Current Staging Strategies for Muscle-Invasive Bladder Cancer and Upper Tract Urothelial Cell Carcinoma.

Please note, the synopsis was used from your supplied original manuscript, and not the accompanying abstract, per journal style: This article discusses current staging strategies in muscle-invasive bladder cancer and upper tract urothelial cell carcinoma. Current staging methods can help identify patients with localized or metastatic disease but are subject to limitations which must be considered.

A Comparative Study of Ablation Boundary Sharpness After Percutaneous Radiofrequency, Cryo-, Microwave, and Irreversible Electroporation Ablation in Normal Swine Liver and Kidneys.

PURPOSE: To compare ablation boundary sharpness after percutaneous radiofrequency ablation (RFA), cryoablation (CA), microwave ablation (MWA) and irreversible electroporation (IRE) ablation in normal swine liver and kidney. MATERIALS AND METHODS: Percutaneous CT-guided RFA (n = 5), CA (n = 5), MWA (n = 5) and IRE (n = 5) were performed in the liver and kidney of four Yorkshire pigs. Parameters were chosen to produce ablations 2-3 cm in diameter with a single ablation probe. Contrast-enhanced CT imaging was performed 24 h after ablation, and animals were killed. Treated organs were removed and processed for histologic analysis with hematoxylin and eosin, and terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL). Three readers independently analyzed CT, H&E and TUNEL stained images of the ablation boundary to delineate regions of (1) viable cells, (2) complete necrosis or (3) mixture of viable and necrotic cells which was defined as the transition zone (TZ). The width of TZ was compared across the techniques and organs. RESULTS: Ablations appeared as non-contrast-enhancing regions on CT with sharp transition to enhancing normal tissue. On TUNEL stained slides, the mean width (µm) of the TZ after MWA was 319 ± 157 in liver and 267 ± 95 in kidney, which was significantly lower than RFA (811 ± 477 and 938 ± 429); CA (452 ± 222 and 700 ± 563); and IRE (1319 ± 682 and 1570 ± 962) (all p < 0.01). No significant differences were observed between the organs. CONCLUSION: Under similar conditions, the width of the TZ at the ablation boundary varies significantly between different ablation techniques.

Normal Porcine Ureter Retains Lumen Wall Integrity but Not Patency Following Catheter-Directed Irreversible Electroporation: Imaging and Histologic Assessment over 28 Days.

PURPOSE: To evaluate the effect of catheter-directed irreversible electroporation (IRE) on the integrity, patency, and function of the normal porcine ureter. MATERIALS AND METHODS: A catheter-mounted electrode was used to perform fluoroscopy-guided IRE in 8 healthy pigs. Two unilateral ablations (90 pulses at 2,000 V, 100 µs) were performed in each animal in the proximal and distal ureter. Serum creatinine measurements and contrast-enhanced computed tomography imaging were performed at 1, 7, 14, 21, and 28 days after IRE, and findings were compared with baseline values by Student t test. Two animals each were euthanized at 1, 7, 14, and 28 days after IRE for histologic assessment of treatment effects. Quantitative histologic analysis of regeneration and healing of the ureteral wall was graded on a five-point scale. RESULTS: IRE was successfully performed in all animals. Preservation of ureteral wall integrity was confirmed by the leakage-free passage of contrast medium in the treated ureter of all animals through the observation period. Ureteral strictures and associated renal pelvicaliceal dilation were observed in all animals by study days 7 (P = .005) and 14 (P = .007) and did not resolve by day 28. Urothelial recovery was observed in tissue samples from day 7, with progressive replacement of the tunica muscularis with granulation tissue. Despite extensive scarring of the tunica muscularis, full recovery of the urothelium was observed by day 28. CONCLUSIONS: The normal porcine ureter retains lumen wall integrity and function following catheter-directed IRE. Scarring of the tunica muscularis in the treated ureter results in stricture formation and reduction of lumen patency.

Bombesin Antagonist-Based Radiotherapy of Prostate Cancer Combined with WST-11 Vascular Targeted Photodynamic Therapy.

