Insertion of double J stent as a therapeutic test in management of adults presenting with loin pain and equivocal ureteropelvic junction obstruction.

PURPOSE: To evaluate temporary double J ureteric stenting (TDJS) as a test to diagnose ureteropelvic junction obstruction (UPJO) in equivocal cases. MATERIALS AND METHODS: One hundred and nine consecutive adult patients with loin pain and ipsilateral equivocal UPJO (EqUPJO) on radioisotope diuretic renogram (RDR) were enrolled in the present study. All patients underwent TDJS for 3 weeks. According to the response (relief of pain) to TDJS, which was assessed by visual analogue pain score (VAPS), patient preference and further management, patients were classified into five groups: Group Ia non-responders who elected conservative treatment for their condition, Group Ib non-responders who elected intervention, Group IIa responders who elected conservative treatment and Group IIb responders who elected intervention. Last group patients were randomized to either early (Group IIb(1)) or delayed intervention 3 months later (Group IIb(2)). Intervention was in the form of pyeloplasty (24 patients) and endopyelotomy (38 patients). All patients were followed up by measuring VAPS and RDR. RESULTS: After at least 6 months from management decision, 97 patients were available for evaluation. The VAPS dropped by 21.25% (P < 0.001), 32% (P = 0.004), 2% (P = 0.6), 54% (P < 0.001) and 65% (P < 0.001) in groups Ia, Ib, IIa, IIb1, and IIb2, respectively. On the other hand the T (1/2) of RDR dropped significantly only in groups Ib, IIb1, and IIb2 by a mean of 6.5 min (P = 0.005), 8.02 min (P < 0.001), and 7.3 min (P < 0.001), respectively. CONCLUSION: TDJS in cases of EqUPJO with loin pain is helpful in defining cases suitable for intervention versus conservative treatment.

Reimbursements and frequency of tests in privately insured testicular cancer patients in the United States: Implications to national guidelines.

OBJECTIVES: The objective of this study was to assess the frequency of utilization and reimbursement of the common diagnostic tests and treatment modalities used in testicular cancer care. METHODS: LifeLink™ (IMS Health, Danbury, CT, USA) Claims Database was used. We identified 877 subjects with a primary diagnosis of testicular cancer (ICD 186.9) between 2007 and 2012. Median reimbursement and frequency of the diagnostic/treatment modalities used were recorded. RESULTS: The most common claim was a vein puncture with median reimbursement of $9.11. Tumor markers, alpha-fetoprotein and beta human chorionic gonadotropin, were ranked 6th and 7th with median reimbursement of $52.13 and $48.71, respectively. Chest X-ray and computerized tomography (CT) scan of the chest were ranked 9th and 13th with median reimbursement of $68.51 and $769, respectively. A contrast CT scan of abdomen and pelvis was the 11th most frequent claim with median reimbursement of $855.89. The three invasive treatment modalities, chemotherapy, radiation therapy, and retroperitoneal lymphadenectomy were ranked 8th, 15th, and 164th with median reimbursement of $2858.38, $3988.25, and $2009.67, respectively. CONCLUSIONS: Testicular cancer is not an inexpensive disease. Surgery is the less utilized than radiation and chemotherapy despite lower cost. This may have implications to national guidelines and training since these treatments often carry the same grade of recommendation.

Computed tomography virtual cystoscopy for follow-up of patients with superficial bladder tumours in comparison to conventional cystoscopy: An exploratory study.

OBJECTIVE: To evaluate and analyse the efficacy of computed tomography (CT) virtual cystoscopy in comparison to conventional cystoscopy for the follow-up of patients with non-muscle-invasive bladder cancer. PATIENTS AND METHODS: The study was done over 3 years, from April 2010 to June 2013, and included 30 patients who all had non-muscle-invasive transitional cell carcinoma (Ta, T1). The patients all underwent complete transurethral resection of the tumour and presented for first follow-up check cystoscopy. The examination was performed using a 16-slice multi-detector (MD) CT scanner. The results were compared for sensitivity and specificity in relation to the site, size, and shape of the tumour. RESULTS: In all, 20 lesions were detected by CT virtual cystoscopy in 18 patients, whilst the remaining 12 were lesion free. Conventional cystoscopy, detected 23 lesions in 19 patients. The sensitivity of the virtual images was 87%; its specificity in identifying lesions was 100%, with a positive predictive value of 100% and negative predictive value of 78.5%. CONCLUSION: CT virtual cystoscopy is a promising technique for detecting bladder tumours and some other bladder lesions. However, the detection rate for recurrent NMIBC does not appear to be adequate to replace conventional cystoscopy.

