This too shall pass: Standardized Gastrografin protocol for partial small bowel obstruction.

BACKGROUND: One of the most common reasons for admission to a surgical service is for a partial small bowel obstruction. There is considerable variation in management. Several studies suggest that the use of diatrizoate (Gastrografin), a hyperosmolar contrast agent, can be helpful as a diagnostic agent as well as possibly therapeutic, reducing the need for operative intervention. There is a paucity of data on the use of Gastrografin in the community setting. We hypothesized that this standardized algorithm of Gastrografin administration would decrease the need for surgery and shorten a patient's length of stay, even outside the confines of a regulated clinical trial. METHODS: We performed a retrospective review of all patients admitted to two major hospitals in our network with the diagnosis of partial small bowel obstruction. Patients were excluded if they were admitted within thirty days of bowel surgery or if they were <18 years of age. The primary variable for analysis was the subsets of patients who were placed on our protocol versus no protocol at the other hospital. The primary outcome was hospital length of stay. Secondary outcomes included rate of surgery during the same admission and readmission within 30 days of discharge. All analyses were performed using Fisher's Exact test of Mann-Whitney U Test, as appropriate. RESULTS: A total of 1302 patients with partial small bowel obstruction were identified (103 on-protocol and 1199 off-protocol at our sister hospital). On-protocol patients had a shorter duration of hospitalization (mean, 4.9 days vs. 6.0 days, p < 0.001), lower rates of surgery (2% vs. 16%, p < 0.001), and similar rates of readmission for the same diagnosis (8% and 5%, p = 0.26), compared to off-protocol patients at our sister institution. CONCLUSION: A protocol utilizing Gastrografin for the management of partial small bowel obstruction decreases the need for surgery and shortens a patient's length of stay in a diverse community setting.

Asthma as a predictor of obstructive sleep apnea in urban African-American children.

BACKGROUND: Asthma is a known co-morbid factor in childhood obstructive sleep apnea (OSA); however, little is known about the effects that asthma might have on the severity of OSA. We hypothesize that children with concomitant asthma and OSA have more severe OSA. METHODS: We conducted a prospective study of 50 children with OSA diagnosed by polysomnography referred for tonsillectomy and adenoidectomy (T&A). The presence of concomitant asthma was determined by ISAAC questionnaire and spirometry. Atopy to common allergens was determined by skin prick testing. Due to the relatively small sample size, we limited hypothesis testing to cross tabulations with Fisher's Exact Test and t testing. We also employed a parsimonious ordinary least squares (OLS) regression assuming a large effect size. RESULTS: Subjects (n = 50) included 32 males and 41 African-Americans. Age at T&A was 9.3 +/- 3.4 years (mean +/- S.D). Thirty-two subjects reported a history of asthma during their lifetimes, but the ISAAC questionnaire detected only 30 subjects. Twenty-two subjects reported current asthma. Atopy was found in 27 subjects. Apnea-hypopnea index (AHI) was lower in the current asthma group than in the lifetime asthma group but did not reach statistical significance. However, AHI was significantly higher in subjects with poorly controlled asthma. Further, in a parsimonious OLS model controlling for sleep efficiency and age, a history of lifetime asthma increased the AHI by 8.8 (p < 0.05). DISCUSSION: In urban African-American children referred for T&A to treat OSA, a history of poorly controlled asthma is associated with more severe OSA.

Surface modification to improve in vitro attachment and proliferation of human urinary tract cells.