Purpose: DOTA-AR, a bombesin-antagonist peptide, has potential clinical application for targeted imaging and therapy in gastrin-releasing peptide receptor (GRPr)-positive malignancies when conjugated with a radioisotope such as 90Y. This therapeutic potential is limited by the fast washout of the conjugates from the target tumors. WST-11 (Weizmann STeba-11 drug; a negatively charged water-soluble palladium-bacteriochlorophyll derivative, Tookad Soluble) vascular targeted photodynamic therapy (VTP) is a local ablation approach recently approved for use in early-stage prostate cancer. It generates reactive oxygen/nitrogen species within tumor blood vessels, resulting in their instantaneous destruction followed by rapid tumor necrosis. We hypothesize that the instantaneous arrest of tumor vasculature may provide a means to trap radiopharmaceuticals within the tumor, thereby improving the efficacy of targeted radiotherapy.Experimental Design: GRPr-positive prostate cancer xenografts (PC-3 and VCaP) were treated with 90Y-DOTA-AR with or without VTP. The uptake of radioisotopes was monitored by Cherenkov luminescence imaging (CLI). The therapeutic efficacy of the combined VTP and 90Y-DOTA-AR in PC-3 xenografts was assessed.Results: CLI of 90Y-DOTA-AR demonstrated longer retention of radiotracer within the VTP-treated PC-3 xenografts compared with the non-VTP-treated ones (P < 0.05) at all time points (24-144 hours) after 90Y-DOTA-AR injection. A similar pattern of retention was observed in VCaP xenografts. When 90Y-DOTA-AR administration was combined with VTP, tumor growth delay was significantly longer than for the control or the monotherapy groups.Conclusions: Tumor vascular arrest by VTP improves 90Y-DOTA-AR retention in the tumor microenvironment thereby enhancing therapeutic efficacy. Clin Cancer Res; 23(13); 3343-51. ©2017 AACR.

Nonthermal Ablation by Using Intravascular Oxygen Radical Generation with WST11: Dynamic Tissue Effects and Implications for Focal Therapy.

Purpose To examine the hypothesis that vascular-targeted photodynamic therapy (VTP) with WST11 and clinically relevant parameters can be used to ablate target tissues in a non-tumor-bearing large-animal model while selectively sparing blood vessels and collagen. Materials and Methods By using an institutional animal care and use committee-approved protocol, 68 ablations were performed in the kidneys (cortex and medulla) and livers of 27 adult pigs. Posttreatment evaluation was conducted with contrast material-enhanced computed tomography in the live animals at 24 hours. Immunohistochemistry was evaluated and histologic examination with hematoxylin-eosin staining was performed at 4 hours, 24 hours, and 7 days. Intravenous infusion of WST11 (4 mg per kilogram of body weight) was followed by using near-infrared illumination (753 nm for 20 minutes) through optical fibers prepositioned in target tissues by using a fixed template. Treated areas were scanned, measured, and statistically analyzed by using the Student t test and two-way analysis of variance. Results Focal WST11 VTP treatment in the liver and kidney by using a single optical fiber resulted in well-demarcated cylindrical zones of nonthermal necrosis concentrically oriented around the light-emitting diffuser, with no intervening viable parenchymal cells. The radius of ablated tissue increased from approximately 5 mm at 150 mW to approximately 7 mm at 415 mW (P < .01). Illumination through fiber triads at 1-cm separation resulted in confluent homogeneous necrosis. Patterns of acute injury within 24 hours were consistent with microcirculatory flow arrest and collagen preservation (demonstrated with trichrome staining). In the peripheral ablation zone, blood vessels at least 40 µm in diameter were selectively preserved and remained functional at 7 days. Ablated tissues exhibited progressive fibrosis and chronic inflammatory cell infiltrates. No histologic changes consistent with thermal injury were observed in blood vessels or collagen. The renal hilum and collecting system did not show treatment effect, despite treatment proximity. Conclusion WST11 VTP induces nonthermal tissue ablation in target tissue while preserving critical organ structures and bystander blood vessels within solid organs. (©) RSNA, 2016 Online supplemental material is available for this article.

Low yield of surveillance imaging after surgery for T1 kidney cancer.

