ETView tracheoscopic ventilation tube for surveillance after tube position in patients undergoing percutaneous nephrolithotomy.

BACKGROUND: Tracheal tube (TT) displacement during general anaesthesia may result in life-threatening complications and continuous direct vision of the position of the tube may enable safer management. The ETView tracheoscopic ventilation tube (TVT) is a single-use TT incorporating a video camera and a light source in its tip. The view from the tip appears continuously on a portable monitor in the anaesthetist's vicinity. This study was designed to test the ETView TVT in monitoring the TT position during general anaesthesia. METHODS: In this prospective study, the ETView TVT was used to ventilate the lungs of 30 adult patients undergoing percutaneous nephrolithotomy (PCNL), which required changing patient position three times. During surgery, the anaesthetist followed the carinal view on the ETView TVT portable monitor. Tube movement within 1 cm was recorded, as was the need for repositioning of the tube when the carina was not seen on the camera monitor. RESULTS: During anaesthesia, tiny movements synchronous with heart beats and lung ventilation were observed. Tube movement of 1 cm was detected in eight (26%) patients. In two (7%) patients, the carina was no longer viewed after moving to the lithotomy position and the tube was repositioned. None of the events was associated with changes in oxygen saturation, end-tidal CO(2), or airway pressure. CONCLUSIONS: We found that the ETView TVT facilitated surveillance of tube position by providing a clear high-quality view of the carina, throughout PCNL with several changes of patient position.

Immuno-chemotherapy in metastatic renal cell carcinoma: long-term results from the rambam and linn medical centers, Haifa, Israel.

Nephrectomy, immuno-chemotherapy and resection of residual disease have been the treatment of choice for patients with metastatic renal cell carcinoma during the past decades. The aim of this study was to report the long-term results of this treatment approach. Sixty-two patients with metastatic renal cell carcinoma participated in a Phase II study. At diagnosis, 32 patients had localized disease, 30 had metastatic disease and 53 underwent nephrectomy. Metastatic sites were lungs, lymph nodes, bones and liver. Immuno-chemotherapy consisted of: interleukin-2, interferon alpha, 5-fluorouracil and vinblastine. All patients were evaluated for toxicity and response to treatment. CR was achieved in 4 patients and PR in 14. Seven patients, with maximum response to immuno-chemotherapy underwent resection of residual tumor and reached CR. Therefore, CR was achieved in 11 patients (18%) with a median survival of +67 months. Flu-like symptoms were the common side effects. Performance status and histology type significantly affected survival. Nephrectomy, immuno-chemotherapy and resection of residual disease are recommended for patients with metastatic renal cell carcinoma.

Hydronephrosis in children after bone marrow transplantation: case reports.

Hydronephrosis post-bone marrow transplantation (BMT) diagnosed in five children, was caused by hemorrhagic cystitis and blood clots in the bladder, congenital uretro-pelvic junction stenosis and ureteral obstruction due to adenoviral infection. Patients received conservative therapy to treat the symptoms. However, hydronephrosis did not change the outcome of BMT. Therefore, we suggest less aggressive procedures to treat children with hydronephrosis.

Extracorporeal shock-wave lithotripsy (ESWL) monotherapy for stones in lower ureter.

Extracorporeal shock-wave lithotripsy (ESWL) has been accepted as the method of choice for most upper urinary tract calculi. However, in cases of stones in the lower ureter, ureteroscopic procedures have generally been preferred. Using the Dornier HM3 lithotriptor with modifications in the patient's position, we were able to successfully treat 155 unselected cases of lower ureteral calculi. The average stone size was 9.6 mm (range 5-23 mm). One hundred forty-three patients had stones located below the lower margin of the sacroiliac joint. These patients were placed in a supine position. The stones were visualized radiologically without use of a ureteral catheter in 78 percent of the patients; in 22 percent a ureteral catheter was inserted prior to ESWL to aid in stone localization. In 145 patients (94%) treatment was completed in one session; 10 patients (6%) required two sessions. Of the patients, 38 percent were free of stones one day after ESWL; 97 percent became stone free within three months, and only 3 patients required endoscopic manipulation, after ESWL. Twelve patients had stones in the midureter overlying the sacroileum. They were placed in the prone position, and the calculi were visualized with the aid of a ureteral catheter. All these patients became free of stones one month after treatment. There were no significant treatment-related complications except for bacteremia in 1 case. In view of the remarkable efficacy, negligible complication rate, and shorter hospital stay as compared to ureteroscopic stone manipulations, we recommend high energy ESWL as the primary monotherapy of mid and lower ureteral stones.

