Long-term follow-up of the treatment of renal angiomyolipomas after selective arterial embolization with alcohol.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. OBJECTIVE: To present our institution's experience of selective embolization of renal angiomyolipomas with alcohol and the long-term follow up data. PATIENTS AND METHODS: This retrospective study included 34 patients treated between October 1997 and October 2007 (29 women and five men, mean age 44 years). Of these patients, nine had tuberous sclerosis, 14 were bilateral and 16 were multifocal. Indications for treatment were previous haemorrhage (14), size >4 cm (19) and increasing size over a short period (one). The largest treated lesion was 24.4 cm, and the mean (range) size was 11.9 (2.9-24.4) cm. All patients were treated by selective embolization using a mixture of alcohol and lipiodol. Three patients also had coiling of aneurysms and two patients had additional embolization with polyvinyl alcohol particles. The follow-up was both radiological and clinical, with recurrence defined as growth by >2 cm or symptoms requiring further treatment. RESULTS: The technical success rate was 100%, with only one significant complication of non-target renal embolization, with self-limiting effects. Minor complications included 11 patients with post-embolization syndrome, all of which settled with conservative measures. The mean (range) combined radiological and clinical follow-up was 44.2 (12-116) months, with all patients having a follow-up of >1 year. Radiological success was achieved in 97%, with only one lesion growing by >2 cm. The combined clinical and radiological success rate was 85%, with two patients undergoing surgery, two having repeat embolization and one currently offered surgery due to a recent increase in size. CONCLUSION: Our study provides long-term evidence that selective arterial embolization with alcohol is a safe and effective method for improving clinical symptoms (85%) and preventing tumour progression (97%) in patients with renal angiomyolipoma.

[Clinical research about balloon dilation before incision for patients with ureteric stricture].

OBJECTIVE: To study the use about balloon dilatation before incision for the patients with ureteric stricture. METHODS: Sixteen patients with ureteric stricture were included in our study. The cases were reviewed retrospectively with regards to the etiological factor, the site of stricture, symptom and diagnosis. Six patients with ureteric stricture were dilated with balloon before incision using Ho YAG laser. Ten patients with ureteric stricture were dilated with rigid ureteroscope before incision using Ho YAG laser. The double "J" stent was kept for 4-6 weeks after operation. All the patients were followed up by ultrasound, BUN and creatinine. Complete success is defined as symptomatic improvement, resolution of hydronephrosis and absence of ureteric stricture 3 months after removal of the double "J" stent. If the hydronephrosis and ureteric stricture did not deteriorate, and symptom improved after stent removal, it was considered as improvement. Failure is defined as deterioration of hydronephrosis and symptoms upon removal of double "J" stent. RESULTS: The length of stenosis was from 0.8 to 1.4 cm. Three patients failed to improve after initial dilatation with rigid ureteroscope, but were later successfully dilated using balloon. All the patients who were treated using balloon dilatation were successful. The operative time of balloon dilatation was shorter than that of dilatation by rigid ureteroscope (P < 0.05). However, the cost of balloon dilatation was higher (P < 0.05). The period of follow-up was 3-28 months. None of the patients had any complications. There were 2 cases of recurrent stricture in patients who underwent ureteroscopic dilatation. CONCLUSIONS: Despite a higher cost, balloon dilatation followed by laser incision for ureteric stricture is safe and effective. This technique may be used for selected patients.

Laparoscopic nephrectomy: new standard of care?