OBJECTIVE: To evaluate the attachment and proliferation of cultured human urinary tract cells to culture plates surface-modified by photochemical immobilization of extracellular matrix (ECM) proteins. MATERIALS AND METHODS: Human uroepithelial (UEC) and smooth muscle (SMC) cells were harvested from ureter and expanded in culture; 24-well culture plates surface-modified by photochemical covalent immobilization of ECM proteins were then seeded with UEC or SMC. To characterize cellular attachment, cells were incubated on surface-modified plates for 30 and 90 min. For proliferation assays the cells were incubated for 3-12 days. Standard tissue culture plates with no surface modification and sham-modified plates served as controls. Differential attachment and proliferation on the various surfaces were assessed using analysis of variance with Fisher's posthoc test for multiple comparisons. RESULTS: Attachment at 30 and 90 min of both UEC and SMC on plates surface-modified with ECM proteins was significantly greater than in control plates. Surface-modification with collagen resulted in significantly greater cellular attachment than with either laminin or fibronectin. UEC proliferation was also significantly greater than in control plates by surface-modification with collagen and fibronectin, but not with laminin. SMC proliferation was significantly better after surface modification than on sham- modified plates, but was no better than standard plates. CONCLUSIONS: Covalent photochemical immobilization of ECM proteins to potential growth surfaces enhances the attachment of cultured UEC and SMC and the proliferation of UEC. This technique might be useful in modifying surface properties of synthetic polymer-based materials in a controlled and defined manner, giving them the capacity to promote and sustain the growth of urinary tract cells. This may lead to development of alternative methods of tissue engineering in the urinary tract.

Flexible ureteroscopy in conjunction with in situ lithotripsy for lower pole calculi.

OBJECTIVES: To demonstrate the efficacy and safety of ureteroscopy as a compromise in treating small and intermediate-size lower pole calculi. The optimal management of lower pole calculi remains controversial. Shock wave lithotripsy is associated with minimal morbidity but with suboptimal stone clearance rates. Conversely, percutaneous nephrostolithotomy has greater morbidity but stone-free rates greater than 90% regardless of size. METHODS: Seventy-two patients underwent ureteroscopy for lower pole calculi 2 cm or less (mean 8.7 mm) during a 3-year period. To minimize confounding, 11 patients with additional calculi at other ipsilateral renal sites and 1 patient with large (2.4 cm each) bilateral calculi were excluded. Two patients with bilateral lower pole calculi and four who required a second procedure were included in the analysis. Thus, the final cohort consisted of 60 patients who underwent 66 procedures. RESULTS: Of patients with follow-up longer than 1 month, 79% were stone free after a single procedure, and this improved to 88% after a second procedure in 4 patients. All 7 patients with follow-up less than 1 month had a reduction in stone burden after successful fragmentation. Overall, 8 patients required an auxiliary procedure. No intraoperative complications, and 7 (11%) postoperative complications occurred. CONCLUSIONS: Ureteroscopy for lower pole calculi is associated with minimal morbidity and stone-free rates comparable to shock wave lithotripsy for smaller stones. The greatest utility of ureteroscopy is in the management of intermediate-size calculi, for which it has substantially higher stone-free rates and lower repeated treatment rates than does shock wave lithotripsy.

Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.

PURPOSE: We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi. MATERIALS AND METHODS: A total of 64 patients with solitary, radiopaque distal ureteral calculi 15 mm. or less in largest diameter were randomized to treatment with shock wave lithotripsy (32) using an HM3 lithotriptor (Dornier MedTech, Kennesaw, Georgia) or ureteroscopy (32). Patient and stone characteristics, treatment parameters, clinical outcomes, patient satisfaction and cost were assessed for each group. RESULTS: The 2 groups were comparable in regard to patient age, sex, body mass index, stone size, degree of hydronephrosis and time to treatment. Procedural and operating room times were statistically significantly shorter for the shock wave lithotripsy compared to the ureteroscopy group (34 and 72 versus 65 and 97 minutes, respectively). In addition, 94% of patients who underwent shock wave lithotripsy versus 75% who underwent ureteroscopy were discharged home the day of procedure. At a mean followup of 21 and 24 days for shock wave lithotripsy and ureteroscopy, respectively, 91% of patients in each group had undergone imaging with a plain abdominal radiograph, and all studies showed resolution of the target stone. Minor complications occurred in 9% and 25% of the shock wave lithotripsy and ureteroscopy groups, respectively (p value was not significant). No ureteral perforation or stricture occurred in the ureteroscopy group. Postoperative flank pain and dysuria were more severe in the ureteroscopy than shock wave lithotripsy group, although the differences were not statistically significant. Patient satisfaction was high, including 94% for shock wave lithotripsy and 87% for ureteroscopy (p value not significant). Cost favored ureteroscopy by $1,255 if outpatient treatment for both modalities was assumed. CONCLUSIONS: Ureteroscopy and shock wave lithotripsy were associated with high success and low complication rates. However, shock wave lithotripsy required significantly less operating time, was more often performed on an outpatient basis, and showed a trend towards less flank pain and dysuria, fewer complications and quicker convalescence. Patient satisfaction was uniformly high in both groups. Although ureteroscopy and shock wave lithotripsy are highly effective for treatment of distal ureteral stones, we believe that HM3 shock wave lithotripsy, albeit slightly more costly, is preferable to manipulation with ureteroscopy since it is equally efficacious, more efficient and less morbid.