PURPOSE: To examine the mode of relapse detection and subsequent treatment after partial or radical nephrectomy in patients with low-risk (pT1, N0, Nx) kidney cancer. METHODS: Retrospective study on 1404 patients treated with partial or radical nephrectomy for low-risk kidney cancer from the years 2000-2012. Scans for chest imaging (X-ray or CT) and abdominal imaging (CT, MRI, or ultrasound) are tabulated. For those patients with relapse, the site, mode of detection, and symptoms were recorded. RESULTS: Twenty-one patients relapsed with a median follow-up of 4.1 years for patients who did not relapse. In 17 (81 %) patients, relapse was detected by imaging alone, while 4 (19 %) patients presented with symptoms. Of the patients who relapsed by imaging, 13 (76 %) were treated immediately, while 4 (24 %) continued observation. During the first 3 years of follow-up, 5762 imaging studies were performed to detect 8 relapses, with 6 patients receiving immediate treatment. The median number of imaging studies per patient per year for the first 3 years was 1.7 (interquartile range 1.0, 2.3) including 30 % CT, 3 % MRI, 36 % X-ray, and 31 % ultrasounds. CONCLUSION: We found a low yield of surveillance imaging in the first 3 years for pT1 kidney cancer. Nearly 1000 imaging studies were performed to detect one relapse that required treatment. Further studies are needed to evaluate the clinical impact of imaging surveillance according to recent guidelines.

The Prognostic Impact of a Positive Vascular Margin on pT3 Clear Cell Renal Cell Carcinoma.

PURPOSE: We examined the impact of positive vascular margins in patients with pT3 clear cell renal cell carcinoma. MATERIALS AND METHODS: After excluding patients with nonvascular positive margins, metastasis, lymph node involvement, neoadjuvant therapy or nonclear cell histology, we identified 224 patients with venous tumor invasion through our institutional database from 1999 to 2013. Kaplan-Meier analysis and log rank tests were used to evaluate whether positive vascular margins were associated with progression-free survival or cancer specific survival. RESULTS: There were 41 patients (18%) with a positive vascular margin. Margin status was directly related to the level of invasion (p <0.0001). Compared to the negative vascular margin group the positive group had a significantly worse progression-free survival (p=0.01) but not cancer specific survival (p=0.3). Similarly the level of vascular thrombus invasion was significantly associated with worse progression-free survival (p=0.02) but not cancer specific survival (p=0.4). The 3-year progression-free survival was worst with inferior vena cava invasion and best with segmental/muscular venous branch invasion (54%, 95% CI 34-70 vs 76%, 95% CI 64-85). Among patients with only main renal vein thrombus, vascular margin status was not associated with progression-free survival (p=0.5) or cancer specific survival (p=0.2). CONCLUSIONS: In patients with pT3N0/XM0 clear cell renal cell carcinoma positive vascular margins are associated with risk of disease progression. However, the risk of relapse associated with positive vascular margins is driven by the extent of vascular thrombus invasion. These findings suggest that the clinical significance of vascular margin status as currently defined in pT3 clear cell renal cell carcinoma is minimal.

Improved Intraoperative Visualization of Nerves through a Myelin-Binding Fluorophore and Dual-Mode Laparoscopic Imaging.

The ability to visualize and spare nerves during surgery is critical for avoiding chronic morbidity, pain, and loss of function. Visualization of such critical anatomic structures is even more challenging during minimal access procedures because the small incisions limit visibility. In this study, we focus on improving imaging of nerves through the use of a new small molecule fluorophore, GE3126, used in conjunction with our dual-mode (color and fluorescence) laparoscopic imaging instrument. GE3126 has higher aqueous solubility, improved pharmacokinetics, and reduced non-specific adipose tissue fluorescence compared to previous myelin-binding fluorophores. Dosing and kinetics were initially optimized in mice. A non-clinical modified Irwin study in rats, performed to assess the potential of GE3126 to induce nervous system injuries, showed the absence of major adverse reactions. Real-time intraoperative imaging was performed in a porcine model. Compared to white light imaging, nerve visibility was enhanced under fluorescence guidance, especially for small diameter nerves obscured by fascia, blood vessels, or adipose tissue. In the porcine model, nerve visualization was observed rapidly, within 5 to 10 minutes post-intravenous injection and the nerve fluorescence signal was maintained for up to 80 minutes. The use of GE3126, coupled with practical implementation of an imaging instrument may be an important step forward in preventing nerve damage in the operating room.

Feasibility of catheter-directed intraluminal irreversible electroporation of porcine ureter and acute outcomes in response to increasing energy delivery.