OBJECTIVE: The pace of implementation of a laparoscopic nephrectomy programme is affected by factors including surgical expertise, case load, learning curves and outcome audits. We report our experience in introducing a laparoscopic nephrectomy programme over a 3-year period. METHODS: From January 2001 to December 2003, 187 nephrectomies were performed (105 by conventional surgery, 82 by laparoscopy). Hand-assisted laparoscopy was used predominantly. The indications for surgery, factors affecting the approach and outcome parameters were studied. A cost comparison was made between patients with similar-sized renal tumours undergoing laparoscopic versus open surgery. RESULTS: Most operations were performed for malignancy in both the open (70%) and laparoscopic (67%) surgery groups. The laparoscopic approach was most commonly used in upper tract transitional cell cancers (TCCs; 70% of 30 patients) and benign pathologies (49% of 35 patients), followed by radical nephrectomies (34% of 99 patients) and donor nephrectomies (44% of 23 patients). There was a rapid rise in laparoscopic surgeries, from 30% in 2001 to 58% in 2002. The median hospital stay was 5.8 days in the laparoscopic group and 8.1 days in the open surgery group. The procedure cost for laparoscopic surgery was 4,943 dollars compared with 4,479 dollars for open surgery. However, due to a shorter hospital stay, the total hospital cost was slightly lower in the laparoscopic group (7,500 dollars versus 7,907 dollars). CONCLUSION: The laparoscopic approach for various renal pathologies was quickly established with a rapid increase in the number of laparoscopic procedures.

Renal cell carcinoma in patients with end-stage renal disease is associated with more favourable histological features and prognosis.

OBJECTIVE: End-stage renal disease (ESRD) patients with acquired cystic kidney disease are at higher risk of developing renal cell carcinoma (RCC) than the general population. The aim of this study was to investigate the clinical and histopathological differences between ESRD patients and the general population with RCC. MATERIALS AND METHODS: Data were retrospectively collected from all nephrectomies performed for localized RCC from 2000 to 2010. Age at nephrectomy, gender, race, symptoms, baseline Eastern Cooperative Oncology Group (ECOG) performance status, Charlson Comorbidity Index score and histological data were extracted. Independent-samples t test and Mann-Whitney test were used for quantitative data, while chi-squared (two-sided) and Fisher's exact tests were used for qualitative data. RESULTS: This study included 627 patients: 73 with and 554 without ESRD. The majority of patients were Chinese. The male to female ratio of 2:1 was identical in both groups. Baseline ECOG performance status and Charlson Comorbidity score were higher in the ESRD group. RCC in ESRD patients was more frequently asymptomatic (56.2% vs 44.9%, p = 0.071), diagnosed earlier (53.6 ± 11.8 years vs 57.9 ± 12.2 years, p = 0.004) and of lower stage (p < 0.001). The ESRD cohort had a higher proportion of the papillary histological subtype (21.9% vs 9.7%, p < 0.001). Importantly, there was a trend towards more favourable outcomes in ESRD patients in terms of cancer-specific (p = 0.203) and relapse-free survival (p = 0.096). CONCLUSION: This study suggests that RCC in ESRD patients is associated with more favourable clinical and histological features and oncological outcome compared with that in patients with normal renal function.

Advances in video and imaging in ureteroscopy.

Advances in image processing and display technologies, such as digital imaging, HDTV, and virtual reality, will ultimately allow integration of endoscopic imaging with diagnosis and therapy during ureteroscopic procedures. Further improvements in simulation technology and telemedicine should improve surgical training and greatly benefit patient care.

Hand-assisted laparoscopic nephrectomy for inflammatory renal conditions.

PURPOSE: Laparoscopic surgery for large renal lesion or kidneys with chronic inflammation has proved to be technically challenging. Hand-assisted laparoscopic surgery might be useful in these complex cases, as it provides surgeons the benefits of tactile feedback, digital retraction, and facilitated dissection of the renal hilar vessels. PATIENTS AND METHODS: Twenty-two patients undergoing hand-assisted laparoscopic (HAL) nephrectomy for benign conditions were compared with patients who underwent HAL radical nephrectomy during the same period. The demographic data, laterality, operative time, estimated blood loss, conversion rate, length of stay, histopathology findings, morbidity, and mortality were reviewed. RESULTS: The main indications for surgery were chronic inflammation and xanthogranulomatous pyelonephritis. Twenty patients had unilateral nephrectomy (10 each on the right and left), and two patients had bilateral nephrectomy. The mean operative times for unilateral and bilateral nephrectomy were 163 minutes (range 55-261 minutes) and 265 minutes (range, 238-291 minutes), respectively. Nine patients (45%) with inflammation had complications (15% major and 30% minor). The mean length of hospitalization for patients undergoing HAL nephrectomy was 7.2 days (range 2-35 days). The patients with inflammatory pathology had longer mean operative times, higher estimated blood loss, longer hospital stay, and higher morbidity than patients undergoing radical nephrectomy. CONCLUSION: Compared with standard laparoscopy, the hand-assisted approach has been reported to reduce operative times and increase safety. The advantages of minimally invasive surgery, such as reduced analgesia, shorter hospital stay, and faster return to normal activity, appear to be similar to those in patients undergoing a pure laparoscopic nephrectomy. Compared with radical nephrectomy for renal tumor, HAL simple nephrectomy can often be more challenging and associated with greater morbidity. For both the community urologist as well as an experienced laparoscopist, this approach is useful in handling these challenging cases.

