including experimental studies. Renovascular hypertension, renal transplantation, the treatment of urinary incontinence and, more recently, impotence are current major interests. However, the staff we have recruited provides even more protean interests and investigations are underway in the fields of urological oncology, immunology, chemotherapy and renal preservation. Our earliest experimental efforts were in the field of tumor transplantation in experimental animals. Although our attempts to grow human tumors in the anterior chamber of the guinea pig eye were not successful, we subsequently achieved considerable success in using the cheek pouch of the hamster treated with cortisone for transplantation of human bladder and kidney tumors. We were able to grow human tumors in literally thousands of hamsters and to test the growth patterns of the tumors in animals receiving cytostatic drugs, singly and in combination. Our laboratory work indicated that mitomycin C (Bristol-Myers investigationat drug; no trade name as yet) was a good drug for human bladder cancer, but its toxicity in humans has limited its use. We also showed that 5fluorouracil and radiation made an effective combination for the inhibition of tumor growth, and this work was applied with some success to human subjects with bladder cancer. However, neither the experimental nor the clinical results were truly dramatic, and our treatment of invasive bladder cancer now consists of preoperative radiation therapy and radical cystectomy. During the last three years we have employed compact preoperative radiotherapy, administering 1600 rads of divided doses over four days immediately prior to the extirpative procedure. In the presence of deeply invasive tumors or high-grade tumors, the patient receives "sandwich" therapy with fractionated radiation to the pelvis after wound healing is complete (3500 additional rads). The latter work has been expanded and various aspects of these studies are being reported by my associate, Dr. D. G. Skinner. As members of the Cooperative Clinical Group for the Study of Bladder Cancer, Kidney Cancer and Renovascular Hypertension, our clinical work at U. C. L. A. has contributed substantially to the national efforts in these fields. A sizeable experience has been gained in the diagnosis and treatment of renovascular hypertension. Our group was the first to describe and state the value of the rapid-sequence intravenous urogram as a screening test for unilateral renal artery stenosis causing underperfusion of the kidney [4]. We also described the use of the upright aortogram, a technique which proved valuable in demonstrating the frequent co-existence of nephrotosis and renal artery stenosis and a method that gave better delineation of stenotic lesions - because the renal arteries are placed on stretch in the upright position [3]. Among surgical techniques that evolved has been the aortorenal bypass using Dacron grafts, and recently we have employed the external velour Dacron graft, which provides a trellis for the ingrowth of fibrous tissue with a laying-down of a smooth, non-thrombogenic International Urology and Nephrology 7, 1975
KauJman : Current scientific interests
97
neointima. We have employed this material in canine experiments (to be published in the American Journal of Surgery) and in approximately 20 cases since 1972. We have also expanded the use of the free autologous hypogastric artery graft. In 31 cases in which this technique was employed for the treatment of mural fibroplasias of the renal artery, the results have been almost uniformly excellent [2]. Our interest in renal autotransplantation was a natural outgrowth of our large experience in renal homotransplantation and renovascular surgery for hypertension. The first case in which this technique was employed was in 1967 in a young boy with a solitary kidney [1]. The graft is functioning eight years later with stabilization of blood pressure at normal levels. Since that time, we have performed autotransplantation in 10 additional cases with excellent results. We believe that in young individuals, particularly, autotransplantation will become a major surgical resource. This is particularly true in young persons with middle aortic syndrome who have an aortitis of probable autoimmune nature affecting the aorta in its primary branches. The subject of renal hypertension in children has been a major interest, and Dr. R. Fay and I have recently contributed a chapter on this subject for the book on Pediatric Urology edited by H. Johnston and W. E. Goodwin. Studies in tumor immunology were done with renal cell carcinoma by Dr. K. Cummings during his residency training in the Division of Urology at U. C. L. A. Dr. Cummings proved that renal cell tumors possessed tumor-specific transplantation antigens, and that autochthonous cell-mediated and humoral cytotoxicity could be demonstrated in the majority of cases, while cross-reactivity (allogeneic) could be demonstrated in approximately half of the cases. These studies are being continued by Dr. Cummings, who is now working with the HelIstroms in Seattle. Further studies on the immunology of bladder