Percutaneous management of caliceal diverticular calculi: technique and outcome.

OBJECTIVE: Symptomatic renal calculi found within caliceal diverticula are difficult to treat. We present a single-surgeon cohort of 21 consecutive patients undergoing percutaneous treatment of stones within caliceal diverticula over a 12-year period. PATIENTS AND METHODS: Each patient was managed by a one-stage percutaneous nephrolithotomy (PCNL). The majority of diverticula were situated at the upper pole. Access was gained via a direct target puncture, a Y puncture from a parallel calix, or through the diverticular stalk in the neighboring calix. The approach was commonly supracostal. A single-stage dilator was used to establish the track. Stones were removed intact or fragmented with ultrasonic lithotripsy, and the diverticular necks were treated with endoscopic division or dilation and splinted with a 22F nephrostomy tube for several days. RESULTS: Total stone clearance was obtained by PCNL alone in 95% of cases. The only case with incomplete clearance was cleared successfully with shockwave lithotripsy (SWL). Twenty patients were assessed with an intravenous urogram at 3 months and then annual plain films and clinical assessment. Further imaging was performed in selected cases. The diverticula were obliterated or had improved drainage in 85% of assessable cases. Three patients developed recurrent stones and were treated with SWL, laparoscopic diverticulectomy, on partial nephrectomy. One further patient required partial nephrectomy for poor drainage and ongoing pain. Of the 21 patients, 17 have remained stone, symptom, and infection free with clinical and radiologic follow-up ranging from 6 months to 12 years. CONCLUSIONS: This series demonstrates that percutaneous surgery can clear calculi from caliceal diverticula and, in most cases, correct or remove the underlying anatomic abnormality.

Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective.

OBJECTIVES: To assess technical preferences and current practice trends of retroperitoneal and pelvic extraperitoneal laparoscopy. METHODS: A questionnaire survey of 36 selected urologic laparoscopic centers worldwide was performed. RESULTS: Twenty-four centers (67%) responded. Overall, 3988 laparoscopic procedures were reported: transperitoneal approach (n = 2945) and retroperitoneal/extraperitoneal approach (n = 1043). Retroperitoneoscopic/extraperitoneoscopic procedures included adrenalectomy (n = 74), nephrectomy (n = 299), ureteral procedures (n = 166), pelvic lymph node dissection (n = 197), bladder neck suspension (n = 210), varix ligation (n = 91), and lumbar sympathectomy (n = 6). Mean number of total laparoscopic procedures performed in 1995 per center was 41 (range 5 to 86). Major complications occurred in 49 (4.7%) patients and included visceral complications in 26 (2.5%) patients and vascular complications in 23 (2.2%). Open conversion was performed in 69 (6.6%) patients, electively in 41 and emergently in 28 (visceral injuries, n = 16; vascular injuries, n = 1 2). Retroperitoneoscopy/extraperitoneoscopy is gaining in acceptance worldwide: in 1993, the mean estimated ratio of transperitoneal laparoscopic cases versus retroperitoneoscopic/ extraperitoneoscopic cases per center was 74:26; however, in 1996 the ratio was 49:51. CONCLUSIONS: Retroperitoneoscopy and pelvic extraperitoneoscopy are important adjuncts to the laparoscopic armamentarium in urologic surgery. The overall major complication rate associated with retroperitoneoscopy/extraperitoneoscopy was 4.7%.

Extraperitoneal laparoscopic caliceal diverticulectomy.

Three women with symptomatic stone-containing caliceal diverticula in the right kidney were treated by extraperitoneal laparoscopic diverticulectomy. The diverticula measured 31 x 21 mm, 15 x 12 mm, and 12 x 9 mm, with the calculi measuring 10 x 8 mm, 5 x 4 mm, and 6 x 6 mm, respectively. The site of the diverticulum was identified by the presence of a depression on the surface of the kidney. The diverticulum was marsupialized, the lining fulgurated, and in the second and third patients, a flap of Gerota's fascia and perirenal fat inserted. The mean operating time was 127 minutes. The mean postoperative analgesic requirement was six doses of pethidine (meperidine). The median time to drainage tube removal was 3 days, and the median time to discharge after surgery was 4 days. Complications were minimal. On follow-up, all patients were stone free and asymptomatic. The first patient had a slight recurrence of the diverticulum, measuring 15 x 7 mm. Laparoscopic caliceal diverticulectomy has been successful in three patients.

A study of the efficacy and safety of transurethral needle ablation (TUNA) treatment for benign prostatic hyperplasia.