Comparison of outcomes of ureteroscopy for ureteral calculi located above and below the pelvic brim.

OBJECTIVES: To compare the safety and efficacy of ureteroscopy performed for proximal and distal ureteral calculi in a contemporary cohort. Ureteroscopy has been used most often for distal ureteral calculi. However, advances in endoscopic equipment have facilitated access to the proximal urinary tract and have broadened the indications for ureteroscopy. METHODS: One hundred ninety-one patients underwent rigid and/or flexible ureteroscopy for ureteral calculi at the University of Michigan between January 1, 1997 and September 30, 1999. Only 7 patients with either bilateral calculi or steinstrasse were excluded. The final cohort consisted of 184 patients who underwent ureteroscopy for distal stones (n = 103) or middle/upper ureteral stones (n = 81). RESULTS: Bivariate analyses of pretreatment and perioperative characteristics were used to assess the sample population. The initial success rate for the distal and proximal ureteral calculi was 96% and 78%, respectively (P = 0.0008). After a "second-look" procedure in 4 and 7 patients with distal and proximal calculi, respectively, the success rate improved to 99% and 88%, respectively (P = 0.004). No differences were noted between groups regarding the intraoperative (P = 0.51) or postoperative (P = 0.85) complication rates. Multivariate logistic regression analysis confirmed that larger stone size (odds ratio 1.2, P = 0.0006) and proximal ureteral location (odds ratio 4.8, P = 0.01) are independent predictors of treatment failure. CONCLUSIONS: Ureteroscopic management of proximal and distal ureteral calculi is highly successful, and the difference in success rates has narrowed substantially. Currently, no greater risk is conferred to the patient for endoscopy of more proximal ureteral calculi.

IL (interleukin)-1alpha promotes nuclear factor-kappaB and AP-1-induced IL-8 expression, cell survival, and proliferation in head and neck squamous cell carcinomas.