tumors, immunotherapy and virology are being conducted by two other members of our department, Dr. S. Brosman and J. deKernion, working together with members of the Microbiology staff under the direction of Dr. J. Fahey. A new member of our Urology staff is Dr. C. O'Toole, who comes to us from the Karolinska Institute with great knowledge of the immunology of bladder tumors. A large grant to pursue these studies has recently been awarded us by the National Cancer Institute. A major advance in applied physiology has been the discovery of a solution for initial perfusion of the kidney which allows prolonged periods of preservation either for workbench surgery at room temperature or for shipping cadaver kidneys for renal allografts. This work was done in cooperation with Drs S. Sacks and P. Petrisch, a resident and fellow, respectively, working in our laboratory on the project of renal preservation. They found by modifying the solution of Collins' in which the intracellular electrolyte composition is duplicated - but with the addition of mannitol to render the solution hyperosmotic - that continuous pulsatile perfusion of the kidney for preservation is unnecessary. The hyperosmotic solution, in effect, dehydrates the renal cells or at least prevents the cells from swelling - as they are want to do with Ringer's lactate or other isotonic solutions when used for perfusion of the kidney. Cell swelling crowds the peritubular capilInternational Urology and Nephrology 7, 1975
98
Kaufman: Current scientific interests
laries and prevents rettow of blood after the kidney is replaced and circulation restored. The tubular necrosis that follows is probably the result of ischemia caused by the "failed reflow". The new solution, infused by simple gravity for 2 - 5 minutes and followed by hypothermic storage without further perfusion, has allowed us to preserve kidneys and to restore complete kidney function in dogs for periods up to 72 hours. In clinical use in over 40 patients, we have found that initial perfusion with the hyperosmotic intracellular fluid and hypothermic storage compared favorably in terms of ultimate kidney function with the mechanical pulsatile perfusion techniques of kidney preservation. For workbench surgery, after an initial perfusion, the kidney can be handled and small vessel surgery or partial nephrectomy can be done at room temperature for periods up to five hours without serious impairment of renal function. This work has been published in Lancet, 1973 (1) and subsequent articles will soon appear in the Am. J. Surg. During the last five years, a major clinical interest has been the surgical treatment of postprostatectomy urinary incontinence. The initial procedure we devised consisted of crossing the crura of the penis in the perineum over the urethra in order to cempress the urethra. This produced results which were fairly good in a little over one-third of patients. We subsequently modified this to merely approximate the liberated crura in the midline and to obtain a longer length of urethral compression, again with results less than 50 per cent satisfactory for longterm follow-up. During the last two years, it has been our practice to use an implantable silicone-gel sponge to compress the urethra, and the recent models of this sponge have been exceptionally successful in our hands for the correction of this disabling condition. The prosthesis was designed with certain physical characteristics making it well-tolerated, quickly fixed by ingrowth of fibrous tissue, and adjustable by postoperative percutaneous injection. The original model of the prosthesis was ovoid in shape with a flat surface on one side and convex surface on the aspect to be applied against the urethra. Its consistency is similar to that of muscle, owing to an interior of silicone gel, a capsule of silastic, and an outer velour of polyurethane which acts as a trellis for ingrowth and fixation by fibrous tissue. The prosthesis is usually leakproof, permitting postoperative injection of the capsule to augment its size and compressing force should there be failure to maintain continence after edema subsides and fibrosis supervenes. The prosthesis is equipped with two or three veloured Dacron straps on either side to fix the capsule snugly against the bulbous urethra. Subsequently the prosthesis was modified in shape so that it is wider at the base than at the dome. Operations to implant the silicone-gel prosthesis have been carried out in 78 patients since March 1972. Forty-four patients had post-transurethral prostatectomy incontinence; 18 patients had incontinence after simple suprapubic or retropubic prostatectomy; and 16 patients were incontinent after radical prostatectomy. Table 1 summarizes the results of the silicone-gel prosthesis procedure. Of the 78 patients operated upon, only 60 have been followed adequately to evalInternational Urology and Nephrology 7, 1975
99
Kaufman: Current scientific interests
Table 1 Incontinence surgery with silicone gel prosthesis (March 1974) 78 patients
1st Operation 40 patients Previous perineal surgery for incontinence x 1 to 4 20 patients GI MI F
Cure
I
28,
GI ,9
MI 3 ~
77~ 5~
.