Outcome of patients undergoing laparoscopic adrenalectomy for primary hyperaldosteronism.

OBJECTIVES: To study the long-term outcome of patients with primary hyperaldosteronism who underwent laparoscopic adrenalectomy and to determine the preoperative predictive factors of persistent hypertension. METHODS: Between 1996 and 2002, 47 patients with primary hyperaldosteronism underwent transperitoneal laparoscopic adrenalectomy at our institution. Their clinical and biochemical parameters were reviewed retrospectively, and the outcome of 46 patients with complete follow-up notes were determined. RESULTS: The study comprised 16 male and 30 female patients with a mean age of 45.6 years (range, 18 to 63 years). Almost all patients had hypertension and hypokalemia at presentation, requiring medication. The average operating time was 127 minutes (range, 70 to 240 min), and the mean postoperative stay was 2.6 days (range, 1 to 5 days). No mortalities occurred, and perioperative morbidity was minimal. Forty-two (91%) patients had adrenal cortical adenoma (including 1 with both adenoma and hyperplasia), and 4 (9%) had adrenal hyperplasia on histology. The average follow-up time was 21 months (range, 1 to 60 months), and at the end of follow-up, all patients had normal serum potassium levels without potassium supplements. Twenty-three (50%) patients were cured of hypertension, and 13 (28%) patients had better control of their hypertension as evidenced by the decrease in the number of antihypertensive medications used. On multivariate analysis, the age of the patient at surgery was shown to be an independent predictive factor of persistent hypertension after successful surgery. CONCLUSION: Laparoscopic adrenalectomy is a safe and effective way to treat primary hyperaldosteronism, especially in controlling hypokalemia and in the management of hypertension. The age of a patient at surgery is an independent preoperative risk factor of persistent hypertension.

Intramuscular gentamicin improves the efficacy of ciprofloxacin as an antibiotic prophylaxis for transrectal prostate biopsy.

INTRODUCTION: Infection-related complications after transrectal ultrasound guided prostatic biopsy (TRPB) could be life threatening. Our centre observed sepsis after TRPB despite prophylactic oral ciprofloxacin. We reviewed all cases of post-TRPB sepsis with their bacteriology and evaluated if the addition of intramuscular (I/M) gentamicin to standard prophylaxis before TRPB could reduce its incidence. MATERIALS AND METHODS: In a single urological centre, we performed an interventional study that compared a prospective group with retrospective control. The latter is known as the "cipro-only" group included consecutive patients who underwent TRPB between 1 September 2003 and 31 August 2004. The addition of I/M gentamicin 80 mg half an hour before TRPB started on 1 September 2004. All subsequent patients who underwent TRPB until 31 August 2005 were included in the "cipro+genta" group. Patients who did not receive the studied antibiotics were excluded. RESULTS: There were 374 patients in the "cipro+genta" group and 367 patients in the "cipro-only" group with comparable profiles. There were 12 cases of post-TRPB sepsis in the "cipro-only" group and 5 cases in the "cipro+genta" group. Ciprofloxacin-resistant Escherichia coli (E. coli) was the only pathogen isolated in both groups. In the "cipro-only" group, 9 patients had positive blood cultures and 8 were sensitive to gentamicin. In the "cipro+genta" group, the only positive E. coli was gentamicin-resistant. One patient in the "cipro+genta" group was admitted to the intensive care unit with septicaemia. CONCLUSION: The addition of I/M gentamicin to oral ciprofloxacin is a safe and effective prophylactic antibiotic regime in reducing the incidence of post-TRPB sepsis.