The objective of this early phase III study was to determine the efficacy and safety of transurethral needle ablation (TUNA) in patients presenting in acute urinary retention due to benign prostatic hyperplasia (BPH). Between September 1993 and August 1994, 20 patients of mean age 68.8 years were entered into a two-center study and treated with TUNA after presenting in acute urinary retention and having failed at least one trial of voiding. A mean of 5.4 lesions at shield temperatures of 54.6 degrees C were produced. Patients were reviewed at 1, 3, 6, and 12 months (mean, 6.2 months). In 17 of 20 patients, voiding was reestablished in a mean of 2.6 days. Three patients required TURP for persistent retention, and 2 patients had delayed TURP for bothersome symptoms. Two voiders died later of unrelated causes. Five patients were lost to follow-up at 6 months but were voiding when last reviewed. Symptom scores decreased from a mean of 19.0 (range 4-35) to 8.25 (range 1-20) at 12 months (p = 0.06). Mean peak flow rate was 11.4 ml/sec (range 6.6-16.8) at 12 months (p = 0.001). Mean prostatic volume at baseline was 65.8 cc and decreased to 56 cc at 12 months (p = 0.111). The treatment was well tolerated by all patients, and side effects were mild, including urinary tract infection and epididymo-orchitis. This study demonstrates the safety and effectiveness of TUNA procedure in patients with urinary retention due to benign prostatic hypertrophy.

Transurethral Needle Ablation of the prostate (TUNA): clinical results and ultrasound, endoscopic, and histologic findings in pilot study of patients in urinary retention.

Transurethral Needle Ablation of the prostate (TUNA) is a new thermal ablation treatment for benign prostatic hyperplasia (BPH) utilizing radiofrequency electric current delivered by needles into the depth of the prostate to produce an area of coagulative necrosis. A pilot study of 10 patients in urinary retention was undertaken to assess the procedure. After treatment, nine patients voided at a median time of 3 days, although a further two required transurethral resection because of chronic infection in one and chronic urinary retention in the other. At 3 months' follow-up, the mean Qmax was 13.0 mL/sec, the mean AUA Symptom Score was 9.1, and the mean quality of life score was 1.6. The mean Pdet fell from 73.3 to 39.0 cm H2O. On transrectal ultrasound at 3 months, cystic lesions were seen in two patients, with a third having large cavities. A 10.2% reduction in mean prostatic volume, from 48.8 cc to 43.8 cc, was noted but considered to be not significant. On endoscopy at 3 months, mucosal retraction was seen in seven patients, with cavities in two patients. Histologic study in patients undergoing transurethral resection 4 to 6 months after TUNA showed necrosis and fibrosis. It is considered that an area of coagulative necrosis is produced by TUNA that resolves either by scar formation with retraction or by liquefaction with cyst formation. If the lesion communicates with the urethra, a cavity may form, which is undesirable. Our early experience is encouraging. The TUNA treatment is effective, can be given without anesthesia, and should be either a day case or an office procedure. It should prove to have a significant place in the treatment of BPH.

Laparoscopic ureterolithotomy: the results of an initial series, and an evaluation of its role in the management of ureteric calculi.

OBJECTIVE: To evaluate the place of laparoscopic ureterolithotomy in the management of ureteric calculi for which extracorporeal shockwave lithotripsy (ESWL) and endourological techniques are unsuitable. PATIENTS AND METHODS: Laparoscopic ureterolithotomy was attempted in nine patients (eight men, one woman) with an age range of 26-81 years (mean 55.5) who had large, long standing and impacted calculi in the upper and mid ureter. The stone size ranged from 5 to 28 mm (mean 13.2) and stone duration ranged from one to 24 months (mean 8.2). The transperitoneal route was used in six patients and the extraperitoneal route in three but was converted to a transperitoneal approach in two. RESULTS: The stone was successfully removed in all nine patients. The operative time ranged from 80 to 260 minutes (mean 158). No intra-operative complication was encountered and no patient required a blood transfusion. Post-operative complications included urinary leak and fever. The post-operative stay ranged from 2 to 13 days (mean 5.2). CONCLUSIONS: Laparoscopic ureterolithotomy has definite advantages over open ureterolithotomy. Furthermore, the more difficult a stone is for treatment by ESWL and endourological techniques, the more suitable it is for laparoscopic removal. For large, hard, long-standing and impacted ureteric calculi, one laparoscopic ureterolithotomy as initial therapy may be preferable to multiple endourological and ESWL procedures.

Laparoscopic needle colposuspension for genuine stress incontinence.

Laparoscopic needle colposuspension offers a minimally invasive endosurgical treatment of genuine stress incontinence. With the patient in the low lithotomy position, three lower abdominal ports are inserted. Bilateral incisions are made in the peritoneum, and the retropubic space is dissected, leaving the urachus intact. A suprapubic incision is made down to rectus fascia only and a Stamey needle inserted into the retropubic space and passed into the vagina under vision. Using No. 1 Ethibond, a double bite of the vaginal wall is taken and the suture pulled into the suprapubic incision. The suture is tied over a silicone button with no slack and no tension. Seven women have been treated by this method, with all having control of their stress incontinence in the short term. The mean operative time was 112 minutes. The catheter was removed on the first postoperative day in six women and on the second day in one woman, with no voiding difficulties. The mean time to discharge was 3.3 days for all except one woman, who had a perforation of the bladder and remained for 12 days. The advantages of the laparoscopic approach are that it allows dissection of the retropubic space, direct examination of the bladder, and observation of the bladder neck during tying of the sutures, allowing them to be tied with no slack and no tension. As a consequence, there is a minimization of the duration of catheterization, voiding difficulties, hospital stay, and postoperative discomfort, with avoidance of scarring of the vaginal wall and urethra.