Pneumopericardium-a life-threatening complication of central venous catheterisation.

A case of central venous catheterisation which was complicated by pneumoperi-cardium is presented. The clinical manifestations and management are described. Haemodynamic stability in this patient could not be achieved by conservative therapy and pericardiocentesis was necessary to save the patient.

The supracostal percutaneous nephrostomy for treatment of staghorn and complex kidney stones.

From March 1995 to May 1997, 104 patients underwent 115 supracostal percutaneous nephrolithotomy (PCNL) procedures for the treatment of 102 complete staghorn calculi, 6 large semistaghorn calculi, 3 large upper-caliceal stones, and 4 significant volumes of residual stone fragments after SWL. Additional renal access was required mainly for complete staghorn stones (23 patients; 20%). Extracor poreal lithotripsy was performed in 30.4% of cases, and second-look PCNL was done in 15.6%. The stone-free rate was 87%, and the infection-free rate at 7 to 33 months was 88.5%. Among 115 supracostal PCNL procedures, complications were encountered in 10 (8.7%). These problems included four large pleural effusions that were drained by chest tube in three patients and by repeated thoracocentesis in one patient. Six patients developed significant atelectasis, which was treated by vigorous physiotherapy in five and flexible bronchoscopy in one. We conclude that the supracostal approach provides direct and optimal access to most staghorn calculi with an excellent stone-free rate. The advantages of this approach can be achieved with a slight and acceptable increase in morbidity.

[Radical retropubic prostatectomy].

Radical prostatectomy may cure most patients in whom the malignant tumor has not invaded through the prostatic capsule. Advances in surgical technique and accumulation of experience have decreased the complication rate significantly. Long-term results of surgical treatment are now better than those of other forms of treatment; hence radical prostatectomy is now recommended for men with life expectancies longer than 10 years. Between 1988 and 1995, 164 men with clinical stages T1 or T2 adenocarcinoma were admitted for radical prostatectomy. Most were not offered a nerve-sparing procedure, so as to allow wider, more complete resection. Those who wanted preservation of sexual function underwent the nerve- preserving procedure. In 6 patients operation was discontinued when metastases to the mac lymph nodes were detected and in 1 when invasion of the pelvic wall was found, 157 underwent radical prostatectomy. Preoperative biopsy revealed a low-grade lesion (Gleason 2-4) in 19.1%, intermediate grade (Gleason 5-6) in 61.8% and high-grade (Gleason 7-9) in 19.1%; however, pathologic grading revealed that only 7.0% had grade 2-4 tumor, 60.5% grade 5-6 and 32.5% grade 7-9. Pathologic staging revealed T2 tumor in 58%, T3 in 38.8% (including microscopic invasion of the capsule or seminal vesicles); microscopic lymph node metastases were found in 3.2%. Tumor invasion through the capsule was found in only 2 of 13 treated with neoadjuvant androgen blockade, compared with 40% in those who did not receive this treatment. There was no operative mortality and only 14.7% has complications. All had urinary incontinence immediately after operation, but regained continence after an average of 4-5 months, 24 were incontinent for more than 12 months, but most of them had only mild stress incontinence. Most patients were impotent after the procedure. There was tumor recurrence, diagnosed by rise in serum PSA, in 26 during an average followup of 26.4 months (range 3-93). Cure rate of prostatic cancer by radical prostatectomy may be increased by improved preoperative staging methods and better patient selection; long term follow up is required for determining cure rate.

[Intrapleural marcaine for postoperative analgesia].

Intrapleural marcaine has been described as an effective method of analgesia following upper abdominal and thoracic operations and is no longer regarded as experimental. We have shown that the same quality of analgesia can be achieved by injecting the drug through a catheter inserted intraoperatively through the surgical incision. In our method, applied in 9 cases, there is no risk of pneumothorax as a result of piercing the chest wall, since intraoperative placement of the intrapleural catheter is very easy. We therefore suggest it as the method of choice for postoperative analgesia in kidney operations. It is especially recommended in elderly patients with chronic pulmonary disease who do not tolerate narcotics well.