Laparoscopic partial nephrectomy for renal tumours: early experience in Singapore general hospital.

INTRODUCTION: To review the perioperative and short-term outcome of all laparoscopic partial nephrectomies (LPN) performed in a single institution. MATERIALS AND METHODS: Thirteen consecutive patients who underwent LPN since the beginning of the programme in March 2002 to January 2008 were enrolled. Demographic, perioperative and follow-up data were retrospectively collected. Transperitoneal approach was used in all cases, and vascular control was achieved with the use of a laparoscopic Satinsky clamp or vascular tape. The tumour was excised using cold scissors. Transected intrarenal vessels were suture ligated and the parenchymal defect was closed primarily with absorbable suture over a bolster. RESULTS: Thirteen patients underwent a total of 14 LPN. The median age of patients was 60 years (range, 41 to 77). The mean tumour size was 24 +/- 11.4 (2SD) mm. The mean operative time was 228 +/- 129 (2SD) minutes and median warm ischaemia time was 35 minutes (range, 24 to 68). Postoperatively, serum haemoglobin level decreased by a mean of 1.4 +/- 2.5 (2SD) gm/dL and serum creatinine increased by a mean of 22.5 +/- 25.8 (2SD) micromol/L. Twelve out of 13 (92%) patients achieved their baseline serum creatinine level within 1 month postoperatively. There was 1 open conversion (7%), and 2 patients (14%) required blood transfusion perioperatively. Two patients (14%) had transient fever postoperatively due to basal atelectasis. No other complications were encountered. Median patient hospital stay was 4 days (range, 2 to 10). Eleven out of 14 (79%) of the tumours were renal cell carcinoma (RCC). At a median follow-up of 12 months (range, 6 to 53), all except 1 patient with RCC were disease-free. CONCLUSIONS: Our experience has shown that laparoscopic partial nephrectomy is a safe, feasible technique in our centre for patients with small exophytic renal tumours. Patients can be discharged early with preservation of renal function and good early cancer control.

Primary hyperaldosteronism secondary to unilateral adrenal hyperplasia: an unusual cause of surgically correctable hypertension. A review of 30 cases.

INTRODUCTION: Unilateral adrenal hyperplasia (UAH) is a rare, surgically correctable cause of primary hyperaldosteronism (PH). We report 2 cases and review the literature for cases of PH secondary to UAH successfully treated via surgery. METHODS: Two cases of UAH treated at our institution were retrospectively reviewed. In addition, we reviewed 28 cases of UAH previously reported in the English literature. RESULTS: Median patient age was 49 (range: 10-62) years, with a male to female ratio of 1.7:1. All patients were hypertensive, with a median preoperative systolic and diastolic blood pressure of 170 (range: 135-250) mmHg and 110 (range: 75-140) mmHg, respectively. Most patients were hypokalemic, with a median serum potassium level of 2.8 (range: 1.4-3.9) mmol/l. Ten out of 13 patients (77%) who underwent postural studies had a decrease or no change in the plasma aldosterone level, suggesting a unilateral source of hyperaldosteronism, and 9/17 patients (53%) who underwent a computed tomography (CT) scan were correctly localized. Twelve patients underwent adrenal scintigraphy with or without dexamethasone suppression, of whom 6 (50%) were correctly localized. In 1 patient, adrenal scintigraphy demonstrated localization to the opposite gland. Adrenal venous sampling (AVS) was performed in 22 patients and successfully localized the lesion in all the patients. At a median follow-up of 12 (range: 3-96) months postsurgery, 47% of patients (14/30) were completely cured of their hypertension and 50% (15/30) had improved control. All 30 patients were cured of hypokalemia. CONCLUSION: Although the existence of UAH remains controversial, it is increasingly accepted as a unique pathologic entity and has an excellent outcome after unilateral adrenalectomy.