PURPOSE: To evaluate the feasibility of focal intraluminal irreversible electroporation (IRE) in the ureter with a novel electrode catheter and to study the treatment effects in response to increasing pulse strength. MATERIALS AND METHODS: Five IRE treatment settings were each evaluated twice for the ablation of normal ureter in 5 Yorkshire pigs (n = 1-4 ablations per animal; total of 10 ablations) with the use of a prototype device under ultrasound and fluoroscopic guidance. Animals received unilateral or bilateral treatment, limited to a maximum of 2 ablations in any 1 ureter. Treatment was delivered with increasing pulse strength (from 1,000 V to 3,000 V in increments of 500 V) while keeping the pulse duration (100 µs) and number of pulses (n = 90) constant. Ureter patency was assessed with antegrade ureteropyelography immediately following treatment. Animals were euthanized within 4 hours after treatment, and treated urinary tract was harvested for histopathologic analysis with hematoxylin and eosin and Masson trichrome stains. RESULTS: IRE was successfully performed in all animals, without evidence of ureteral perforation. Hematoxylin and eosin analysis of IRE treatments demonstrated full-thickness ablation at higher field strengths (mucosa to the adventitia). Masson trichrome stains showed preservation of connective tissue at all field strengths. CONCLUSIONS: Intraluminal catheter-directed IRE ablation is feasible and produces full-thickness ablation of normal ureters. There was no evidence of lumen perforation even at the maximum voltages evaluated.

The role of robot-assisted radical prostatectomy and pelvic lymph node dissection in the management of high-risk prostate cancer: a systematic review.

CONTEXT: The role of robot-assisted radical prostatectomy (RARP) for men with high-risk (HR) prostate cancer (PCa) has not been well studied. OBJECTIVE: To evaluate the indications for surgical treatment, technical aspects such as nerve sparing (NS) and lymph node dissection (LND), and perioperative outcomes of men with HR PCa treated with RARP. EVIDENCE ACQUISITION: A systematic expert review of the literature was performed in October 2012, searching the Medline, Web of Science, and Scopus databases. Studies with a precise HR definition, robotic focus, and reporting of perioperative and pathologic outcomes were included. EVIDENCE SYNTHESIS: A total of 12 papers (1360 patients) evaluating RARP in HR PCa were retrieved. Most studies (67%) used the D'Amico classification for defining HR. Biopsy Gleason grade 8-10 was the most frequent HR identifier (61%). Length of follow-up ranged from 9.7 to 37.7 mo. Incidence of NS varied, although when performed did not appear to compromise oncologic outcomes. Extended LND (ELND) revealed positive nodes in up to a third of patients. The rate of symptomatic lymphocele after ELND was 3%. Overall mean operative time was 168 min, estimated blood loss was 189 ml, length of hospital stay was 3.2 d, and catheterization time was 7.8 d. The 12-mo continence rates using a no-pad definition ranged from 51% to 95% with potency recovery ranging from 52% to 60%. The rate of organ-confined disease was 35%, and the positive margin rate was 35%. Three-year biochemical recurrence-free survival ranged from 45% to 86%. CONCLUSIONS: Although the use of RARP for HR PCa has been relatively limited, it appears safe and effective for select patients. Short-term results are similar to the literature on open radical prostatectomy. Variability exists for NS and the template of LND, although ELND improves staging and removes a higher number of metastatic nodes. Further study is required to assess long-term outcomes.

Impact of a common clinical pathway on length of hospital stay in patients undergoing open and minimally invasive kidney surgery.

PURPOSE: Clinical pathways are designed to reduce variability in patient care practices and improve clinical outcomes. We evaluated the effect of implementing a clinical care pathway on length of stay in patients undergoing kidney surgery. MATERIALS AND METHODS: After receiving institutional review board approval we evaluated prospective data on consecutive cases of partial and radical nephrectomy performed at our institution from 2000 to 2011. We identified 1,775 partial nephrectomies (1,449 open and 326 minimally invasive) and 1,025 radical nephrectomies (857 open and 168 minimally invasive). We used multivariate linear regression to test for an interaction between procedure type and surgery before vs after the clinical pathway was begun. RESULTS: Median length of stay decreased 40% (from 5 to 3 days) for open surgery and 33% (from 3 to 2 days) for minimally invasive surgery after clinical pathway implementation. Length of stay in patients treated with minimally invasive or open partial nephrectomy and open radical nephrectomy decreased while it remained stable in those who underwent minimally invasive radical nephrectomy. The difference in length of stay between open and minimally invasive partial nephrectomy before and after implementing the clinical pathway decreased by 1.5 days (95% CI 0.56-2.5, p = 0.002). At 30 days postoperatively major complication rates remained similar. CONCLUSIONS: The clinical pathway resulted in a significantly shorter length of stay in patients treated with partial and radical nephrectomy without a discernible impact on safety or quality of care. Clinical pathways for kidney surgery should be used and continually optimized to enhance efficiency, patient safety and outcomes.