Interleukin 1alpha (IL-1alpha) is an important regulatory cytokine, the release of which after an injury can induce activation of transcription factors nuclear factor (NF)kappaB and activator protein (AP-1), which promote expression of genes involved in cell survival, proliferation, and angiogenesis. IL-1alpha is expressed autonomously by head and neck squamous cell carcinomas (HNSCCs) and a variety of other cancers, raising the possibility that IL-1alpha may serve as an autocrine factor that stimulates the activation of prosurvival transcription factors and target genes in cancer. In this study, we examined the role of IL-1alpha in the activation of NFkappaB and AP-1, the expression of proangiogenic cytokine IL-8, and in the survival and proliferation of HNSCC cell lines. HNSCCs were found to secrete and respond to functional IL-1alpha, in that culture supernatant from a high IL-1alpha-secreting line, UM-SCC-11B, could induce secretion of cytokine IL-8 by a low IL-1alpha-secreting line, UM-SCC-9; and the induction of IL-8 secretion could be blocked by the anti-IL-1alpha-neutralizing antibody or the IL-1 receptor antagonist (IL-1RA). Furthermore, IL-1alpha could induce the expression of IL-8 through an autocrine mechanism, in that transfection of UM-SCC-9 cells with a plasmid encoding IL-1alpha resulted in the increased coexpression of IL-1alpha and IL-8; whereas transfection with a plasmid encoding IL-1RA lacking the secretory leader sequence led to the decreased coexpression of IL-1alpha and IL-8. IL-1alpha was found to induce coexpression of IL-8 through the activation of NFkappaB and AP-1, in that mutation of the NFkappaB site within the IL-8 promoter abolished autocrine- and recombinant IL-1alpha-induced IL-8 reporter gene activity, whereas mutation in AP-1 partially decreased IL-8 reporter gene activity in UM-SCC-9 cells. Intracellular expression of IL-1RA decreased NFkappaB reporter gene activity, indicating that endogenously expressed IL-1alpha contributes to constitutive NFkappaB activation in this HNSCC line. Expression of IL-1alpha affected survival of UM-SCC-9, inasmuch as transfection of cells with plasmid encoding IL-1alpha or IL-1RA led to the increased or decreased survival of cells cotransfected with a beta-galactosidase reporter gene, respectively. IL-1alpha was also found to promote the increased growth of UM-SCC-9 cells in vitro. We demonstrate that exogenous and endogenous IL-1alpha contributes to the transcriptional activation of NFkappaB and AP-1, to the expression of IL-8, and to cell survival and the growth of HNSCC in vitro.

Indications, technique, and results of laparoscopic pelvic lymphadenectomy.

Despite considerable clinical research, there is still controversy about the optimal management of the pelvic lymph nodes in men with prostate cancer. This article reviews the creation and application of selection criteria for laparoscopic pelvic lymphadenectomy and describes the various techniques.

Laparascopic partial nephrectomy.

The role of laparoscopy in urologic surgery has greatly increased over the past decade as has the popularity of elective nephron-sparing surgery. The emergence of these trends in conjunction with improvements in equipment and expertise has led to the increasing application of laparoscopic partial nephrectomy. Initially, this modality was applied in patients with benign diseases, such as chronic pyelonephritis and calculus disease with associated atrophy. Concerns of tumor spillage and local-regional control precluded the application of the laparoscopic modality to small, indeterminate renal masses. However, increasing experience with the technique and advances in intraoperative imaging have prompted its use in removing small renal masses. Herein, we describe the indications for laparoscopic partial nephrectomy, the two approaches (transperitoneal and extraperitoneal) to gain access to the kidney, current options to assist in controlling intraoperative hemorrhage, a comprehensive assessment of the results for benign and malignant resections, and an examination of the similarities and contrasts between open and laparoscopic techniques.

Comparison of 2-octyl cyanoacrylate adhesive, fibrin glue, and suturing for wound closure in the porcine urinary tract.

OBJECTIVES: To evaluate 2-octyl cyanoacrylate glue (OCG) for wound closure in the urinary tract and compare the ability of OCG, fibrin glue (FG), and suture to withstand physiologic and supraphysiologic stress, because the use of tissue adhesives such as OCG or FG might simplify laparoscopic surgery. METHODS: Female domestic pigs (n = 22) underwent a 7.5-cm cystotomy. Of these, 8 had closure with OCG and 8 with FG (6 open and 2 laparoscopic in each group). The controls were closed with suture (n = 4) or not at all (n = 2). Postoperative catheter drainage was not used. At 2 days or 4 weeks postoperatively, the bladders were filled with saline to 200 mm Hg pressure and the cystotomy scars inspected for leakage. The excised scars were also examined histologically. RESULTS: The 2 OCG and 2 FG pigs tested on postoperative day 2 leaked at less than 200 mm Hg. None of the 6 OCG pigs tested at 4 weeks leaked at less than 200 mm Hg, including the 2 closed laparoscopically. Of the 6 FG pigs intended for study at 4 weeks, 3 (including the 2 closed laparoscopically) died from a massive urine leak, 1 tested at 4 weeks leaked, and 2 did not leak. Thus, 4 of 6 FG pigs leaked by 4 weeks compared with none in the OCG group (P = 0.06). The histologic examination was similar in the two groups. CONCLUSIONS: Preliminary results suggest that OCG provides enough strength to hold together a large bladder wound. In the same model, FG did not consistently provide adequate closure.