41%
}
F ~8
23~o J2
3,
59~
,8
Greatly Improved (wears only a little protective pad) Moderately Improved (wears padding requiring changes X 4 daily) Failure (still needs collecting appliance or clamp)
uate. Forty of the patients had implantation of the silicone-gel prosthesis without previous attempts to repair urinary incontinence by surgical procedures, whereas 20 patients had previous unsuccessful perineal or suprapubic operations. Of the 40 patients in Group I, 28 obtained excellent results, i.e., perfectly dry. Nine patients were substantially improved to the point where they wore only a small amount of padding for occasional leakage. Thus 77 per cent of the patients in this category obtained good or perfect results. Sixteen of these patients required one or more injections of the prosthesis to obtain the benefit. Three patients obtained moderate improvement to the point where they no longer required wearing a clamp or collecting device, but required changing of padding more than four times daily. Eight patients were failures in that they had to revert to wearing a clamp or collecting device. Three patients in this initial group cannot be classified according to control status since the prosthesis caused urethral erosion and required removal and urethral repair. In Group II there were 20 patients, of whom two required re-operation for a persistent draining perineal sinus. The prosthesis (and in both cases a Marlex roll from previous operation) required removal. In this group, five (30 per cent) obtained a perfect result, two were greatly improved; a substantial improvement score of 41 per cent. Eight patients were failures (44 per cent) and three patients (15 per cent) were moderately improved. Thus it is apparent that the results are approximately half as good in the patients who have had failure to be cured by previous anti-incontinence operations. It is felt that with the new improved design of the prosthesis and with careful patient selection, the results will be even better. Another effort has been expended in attempting to devise a better means of simulating erection in the impotent male. We have used an inflatable device in the form of paddles placed under the skin, or in the form of a subcutaneous cuff about Buck's fascia. Fluid is transferred from a reservoir by compression and returned to the reservoir by means of conduits regulated by a valve. However, mechanical problems and particularly erosion of the prosthesis at small areas of International Urology and Nephrology 7, 1975
100
Kaufman: Current scientific interests
the skin have led us to abandon the technique for the time being. We are now employing double silastic rods in each corpus, using the models designed by Drs Small and Carrion, for our patients with total erectile impotence, and a thinner model of our own design for a penile assist in patients who are capable of a partial erection. The results using these solid rods placed in the corpora have been extremely good, and we believe that the operation is simpler and better than other procedures - such as that devised by Pearman, of our U. C. L. A. Clinical Staff, in which a single solid rod is placed in the midline of the penis. The operation is extremely simple and is done through a hemicircumcision approach, reflecting the skin of the penis proximally and making small windows on the lateral aspect of each corpus for the insertion of the prostheses. These have been my major "hobbies", but in this communication I would be remiss if I did not say a few words about the training program in Urology at U. C. L. A. The core residency is of four years following internship, and at least one year of General Surgery. Each year we accept three residents to enter the program. We have five teaching hospitals through which the residents rotate in order to provide a complete and panoramic exposure to the various urological procedures. The first year is spent in a general indoctrination, including endoscopic work; the second