Abdominal compartment syndrome due to delayed identification of a ureteral perforation following abdomino-perineal resection for rectal carcinoma.

Abdominal compartment syndrome develops whenever the mean intraperitoneal pressure rises above the physiological pressure, leading to renal and mesenteric ischemia and respiratory decompensation due to pressure on the diaphragm. Abdominal compartment syndrome may occur after conditions such as peritonitis, intestinal obstruction, laparoscopic procedures, or abdominal tumors. Leakage from the urinary tract may cause accumulation of urine in the peritoneal cavity which commonly manifests as single or multiple urinomas, or urinary ascites. The case of a patient who had delayed identification of a ureteral perforation following the abdomino-perineal resection of a rectal carcinoma is presented. Massive urinary leakage into the peritoneal cavity led to the abdominal compartment syndrome. Peritoneal drainage and ureteral stenting improved her condition. A high index of suspicion is necessary in order to diagnose this rare condition.

A placebo-controlled double-blind study of the effect of phenoxybenzamine in benign prostatic obstruction.

A double-blind placebo-controlled study of phenoxybenzamine for the symptomatic treatment of benign prostatic obstruction is reported. Statistically significant evidence of an improvement in both the peak and mean flow-rates was found. Both diurnal and nocturnal frequency were significantly diminished. Residual urine was unaffected, and the possible reasons for this are discussed. Urethral pressure recordings confirmed the reduction in the closure pressure in the prostatic segment of the urethra. It was concluded that there was good evidence that the treatment is effective.

Alpha 1 adrenoceptor subtypes in the human prostate.

High affinity alpha 1 adrenoceptors have been characterized in the human prostate. The tension of prostatic smooth muscle is mediated by the alpha 1 adrenoceptor. The present study represents the first characterization of human alpha 1 adrenoceptor subtypes using radioligand receptor binding techniques. Binding studies were performed on tissue homogenates obtained from the human prostate. Competitive inhibition studies were performed in the presence of an 80 pM. 125I-Heat and 16 concentrations of unlabelled 5-methylurapidil (5 MU) or WB-4101 (10(-10) M. to 10(-5) M.). Saturation experiments were also performed with and without chloroethylclonidine (CEC, 10(-5) M.), a compound that selectively inactivates the alpha 1B subtype. The individual displacement plots for WB-4101 and 5-MU in the human prostate were consistently best fit by a 2 binding site model. WB-4101 and 5-MU exhibited a 594- and 186-fold higher affinity for the prostatic alpha 1A binding site relative to the alpha 1B binding site. The ratios of prostatic alpha 1A/alpha 1B binding sites discriminated by WB-4101 and 5-MU were 1.8 and 1.6, respectively. CEC inactivated 44% of the prostatic alpha 1 binding sites. The binding studies suggest that the dominant alpha 1 subtype in the human prostate is the alpha 1A. We are characterizing the functional properties of the alpha 1 subtypes in the human prostate.

Nontraumatic spontaneous rupture of the urinary bladder.

Rupture of the urinary bladder without a history of recent trauma or instrumentation is rare; it is usually associated with bladder disease or outlet obstruction. The patient is usually seen as an emergency case and has an atypical clinical picture. The four patients in this report were initially seen and treated by a general surgeon; in only two was the diagnosis established preoperatively and confirmed by retrograde cystography. Awareness on the part of the consulting surgeon that bladder rupture is possible in a predisposed patient may lead to a correct preoperative diagnosis. In this series, early operation--removing urine from the peritoneal cavity or retropubic space, closing the rupture and securing good vesical drainage--resulted in resumption of vesical function in all four patients and there were no deaths.

Binding and functional properties of alpha1 adrenoceptors in different regions of the human prostate.

