Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less.

PURPOSE: The optimal management of lower pole renal calculi is controversial. We compared shock wave lithotripsy (SWL) and ureteroscopy (URS) for the treatment of patients with small lower pole stones in a prospective, randomized, multicenter trial. MATERIALS AND METHODS: A total of 78 patients with 1 cm or less isolated lower pole stones were randomized to SWL or URS. The primary outcome measure was stone-free rate on noncontrast computerized tomography at 3 months. Secondary outcome parameters were length of stay, complication rates, need for secondary procedures and patient derived quality of life measures. RESULTS: A total of 67 patients randomized to SWL (32) or URS (35) completed treatment. The 2 groups were comparable with respect to age, sex, body mass index, side treated and stone surface area. Operative time was significantly shorter for SWL than URS (66 vs 90 minutes). At 3 months of followup 26 and 32 patients who underwent SWL and URS had radiographic followup that demonstrated a stone-free rate of 35% and 50%, respectively (p not significant). Intraoperative complications occurred in 1 SWL case (unable to target stone) and in 7 URS cases (failed access in 5 and perforation in 2), while postoperative complications occurred in 7 SWL and 7 URS cases. Patient derived quality of life measures favored SWL. CONCLUSIONS: This study failed to demonstrate a statistically significant difference in stone-free rates between SWL and URS for the treatment of small lower pole renal calculi. However, SWL was associated with greater patient acceptance and shorter convalescence.

Randall's plaque of patients with nephrolithiasis begins in basement membranes of thin loops of Henle.

Our purpose here is to test the hypothesis that Randall's plaques, calcium phosphate deposits in kidneys of patients with calcium renal stones, arise in unique anatomical regions of the kidney, their formation conditioned by specific stone-forming pathophysiologies. To test this hypothesis, we performed intraoperative biopsies of plaques in kidneys of idiopathic-calcium-stone formers and patients with stones due to obesity-related bypass procedures and obtained papillary specimens from non-stone formers after nephrectomy. Plaque originates in the basement membranes of the thin loops of Henle and spreads from there through the interstitium to beneath the urothelium. Patients who have undergone bypass surgery do not produce such plaque but instead form intratubular hydroxyapatite crystals in collecting ducts. Non-stone formers also do not form plaque. Plaque is specific to certain kinds of stone-forming patients and is initiated specifically in thin-limb basement membranes by mechanisms that remain to be elucidated.

Acute effects of percutaneous tract dilation on renal function and structure.

BACKGROUND: Percutaneous nephrolithotomy (PCNL) is performed on a routine basis for the rapid and efficient removal of large caliceal stones. After percutaneous puncture, rigid dilators or an inflatable balloon are used to dilate the nephrostomy tract to allow access to the collecting system for stone removal. Little is known of the acute impact of tract dilation procedures on renal function. MATERIALS AND METHODS: We compared renal hemodynamic and excretory function in female pigs immediately before and up to 5 hours after percutaneous nephrostomy (PCN) using sequential Amplatz dilators (N = 8) or Nephromax balloon inflation (N = 7) and control pigs with no PCN access (N = 8). We also examined renal function in patients undergoing PCNL. RESULTS: The two PCN procedures produced a renal lesion of comparable size and morphology, as well as similar changes in renal function. Glomerular filtration rate (GFR), renal plasma flow (RPF), and urinary sodium excretion (U(Na)V) were significantly reduced in Amplatz- and Nephromax-treated kidneys throughout the 5-hour observation period, by about 50%, 60%, and 80%, respectively. In control pigs, GFR and RPF remained stable and U(Na)V declined progressively to about 50% of baseline over the course of the experiment. The contralateral kidney showed changes in renal function similar to those in the PCN-treated or control kidney in all three groups. A retrospective analysis of 196 adults with normal renal function who underwent unilateral PCNL using the Nephromax balloon dilator revealed a significant increase in serum creatinine of 0.14 mg/dL at 1 day. CONCLUSION: Both animal and human studies show that PCN is associated with an acute decline in renal function.