year is spent in the laboratory or in affiliating in other services. Several of our residents have had a rich experience in this respect with Mr. D. InnesWilliams in London, or with Dr. H. Hendren in Boston. The third year is spent as a senior resident, during which time the resident perfects his skills in transurethral operations and in the majority of open major surgical procedures. The final year is spent as a chief resident, during which time the resident makes major decisions, runs the respective clinical services, and performs complicated procedures of urological surgery. Each year we also take approximately four foreign scholars who work in the clinical care of urologic patients and, occasionally, in the laboratory. This provides a resident cadre of approximately 20 highly qualified men who are training for Board certification, and a good number of these residents go on to academic appointments and have their own training services. Thus we have, among the leaders of Urology in the United States, some outstanding men who have trained in the U. C. L. A. program: Dr. Chester Winter, professor and head of the Division of Urology at Ohio State University; Dr. A. T. K. Cockett, professor and chief of urology at the Rochester School of Medicine, New York; Dr. D. Martin, professor and head of urology at the Univeisity of California School of Medicine at Irvine; and Dr. P. C. Walsh, who assumed the chair of urology at the Johns Hopkins Hospital in Baltimore, in July of 1974. Dr. R. F. Gittes, professor and head of urology at the University of California School of Medicine at San Diego, spent time at U. C. L. A. after completing his residency under Dr. W. F. Leadbetter at Massachusetts General Hospital in Boston. In addition, Dr. L. Klein is chief of urology at the Beth lsrael Hospital in Boston; Dr. G. Dale is an assistant professor at the University of Tennessee School of Medicine, in Memphis; Dr. A. Melman is assistant professor at the University of Indiana School of Medicine International Urology and Nephrology 7, 1975
Kaufman: Current scientific interests
101
in Indianapolis, and Dr. W. Bonney is assistant professor at the University of I o w a School of Medicine in Iowa City. Fellows f r o m abroad who have trained at U. C. L. A. and who are now highly respected leaders in their foreign countries, are: J. C. Smith, professorat Oxford University; Dr. M. Royle of Sussex, England; Dr. F. Schroeder and P. Lichtenauer, of Germany; Dr. R. Vargas, protessor of urology in Santiago, Chile; Dr. R. V. Navarrete, who is on the teaching staff at the University of Madrid; Dr. Sreenivasen, of Malaysia; Dr. C. H. Leong, of H o n g Kong; Dr. P. Petrisch of Gratz, Austria, and Dr. P. Dragon, of Rumania:
References 1. Kaufman, J. J., Alferenz, C., Vela Navarrete, R. : Autotransplantation of a solitary functioning kidney for renovascular hypertension. J. Urol. (BAR.), 102, 146 (1969). 2. Kaufman, J. J., Lupu, A. N. : Treatment of renal artery stenosis utilizing free autologous hypogastric artery grafts. J. Urol. (Balt.) 106, 9 (1971). 3. Kaufman, J. J., Maxwell, M. H. : The value of upright aortography in the study of nephroptosis stenotonic lesions of the renal artery and hypertension. Su~q., 53, 736 (1963). 4. Maxwell, M. H., Gonick, H., Kaufman, J. J.: Rapid leguence intravenous pyelogram in the diagnosis of renovascular hypertension. New Engl. J. Med. 270, 213 (1964). 5. Sacks, S. A., Petrisch, P. H., Kaufman, J. J. : Canine kidney preservation using a new perfusate. Lancet, 1, 1024 (1973).
International Urology and Nephrology 7, 1975
Current Scientific Interests of Division of Urology, U. C. L. A. J. J. KAUFMAN
Division of Urology School of Medicine, University of California, Los Angeles, California (Received August 26, 1974)
The purpose of this communication is to acquaint the urological community at large with my personal interests ("hobbies") and with activities of the Division of Urology at University of California, Los Angeles (U. C. L. A.).