Functional effects of unilateral laser papillectomy in the pig.

OBJECTIVES: To evaluate the use of endoscopic laser papillectomy in a multi-papillary animal model to unilaterally impair concentrating ability and increase the urinary flow rate. METHODS: Domestic pigs underwent unilateral retrograde flexible nephroscopy. With a holmium:yttrium-aluminum-garnet laser, varying numbers of papillae were ablated. Four weeks after the procedure, renal function studies were performed during hydropenia and after hydration, the animals were killed, and the kidneys were examined histologically. RESULTS: The urine flow rate per 100 mL creatinine clearance was significantly increased in the papillectomized kidney compared with the control kidney during hydropenia (1.50 versus 0.94, P <0.01). The papillectomized kidneys were unable to concentrate the urine as well as the control kidneys during both hydropenia (urine osmolarity 430 versus 534 mOsm/L, P <0.01) and after hydration (329 versus 362 mOsm/L, P = 0.02). The free water reabsorption per 100 mL creatinine clearance was impaired in the papillectomized kidneys compared with the control kidneys (0.48 versus 1.00, P = 0.02) after hydration. A significant correlation existed between the percentage of papillae ablated and the difference in osmolarity between the operated and control kidneys (r(2) = 0.50, P = 0.015). Histologic examination demonstrated transitional re-epithelialization with moderate collecting duct dilation and medullary fibrosis underlying the ablated papillae early in the series; however, the histologic features normalized and the creatinine clearance was less impaired with a more proficient technique later in the series. CONCLUSIONS: Endoscopic laser papillectomy results in increased urine flow and impaired urinary concentrating ability. This surgical technique should be investigated further for its role in the prevention of nephrolithiasis.

Routine placement of ureteral stents is unnecessary after ureteroscopy for urinary calculi.

OBJECTIVES: To report a matched comparison of patients with and without stenting after ureteroscopy for calculi, including middle or proximal ureteral and renal calculi. The elimination of routine stenting after ureteroscopy would prevent stent pain, minimize the need for re-instrumentation, and reduce costs-as long as efficacy and safety are not diminished. METHODS: Of 318 patients who underwent ureteroscopy, 81 (25%) did not have a ureteral stent placed. Of those, 51 were suitable for analysis and included patients with distal ureteral (n = 22), middle or proximal ureteral (n = 11), and renal calculi (n = 18). This cohort was matched to a stented group by stone size and location. RESULTS: The preoperative characteristics of the groups were similar. A stone-free rate of 86% and 94% was achieved in the stented and nonstented groups, respectively (P = 0.32). Complications in the nonstented group were less frequent (flank pain in 3 and postoperative nausea in 1) than in the stented group (hospital visits for flank pain in 12, persistent nausea and vomiting in 1, sepsis in 1, perinephric hematoma in 1, and urinary retention in 1) (total of 4 versus 16, P = 0.025). CONCLUSIONS: Ureteroscopy for distal ureteral stones without ureteral stent placement has been previously described. Our experience expands to include the elimination of stent placement after ureteroscopy for middle or proximal ureteral (22%) and renal (35%) calculi. Our data suggest that after ureteroscopies with short operative times and minimal ureteral trauma, ureteral stents may not be necessary, even if proximal ureteral or renal ureteroscopy has been performed.

Evaluation and management of traumatic posterior urethral disruption with flexible cystourethroscopy.