High-powered holmium-laser ablation: comparison of setting effectiveness using tissue-surrogate model.

BACKGROUND AND PURPOSE: The 100-W holmium laser, in conjunction with a sidefiring 550-microm fiber, can ablate prostate glands as large as 40 g to relieve lower urinary-tract symptoms. We evaluated the effect of various setting combinations on ablation efficiency using beef kidney as a tissue-surrogate model. MATERIALS AND METHODS: Beef kidney specimens (mean weight 44.8 +/- 3.1 g) were secured in a cylinder, which was submerged in a water-filled tank through which a 27F resectoscope and 550-microm sidefiring fiber were positioned. Four energy/frequency combinations were tested, with each used to treat 10 kidney specimens. The difference between the mean pretreatment and post-treatment weights of each treatment group were compared statistically with Student's t-test. RESULTS: The largest mean weight difference after treatment (8.94 +/- 2.38 g) was achieved using 3.2 J and 25 Hz. This mass reduction was significantly greater than that of all other combinations except 2.5 J and 40 Hz. CONCLUSIONS: Use of the 3.2 J and 25 Hz setting combination resulted in the greatest amount of ablation in this tissue-surrogate model, suggesting that maximal energy settings may provide an advantage in tissue vaporization using the 100-W holmium laser. Clinical assessment must be performed to substantiate these findings.

Using and choosing a nephrostomy tube after percutaneous nephrolithotomy for large or complex stone disease: a treatment strategy.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is a well-accepted technique for removal of large or complex renal calculi. However, little attention has been paid to strategies for nephrostomy tube (NT) selection. We reviewed the reasons for selecting three types of NT after PCNL for large or complex stone disease. PATIENTS AND METHODS: A series of 106 consecutive renal units undergoing PCNL for stone burdens >2 cm by a single surgeon (JEL) were reviewed. Noncontrast CT (NCCT) was carried out on postoperative day 1, and secondary procedures were performed if fragments remained. The NTs studied were 8.5F and 10F Cope loops (CP), 20F reentry Malecot catheters (REM), and 20F circle loops (CL). Patient demographics, access site and number, complications, and stone type were examined. "Stone free" was defined as a negative NCCT or negative second-look PCNL. RESULTS: A total of 134 accesses were created in 106 renal units: 35 upper, 7 mid, and 92 lower; however, only 111 NTs were placed: 85 CP (76.6%), 19 REM (17.1%), and 7 CL (6.3%). Sixteen accesses were performed tubeless; all but two were in the upper pole. All 16 of these renal units had a concomitant NT placed in the lower pole. Multiple sites were accessed in 21 patients; 7 of these patients had CL placed. Five of ten patients with spinal-cord injury had REM/CL placed. Nineteen REM were placed: 10 for drainage of infection, and 9 for difficult anatomy. All renal units were rendered stone free: 31.1% with a single procedure and 95.6% with one or two procedures. There were no difficulties with drainage or access for secondary PCNL regardless of the NT employed. Complications included two hydrothoraces, one arteriovenous fistula, and one ureteral perforation. Three of four renal units in patients requiring transfusions underwent bilateral PCNL, and at least one renal unit required multiple accesses. Of kidneys with infection stones, 57.1% required REM or CL; only 12.0% of nonstruvite stones necessitated REM or CL. CONCLUSIONS: All patients having PCNL done for complex stone disease should have an NT placed; however, small (8.5F-10F) CP suffice in most cases and can provide greater patient comfort. To minimize pleural morbidity, tubeless upper-pole access should be considered if the kidney is judged to be stone free at the conclusion of PCNL. Circle loops are useful when multiple accesses are necessary, whereas REM are appropriate if access is difficult, gross residual stone remains, or pain is not an issue (i.e., spinal-cord injury).