Use of Stone Cone minimizes stone migration during percutaneous nephrolithotomy.

We describe a simple and effective method using the Stone Cone to prevent migration of stone fragments into the ureter during percutaneous nephrolithotomy. This maneuver may reduce the need for antegrade ureteroscopy to remove residual fragments, thereby saving time and obviating the need for placement of an occlusion balloon.

Team-based approach reduces learning curve in robot-assisted laparoscopic radical prostatectomy.

AIM: We assessed the team approach in reducing the learning curve during our 2-year experience transiting from open to robot-assisted laparoscopic radical prostatectomy (rLRP). METHODS: A team of three urologists progressed through assistant phase to console phase to obtain competency in robotic prostatectomy. One hundred patients underwent rLRP by this team using the da Vinci robotic surgical system from 1 February 2003 to 15 May 2005. RESULTS: The immediate perioperative outcome was divided into three corresponding time frames and the results demonstrated gradual improvement in outcome parameters. The mean set-up time and dissection time were 24+/-14 min and 182+/-52 min, respectively. The mean perioperative blood loss was 272+/-240 mL, and 7% of patients (n=7) required blood transfusion. The mean duration of bladder catheterization was 8.4+/-4.1 days, and mean hospital stay was 2.9+/-1.6 days. There was no perioperative mortality or conversion to open radical prostatectomy. Major complications (4%) included urethrovesical leak requiring re-operation, postoperative cerebrovascular accident, and transient ureteric obstruction. Minor complications (7%) included minor urethrovesical leak, bladder neck stenosis, and urinary tract infection. Mean follow up was 6.6+/-5.0 months. Pathological assessment showed pT2 disease in 55% and pT3 in 45% of specimens. CONCLUSIONS: A team-based approach to robot-assisted LRP helped to reduce the learning curve of the procedure for individual surgeons and continued to show significantly lower perioperative blood loss, transfusion requirements and postoperative pain compared to open radical retropubic prostatectomy.

How significant are clinically insignificant residual fragments following lithotripsy?

PURPOSE OF REVIEW: Extracorporeal shock-wave lithotripsy had revolutionized the treatment of kidney stones. Residual fragments smaller than 4 or 5 mm which are asymptomatic and likely to pass spontaneously are termed as clinically insignificant residual fragments. This article reviews the current literature with regards to the management of clinically insignificant residual fragments. RECENT FINDINGS: However, the term is controversial because no consensus has been reached regarding its exact definition or interval after extracorporeal shock-wave lithotripsy to evaluate its presence. While most small residual stone fragments might be managed expectantly, a significant number of patients might become symptomatic or require intervention. These so-called clinically insignificant residual fragments have the potential to cause obstruction and are important risk factors for stone recurrence and re-growth. SUMMARY: Residual fragments require close monitoring for stone growth, potential complications and subsequent intervention. Secondary procedures may be applied selectively to those patients who have significant symptoms of obstruction associated with the residual stone. Medical therapy might play an important role in the management of residual fragments.

Intravesical prostatic protrusion predicts the outcome of a trial without catheter following acute urine retention.

PURPOSE: We prospectively evaluated a simple, noninvasive method to predict the outcome of a voiding trial following acute urine retention (ARU) based on intravesical prostatic protrusion (IPP) using transabdominal ultrasound. MATERIALS AND METHODS: Males older than 50 years presenting with an initial episode of ARU were included in the study. Patients with prostatic cancer, urinary tract infection, bilateral hydronephrosis or neurological disease were excluded. The duration of catheterization, residual urine volume, serum prostate specific antigen and prostate volume were recorded. The patient bladder was filled with 200 ml normal saline via a catheter in situ. IPP was measured in the mid sagittal section using transabdominal ultrasound. The degree of protrusion was classified as grades 1--5 mm or less, 2--greater than 5 to 10 mm and 3--greater than 10 mm. Uroflowmetry and post-void residual urine were recorded after catheter removal. The voiding trial was judged to be unsuccessful if the patient failed to reestablish satisfactory micturition, with post-void residual urine greater than 100 ml and maximum urine flow less than 10 ml per second. RESULTS: A total of 100 patients were included in the study. The failure rate of the voiding trial based on grades 1 to 3 IPP were 36% (13 of 36 cases), 58% (11 of 19) and 67% (30 of 45). This rate was significant (chi-square test for trend 0.007). CONCLUSIONS: IPP is a useful predictor for evaluating the success of a voiding trial following ARU. Patients with a grade 1 prostate may benefit from a trial without a catheter. However, patients with a grade 3 prostate are less likely to do so and would require a more definitive surgical procedure.