The objective of the present study was to determine the density and functional properties of alpha 1 adrenoceptors in different regions of the human prostate. Binding and functional studies were performed on eight different topographical regions of the prostate. The contractile response (gm. force/mm.2 cross-sectional area [CSA]) was determined at varying concentrations of phenylephrine, and saturation experiments were performed at seven different concentrations of 125I-Heat. The maximal response to phenylephrine (Emax) ranged from 0.067 to 0.272 gm. force/mm.2 The CSA and the EC50 ranged from 25 to 41 microM. The differences between EC50 and Emax were not significantly different among the eight prostatic regions. A 1.8-fold difference between the Emax for peripheral and central regions of the prostate was statistically significant (p = 0.04). The equilibrium dissociation constant (Kd) of 125I-Heat and the receptor density Bmax were determined from the Scatchard plots. The mean Kd and Bmax ranged from 0.15 to 0.26 nM. and 0.30 to 0.72 fmol. per mg. wet weight, respectively. There were no statistically significant differences between mean Kd and mean Bmax for the eight prostatic regions. The 1.7-fold difference between central and peripheral mean Bmax was not statistically significant (p = 0.07). A direct relationship was not observed between phenylephrine mean Emax and mean Bmax. The present study demonstrates regional differences of the binding and functional properties of prostatic alpha 1 adrenoceptors in the human prostate. These regional differences must be taken into account when investigating the pharmacologic and physiologic properties of the prostate.

Retroperitoneoscopy: foreign body retrieval.

Retroperitoneoscopy is a rarely indicated procedure for the urological surgeon. However, it can be a useful means to approach some types of ureteral pathology and foreign bodies. We describe a case in which a severed surgical drain was removed from deep within the retroperitoneum by using a percutaneous retroperitoneal approach.

The safety, efficacy and compliance of terazosin therapy for benign prostatic hyperplasia.

The primary objective of the present interim analysis of an open label study initiated in December 1988 is to provide further insight into the long-term safety, efficacy and compliance of terazosin, a long-acting selective alpha 1-blocker, for the treatment of symptomatic benign prostatic hyperplasia (BPH). A total of 45 normotensive patients with symptomatic BPH was enrolled into this study. The dose of terazosin was titrated to 5 mg. during a 1-month period provided adverse reactions and orthostatic hypotension were not observed. The subjects were maintained on 5 mg. terazosin throughout the 24-month followup. The peak and mean urinary flow rates, obstructive and irritative Boyarsky symptom scores, and systolic and diastolic blood pressures were evaluated at 2, 6, 12, 18 and 24 months after initiation of therapy. Of the 45 subjects 21 (47%) exhibited a durable clinical response with no significant adverse events during the 24-month followup. The obstructive and irritative symptom scores decreased by 63% and 35%, respectively, after 2 months of terazosin therapy. These improvements in obstructive and irritative symptom scores were maintained throughout the 2-year followup. The peak and mean urinary flow rates improved by 42% and 48%, respectively, after 2 months of terazosin therapy. The changes in mean urinary flow rate increased, whereas the changes in peak urinary flow rate decreased during followup. Of the patients 6 (13%) were withdrawn from the study due to an adverse event. Our study demonstrates the safety, efficacy and compliance of terazosin therapy for BPH during a 2-year followup.

Endopyelotomy: comparison of ureteroscopic retrograde and antegrade percutaneous techniques.

To date 2 approaches have been developed for performing endopyelotomy, that is the antegrade and retrograde approaches. Experience with antegrade transnephrostomy endopyelotomy is quite large and the results have been excellent. However, the need for percutaneous nephrostomy and prolonged hospitalization have been 2 drawbacks to this approach. In contrast, experience with retrograde transureteral endopyelotomy is scant. However, a ureteroscopic approach is attractive from the standpoint of eliminating the need for a large nephrostomy tube and because of the possibility of performing this procedure on an outpatient basis or during a short hospital stay. We report our experience with antegrade and retrograde endopyelotomy in 41 patients. The hospital stay (3.4 versus 4.0 days), nephrostomy tube size (8F to 10F versus 20F to 22F) and nephrostomy tube duration (2.9 versus 3.8 days) were all less with the retrograde approach. The initial success rate was similar between the 2 methods: 79% (retrograde) versus 78% (antegrade). However, the analgesic requirements (5.3 versus 3.5 doses) and the occurrence of significant complications (that is late ureteral stricture in 20%) were greater with the ureteroscopic approach. With the methods currently available, we believe that antegrade endopyelotomy is the preferred approach for endopyelotomy.

Ureteronephroscopic marsupialization of obstructing peripelvic renal cyst.

Flexible ureteronephroscopy has been used for numerous therapeutic applications in the upper urinary tract. We report a case of a large peripelvic renal cyst causing obstruction to the ureteropelvic junction, which was treated by incising the wall of the cyst into the renal pelvis with the ureteronephroscope.