Failure of cryosurgical treatment of experimental intradermal tumors to eradicate microscopic lymph node metastases in guinea pigs.

Inbred Sewall Wright strain 2 male guinea pigs with established intradermal tumors and microscopic lymph node metastases were treated either by local excision, cryosurgery, or intralesional injection of BCG. Cryosurgery and local excision were effective in eliminating growth of the primary tumor but failed to prevent growth of lymph node metastases. In contrast, intralesional injection of BCG caused regression of primary tumors and prevented growth of lymph node metastases.

In vitro demonstration of cryosurgical augmentation of tumor immunity.

C57B1 mice bearing methylcholanthrene-induced fibrosarcomas (MCA-10) and receiving a single cryosurgical treatment to those tumors showed significantly greater humoral and lymphocyte-mediated cytotoxicity to MCA-10 target cells than did untreated tumor-bearing animals or mice which had undergone tumor amputation. Sera and lymphocytes from normal animals receiving crycosurgery demonstrated no immunity to the MCA-10 target cells. Specific immunity to the MCA-10 line following tumor cryosurgery was demonstrated since lymphocytes and sera from cryosurgically treated tumor-bearing mice were not cytotoxic to a different methylcholanthrene-induced sarcoma (MCAP) in C57 mice or a malignant melanoma (S91) being transferred in Balb/C mice. It can be concluded that cryosurgical treatment of the MCA-10 sarcoma does not produce heightened immunity to H-2 transplantation antigens, nor does it nonspecifically stimulate the immune system. Instead, the result of tumor cryosurgery appears to be a boosting of the immune response to the tumor-specific antigens of the sarcoma.

Cefoxitin concentration in wound fluid.

The concentration of cefoxitin was determined in fluid obtained from human surgical wounds during the first postoperative day. Intravenous administration of cefoxitin sodium at a dosage of 1 or 2 g every six hours rapidly produced wound-fluid concentrations greater than the minimal inhibitory concentration for most susceptible organisms. After three hours, wound-fluid concentrations surpassed the serum concentrations of cefoxitin. The higher dosage resulted in higher wound-fluid levels.

Ureteral endoscopy with passively deflectable, irrigating flexible ureteroscopes.

Flexible, passively deflectable fiberoptic ureteroscopes were used in 18 selected patients. The flexible endoscope must be stabilized with a cystoscope, flexible introducer sheath, or guide wire for placement through the urethra and bladder into the ureter. Irrigation through the instrument is beneficial in clearing the visual field and distending the lumen. These instruments can visualize the lumen of the ureter, and the medial and superior portion of the renal pelvis and intrarenal collecting systems. Their diagnostic value is limited to selected clinical situations.

Flexible ureteropyeloscopy with modular, "disposable" endoscope.

A flexible modular ureteropyeloscope has been utilized in 36 patients. The flexible tips of this instrument can be replaced and have been available in sizes 6.0F, 8.5F, and 11.0F. The instrument was passed successfully into the ureter in 37 of 38 patients. The most frequent indications were surveillance for fragments after lithotripsy and for diagnosis of radiographic abnormalities in the upper tracts. The high success rate in these patients supports wider application of these techniques and indicates the potential for therapeutic procedures through flexible ureteroscopes.

Removal of upper urinary tract calculi with flexible ureteropyeloscopy.

Flexible ureteropyeloscopy is an endoscopic technique which can give access to the entire intrarenal collecting system. Retrieval instruments or lithotriptors, electrohydraulic or pulsed dye laser, can be employed. In 70 patients, 72 procedures were used to treat 77 calculi. The calculus could be reached in each patient. Previous treatment included shock-wave lithotripsy or attempts at repositioning and open surgical exploration. There were multiple calculi in 18 patients, and 3 patients weighed more than 300 pounds. Calculi were successfully removed or moved to the distal ureter in 62 of 77 cases (80.5%). The success rate was better with mid or proximal ureteral stones and renal pelvic stones than distal calculi. In 21 patients lithotripsy was employed. Flexible ureteropyeloscopy can be utilized for the successful treatment of upper urinary tract calculi.

Reverse lithotomy: modified prone position for simultaneous nephroscopic and ureteroscopic procedures in women.

Occasionally there is need for nephroscopic and ureteroscopic access during the same surgical procedure. Patient positioning is problematic and usually the patient must be turned from supine to prone position or vice versa. Simultaneous access is possible by placing the patient in a prone position with the thighs and knees cradled laterally in a "boot" type stirrup. Thus access is afforded to a percutaneous nephrostomy tract and to the urethra for nephroscopic and ureteroscopic procedures, and at the same time adequate operator comfort is maintained. This approach has been used four times in 3 patients and has been a valuable factor in the endoscopic removal of massive renal and ureteral calculi.

Ureteroscopic diagnosis and treatment of urinary calculi during pregnancy.