Upon the retirement of W. E. Goodwin in 1970, I assumed direction of the Division of Urology at U. C. L. A. Dr. Goodwin, having spent a zealous nineteen years of intense activity, developed a department that was truly outstanding. Under his inspiring leadership, we became pioneers in the field of kidney transplantation. He was the first to describe the use of large doses of corticosteroids to prevent the rejection reaction. And the first to use ureteropyelostomy in kidney transplantation as well as fetal transplants. Prior to his voluntary retirement to become more active in Pediatric Urology, we had performed over 250 kidney transplants at U. C. L.A. Together with colleagues in the division, we have reported our experience in the technique, medical management and complications of the kidney transplantation. Professor Goodwin made an excellent motion picture in 1962 on "The Technique of Kidney Transplantation in the Dog", and this became a prototype for experimental work in canine models. Under Dr. Goodwin's direction and inspiration, the use of the intestine for urinary tract replacement and augmentation flourished, and ours continues to be one of the largest experiences in the world. Dr. Goodwin and I did extensive laboratory studies on renal lymphatics. We published our review of the subject in Urologic Survey, 6, 305-329, 1956. We also reported the clinical implications of our renal lymphatic work in the Annals of Internal Medicine, 49, 109-119, 1958. Dr. A. T. K. Cockett was formerly associated with our group and he has followed-up on the renal lymphatic work with respect to its role in renal infection and antibiotic therapy, transplantation, etc. Dr. Goodwin's main interest since 1969 has been in the field of Pediatric Urology and he devotes the major portion of his time and effort in this specialty. He is editing a book on Pediatric Urology with Mr. H. Johnston and he has inspired a number of young urologists to enter a career in Pediatric Urology. He continues to use innovative reconstructive techniques and has a major interest in pediatric urological oncology. 1"
International Urology and Nephrology 7, 1975
96
Kaufman: Current scientific interests
I, personally, had worked with Dr. Goodwin as one of his first residents at U. C. L. A. in 1951. After a period of private practice, I resumed full-time academic pursuits in 1960. My own major interests have been in the field of urological oncology, including experimental studies. Renovascular hypertension, renal transplantation, the treatment of urinary incontinence and, more recently, impotence are current major interests. However, the staff we have recruited provides even more protean interests and investigations are underway in the fields of urological oncology, immunology, chemotherapy and renal preservation. Our earliest experimental efforts were in the field of tumor transplantation in experimental animals. Although our attempts to grow human tumors in the anterior chamber of the guinea pig eye were not successful, we subsequently achieved considerable success in using the cheek pouch of the hamster treated with cortisone for transplantation of human bladder and kidney tumors. We were able to grow human tumors in literally thousands of hamsters and to test the growth patterns of the tumors in animals receiving cytostatic drugs, singly and in combination. Our laboratory work indicated that mitomycin C (Bristol-Myers investigationat drug; no trade name as yet) was a good drug for human bladder cancer, but its toxicity in humans has limited its use. We also showed that 5fluorouracil and radiation made an effective combination for the inhibition of tumor growth, and this work was applied with some success to human subjects with bladder cancer. However, neither the experimental nor the clinical results were truly dramatic, and our treatment of invasive bladder cancer now consists of preoperative radiation therapy and radical cystectomy. During the last three years we have employed compact preoperative radiotherapy, administering 1600 rads of divided doses over four days immediately prior to the extirpative procedure. In the presence of deeply invasive tumors or high-grade tumors, the patient receives "sandwich" therapy with fractionated radiation to the pelvis after wound healing is complete (3500 additional rads). The latter work has been expanded and various aspects of these studies are being reported by my associate, Dr. D. G. Skinner. As members of the Cooperative Clinical Group for the Study of Bladder Cancer, Kidney Cancer and Renovascular Hypertension, our clinical work at U. C. L. A. has contributed substantially to the national efforts in these fields. A sizeable experience has been gained in the diagnosis and treatment of renovascular hypertension. Our group was the first to describe and state the value of the rapid-sequence intravenous urogram as a screening test for unilateral renal artery stenosis causing underperfusion of the kidney [4]. We also described the use of the upright aortogram, a technique which proved valuable in demonstrating the frequent co-existence of nephrotosis and renal artery stenosis and a method that gave better delineation of stenotic lesions - because the renal arteries are placed on stretch in the upright position [3]. Among surgical techniques that evolved has been the aortorenal bypass using Dacron grafts, and recently we have employed the external velour Dacron graft, which provides a trellis for the ingrowth of fibrous tissue with a laying-down of a smooth, non-thrombogenic International Urology and Nephrology 7, 1975
