Urologic complications in renal transplant recipients by donor type.

BACKGROUND AND PURPOSE: Reduced donor morbidity has been established after laparoscopic donor nephrectomy compared with open harvest, but differences in recipient outcomes remain less obvious. We compared the urologic complications in patients receiving kidneys procured by cadaveric, open, and laparoscopic harvest. PATIENTS AND METHODS: A retrospective study of all the kidney transplantations performed between January 1998 and December 2003 was undertaken to extract 100 consecutive patients in each group. All urologic complications were obtained and grouped by the type of donor procurement. RESULTS: Overall, 48 of the 276 transplant patients (17%) had urologic complications: 14% of the cadaveric-donor recipients, 20% of the open-donor recipients, and 18% of the laparoscopic-donor recipients. There were no ureteral complications in the laparoscopic group. CONCLUSIONS: Laparoscopically procured donor kidneys were associated with significantly fewer recipient ureteral complications than open cadaver or live-donor procurement.

Laryngeal metastasis 7 years after radical nephrectomy.

Metastasis of renal cell carcinoma to the head and neck, especially the larynx, is an extremely rare event. Most previously reported cases have involved a presenting laryngeal lesion that lead to the discovery of an underlying primary renal cell carcinoma. Even more unusual is the occurrence of an isolated laryngeal metastasis revealing itself years after nephrectomy, with an interim of undetected recurrence. We believe this case to be the first reported example of an isolated supraglottic laryngeal renal cell carcinoma metastasis occurring 7 years after radical nephrectomy. Local excision of such isolated lesions seems to offer a favorable prognosis.

Adverse effects of oxidative stress on renal cells and its prevention by antioxidants.

BACKGROUND AND PURPOSE: Recent reports suggest that reactive oxygen species; e.g., hydrogen peroxide (H(2)O(2)), could be the primary cause of various drug-induced renal injuries. We investigated the effects of H(2)O(2) on renal cells to understand its mode of action and to explore cytoprotection from such a fatal injury. MATERIALS AND METHODS: Renal proximal tubular LLC-PK(1) cells were exposed to various concentrations of H(2)O(2), and cell viability was determined at specified times. Lipid peroxidation assay and Western blot analysis of heat shock proteins (Hsp70 and Hsp90) were performed to assess the cellular effects. RESULTS: The dose-response study showed that H(2)O(2) > or = 100 microM was severely cytotoxic. Even a 1-h exposure was sufficient to induce >95% cell death in 24 h. Lipid peroxidation was significantly (>50%) increased, while Hsp90, but not Hsp70, was partially degraded, to an approximately 85-kDa fragment, after a 3-h H(2)O(2) exposure. However, such cytotoxic cell death was remarkably ( approximately 90%) prevented by the antioxidants pyruvate or N-acetylcysteine (NAC), and Hsp90 remained intact. CONCLUSION: Hydrogen peroxide-induced renal cell death involves increased lipid peroxidation and partial degradation of Hsp90. Both pyruvate and NAC are capable of detoxifying H(2)O(2) to maintain cell viability and Hsp90 integrity. Acute renal injuries associated with oxidative stress might preventable by appropriate antioxidants.

Malignant renal tumor with extension to the inferior vena cava.

BACKGROUND: Management of malignant renal tumors involving the inferior vena cava (IVC) depends on tumor extension within the cava. METHODS: Of 295 patients treated for renal cancer, propagation of tumor mass through the renal vein to IVC was seen in 22 (7%) patients. Cephalad extension of the tumor was suprarenal: infrahepatic in 12, retrohepatic in 6, and within the right atrium in 4 patients. All patients had radical nephrectomy, cavotomy, and complete resection of tumors except 1 with diffuse peritoneal metastasis. RESULTS: Twenty-one patients had curative resections. No operative deaths and no instances of pulmonary embolism or exsanguination occurred. Seventeen patients were alive at 2 years and 12 at 5 years, resulting in 77% and 55% survival rates, respectively. CONCLUSIONS: An aggressive approach for vena cava involvement from malignant renal neoplasms resulted in prevention of tumor embolus, minimization of blood loss, and maintenance of venous return to the heart.

Bilateral same session ureteroscopy.

During a period of 4 years we performed 15 bilateral 1-session ureteroscopic examinations in 13 patients. Indications included bilateral ureteral and/or renal calculi, unexplained hydronephrosis, hematuria or filling defects, and bilateral ureteral stent placement in situations when conventional retrograde methods of stent placement failed. Balloon or hydraulic intramural ureteral dilation was performed in all cases before rigid or flexible endoscopy. There were no major short-term or long-term complications resulting from bilateral 1-session ureteroscopy.

Techniques to negotiate the tortuous ureter.

A tortuous ureter can prevent successful retrograde ureteral access. Forceful attempts at catheterizing a ureteral kink may result in perforation and urinary extravasation. We review the currently recommended techniques to negotiate the tortuous ureter and present an additional endourological maneuver to bypass those kinks refractory to conventional methods.

Morphological and physiological changes in the urinary tract associated with ureteral dilation and ureteropyeloscopy: an experimental study.