Extraperitoneal laparoscopy: early experience and evaluation.

This paper evaluates the use of various balloon dilators in the flank, iliac fossa and retro-pubic regions to create extraperitoneal spaces for subsequent extraperitoneal laparoscopy. Eight patients were investigated, three undergoing pelvic surgery, four renal surgery (two nephrectomies) and one laparoscopic ureterolithotomy. Extraperitoneal balloon dilatation was simple, safe and easy and provided large tamponaded bloodless cavities and excellent vision. Port access was slightly restricted by the lateral peritoneal reflections and bony prominences of the thorax and pelvis. This approach for laparoscopy is safe, simple and deserving of further evaluation.

The visual endourological removal of ureteric calculi.

A prospective study was carried out of new techniques that allow the endoscopic removal of all ureteric calculi. Over 19 months, 50 consecutive patients with ureteric calculi that required surgical intervention were treated initially by 53 visual endourological procedures. This was successful for 45 (90%) patients, which included all patients with calculi in the upper and lower thirds of the ureter. Five patients with mid-ureteric calculi required open ureterolithotomy. The mean stone size was 8.8 mm (range, 5-22 mm). For patients with calculi in the upper third of the ureter, the most effective procedures were retrograde manipulation of calculi which was followed by percutaneous nephrolithotomy and antegrade ureteroscopy, with extraction or ultrasonic lithotripsy. For patients with calculi in the lower third of the ureter, retrograde ureteroscopy with extraction or lithotripsy was successful in all cases. Midureteric calculi presented the greatest problem and may require open ureterolithotomy. Means of improving the success of endoscopic procedures for these stones are discussed. Complications occurred in eight (16%) patients, but were resolved with conservative measures. The mean postoperative length of stay in hospital after a successful endourological procedure was 4.5 days (range, 1-21 days). We conclude that visual endourological techniques are safe and effective, and offer the advantages of the avoidance of open surgery, a reduced hospital stay and a shortened convalescence time.

The significance of urothelial dysplasia as diagnosed by cup biopsies.

A prospective study was carried out in which four quadrant cold cup biopsies of the bladder were taken from patients with either a bladder tumour (57) or irritative bladder symptoms (44), and a control group (23). Five histopathological patterns were recognized: normal urothelium, mild, moderate and severe dysplasia, and carcinoma in situ (CIS). In the control group, 22 of the 23 patients had normal urothelium, giving a 4% incidence of mild dysplasia. Of the 57 patients with all stages and grades of transitional cell carcinoma, 38 (67%) had dysplastic urothelium. This association is significant (P less than 0.01, chi-squared). Thirty-seven patients had Ta or T1 tumours, and 24 (65%) of these had dysplasia, including four (11%) with CIS. Twenty patients had T2-T4, Grade 111 tumours and 14 (70%) of these had dysplasia, including five (25%) with CIS. There was no statistical difference between these two groups. The recurrence rate was evaluated for all patients presenting with a first bladder tumour. Seventy-three percent of patients with normal cup biopsies remained recurrence free during a mean follow-up of 3 years (s.d. 1.15 years). Of patients with dysplastic urothelium, 72% remained recurrence free over a mean follow-up of 3.25 years (s.d. 1.23 years). Hence, the presence of dysplasia did not predict the likelihood of tumour recurrence. Thirty patients had dysuria or suprapubic pain for which there was no explanation. Sixteen (53%) had dysplasia on cup biopsy including three (10%) with CIS (P less than 0.01, chi-squared). It seems clear, therefore, that the dysplasia was the cause of these symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Percutaneous ultrasonic disintegration and removal of renal calculi.

We report the first use in Australia of the technique of percutaneous ultrasonic disintegration and removal of renal calculi. The first three patients who underwent the procedure had a successful outcome. These three patients are described, the method is detailed and the problems which were encountered are discussed.

Treatment of advanced bladder cancer using cis-platinum.

Cis-platinum (120 mg/m2) was given to 14 patients with locally inoperable or metastatic transitional cell carcinoma of the bladder. Five patients (35%) showed a response, two complete (14%), and three partial (21%). Nine patients (65%) had no response. The median duration of survival was 3.5 months for non-responders; 6.5 months for partial responders; and 25 months for complete responders. The side effects and implications of treatment using this agent are discussed.