Intraoperative removal of pancreatic duct calculus with a rigid ureterorenoscope and ultrasonic lithotripsy.

A 51-year-old man with chronic relapsing pancreatitis and recurrent episodes of acute attacks had an impacted ductal stone deep in the head of the pancreas. A staghorn calculus, 1 cm in diameter, was successfully disintegrated and removed intraoperatively with use of a visual endourologic technique and ultrasonic lithotripsy. Because of a dilated pancreatic duct and pseudocyst formation near the tail of the pancreas, distal pancreatic resection and longitudinal pancreaticojejunostomy were performed. Postoperatively, no pancreas irritation has been verified, and the patient has remained without symptoms.

Surgical treatment of ureteric obstruction in idiopathic retroperitoneal fibrosis.

Thirteen patients who received surgical treatment for histologically proven retroperitoneal fibrosis were reviewed retrospectively. All patients had idiopathic disease, bilateral in 11 patients. Elevated ESR occurred in 12 patients and in eight patients the hemoglobin value was decreased preoperatively. Intravenous urography on admission was normal in six kidneys, excretion was delayed in four kidneys and another four upper urinary tracts were dilated. No excretion was seen in four kidneys and eight kidneys were not examined urographically because of uremia. Ureteric obstruction was treated surgically by ureterolysis alone in two ureters, by ureterolysis and lateral displacement in eight ureters, by ureterolysis and intraperitonealization in 12 ureters and by ureterolysis and omental wrapping in two ureters. After primary surgery one nephrectomy was performed because of a nonfunctioning kidney. Postoperatively 19 kidneys are functioning well, in three the function is poor and there is no function in three kidneys. According to our experience the cornerstone of the surgical treatment is complete and extensive ureterolysis and permanent displacement of the ureter from the area of fibrosis.

Salvage cystectomy. Review of 19 cases.

Nineteen salvage cystectomies were performed during a period of 17 years, either on patients who failed definitive radiation therapy of bladder carcinoma or on those with massive bleeding or incapacitating irritative bladder symptoms after irradiation. In 16 cases a single-stage and in 3 a two-stage procedure was used. The postoperative hospital mortality rate was 11%. Early complications developed in 63%, late complications in 47% of the patients. The 5-year survival rate was 5%. In 11 cases, widespread transitional cell carcinoma was the cause of death. With more accurate preoperative tumor staging and subsequent patient selection, better results can be obtained by this procedure. A proposal for the treatment of patients with T3 bladder cancer is made.

Ileal conduit urinary diversion: a review of 148 patients.

A series of 148 ileal conduit urinary diversions is described. In 127 patients (86%) the operation was done because of malignant neoplastic disease, whereas in 21 patients the underlying disease was benign. 77% of the patients had bladder carcinoma. Simultaneous cystectomy was performed in half of the cases. The mortality of the procedure was 9.5%. Postoperative complications occurred early in 36% and late in 49% of patients. Most of the complications could be treated conservatively but 25 patients required re-operation(s) for early and 35 for late complications. The treatment of patients with urinary leakage and the reason for the high incidence of upper urinary tract deterioration (50%) is discussed in detail.

Early experiences with continent bladder substitution.

Since January 1987 a total of 14 patients have undergone continent bladder replacement procedure. The bladder substitute was constructed of ileum (ileal neobladder) in three patients, of an ileocaecal segment (Mainz pouch) in five patients while in six patients a segment of ascending colon (Mayo pouch) was used. Nine male patients underwent a complete bladder substitution after cystoprostatectomy. In five patients a bladder augmentation was performed. Four of these patients were female. They were subjected to subtotal cystectomy which left only one cm of the bladder neck, while the ureters were reimplanted into the pouch. Seven of the nine patients with total bladder substitution are continent during the day and seven at night. All patients in the bladder augmentation group are continent day and night, but one of them has to empty his bladder by intermittent catheterization. Because of stenosis at the ureterocolonic anastomosis, reoperation was performed on two patients more than one year after the primary operation. Except for these two patients, who required surgical revision, the initial results are encouraging and patient acceptance has been excellent.

Upper urinary tract transitional cell carcinoma after total cystectomy for bladder cancer.

During a 17-year-period from 1967 to 1983, 110 total cystectomies for transitional cell bladder cancer have been performed in our clinic. During the postcystectomy period, upper urinary tract urothelial cancer developed in seven patients (6.4%). In every case a multifocal, low stage transitional cell cancer had been found in the bladder. The time between the cystectomy and discovery of the upper tract tumour varied from less than three months to almost 13 years. In five cases the first sign of occurrence of the tumour was malignant conduit urine cytology, in two macroscopic haematuria with subsequent malignant cells in urine. In one patient bilateral renal pelvic tumours were found. Five patients could be surgically treated. The need for regular conduit urine cytological studies at short intervals in patients with multifocal low stage and high grade transitional cell carcinoma in the cystectomy specimen is emphasised.

Single-stage versus two-stage diversion-cystectomy in treatment of bladder cancer: a comparative study.