Metabolic risk factors and the impact of medical therapy on the management of nephrolithiasis in obese patients.

PURPOSE: Previous studies have demonstrated that obesity can increase the risk of stone formation as well as recurrence rates of stone disease. Yet appropriate medical management can significantly decrease the risk of recurrent stone disease. Therefore, we analyzed our obese patient population, assessing the risk factors for stone formation and the impact of selective medical therapy on recurrent stone formation. MATERIALS AND METHODS: A retrospective chart review was performed to identify obese patients with stone disease from our Stone Center. Metabolic risk factors for stones were identified as well as patient response to medical therapy. A similar analysis was performed on a group of age and sex matched nonobese stone formers. RESULTS: Of 1,021 patients 140 (14%) were identified as obese (body mass index greater than 30). Of these patients complete metabolic evaluations were available in 83 with an average followup of 2.3 years. The most common presenting metabolic abnormalities among these obese patients included gouty diathesis (54%), hypocitraturia (54%) and hyperuricosuria (43%), which presented at levels that were significantly higher than those of the nonobese stone formers (p <0.05). Stone analysis was available in 32 obese patients with 63% having uric acid calculi. After initiating treatment with selective medical therapy obese and nonobese patients demonstrated normalization of metabolic abnormalities, resulting in an average decrease in new stone formation from 1.75 to 0.15 new stones formed per patient per year in both groups. CONCLUSIONS: Obesity, as a result of dietary indiscretion, probable purine gluttony and possible type II diabetes, appears to have a significant role in recurrent stone formation. Appropriate metabolic evaluation, institution of medical therapy and dietary recommendations to decrease animal protein intake can significantly improve the risk of recurrent stone formation in these often difficult to treat patients.

Hand assisted laparoscopic training for postgraduate urologists: the role of mentoring.

PURPOSE: Hand assisted laparoscopy (HAL) has recently been accepted as a safe alternative for nephrectomy. HAL courses have been offered at several institutions to train novice laparoscopic surgeons in this minimally invasive surgical procedure. Mentoring by a course instructor or an experienced laparoscopist provides assistance to surgeons with their initial operation. However, to our knowledge the impact of mentoring on the clinical practice of HAL is not known. Therefore, we evaluated the clinical practice patterns of urologists following a postgraduate HAL course, comparing course graduates who underwent subsequent mentoring with those who were not mentored. MATERIALS AND METHODS: A total of 71 urologists attended a postgraduate training course in HAL at our institution between March 2002 and October 2002. Graduates were given the opportunity for one of the instructors to travel to their home institution and mentor them during their initial case(s). Followup surveys were mailed to the graduates in March 2003 to evaluate their practice patterns. Responses from returned surveys were entered into a dedicated database and data analysis was performed. RESULTS: Of the 71 surveys mailed 56 were returned (79%). The majority of respondents (91%) described themselves as community based general urologists. Respondents were categorized into 1 of 2 groups, namely group 1-those who had mentoring by a course instructor (23.2%) or another experienced laparoscopist (30.4%) and group 2-those who were not mentored (46.4%). The majority of group 1 respondents (93%) reported that they were still performing laparoscopic procedures at 6 months of followup. However, only 44% of the surgeons in group 2 were performing laparoscopy at 6 months. The majority of surgeons in group 1 (72%) reported that their laparoscopic experience had been sufficient to maintain their expertise compared to only 42% in group 2. CONCLUSIONS: Mentoring provides a useful adjunct to postgraduate urological training and the integration of laparoscopic techniques into the community based practice of urology.