Flexible ureteroscopy has been utilized in two pregnant patients. In one, the procedure was for diagnosis of symptoms simulating ureteral colic, and in the other for the removal of a distal ureteral calculus. The diagnostic procedure was completed with local anesthesia alone, and both procedures were performed without radiation to the mother or fetus. The potentially great benefit must be weighed against the risks of minimal endoscopic intervention in each patient. We advocate the early but judicious use of flexible ureteroscopy in pregnant patients with urinary calculi.

Percutaneous antegrade flexible ureteroscopy.

A flexible endoscope has been used for antegrade percutaneous ureteroscopy after percutaneous lithotripsy. The instrument, the ACMI Flexiscope, is 2.5 mm in diameter and has fiberoptic bundles for illumination and visualization but no channel for irrigation. Techniques for introduction and irrigation are considered. The use of this instrument demonstrates the need for deflectability in a ureteroscope.

Ureteroscopic retrieval of proximally located ureteral stents.

Indwelling self-retaining ureteral stents are important for the maintenance of urinary drainage in the ureter threatened by obstruction by neoplasm, edema, or calculus. Proximal migration of the stent into the ureter prevents simple cystoscopic retrieval and necessitates removal by other techniques. In this series both rigid and flexible ureteroscopes were used to remove stents from locations ranging from the renal pelvis to the distal ureter in 16 patients. Three-pronged wire graspers was the retrieval instrument most frequently used. Stents were removed in all patients without complication. Ureteroscopy provides the most convenient and least invasive technique for removing stents proximally located in the upper urinary system.

Upper-tract transitional cell carcinoma.

Advances in ureteroscopic techniques have made it possible to treat many upper-tract tumors conservatively. Such treatment has demonstrated acceptable survival and renal preservation in high-risk patients, particularly those with a solitary kidney, bilateral tumors, poor renal function, or prohibitive operative risk. It is also preferred in patients with grade I TCC, particularly when located in the distal ureter. For patients with regionally extensive upper-tract urothelial neoplasms, use of endourologic techniques should be considered to control hemorrhage, relieve obstruction, and preserve as much functioning renal tissue as possible. Success with small, solitary, low-grade tumors allows the application of this technique to patients with a normal contralateral kidney on an elective basis. Adjuvant BCG or mitomycin C therapy appears to be safe, but confirmation of any benefits awaits the results of larger trials. Benign neoplasms can occur in the upper urinary tract and should be distinguished from TCC, thus avoiding more radical treatment for a benign lesion. Endoscopic surveillance should be maintained because recurrences can develop without radiographic evidence.

The 6.9 F semirigid ureteroscope in clinical use.

The 6.9 F semirigid ureteroscope has a hybrid design that shares the rigid ureteroscope body with the fiberoptic imaging bundle of the flexible ureteroscopes. This allows more space for the inner channel, so that there are two working channels of 3.4 F and 2.3 F. This ureteroscope was used in 65 cases on 57 patients without dilatation of the intramural ureter. It was mainly used for the management of ureteral calculi (29 cases) and for visual diagnostic purposes (28 cases). The double-channel design proved extremely helpful in lithotripsy, while the ability to access the ureter without dilatation gave a consistently clearer picture for diagnostic purposes. Forty-two cases were done under local anesthesia with sedation. In 1 patient a minor perforation developed secondary to use of electrohydraulic lithotripsy (EHL). Postoperatively, 7 patients complained of colic, and in 5 patients a low grade fever developed, while 2 patients had both.

Management of upper urinary tract calculi with ureteroscopic techniques.

OBJECTIVES: To evaluate our experience in treating 155 patients with upper urinary tract calculi ureteroscopically. The treatment of urinary calculi has remained the most frequent application of ureteroscopy. Miniaturization of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. METHODS: Ureteroscopic stone treatment was attempted in 155 patients with upper urinary tract calculi between November 1995 and March 1997. Fifty-nine (38.1%) patients had renal calculi, 82 (52.9%) ureteral, and 14 (9%) had both renal and ureteral calculi. Both semirigid and flexible ureteroscopes were used for treatment (rigid alone in 21 [13.5%], flexible in 64 [41.3%], and both rigid and flexible in 70 [45.2%] patients). Lithotripsy was required in 122 (79%) of the patients. The holmium:yttrium-aluminum-garnet laser was used in 113 (92.6%) of these patients. RESULTS: All patients with ureteral calculi (29 proximal, 19 mid, and 34 distal) were successfully cleared after one endoscopic procedure except for 1 patient with a proximal ureteral calculus who had a 4-mm residual fragment in the kidney. Of the 59 patients with renal calculi, 47 (79.7%) were totally clear of stones 1 month after treatment. The remaining 12 (20.3%) patients had evidence of residual calculi 3 to 4 mm or less in diameter. In patients with combined renal and ureteral calculi, 1 1 of 14 (78.6%) were rendered stone free. The remaining 3 (21.4%) patients had evidence of residual calculi 4 mm in diameter. Overall, 95% of the patients were treated in an outpatient setting. Morbidity was low, with no evidence of stricture. CONCLUSIONS: Ureteroscopy and laser lithotripsy in experienced hands are a safe and reliable method for the treatment of ureteral and even intrarenal calculi.