We have compared the results of 26 single-stage and 16 two-stage diversion-cystectomies performed for bladder carcinoma at the Helsinki University Central Hospital, Finland in the period December 1974-April 1983. All the patients underwent pre-cystectomy radiation. An ileal conduit urinary diversion was used in every patient. No benefit relative to surgical mortality or early and late complications seemed to be derived from using the staged procedure. The single-stage operation, in addition to sparing the patients the inconveniences of the second operation, saves social expenditure by reducing the total length of hospital stay and the total operating time. The two-stage procedure should, however, be considered for fragile patients and those with serious operative risk factors.

Hemi-Kock reconstruction following cystectomy: experience and results from a small urological unit.

Between December 1988 and January 1992, 11 men underwent lower urinary tract reconstruction by means of the hemi-Kock ileal reservoir following radical cystoprostatectomy (ten patients) and subtotal cystectomy (one patient). Six of the 11 patients developed an early postoperative complication, with a fatal outcome in two of them. One patient succumbed to subarachnoidal bleeding and one to septic shock. During the follow-up, another two men died of advanced bladder carcinoma. The late complication rate was low. Most patients regained their continence within six months. A good continence was achieved in all the nine remaining patients during the day and in six of them at night. This experience suggests that the hemi-Kock reservoir is a useful method for the urinary tract reconstruction following cystectomy.

Neurofibromatosis of the bladder.

Multiple neurofibromatosis, von Recklinghausen's disease, is a rare disease of the neurilemmal cells. It is an inherited disorder transmitted as a mendelian dominant and characterized by multiple subcutaneous tumours and café-au-lait spots. The first time its symptoms were described was by Smith in 1849.

99mTc-DTPA and 99mTc-DMSA renal gamma imaging in the surveillance of patients with conduit urinary diversion.

We studied renal anatomy and function using 99mTc-2-3 dimercaptosuccinic acid (DMSA) and 99mTc-diethylenetriaminepentaacetic acid (DTPA) in 27 patients with conduit urinary diversion. In this condition, free ureteral reflux is often associated with bacteriuria, and these factors are thought to precipitate progressive renal deterioration. Gamma-camera images provided valuable information concerning the structure of the renal parenchyma, the function of individual kidneys and possible ureteral obstruction, thus helping us to decide whether or not to instigate further treatment. The information gained using renal gamma imaging with 99mTc-DTPA and 99mTc-DMSA was complementary and partly overlapping. We preferred the use of 99mTc-DTPA because of its ability to visualise the ureters and the region of ureteroconduit anastomosis. Using diuretic medication, we were able to differentiate true ureteral obstruction from atony in 9 patients using 99mTc-DTPA.

Radical prostatectomy for localized prostatic carcinoma in a renal transplant patient.

Long-term immunosuppression increases the incidence of many forms of malignancies. We present a case report of a renal transplant patient who developed a prostatic cancer 4 years after transplantation. Radical prostatectomy is a suitable option in the treatment of localized prostatic cancer in a renal transplant patient.

Early experience with percutaneous nephrolithotomy.

Fifty-four percutaneous nephrolithotomy (PNL) procedures were performed in 41 patients between May 1986 and December 1987. Six patients required more than one procedure and there was one failure which was treated by open ureterolithotomy. Most of the stones were initially found in the pelvicalyceal system, one in the lower third and nine in the middle or upper third of the ureter. There were five significant complications: one "steinstrasse" (accumulation of stone fragments in the distal ureter after the procedure), one massive perirenal haematoma, one intramural perforation by a ureteric catheter and two extravasations of irrigation fluid one of which necessitated intensive care. Most of the renal and upper ureteric stones have now been successfully removed percutaneously with good patient tolerance.

The occurrence of vasculitis in perianeurysmal fibrosis.

The histological findings of retroperitoneal fibrosis in 17 operated patients are described. Of these patients 6 showed a simultaneous aneurysm of the abdominal aorta verified either by computerized tomography, ultrasound, arteriography or during an operation. Of the patients 14 were operated on primarily because of ureteral obstruction, 2 because of aortic aneurysm and 1 because of rupture of the abdominal aorta. Advanced fibrosis with varying amounts of inflammation was detected in all 17 patients. The same histological pattern was present in patients with aneurysm of the abdominal aorta and in those without aneurysm. Accompanying vasculitis with destruction of the vascular wall was noted in 8 patients, including 6 with an abdominal aortic aneurysm. In 3 patients who underwent aneurysm resection as well as in 1 patient with aortic rupture the process extended into the aortic wall. The only patient with vasculitis and no aortic process suffers from severe rheumatoid arthritis. On the basis of the different histological findings we suggest that retroperitoneal fibrosis with vasculitis and aneurysm may represent a distinct pathological entity.

Pyelo-intestino-cutaneous conduit in the treatment of renal carcinoma of solitary kidneys.

A pyelo-intestino-cutaneous conduit, either by colonic or ileal segment, was used successfully in 4 patients with urothelial carcinoma affecting a solitary kidney. Primary healing was good but involved the risk of stricture formation. During the follow-up period (10-48 months), repeated endoscopic check-ups were easily performed through the conduit, enabling coagulation of recurrent tumour growth. Two patients are still alive and well; 2 are dead.