The unidirectional barbed suture for renorrhaphy during laparoscopic partial nephrectomy: Stanford experience.

PURPOSE: Using barbed suture represents a novel technical modification in the performance of minimally invasive partial nephrectomy. Our purpose of this study was to evaluate the safety and efficacy of this suture for renorrhaphy during laparoscopic partial nephrectomy (LPN). PATIENTS AND METHODS: Thirteen consecutive patients underwent LPN using V-Loc™ 180 (Covidien, Dublin, Ireland) suture, and a nonconsecutive control group of 24 patients, matched according to tumor size and R.E.N.A.L. nephrometry score, underwent LPN using absorbable polyglactin suture. All 37 patients underwent LPN performed by a single surgeon. Perioperative and postoperative indicators of morbidity, estimated blood loss, and warm ischemia time (WIT) were compared between the groups. RESULTS: Baseline characteristics including age, body mass index, American Society of Anesthesiologists score, tumor size, laterality, and R.E.N.A.L nephrometry score were identical between the groups. On multivariable analysis, there were no significant differences between the two groups with regard to operative time, estimated blood loss, transfusion rates, rates of surgical complications, and length of hospital stay. However, mean WIT was significantly shorter in the V-Loc group compared with the control group (24.5±5.3 minutes versus 31.9±8.9 minutes, P=.01). CONCLUSIONS: The use of V-Loc sutures for renorrhaphy during LPN is safe and feasible and, in our series, significantly reduces WIT. Further studies are needed to corroborate these findings, but these results indicate a promising development in reducing WIT during minimally invasive partial nephrectomy.

Methods for registration of magnetic resonance images of ex vivo prostate specimens with histology.

PURPOSE: To evaluate two methods of scanning and tissue processing to achieve accurate magnetic resonance (MR)-histologic correlation in human prostate specimens. MATERIALS AND METHODS: Two prostates had acrylic paint markers injected to define the plane of imaging and serve as internal fiducials. Each was placed on a polycarbonate plane-finder device (PFD), which was adjusted to align the imaging and cutting planes. Three prostates were aligned by use of a plane finder key (PFK), a polycarbonate plate that locks the specimen in a cylindrical carrier. Markers were injected for registration analysis. Prostates were imaged, then sectioned. Imaging software was used to create registration maps of the MR and histology images. Measurements between control points were made and compared. RESULTS: Accurate correlation was achieved between MR and histologic images. The mean displacement (MD) between the corresponding registration points using the PFD technique ranged from 1.11-1.38 mm for each section. The MD for all sections was 1.24 mm. The MD using the PFK technique ranged from 0.79-1.01 mm for each section, and the MD across all sections for the PFK was 0.92 mm. CONCLUSION: We describe two methods that can achieve accurate, reproducible correlation between MR imaging and histologic sections in human prostatectomy specimens.

Comparison of holding strength of suture anchors on human renal capsule.