The gross and microscopic effects of four common modes of ureteral dilation and ureteroscopy were examined in 26 renoureteral units in 13 minipigs. Acutely, ureters subjected to mechanical (bougie, Teflon, or balloon) ureteral dilation and ureteropyeloscopy (UPS) demonstrated active mucosal bleeding with multiple sites of perforation, whereas ureters subjected to hydraulic dilation and UPS were significantly less traumatized. Two weeks after mechanical ureteral dilation and UPS, 3 of 6 ureters were obstructed radiographically, whereas all 7 hydraulically dilated ureters were unobstructed. By 6 weeks, all radiographic evidence of obstruction had resolved in the mechanically dilated group. While 5 of 6 mechanically dilated ureters showed extensive scarring with muscle loss 4 to 6 weeks after dilation, no scarring was seen in those ureters dilated hydraulically. Renal pelvic pressure (RPP) was measured continuously with a nephrostomy catheter in vivo during (bougie, Teflon, balloon and hydraulic) ureteral dilation and UPS. Renal pelvic pressure during rigid ureteroscopy approximated the resting pelvic pressure plus the irrigant height above the kidney or set pressure on a hydraulic pump, plus a "scope effect" which was characterized by a 20 to 25 mm. Hg increase in RPP produced by moving the endoscope in the ureter without flow. The effects on RPP of continuous bladder drainage with a uretheral catheter and renal pelvic decompression with an open-ended ureteral catheter passed into the renal pelvis through the ureteroscope working channel were also examined. The maximum RPP was evaluated in vitro in a separate group of 16 freshly harvested pig kidneys of similar weight examined immediately after sacrifice and was found to be 439 mm. Hg. We also studied the immediate and long-term effects of low (< 120 cm. H2O or 90 mm. Hg) versus high (> 200 cm. H2O or 150 mm. Hg) RPP on renal histology. Acutely, high pressure caused diffuse denudation and flattening of the caliceal urothelium, submucosal edema and congestion not seen in calyces subjected to low irrigant pressure. Four to six weeks later, there was a higher incidence of columnar metaplasia, subepithelial nests and pericalyceal vasculitis in calyces subjected to high pressure as compared with those subjected to low irrigant pressure. Acutely, renal tubules subjected to high irrigant pressure demonstrated marked vacuolization and degeneration, whereas tubules subjected to low pressure appeared normal. At 4 to 6 weeks, focal scarring was seen in 5 of 7 kidneys subjected to high irrigant pressure, whereas no scarring was noted in all 6 kidneys subjected to low irrigant pressure.(ABSTRACT TRUNCATED AT 400 WORDS)

New Cavitron system (CUSA/CEM): its application for kidney surgery.

A new Cavitron Ultrasonic Surgical Aspirator system (CUSA/CEM), which contains electrocautery function at the hand piece, was used for partial nephrectomies in dogs without clamping the renal artery. The advantages of this new device (CUSA/CEM) over the original CUSA are: (1) it enabled more precise resection of the tissue in a dry field, (2) shorter operating time, and eventually (3) helpful for reduction of blood loss. The microscopic examination of the resected kidney revealed minimal reaction and damage to the adjacent kidney tissue as compared with the effect by electrocautery or microwave tissue coagulator.

Application of microwave tissue coagulation in partial nephrectomy.

Microwave tissue coagulation was used during partial nephrectomy in 10 mongrel dogs, without clamping the renal artery. There were no major complications, such as retroperitoneal hematoma, abscess formation, or macroscopic infarction of the kidney tissue related to this new procedure. The advantages of microwave coagulation are reduced blood loss, shorter operative time, and minimal risk of vascular injury.

Maintenance intravesical bacillus calmette-guerin for superficial transitional cell carcinoma of bladder. A retrospective study.

Eighteen patients with recurrent and/or multifocal superficial transitional cell carcinoma of the bladder who were rendered tumor-free by transurethral resection and were then treated with either a single or second six-week course of induction Bacillus Calmette-Guerin (BCG) therapy, followed by maintenance therapy, were retrospectively reviewed. A 73 percent complete response rate was achieved in those patients treated prophylactically, while a 70 percent complete response rate was observed in patients treated for carcinoma in situ (CIS) with an average follow-up of twenty-nine months. Maintenance therapy may be warranted in those patients able to tolerate it without significant side effects.

Establishment of new human prostatic cancer cell line (JCA-1).

The establishment of a new human prostatic cancer cell line is described. This cell line was derived from a poorly to moderately differentiated prostatic adenocarcinoma. It has been maintained in tissue culture for fourteen months and has been passed fifty-two times. This cell line has an ability to form colonies in soft agar suspension cultures, and also is transplantable to nude mice. Tumors grown in nude mice revealed a poorly differentiated adenocarcinoma with positive PSA staining. Acid phosphatase activity was detected in freeze-thawed cells by enzymatic assay. A karyotype analysis demonstrated aneuploidy with a model chromosomal number of 69 and six marker chromosomes.

Expanding the role of the ureteroscope.