KauJman : Current scientific interests
97
neointima. We have employed this material in canine experiments (to be published in the American Journal of Surgery) and in approximately 20 cases since 1972. We have also expanded the use of the free autologous hypogastric artery graft. In 31 cases in which this technique was employed for the treatment of mural fibroplasias of the renal artery, the results have been almost uniformly excellent [2]. Our interest in renal autotransplantation was a natural outgrowth of our large experience in renal homotransplantation and renovascular surgery for hypertension. The first case in which this technique was employed was in 1967 in a young boy with a solitary kidney [1]. The graft is functioning eight years later with stabilization of blood pressure at normal levels. Since that time, we have performed autotransplantation in 10 additional cases with excellent results. We believe that in young individuals, particularly, autotransplantation will become a major surgical resource. This is particularly true in young persons with middle aortic syndrome who have an aortitis of probable autoimmune nature affecting the aorta in its primary branches. The subject of renal hypertension in children has been a major interest, and Dr. R. Fay and I have recently contributed a chapter on this subject for the book on Pediatric Urology edited by H. Johnston and W. E. Goodwin. Studies in tumor immunology were done with renal cell carcinoma by Dr. K. Cummings during his residency training in the Division of Urology at U. C. L. A. Dr. Cummings proved that renal cell tumors possessed tumor-specific transplantation antigens, and that autochthonous cell-mediated and humoral cytotoxicity could be demonstrated in the majority of cases, while cross-reactivity (allogeneic) could be demonstrated in approximately half of the cases. These studies are being continued by Dr. Cummings, who is now working with the HelIstroms in Seattle. Further studies on the immunology of bladder tumors, immunotherapy and virology are being conducted by two other members of our department, Dr. S. Brosman and J. deKernion, working together with members of the Microbiology staff under the direction of Dr. J. Fahey. A new member of our Urology staff is Dr. C. O'Toole, who comes to us from the Karolinska Institute with great knowledge of the immunology of bladder tumors. A large grant to pursue these studies has recently been awarded us by the National Cancer Institute. A major advance in applied physiology has been the discovery of a solution for initial perfusion of the kidney which allows prolonged periods of preservation either for workbench surgery at room temperature or for shipping cadaver kidneys for renal allografts. This work was done in cooperation with Drs S. Sacks and P. Petrisch, a resident and fellow, respectively, working in our laboratory on the project of renal preservation. They found by modifying the solution of Collins' in which the intracellular electrolyte composition is duplicated - but with the addition of mannitol to render the solution hyperosmotic - that continuous pulsatile perfusion of the kidney for preservation is unnecessary. The hyperosmotic solution, in effect, dehydrates the renal cells or at least prevents the cells from swelling - as they are want to do with Ringer's lactate or other isotonic solutions when used for perfusion of the kidney. Cell swelling crowds the peritubular capilInternational Urology and Nephrology 7, 1975
98
Kaufman: Current scientific interests
laries and prevents rettow of blood after the kidney is replaced and circulation restored. The tubular necrosis that follows is probably the result of ischemia caused by the "failed reflow". The new solution, infused by simple gravity for 2 - 5 minutes and followed by hypothermic storage without further perfusion, has allowed us to preserve kidneys and to restore complete kidney function in dogs for periods up to 72 hours. In clinical use in over 40 patients, we have found that initial perfusion with the hyperosmotic intracellular fluid and hypothermic storage compared favorably in terms of ultimate kidney function with the mechanical pulsatile perfusion techniques of kidney preservation. For workbench surgery, after an initial perfusion, the kidney can be handled and small vessel surgery or partial nephrectomy can be done at room temperature for periods up to five hours without serious impairment of renal function. This work has been published in Lancet, 1973 (1) and subsequent articles will soon appear in the Am. J. Surg. During the