Change in serum prostate specific antigen concentration after holmium laser enucleation of the prostate: a marker for completeness of adenoma resection?

BACKGROUND AND PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is a well-established technique for the treatment of benign prostatic hyperplasia (BPH). To date, changes in serum prostate specific antigen (PSA) after HoLEP have not been published. We hypothesized that HoLEP produces a diminution in PSA similar to that produced by the gold-standard therapies for BPH. To test this hypothesis, we have examined PSA data before and after HoLEP from two institutions performing high volumes of this procedure. PATIENTS AND METHODS: Between August 1998 and September 2004, 509 HoLEPs were performed at two institutions for which complete PSA data were available. Preoperative demographic and transrectal ultrasonography (TRUS) volume measurements were recorded; postoperative pathology and TRUS volume were obtained. Change in PSA as a function of the weight of prostate resected and the relation of preoperative TRUS volume to PSA was determined. RESULTS: The average weight of adenoma resected was 49.8 g (range 5-300 g) in the McGill group and 90.4 g (range 7.9-312 g) in the Methodist Hospital group. The mean decrease in PSA was 81.7% in the McGill group (range 6.0-1.1 ng/mL; P < 0.0001) and 86.0% in the Methodist Hospital group (range 8.6-1.2 ng/mL; P < 0.0001). Log transformed preoperative PSA correlated well with TRUS volume (r = 0.45), as did the weight of adenoma resected with absolute change in PSA (r = 0.38). The TRUS volume decreased significantly, from 111.9 cc to 26.5 cc, in the Methodist Hospital group (P < 0.0001). CONCLUSION: The HoLEP procedure produces a significant diminution in PSA that correlates well with the weight of adenoma resected. Measurement of PSA may be a useful tool for the objective assessment of ablative therapies for BPH, as the reduction in PSA corresponds well with the amount of adenoma removed.

Holmium laser enucleation of the prostate: a comparison of efficiency measures at two institutions.

BACKGROUND AND PURPOSE: Holmium laser enucleation of the prostate (HoLEP) is perceived to be technically difficult, time consuming, and inefficient. We assessed the efficiency of HoLEP by documenting the technical features of the procedure at two hospitals located on different continents. PATIENTS AND METHODS: A retrospective analysis of all patients who underwent HoLEP at the Methodist Hospital of Indiana and Tauranga Hospital in New Zealand was performed. A series of 40 patients from the Indiana cohort were pair-matched, by the weight of prostate tissue retrieved, with 40 patients from the New Zealand cohort. Enucleation time and morcellation time were compared in the two groups. RESULTS: The mean weight of the tissue retrieved from the Indiana cohort was 27.1 g and that from the New Zealand cohort was 22.9 g (P = 0.41). The mean enucleation times were 47.6 minutes and 29.2 minutes, respectively (P < 0.001). The mean morcellation times were 9.9 minutes and 7.7 minutes (P = 0.201). The mean rates of enucleation were 0.58 g/min and 0.71 g/min (P = 0.17). The mean rates of morcellation were 3.4 g/min and 4.3 g/min (P = 0.20). The HoLEP efficiency increased as a function of gland size (R(2) = 0.56). CONCLUSIONS: Holmium laser enucleation of the prostate is a reproducible technique, as there is little variation in efficiency from one surgeon to another. Furthermore, the efficiency of HoLEP increases as prostate size increases, which suggests that HoLEP may be an ideal treatment for men with large prostates.

Phase I trial of a temporary ureteral drainage stent.