INTRODUCTION: The use of surgical clips as suture anchors has made laparoscopic partial nephrectomy (LPN) technically simpler by eliminating the need for intracorporeal knot tying. However, the holding strength of these clips has not been analyzed in the human kidney. Therefore, the safety of utilizing suture anchors is unknown as the potential for clip slippage or renal capsular tears during LPN could result in postoperative complications including hemorrhage and urinoma formation. With the above in mind, we sought to compare the ability of Lapra-Ty clips and Hem-o-lok clips to function as suture anchors on human renal capsule. METHODS: Fresh human cadaveric kidneys with intact renal capsules were obtained. A Lapra-Ty clip (Ethicon, Cincinnati, OH) or a Hem-o-lok clip (Weck, Raleigh, NC) was secured to a no. 1 Vicryl suture (Ethicon) with and without a knot, as is typically utilized during the performance of LPN. The suture was then placed through the renal capsule and parenchyma and attached to an Imada Mechanical Force Tester (Imada, Northbrook, IL). The amount of force required both to violate the renal capsule and to dislodge the clip was recorded separately. RESULTS: Six Lapra-Ty clips and six Hem-o-lok clips were tested. The mean force in newtons required to violate the renal capsule for the Lapra-Ty group was 7.33 N and for the Hem-o-lok group was 22.08 N (p < 0.001). The mean force required to dislodge the clip from the suture for the Lapra-Ty group was 9.0 N and for the Hem-o-lok group was 3.4 N (p < 0.001). When two Hem-o-lok clips were placed on the suture in series, the mean force required to dislodge the clips was 10.6 N. CONCLUSION: When compared with Lapra-Ty clips, using two Hem-o-lok clips may provide a more secure and cost-effective method to anchor sutures on human renal capsule when performing LPN.

Suppressive roles of calreticulin in prostate cancer growth and metastasis.

Calreticulin is an essential, multifunctional Ca(2+)-binding protein that participates in the regulation of intracellular Ca(2+) homeostasis, cell adhesion, and chaperoning. Calreticulin is abundantly expressed and regulated by androgens in prostate epithelial cells. Given the importance of both calreticulin in multiple essential cellular activities and androgens in prostate cancer, we investigated the possibility of a role for calreticulin in prostate cancer progression. Immunohistochemistry revealed the down-regulation of calreticulin in a subset of human prostate cancer specimens. Prostate cancer cells overexpressing exogenous calreticulin produced fewer colonies in both monolayer culture and soft agar. Furthermore, calreticulin overexpression also inhibited tumor growth in the orthotopic PC3 xenograft tumor model and macroscopic lung metastasis in the rat Dunning AT3.1 prostate tumor model. To address the potential mechanism of calreticulin suppression of prostate cancer, we generated calreticulin mutants with different functional domains deleted. The calreticulin mutants containing the P-domain, which binds to other endoplasmic reticulum chaperone proteins, were sufficient for the suppression of PC3 growth in colony formation assays. Overall, our data support the hypothesis that calreticulin inhibits growth and/or metastasis of prostate cancer cells and that this suppression requires the P-domain.

Congenital coronary artery anomalies presenting in late adulthood with concurrent acquired heart disease: report of two cases.

Congenital coronary anomalies can be found in up to 1% of patients undergoing angiography. The most severe of these lesions become symptomatic in early childhood, while others can remain without consequence. However, while being silent in the early decades of life, these asymptomatic anomalies can contribute to the presentation of acquired heart disease and can themselves become clinically significant. We describe the clinical course of two patients with congenital coronary artery anomalies presenting beyond the fifth decade of life with concurrent acquired heart disease.

Management of distal ureter in laparoscopic nephroureterectomy--a comprehensive review of techniques.

Approximately 5% of all urothelial tumors in adults arise from the upper tracts. While the gold standard treatment is open nephroureterectomy, laparoscopic nephroureterectomy is becoming increasingly popular. Oncologic principles dictate that complete excision of the transmural ureter and bladder cuff and avoidance of urine spillage are paramount. This can be challenging laparoscopically and multiple techniques have been described. We review described surgical techniques, published oncologic data, as well as advantages and disadvantages for each technique including open excision, cystoscopic detachment and ligation, laparoscopic stapling, ureteral intussusception, transurethral resection of ureteral orifice (TURUO) and modifications of TURUO. To date, no controlled studies have been performed demonstrating one technique's superiority.

Novel technique for management of distal ureter and en block resection of bladder cuff during hand-assisted laparoscopic nephroureterectomy.