last five years, a major clinical interest has been the surgical treatment of postprostatectomy urinary incontinence. The initial procedure we devised consisted of crossing the crura of the penis in the perineum over the urethra in order to cempress the urethra. This produced results which were fairly good in a little over one-third of patients. We subsequently modified this to merely approximate the liberated crura in the midline and to obtain a longer length of urethral compression, again with results less than 50 per cent satisfactory for longterm follow-up. During the last two years, it has been our practice to use an implantable silicone-gel sponge to compress the urethra, and the recent models of this sponge have been exceptionally successful in our hands for the correction of this disabling condition. The prosthesis was designed with certain physical characteristics making it well-tolerated, quickly fixed by ingrowth of fibrous tissue, and adjustable by postoperative percutaneous injection. The original model of the prosthesis was ovoid in shape with a flat surface on one side and convex surface on the aspect to be applied against the urethra. Its consistency is similar to that of muscle, owing to an interior of silicone gel, a capsule of silastic, and an outer velour of polyurethane which acts as a trellis for ingrowth and fixation by fibrous tissue. The prosthesis is usually leakproof, permitting postoperative injection of the capsule to augment its size and compressing force should there be failure to maintain continence after edema subsides and fibrosis supervenes. The prosthesis is equipped with two or three veloured Dacron straps on either side to fix the capsule snugly against the bulbous urethra. Subsequently the prosthesis was modified in shape so that it is wider at the base than at the dome. Operations to implant the silicone-gel prosthesis have been carried out in 78 patients since March 1972. Forty-four patients had post-transurethral prostatectomy incontinence; 18 patients had incontinence after simple suprapubic or retropubic prostatectomy; and 16 patients were incontinent after radical prostatectomy. Table 1 summarizes the results of the silicone-gel prosthesis procedure. Of the 78 patients operated upon, only 60 have been followed adequately to evalInternational Urology and Nephrology 7, 1975
99
Kaufman: Current scientific interests
Table 1 Incontinence surgery with silicone gel prosthesis (March 1974) 78 patients
1st Operation 40 patients Previous perineal surgery for incontinence x 1 to 4 20 patients GI MI F
Cure
I
28,
GI ,9
MI 3 ~
77~ 5~
.
41%
}
F ~8
23~o J2
3,
59~
,8
Greatly Improved (wears only a little protective pad) Moderately Improved (wears padding requiring changes X 4 daily) Failure (still needs collecting appliance or clamp)
uate. Forty of the patients had implantation of the silicone-gel prosthesis without previous attempts to repair urinary incontinence by surgical procedures, whereas 20 patients had previous unsuccessful perineal or suprapubic operations. Of the 40 patients in Group I, 28 obtained excellent results, i.e., perfectly dry. Nine patients were substantially improved to the point where they wore only a small amount of padding for occasional leakage. Thus 77 per cent of the patients in this category obtained good or perfect results. Sixteen of these patients required one or more injections of the prosthesis to obtain the benefit. Three patients obtained moderate improvement to the point where they no longer required wearing a clamp or collecting device, but required changing of padding more than four times daily. Eight patients were failures in that they had to revert to wearing a clamp or collecting device. Three patients in this initial group cannot be classified according to control status since the prosthesis caused urethral erosion and required removal and urethral repair. In Group II there were 20 patients, of whom two required re-operation for a persistent draining perineal sinus. The prosthesis (and in both cases a Marlex roll from previous operation) required removal. In this group, five (30 per cent) obtained a perfect result, two were greatly improved; a substantial improvement score of 41 per cent. Eight patients were failures (44 per cent) and three patients (15 per cent) were moderately improved. Thus it is apparent that the results are approximately half as good in the patients who have had failure to be cured by previous anti-incontinence operations. It is felt that with the new improved design of the prosthesis and with careful patient selection, the results will be even better. Another effort has been expended in attempting to devise a better means of simulating erection in the impotent male. We have used an inflatable device in the form of paddles placed under the skin, or in the form of a subcutaneous cuff about Buck's fascia. Fluid is transferred from a reservoir by compression and returned to the reservoir by means of conduits regulated by a valve. However, mechanical problems and particularly erosion of the prosthesis at small areas of International Urology and Nephrology 7, 1975