BACKGROUND AND PURPOSE: The temporary ureteral drainage stent (TUDS; Boston Scientific/Microvasive, Natick, MA) is a biodegradable device that is designed to maintain patency for 48 hours with gradual softening and spontaneous expulsion thereafter. We evaluated the durability, patency, and safety of TUDS in a Phase I clinical trial. PATIENTS AND METHODS: Eighteen stone patients requiring sequential percutaneous nephrolithotomies (PNL) for complex stone disease underwent antegrade TUDS placement following initial percutaneous treatment. Nineteen devices were placed in 21 attempts, with one patient undergoing bilateral TUDS placement. Day 2 nephrostograms were performed to allow assessment of stent status and to demonstrate antegrade flow. Stents were removed at the time of the secondary PNL (day 2 or 3). RESULTS: No complications occurred during TUDS placement. On day 2, 1 stent had passed into the bladder. Eleven stents were completely intact, with seven others partially intact. Day 2 ureteral patency was demonstrated in all 19 stented ureters. Eighteen TUDS were removed completely during the secondary PNL with one incident of partial retention. All stent material had passed out of the body in all patients by 1 month. No adverse events were attributable to the TUDS. CONCLUSIONS: The TUDS appears to facilitate ureteral drainage for at least 48 hours after placement. Although occasional stent tail detachments were noted, these did not interfere with device function. The safety profile of TUDS was favorable, with no complications attributable to the device itself. A larger prospective clinical study in patients receiving TUDS placed retrograde after uncomplicated ureteroscopic manipulation appears appropriate on the basis of these initial findings.

Shockwave lithotripsy: anecdotes and insights.

Shockwave lithotripters have evolved considerably since the introduction of the Dornier HM3 machine 20 years ago. Although shockwave lithotripsy (SWL) remains the preferred treatment for the majority of symptomatic upper urinary-tract calculi, newer lithotripters are not as effective and may have a higher risk of side effects. Lack of progress in lithotripter evolution is attributable to inadequate understanding of how and why shockwaves produce effects on stone and tissue. Current knowledge suggests that stones fragment by the mechanisms of compression fracture, spallation, squeezing, and acoustic cavitation, while tissue damage from shockwaves is secondary to cavitation and non-cavitational forces such as sheer stress. It appears likely that most tissue damage from shockwaves is caused by cavitation. As the understanding of SWL matures, new lithotripter designs may emerge that truly represent an improvement on the original Dornier HM3 machine.

Simultaneous holmium laser enucleation of prostate and upper-tract endourologic stone procedures.

BACKGROUND AND PURPOSE: The holmium laser is a versatile urologic tool. Its unique cutting and coagulating properties allow multiple procedures, such as stone fragmentation and laser enucleation of the prostate (HoLEP), to be performed with a single set-up. This paper reviews our experience with simultaneous HoLEP and endourologic upper-tract stone procedures. PATIENTS AND METHODS: We retrospectively reviewed all 11 patients (12 renal units) treated with the combined approach of HoLEP and an upper-tract endourologic procedure for stone disease. All patients initially underwent HoLEP, followed immediately by percutaneous nephrolithotomy (PCNL)(N=2), ureteroscopy (URS)(N=8), or both (N=1). The mean stone diameter was 34.7 mm for PCNL and 6.7 mm for URS. Outcome data and complications were recorded. RESULTS: The mean preoperative and postoperative American Urological Association Symptom Scores were 21.8 and 6.3, respectively. The mean prostatic specimen weight was 118 g (range 21-376 g), and the mean hospital stay was 1.4 days. For 10 patients with available prostatic specific antigen (PSA) data, the mean preoperative and postoperative values were 6.2 and 0.9 ng/mL, respectively. All patients were catheter free at discharge. All three PCNL patients were rendered stone free; all four URS patients who had radiographic follow-up were stone free. There were no short- or long-term complications, and no transfusions were necessary. CONCLUSIONS: Simultaneous HoLEP and laser lithotripsy are feasible, emphasizing the unique capabilities of the holmium laser. The hemostasis offered by HoLEP allows safe removal of prostatic tissue and urinary calculi, obviating multiple procedures.

Laparoscopic ileocytoplasty and continent ileovesicostomy in a porcine model.