Laparoscopic partial adrenalectomy for recurrent pheochromocytoma in a boy with Von Hippel-Lindau disease.

We describe a case of a boy with Von Hippel-Lindau disease who presented with recurrent right adrenal pheochromocytoma 4.5 years after laparoscopic bilateral partial adrenalectomy. The boy had a second laparoscopic adrenal-sparing removal of the tumor. By this technique, not only the recurrent tumor was successfully removed but also the unaffected adrenal cortex could be preserved for the second time. To our knowledge, this is the first published case of its type.

Laparoscopic approaches in urology.

The use of laparoscopy was one of the most important steps in the progress of medicine, and has developed through the 20th century. Gynaecologists took the initial lead in introducing this technology, followed by general surgeons. Since the first laparoscopic nephrectomy in 1990, most ablative and reconstructive urological surgery has been attempted laparoscopically. Laparoscopic urological surgical approaches include conventional transperitoneal and extraperitoneal; in this review the different approaches, with the relevant anatomical considerations, are discussed.

Laparoscopic wedge resection for renal cell carcinoma.

PURPOSE OF REVIEW: Because an increasing number of small renal cell tumors suitable for nephron sparing surgery are being diagnosed incidentally, the standardization of laparoscopic wedge resection has now become a major issue. RECENT FINDINGS: In this article we reviewed mainly recent literature published since November 2001 focusing our interest to clearly present the different techniques for wedge resection. These techniques are shown under two main subtitles: resection with or without ischemia. Also new alternative techniques for resection without ischemia are reviewed. SUMMARY: Wedge resection can be done laparoscopically by different techniques. Each technique has its inherent advantages and disadvantages. Further studies and modifications on each technique are expected in the future.

Ligation of the renal vein during laparoscopic nephrectomy: an effective and reliable method to replace vascular staplers.

PURPOSE: Application of the endovascular gastrointestinal anastomosis stapler has become a standard procedure to control renal vein during laparoscopic nephrectomy. However, device malfunction resulting in significant complications has been reported. We present a safe and cost-effective technique for renal vein ligation during laparoscopic nephrectomy. MATERIALS AND METHODS: From October 2002 to April 2003 we applied our new technique of renal vein ligation in 20 cases. After renal pedicle dissection the renal artery was secured with Hem-o-lok (Weck Closure Systems, Research Triangle Park, North Carolina) clips. The renal vein was encircled with a suture, which was knotted extracorporeally and pushed down by a knot pusher to shrivel a vein of any size. Subsequently 10 mm Hem-o-lok clips were applied to the vein to occlude it completely. RESULTS: All procedures were successfully completed. The operative costs of vein ligation were decreased. There was no significant increase in mean operative time. CONCLUSIONS: Our approach is a safe, reliable, rapid and inexpensive method to ligate the renal vein during laparoscopic nephrectomy. Therefore, this technique has replaced endovascular gastrointestinal anastomosis stapler use at our center.

Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion.

PURPOSE: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. We describe our initial experience with laparoscopic partial nephrectomy in cold ischemia achieved by renal artery perfusion. MATERIALS AND METHODS: From November 2001 to March 2003 laparoscopic partial nephrectomy in cold ischemia was performed in 15 patients with renal cell carcinoma. Cold ischemia was achieved by continuous perfusion of Ringers lactate at 4C through the renal artery, which was clamped. Tumor excision was performed in a bloodless field with biopsy taken from the tumor bed. The collecting system was repaired if needed. Renal reconstruction was performed by suturing over hemostatic bolsters. RESULTS: All procedures were successfully completed laparoscopically by our new technique. Mean operative time was 185 minutes (range 135 to 220). Mean ischemia time was 40 minutes (range 27 to 101). Estimated mean intraoperative blood loss was 160 ml (range 30 to 650). Entry to the collecting system in 6 patients was repaired intraoperatively. Additional vascular repair was done in 2 patients. There were no significant postoperative complications. Postoperative followup in 8 patients showed that the renal parenchyma was not damaged by the ischemic period. CONCLUSIONS: Our initial experience of incorporating cold ischemia via arterial perfusion into laparoscopic partial nephrectomy shows the feasibility and safety of the technique. We believe that this approach has the potential to make laparoscopic partial nephrectomy for renal cell carcinoma safe and reliable.