Although the rigid ureteroscope was designed exclusively for the diagnosis and treatment of pathological conditions of the ureter, its smaller diameter and extended length allow for its increased use in endoscopic procedures that cannot be performed successfully with a cystoscope. The indications can be divided into 3 categories: 1) difficult ureteral catheterizations, 2) augmented bladders and diverticula, and 3) narrow, strictured urethras and bladder necks. Several cases from each category are presented to illustrate the expanded role of the rigid ureteroscope in daily urological practice.

Benign soft-tissue neoplasm simulating sarcoma of spermatic cord.

A large, painless, slow-growing mass arising in the scrotum of a twenty-three-year-old man, which proved to be benign myxoma, simulated a primary sarcoma of the spermatic cord. Only 1 case of myxoma involving the spermatic cord has been reported previously. It is extremely important that multiple microscopic sections of the specimen be examined carefully so that the proper tissue diagnosis can be made. A false diagnosis of malignancy may lead to treatment that is not indicated and that has a high morbidity.

Pseudodiverticulum of the bladder: an unusual complication of pelvic trauma.

Investigation of frequent urinary tract infections 2 months after an accident in which a man sustained pelvic fractures and a head injury revealed a large pseudodiverticulum between the left bladder wall and pelvis, and extending inferiorly and medially through the separated symphysis pubis into the upper left thigh.

Renal effects of percutaneous stone removal.

Preoperative and postoperative renography with 99mTechnetium-diethylene-triamine pentaacetic acid was performed on 33 patients who were free of renal scarring, infection, and obstruction and who underwent percutaneous renal stone removal. Although there was a transient decrease in renal function postoperatively in some patients, statistically significant reductions in renal function occurred only in 1 patient with an arteriovenous malformation that was embolized and in 1 patient who had a postoperative ureteropelvic junction stricture. The creation of more than one nephrostomy tract did not affect the results. In the absence of serious complications, percutaneous nephrostomy does not have a significant effect on renal function.

Pressure-controlled hydraulic dilation of the ureter: "one-step" ureteroscopy.

A controlled pressure pump was used to dilate the ureteral orifice hydraulically with irrigant flow through the ureteroscope in 50 ureters in 48 patients. The method was successful in all but 1 patient, who had a dense, fibrotic intramural segment that required extensive ureteral meatotomy before the instrument could be inserted. All subsequent procedures (stone removal, relief of obstruction or diagnostic evaluation) were successful, and there were no cases of sepsis or signs of excessive intraureteral or intrapelvic pressure. Hydraulic dilation drastically reduced the time required for ureteroscopy and probably reduced the frequency of complications. Details of the technique and the precautions are provided.

Fibroepithelial polyp associated with congenital ureteral diverticulum: report of 2 cases.

We report 2 cases of a single fibroepithelial polyp in conjunction with ureteral diverticula. Ureterorenoscopy is valuable in the identification of the benign nature of these lesions preoperatively to avert unnecessary nephroureterectomy. The etiology of fibroepithelial polyps remains unknown, although many theories have been proposed. Recent evidence has suggested that these lesions may be a developmental anomaly. Congenital ureteral diverticula also are thought to be of developmental origin. We hypothesize that fibroepithelial polyps and congenital diverticula of the ureter are part of a spectrum of the same developmental anomaly.

Dilatation of ureteral orifice for ureterorenoscopy.

The history of endoscopic ureteral dilatation began before the turn of the century, and many of those older methods are still in use with the aid of updated instruments. The recent development of controlled hydraulic dilatation promises to make ureteroscopy a one-step procedure.

Value of proximal diversion and ureteral stenting in management of penetrating ureteral trauma.

Cases of penetrating ureteral trauma (17 gunshot wounds and 4 stab wounds) seen at two New York City hospitals over a nine-year period were reviewed. Early urologic complications (defined as urine drainage from the wound for greater than 2 weeks or need for a second operation) occurred in 50 percent of patients with a proximal ureteral injury but were less common when a nephrostomy and stent were used in the repair. A similar beneficial effect of stenting was seen in published cases, with a 91 percent complication rate for unstented repairs and a 15 percent rate when stenting and nephrostomy drainage were both used. The effect of stenting on midureteral repairs was less obvious, but the rate of urologic complications was lower in stented cases. None of the patients with distal ureteral injuries suffered a urologic complication. Stenting with and without a nephrostomy tube also produced good results in 2 patients with proximal ureteral injuries diagnosed late. We conclude that repair of penetrating ureteral injuries should include stenting and nephrostomy tube drainage in cases of proximal injuries, as well as generous debridement and water-tight closure. Midureteral injuries accompanied by gastrointestinal, pancreatic, and major vascular injuries should be stented and proximal diversion considered when prosthetic materials are used for vascular repairs.

Bladder neck obstruction secondary to Brunn's cyst.

A large solitary Brunn's cyst caused a ball-valve type of obstruction of the bladder neck in a 29-year-old man without endoscopic or histological evidence of bladder inflammation. Unroofing and drainage restored normal voiding. The histopathological features of Brunn's nests are reviewed.