BACKGROUND AND PURPOSE: Bladder augmentation with autologous bowel is commonly accompanied by a continent ileovesicostomy (the Monti procedure). Herein, we describe our initial experience with laparoscopy-assisted ileocystoplasty and continent ileovesicostomy in a porcine model. MATERIALS AND METHODS: Thirteen Yucatan minipigs with an average weight 49 lb underwent a laparoscopy-assisted ileocystoplasty and ileovesicostomy (Monti procedure) using a four-port technique. After catheter removal at 3 weeks, the animals underwent twice-daily catheterization of the ileovesicostomy until complete occlusion of the ileovesicostomy occurred. RESULTS: All animals survived the initial surgery, with 10 animals being available for catheterization at 3 weeks. The average Monti anastomotic time, average ileal patch-bladder anastomotic time, and average total surgery times were 47 minutes, 89 minutes, and 307 minutes, respectively. Eight of ten animals developed stomal stenosis after catheter removal (average time to complete occlusion of 6 days; range 1-13 days), with two animals also demonstrating partial obstruction at the Monti-bladder anastomosis and four partial obstruction at the fascial level of the Monti tube. Pathologic review of select bladder augmentation and Monti tube specimens revealed moderate to severe acute and chronic inflammation with severe scarring at the Monti-skin stoma site in the majority of specimens. CONCLUSIONS: We have demonstrated the feasibility of laparoscopic ileocystoplasty and continent ileovesicostomy in a porcine model. The development of stomal stenosis may be related to the intrinsic properties of the pig skin, but additional investigation is required prior to human studies of this novel surgical technique.

In vitro assessment of lithoclast ultra intracorporeal lithotripter.

PURPOSE: The Lithoclast Ultra (Boston Scientific Corporation, Natick, MA) enables the simultaneous application of ultrasonic and pneumatic modalities for the fragmentation and removal of stones during percutaneous nephrolithotomy (PCNL). We evaluated the effectiveness of this unit using a hands-free in vitro testing system. MATERIALS AND METHODS: An in vitro test system was used to assess the efficiency of stone penetration when the Lithoclast Ultra was operated at different settings of ultrasonic power and pneumatic frequency. The pneumatic and ultrasonic handpieces were assembled, the probes were inserted into an irrigation sheath (Cook Urological, Spencer, IN), and the complete unit was mounted upright (probe tip up). A gypsum artificial stone (mean length 12.8 +/- 0.6 mm; mean diameter 7.6 +/- 0.1 mm) was centered on the probe tip. A weight (63.4 g) was placed atop the stone to provide a constant force. Pneumatic frequency settings of 12, 8, 4, and 1 Hz were tested in conjunction with ultrasonic power settings of 100%, 70%, and 40%. The times required for complete stone penetration were assessed for each combination of settings. Differences in mean stone penetration times were compared using ANOVA. RESULTS: The combination of 12 Hz and 100% produced the fastest mean stone penetration time (8.9 +/- 1.1 seconds). Stone penetration times decreased significantly with increases in pneumatic frequency (P< 0.001) as well as with increases in ultrasonic power (P= 0.001). When analyzing the effect of each modality on the total improvement in penetration time, increasing the pneumatic frequency accounted for approximately 80% of the performance improvement. The stone penetration times were better than those of the most efficient ultrasonic device previously evaluated using this test system. CONCLUSIONS: The Lithoclast Ultra exhibited excellent stone penetration efficiency when evaluated with a hands-free in vitro test system. Increases in either pneumatic frequency or ultrasonic power significantly improve penetration times, with the pneumatic modality contributing the majority of the effect.

Topiramate-induced nephrolithiasis.

Topiramate is a recently developed antiepileptic medication that is becoming more widely prescribed because of its efficacy in treating refractory seizures. Urologists should be aware that this medication can cause metabolic acidosis in patients secondary to inhibition of carbonic anhydrase. In addition, a distal tubular acidification defect may result, thus impairing the normal compensatory drop in urine pH. These factors can lead to the development of calcium phosphate nephrolithiasis. We report the first two cases of topiramate-induced nephrolithiasis in the urologic literature.

