Percutaneous nephrolithotomy for removal of encrusted ureteral stents: a multicenter study.

PURPOSE: Encrusted ureteral stents are a challenging endourologic problem. We performed a multi-institutional review of percutaneous nephrolithotomy (PCNL) as primary treatment for encrusted stents. MATERIALS AND METHODS: We identified 36 patients who underwent PCNL for treatment of an encrusted stent. A retrospective review was performed to compile details of procedures and outcomes for these patients. RESULTS: In 36 patients, 38 renal units underwent PCNL for encrusted ureteral stents. The mean patient age was 47.1 years (±16.7), and the female:male ratio was 15:21. Mean stent indwelling time before removal was 28.2 months (±27.8). The reason for long indwelling time was reported in 25 cases; these reasons included "patient unaware stent needed to be removed" (17 cases), pregnancy (2 cases), other comorbidities (3 cases), and patient incarceration (3 cases). In 3 cases, the stent had become encrusted within 3 months of placement. Mean operative time was 162 minutes (±71). There were no major intraoperative complications, and no patients required blood transfusion. Litholapaxy was required for bladder coil encrustations in 22 cases (58%), and ureteroscopy with lithotripsy was required for encrustation of the ureteral portion of the stent in 13 cases (34.2%). Second look percutaneous procedures were required in 13 cases (34.2%). The stent was removed at the time of PCNL without need for concomitant or delayed ureteroscopy and/or cystolitholapaxy in 8 cases (21%). Ultimately, all stents were removed successfully. Patients were rendered stone free according to radiographs in 24 cases (63%). CONCLUSIONS: In this multicenter review, PCNL is confirmed to be a safe and effective means of addressing the retained and encrusted ureteral stent. PCNL without ureteroscopy or litholapaxy was sufficient in a minority of cases (21%). Adjunctive endourologic modalities are often required, and the surgeon should anticipate the need for concomitant antegrade ureteroscopic laser lithotripsy and/or cystolitholapaxy. Although complete stent removal can be anticipated, residual fragments are not uncommon.

Second prize: In-vivo physiological impact of alpha blockade on the porcine ureter with distal ureteral obstruction.

PURPOSE: Alpha blockade has been well described clinically for expulsion of distal ureteral stone. However, the in-vivo effects of α-blockade on ureteral dynamics during stone passage are not clear. We studied the effects of oral alfuzosin on ureteral pressure and peristalsis in a distally obstructed porcine ureter. METHODS: Twenty-four female domestic swine (75-82 kg) were incorporated into the study. The study was powered to detect a 30% difference in distal ureteral pressure, with a secondary endpoint of frequency of ureteral peristalsis. The animals were divided into four equal groups: a control group without α-blockade or ureteral obstruction, a group with α-blockade and no ureteral obstruction, a cohort without α-blockade but with distal ureteral obstruction, and a group with α-blockade and distal obstruction. Peristalsis was measured by a magnetic sensor and ureteral pressure through a 5F ureteral balloon catheter. Observations were recorded for 10-minute intervals every hour for 5 consecutive hours. RESULTS: There was increase in ureteral pressure and peristaltic rate with distal ureteral obstruction (p < 0.01). Alpha blockade did not produce significant changes in the above parameters with or without ureteral obstruction compared with the nonmedicated groups. We observed a 0.2 mm Hg lower increase in change of ureteral pressure during peristalsis compared with resting ureteral pressure (delta pressure) in the treated obstructed model (95% confidence interval: -0.55 -0.10; p = 0.06). CONCLUSIONS: In the porcine model, alfuzosin appears to decrease the delta pressure in the distal ureter during obstruction; however, statistical significance was not reached. Further investigation into the in-vivo physiology of medical expulsive therapy is warranted.

Temporal relationship between positive margin rate after laparoscopic radical prostatectomy and surgical training.

OBJECTIVES: To evaluate the potential impact of the experience of the first assistant on the positive surgical margin rate (PSMR) after laparoscopic radical prostatectomy (LRP). The impact of training surgical residents and fellows on patient outcomes is difficult to quantify. METHODS: A single-institution prospective database of 303 patients who underwent LRP between 2003 and 2008 was evaluated. The potential impact of the experience of the first assistant on the PSMR was evaluated by examining the relationship between the PSMR and the time of the academic year. Multivariable logistic regression analysis was used to adjust for patient age, Gleason's sum, tumor density, and pathologic stage. RESULTS: Overall positive margin rate was 18.2%. Positive margin rate for July and August (14/45, 31.1%) was significantly higher than for the remaining 10 months (41/258, 15.9%) P = .015. The increased risk of positive margin in July/August remained significant after adjusting for age, Gleason's sum, tumor density, and pathologic stage (OR 2.65, 95% CI 1.21-5.79, P = .015) CONCLUSIONS: LRP performed with the first assistant in the first 2 months of the academic training year have a significantly higher PSMR.

Catheter-free 120W lithium triborate (LBO) laser photoselective vaporization prostatectomy (PVP) for benign prostatic hyperplasia (BPH).

INTRODUCTION AND OBJECTIVE: We evaluate the safety and efficacy of catheter-free LBO laser PVP for the treatment of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). METHODS: We prospectively evaluated our initial LBO laser PVP experience and the need for urethral catheterization. RESULTS: Seventy consecutive patients were identified. 49 (70%) were discharged without (C-) and 21 (30%) were discharged with (C+) a urethral catheter. There were no significant differences in pre-operative parameters, including age (C-: 65+/-10 vs. C+: 69+/-9 years), AUASS (C-: 22+/-6 vs. C+: 21+/-6), Qmax (C-: 10+/-4 vs. C+: 8+/-3 ml/second), PVR (C-: 62+/-105 vs. C+: 57+/-82 ml) and prostate volume (C-: 65+/-35 vs. C+: 86+/-53 ml). There were no significant differences in laser time and energy usage. AUASS, Qmax and PVR values showed significant improvement within each group (P<0.05), but there were no significant differences between the two groups. All were outpatient procedures. 2/70 (2.9%) patients required catheter reinsertion in C+. The overall incidence of adverse events was low and did not differ between the two groups. CONCLUSIONS: Our experience suggests that catheter-free LBO laser PVP is safe and effective for the treatment of LUTS secondary to BPH.

Right-sided intrarenal splenosis mimicking a renal carcinoma.

We describe a patient who underwent nephrectomy for an enhancing right renal mass that was subsequently pathologically confirmed as right renal splenosis. Since renal splenosis is quite rare and has previously been reported only in the left kidney, we did not consider splenosis in our differential diagnosis during the evaluation of the renal mass. Magnetic resonance imaging, as well as radionucleotide scan using 99mTc-labelled red blood cells, has been utilized for identifying ectopic splenic tissue. An elevated index of suspicion must be present in patients with a history of splenectomy or traumatic splenic rupture to avoid undue nephrectomy.