Inverted papilloma of renal pelvis: flexible ureteroscopic diagnosis and treatment.

A case is reported of inverted papilloma of the renal pelvis in a patient with previous transitional cell carcinoma of the bladder. The renal pelvic lesion was diagnosed and treated with a flexible ureteropyeloscope. Although nephroureterectomy was avoided, the patient must be carefully followed endoscopically and radiographically for recurrence of lesions throughout the urinary tract. This case represents the first report of the endoscopic diagnosis and treatment of an inverted papilloma of the renal pelvis. It demonstrates the vast potential for endoscopic diagnosis, treatment, and surveillance throughout the urinary tract.

Impotence in the elderly. Evaluation of erectile failure in men older than seventy years of age. Jefferson Sexual Function Center.

A total of 102 patients over seventy years of age were evaluated in a multidisciplinary center for erectile dysfunction. The primary diagnosis was organic in 80 percent, but there were multiple associated factors. Erectile failure had persisted more than twenty-four months in 84 percent and the last successful intercourse was over one year prior to evaluation in 68 percent. There appears to be distinct differences in the pattern and etiology of erectile failure in elderly patients.

Ureteroscopic biopsy: technique and specimen preparation.

Because tissue samples obtained ureteroscopically are small, the techniques for biopsy and for handling and processing the samples are crucial. Our aim is to describe the biopsy technique in great detail so other centers can reproduce it. Patients were evaluated by retrograde ureteropyelography and ureteroscopy for diagnosis. The entire collecting system was examined using a combination of small-diameter rigid and flexible ureteroscopes. Samples were retrieved by aspiration, saline lavage, or, when possible, biopsy of visible tumor by a basket or cup forceps. Multiple samples were obtained from all patients. Fresh specimens were hand delivered to the cytopathology laboratory, where they were evaluated with the cytospin technique. A cell block was prepared whenever there was any visible tissue in the sample. Since we have practiced this technique of handling specimens, our ability to diagnose and grade upper tract neoplasms ureteroscopically has improved markedly. Use of this technique can improve the diagnostic accuracy of ureteroscopic biopsy.

Upper urinary tract inverted papillomas.

Inverted papilloma is a rare, benign tumor. Only 33 cases to date have been reported to have occurred in the upper urinary tract. These lesions have a male predominance, are difficult to diagnose, and are associated with urothelial malignancy. Because transitional cell carcinoma can present even 8 years after surgery and in other sites within the urinary system, careful follow-up is essential. This article adds 2 new cases and 1 follow-up of a previously reported case from 1990.

Atraumatic perforation of bladder. Necessary differential in evaluation of acute condition of abdomen.

Perforation of the urinary bladder without history of antecedent trauma is a rare clinical occurrence. However, in patients with acute conditions of the abdomen, especially those with previous voiding symptoms, the diagnosis should be considered. Three cases are reported. Patients presented with an atraumatic bladder perforation and peritonitis secondary to chronic inflammation, bladder outlet obstruction, and transitional cell carcinoma. After review of the literature, a classification of atraumatic bladder perforation has been revised to include presently available reports of this entity.

Age-related changes in hormones in impotent men. Jefferson Sexual Function Center.

A total of 818 impotent men were evaluated in a multidisciplinary Sexual Function Center for reproductive hormone levels. Data are presented demonstrating an overall rate of endocrinopathy at 19.3 percent. Various age-dependent trends in the incidence of abnormal levels are noted. Hypogonadism as well as hyperpituitarism appear to increase in incidence with increasing age. Hyperprolactinemia, however, seems to be relatively constant in occurrence. Because of the likelihood of detecting endocrine abnormalities, a recommendation is made for routine hormonal screening of all patients complaining of impotence.

Ureteroscopy under local anesthesia.

Ureteroscopy has been performed with local anesthesia with and without sedation in 30 patients. Flexible endoscopes were used in 18, rigid endoscopes alone in 7, and rigid and flexible instruments in 5 patients. The flexible instruments ranged in size from 4F to 10F, while rigid instruments were 10F to 12F. Although most procedures were diagnostic, calculi were removed from the distal ureter in 4 patients and from the midureter in 1 patient. Ultrasonic lithotripsy was utilized in 1 patient. The success and tolerance of flexible or distal rigid ureteroscopy with local anesthesia permits its recommendation in carefully selected patients.