Renal nerves mediate changes in contralateral renal blood flow after extracorporeal shockwave lithotripsy.

Renal blood flow falls in both kidneys following delivery of a clinical dose of shockwaves (SW) (2000 SW, 24 kV, Dornier HM3) to only one kidney. The role of renal nerves in this response was examined in a porcine model of renal denervation. Six-week-old pigs underwent unilateral renal denervation. Nerves along the renal artery of one kidney were identified, sectioned and painted with 10% phenol. Two weeks later the pigs were anesthetized and baseline renal function was determined using inulin and PAH clearances. Animals then had either sham-shockwave lithotripsy (SWL) (group 1), SWL to the innervated kidney (group 2) or SWL to the denervated kidney (group 3). Bilateral renal function was again measured 1 and 4 h after SWL. Both kidneys were then removed for analysis of norepinephrine content to validate the denervation. Renal plasma (RPF) flow was significantly reduced in shocked innervated kidneys (group 2) and shocked denervated kidneys (group 3). RPF was not reduced in the unshocked denervated kidneys of group 2. These observations suggest that renal nerves play a pivotal role in modulating the vascular response of the contralateral unshocked kidney to SWL, but only a partial role, if any, in modulating that response in the shocked kidney.

Holmium Laser Enucleation of the Prostate (HoLEP): A Technical Update.

INTRODUCTION: Holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation represents the latest refinement of holmium:YAG surgical treatment for benign prostatic hyperplasia (BPH). Utilizing this technique, even the largest of glands can be effectively treated with minimal morbidity. The learning curve remains an obstacle, preventing more widespread adoption of this procedure. This paper provides an outline of the HoLEP technique as is currently used at two centers in hopes of easing the initial learning curve. TECHNICAL CONSIDERATIONS: Detailed descriptions of the major steps of the HoLEP procedure are provided with attention to critical steps such as identification of the surgical capsule, median and lateral lobe enucleation, and morcellation of enucleated tissue. CONCLUSIONS: HoLEP is a promising alternative for the surgical treatment of BPH which allows complete removal of intact lobes of the prostate. Obstruction is relieved immediately with superior hemostasis, no risk of TUR syndrome, and a minimal hospital stay.

The use of blunt-tipped 12-mm trocars without fascial closure in laparoscopic live donor nephrectomy.

OBJECTIVES: Blunt-tipped trocar placement may eliminate the need for fascial closure in transperitoneal laparoscopic live donor nephrectomies (LDN). The process of 12-mm blunt-tipped trocar insertion through the abdominal wall involves fascial and muscle spreading, not incision. Coaptation of the tissue layers occurs during withdrawal of the trocar, preventing volume gaps that can be prone to herniation. METHODS: We retrospectively assessed the safety and efficacy of fascial nonclosure after 12-mm blunt-tipped port insertion in 70 transperitoneal LDNs performed between October 1998 and March 2001. Five ports (two 12-mm blunt-tipped and three 5-mm blunt-tipped) were used in all cases. The 12-mm trocars were inserted at the lateral border of the rectus muscle, approximately 8 cm below the costal margin and also along the anterior axillary line approximately 8 cm below the costal margin. Fascial non-closure was performed in all 70 patients. Postoperative data were analyzed regarding complications and long-term outcomes. RESULTS: Three major and 7 minor complications occurred in this series. No patient developed clinically detectable trocar-site hernias or other complications related to blunt-trocar placement. CONCLUSIONS: Our data shows that fascial nonclosure after transperitoneal 12-mm blunt-tipped trocar insertion is safe. Visualization of the tissue layers during port placement facilitated the insertion process. Further application of this method in a larger number of patients is needed to confirm its clinical applicability.

The pathogenesis of calyceal diverticular calculi.