100
Kaufman: Current scientific interests
the skin have led us to abandon the technique for the time being. We are now employing double silastic rods in each corpus, using the models designed by Drs Small and Carrion, for our patients with total erectile impotence, and a thinner model of our own design for a penile assist in patients who are capable of a partial erection. The results using these solid rods placed in the corpora have been extremely good, and we believe that the operation is simpler and better than other procedures - such as that devised by Pearman, of our U. C. L. A. Clinical Staff, in which a single solid rod is placed in the midline of the penis. The operation is extremely simple and is done through a hemicircumcision approach, reflecting the skin of the penis proximally and making small windows on the lateral aspect of each corpus for the insertion of the prostheses. These have been my major "hobbies", but in this communication I would be remiss if I did not say a few words about the training program in Urology at U. C. L. A. The core residency is of four years following internship, and at least one year of General Surgery. Each year we accept three residents to enter the program. We have five teaching hospitals through which the residents rotate in order to provide a complete and panoramic exposure to the various urological procedures. The first year is spent in a general indoctrination, including endoscopic work; the second year is spent in the laboratory or in affiliating in other services. Several of our residents have had a rich experience in this respect with Mr. D. InnesWilliams in London, or with Dr. H. Hendren in Boston. The third year is spent as a senior resident, during which time the resident perfects his skills in transurethral operations and in the majority of open major surgical procedures. The final year is spent as a chief resident, during which time the resident makes major decisions, runs the respective clinical services, and performs complicated procedures of urological surgery. Each year we also take approximately four foreign scholars who work in the clinical care of urologic patients and, occasionally, in the laboratory. This provides a resident cadre of approximately 20 highly qualified men who are training for Board certification, and a good number of these residents go on to academic appointments and have their own training services. Thus we have, among the leaders of Urology in the United States, some outstanding men who have trained in the U. C. L. A. program: Dr. Chester Winter, professor and head of the Division of Urology at Ohio State University; Dr. A. T. K. Cockett, professor and chief of urology at the Rochester School of Medicine, New York; Dr. D. Martin, professor and head of urology at the Univeisity of California School of Medicine at Irvine; and Dr. P. C. Walsh, who assumed the chair of urology at the Johns Hopkins Hospital in Baltimore, in July of 1974. Dr. R. F. Gittes, professor and head of urology at the University of California School of Medicine at San Diego, spent time at U. C. L. A. after completing his residency under Dr. W. F. Leadbetter at Massachusetts General Hospital in Boston. In addition, Dr. L. Klein is chief of urology at the Beth lsrael Hospital in Boston; Dr. G. Dale is an assistant professor at the University of Tennessee School of Medicine, in Memphis; Dr. A. Melman is assistant professor at the University of Indiana School of Medicine International Urology and Nephrology 7, 1975
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in Indianapolis, and Dr. W. Bonney is assistant professor at the University of I o w a School of Medicine in Iowa City. Fellows f r o m abroad who have trained at U. C. L. A. and who are now highly respected leaders in their foreign countries, are: J. C. Smith, professorat Oxford University; Dr. M. Royle of Sussex, England; Dr. F. Schroeder and P. Lichtenauer, of Germany; Dr. R. Vargas, protessor of urology in Santiago, Chile; Dr. R. V. Navarrete, who is on the teaching staff at the University of Madrid; Dr. Sreenivasen, of Malaysia; Dr. C. H. Leong, of H o n g Kong; Dr. P. Petrisch of Gratz, Austria, and Dr. P. Dragon, of Rumania:
References 1. Kaufman, J. J., Alferenz, C., Vela Navarrete, R. : Autotransplantation of a solitary functioning kidney for renovascular hypertension. J. Urol. (BAR.), 102, 146 (1969). 2. Kaufman, J. J., Lupu, A. N. : Treatment of renal artery stenosis utilizing free autologous hypogastric artery grafts. J. Urol. (Balt.) 106, 9 (1971). 3. Kaufman, J. J., Maxwell, M. H. : The value of upright aortography in the study of nephroptosis stenotonic lesions of the renal artery and hypertension. Su~q., 53, 736 (1963). 4. Maxwell, M. H., Gonick, H., Kaufman, J. J.: Rapid leguence intravenous pyelogram in the diagnosis of renovascular hypertension. New Engl. J. Med. 270, 213 (1964). 5. Sacks, S. A., Petrisch, P. H., Kaufman, J. J. : Canine kidney preservation using a new perfusate. Lancet, 1, 1024 (1973).
International Urology and Nephrology 7, 1975