BACKGROUND: We sought to consolidate evaluation and management of traumatic urethral disruption using cystourethroscopic evaluation without retrograde urethrogram or suprapubic cystostomy placement. METHODS: We review our experience with initial flexible cystourethroscopic evaluation of suspected urethral injury from blunt trauma with placement of a Council urethral catheter to provide primary endoscopic realignment of the urethra. RESULTS: Access into the bladder was achieved in 8 of 10 patients. After a mean follow-up of 18 months (range, 9-27 months) in the six living patients, only three have required treatment for urethral stricture--direct vision internal urethrotomy in two, and open perineal urethroplasty in one. Urinary continence has been achieved in five of six patients. CONCLUSION: Primary flexible cystourethroscopy with placement of a urethral catheter streamlines evaluation of traumatic posterior urethral injury. In the presence of partial disruption it provided stricture-free outcomes in three of three surviving patients.

Use of bowel in laparoscopic urology.

Minimally invasive urology is a rapidly expanding field. What once was thought technically impossible is now becoming a reality, especially with the advent of intracorporeal stapling and automated suturing devices. Laparoscopic assistance and pure laparoscopy improve convalescence and cosmesis in comparison with open surgical procedures. Minimally invasive continent urinary stomas, ACE procedures, bladder augmentation, urinary diversion, and urinary undiversion have all been described in clinical practice. Continent urinary diversions and ileal bladder augmentations are being developed. Eventually, even the most challenging urologic procedures will be performed in a minimally invasive manner.

Asymptomatic microscopic hematuria in adults: summary of the AUA best practice policy recommendations.

The American Urological Association (AUA) convened the Best Practice Policy Panel on Asymptomatic Microscopic Hematuria to formulate policy statements and recommendations for the evaluation of asymptomatic microhematuria in adults. The recommended definition of microscopic hematuria is three or more red blood cells per high-power microscopic field in urinary sediment from two of three properly collected urinalysis specimens. This definition accounts for some degree of hematuria in normal patients, as well as the intermittent nature of hematuria in patients with urologic malignancies. Asymptomatic microscopic hematuria has causes ranging from minor findings that do not require treatment to highly significant, life-threatening lesions. Therefore, the AUA recommends that an appropriate renal or urologic evaluation be performed in all patients with asymptomatic microscopic hematuria who are at risk for urologic disease or primary renal disease. At this time, there is no consensus on when to test for microscopic hematuria in the primary care setting, and screening is not addressed in this report. However, the AUA report suggests that the patient's history and physical examination should help the physician decide whether testing is appropriate.

Prospective comparison between hand-assisted laparoscopic and open surgical nephroureterectomy for urothelial cell carcinoma.

OBJECTIVES: To prospectively compare open surgical and the new hand-assisted approach to laparoscopic nephroureterectomy for urothelial cell carcinoma. Previous retrospective studies have suggested that standard laparoscopic nephroureterectomy provides a briefer convalescence than open surgical nephroureterectomy. METHODS: Between March 1997 and September 1999, 16 hand-assisted laparoscopic and 11 open surgical nephroureterectomies were performed, without randomization. Validated questionnaires were prospectively administered preoperatively and 2 and 6 weeks postoperatively. RESULTS: The operative time was longer with the laparoscopic approach (320 versus 199 minutes, P <0.001), but the hospital stay was shorter (3.9 versus 5.2 days, P = 0.03). Patient recovery favored the laparoscopic group with regard to time to drive (17.1 versus 37.7 days), time to normal, nonstrenuous activity (18.2 versus 38.1 days), and the mental component score of the SF-12 survey at 6 weeks (57.1 versus 43.0) (P <0.05 for all). Minor complications occurred in 19% of the laparoscopic and 45% of the open surgical procedures; major complications occurred in 19% of laparoscopic and 27% of open surgical procedures (P >0.1 for both). Cancer control was similar between both groups. The mean operating room cost was 56% more for the laparoscopic group (P <0.001), but the overall hospital cost was only 8% greater (P >0.3). CONCLUSIONS: Hand-assisted laparoscopic nephroureterectomy is a safe and effective alternative to an open surgical approach. Indexes of patient recovery suggest that patient convalescence is less than after an open surgical nephroureterectomy. Increased operative costs may be offset by a shorter hospital stay and fewer complications, resulting in similar overall hospital costs.