OBJECTIVES: To report our experience with a novel flexible cystoscopic approach to excise the en block bladder cuff and juxtavesical ureter during hand-assisted laparoscopic nephroureterectomy. The optimal technique for excising the distal ureter and bladder cuff during nephroureterectomy continues to evolve. METHODS: Hand-assisted laparoscopic nephroureterectomy was performed in 6 patients. A hand-assist device and two 5 to 12-mm ports were placed in the mid and upper abdomen. Two 10-mm clips were placed on the proximal ureter to occlude it, and the kidney was resected in the usual fashion. An additional 5 to 12-mm port was placed in the midline between the umbilicus and symphysis pubis. The ureter was dissected down into the pelvis to the level of the bladder. Without repositioning the patient, a flexible cystoscope was inserted into the bladder and a 2-cm bladder cuff excised using a 5F electrode on cutting current, with coagulating current used as needed. The specimen was removed intact through the hand port. RESULTS: The mean time to resect the distal bladder cuff was 30 minutes (range 22 to 35). The mean estimated blood loss was 254 mL. The mean operating room time was 264 minutes, mean hospital stay 6.3 days, and mean time to a general diet 2.6 days. All patients underwent cystography at 7 to 10 days postoperatively, with no extravasation or diverticula. Cystoscopic and computed tomography follow-up demonstrated no evidence of recurrence. CONCLUSIONS: This technique allows for complete resection of the kidney, distal ureter, and a cuff of bladder, avoiding repositioning.

Coronal imaging to assess urinary tract stone size.

PURPOSE: Urinary tract stones are typically measured using axial images from computerized tomography (CT). Such images provide a precise measurement of stone length and width. However, cephalocaudad dimensions can be difficult to determine from axial images. Coronal reconstructions, which can more accurately measure cephalocaudad dimensions, are seldom used to measure stones. We determined if coronal reconstructions could aid in more precisely determining stone size. MATERIALS AND METHODS: CT in patients who had undergone CT to evaluate urolithiasis at our institution during the 9-month period of January 2001 to September 2001 were reviewed. Length and width were measured using axial images, and cephalocaudad length and width were measured using coronal reconstructions. Cephalocaudad length was also estimated from axial images. Total area was calculated from axial and coronal reconstructions. The paired t test was used to assess statistical significance. RESULTS: The CT images of 102 patients with a total of 151 stones had undergone coronal reconstructions and, thus, were included in the study. Mean area in the axial and coronal reconstruction groups was 22.23 and 31.29 mm, respectively. Mean greatest axial dimension (length or width) was 4.87 mm and mean greatest coronal dimension (cephalocaudad length) was 6.51 mm. Cephalocaudad length estimated from axial images was 8.8 mm. Differences for all 3 of these comparisons (axial vs coronal area, greatest axial vs coronal dimension and estimated vs actual cephalocaudad length) proved to be statistically significant (p <0.0001). CONCLUSIONS: While urinary tract stones have typically been measured using axial images, coronal images provide a different impression of stone size. These data demonstrate that examining only axial images provides an inaccurate measure of stone size. We suggest that coronal images should also be used to measure more accurately stone size, which is critical for clinical decision making.

Efficacy and safety of the Healthtronics LithoTron lithotripter.

PURPOSE: To evaluate our experience with the LithoTron lithotripter (Healthtronics, Atlanta, GA), a dry portable system that utilizes a spark-gap electrode as an energy source. PATIENTS AND METHODS: We prospectively evaluated the first 312 treatments performed on 199 men and 99 women with an average age of 43.5 years (range 4 months-80 years), over a 25-month period between May 1999 and June 2001. Of the 468 stones treated, 136 were located in the ureter, 52 in the renal pelvis or ureteropelvic junction, and 230 in the kidney; the sites of 50 were not specified in our database. The average stone size was 8.0 mm (range 1-40 mm). Follow-up included a plain (KUB) film, CT scan, or intravenous urogram (IVU) and was available for 256 patients. "Stone free" was defined as no fragments visible on postoperative images. The mean radiographic follow-up was 74 days (range 0-866 days). Data collection was initially done manually by data sheets, but a Web-based medical database application was developed in order to enter, store, retrieve, and analyze the data more efficiently. RESULTS: The average number of shocks delivered per renal unit was 2689 at 25.8 kV. Seventy-five percent of the procedures were performed with intravenous sedation. Two thirds (169/256) of the patients were rendered stone free with one treatment. According to size, 71% (209/294) of stones <1 cm, 57% (39/68) of stones between 1.0 and 1.5 cm, and 22% (8/36) of stones >1.5 cm were eliminated. There were 23 patients who required further treatment; from the available data, 18 of them are currently stone free. Perioperative complications occurred in 6 patients (2%). No patient had worsening renal function or new-onset hypertension. The effectiveness quotient was 59.3%. CONCLUSION: The LithoTron lithotripter is satisfactory for stones <1 cm.