Controversy exists over whether metabolic factors or urinary stasis predominate in the pathogenesis of calyceal diverticular calculi. We performed a study to better define the effects urinary stasis and metabolic abnormalities have in the pathogenesis of calyceal diverticular stones. Twenty-nine patients who underwent percutaneous treatment of calyceal diverticular calculi were studied. All patients underwent 24 h urine collection to evaluate metabolic risk factors. In three patients, urine was sampled directly from the diverticulum for metabolic studies. The urinary stone risk parameters of the patients with calyceal diverticular stones (Tic SF) were similar to those of a well-characterized cohort of calcium oxalate stone formers (CaOx SF). When compared to a group of normal people, the Tic SF and CaOx SF were significantly more hypercalciuric and their urine was significantly more supersaturated with calcium oxalate. Urine aspirated directly from the diverticulum had the lowest SSCaOx when compared to ipsilateral and contralateral renal pelves. The urinary risk profiles of patients with diverticular calculi are similar to those of CaOx SF, suggesting a metabolic etiology of diverticular stones. However, the SS CaOx of urine aspirated directly from the diverticula is significantly lower than that of the renal pelves; these data support the hypothesis that urinary stasis significantly contributes to the pathogenesis of calyceal diverticular calculi. Taken together, it seems likely that calyceal diverticular calculi arise from a combination of metabolic abnormalities and urinary stasis.

In vitro assessment of a novel dual probe ultrasonic intracorporeal lithotriptor.

PURPOSE: The Cyberwand (Cybersonics, Erie, Pennsylvania) is a novel intracorporeal lithotrite that uses coaxial ultrasonic elements operating at 2 frequencies. We compared this device to the LithoClast(R) Ultra, which we previously noted is the most efficient commercially available intracorporeal lithotripsy device. MATERIALS AND METHODS: An in vitro test system was used to assess the efficiency of stone penetration for the Cyberwand and the LithoClast Ultra. The devices were mounted upright with the probe tip up in a modified irrigation sheath. A gypsum artificial stone was centered on the probe tip and a mass was placed atop the stone to provide a constant force. The manufacturer recommended setting was selected for the Cyberwand, while for the LithoClast Ultra a pneumatic frequency of 12 Hz with an ultrasonic power setting of 100% was selected, representing optimal settings in previous in vitro tests. The time required for complete stone penetration was measured. Differences in mean stone penetration times were compared using ANOVA. RESULTS: Mean +/- SD penetration time for the Cyberwand was significantly shorter than for the LithoClast Ultra (4.8 +/- 0.6 vs 8.1 +/- 0.6 seconds, p <0.0001). Neither device showed any difficulties with overheating, occlusion or another malfunction. CONCLUSIONS: Initial assessment using our hands-free in vitro test system, in which stone penetration time is not affected by operator bias, suggests that the Cyberwand is an efficient lithotrite. These promising results justify in vivo testing.

The camera phone: a novel aid in urologic practice.

OBJECTIVES: To describe a novel use of the camera phone for efficient, reliable, and cost-effective collection and transmission of medical data in the urologic setting. METHODS: We used camera phones (Verizon VGA and Sanyo-Sprint PCS) with a resolution of 640 x 480 pixels to capture images in the operating room, as well as in the outpatient clinic. Images were obtained directly from the monitor or the x-ray viewing box. These were then immediately transmitted to the office computer through a secure Internet connection. The images were then incorporated into operative and office notes, as needed. RESULTS: The images obtained with this method were of adequate quality for demonstration purposes, with the added advantage of allowing secure transmission and storage. The best-quality images were those obtained directly from the x-ray viewing box or from a liquid crystal display monitor. In addition, the images could be edited and labels added with the aid of the software that came with the camera phone. CONCLUSIONS: This method allows the acquisition of fair-quality digital images of surgical procedures and radiographic studies with simultaneous data transmission and storage for clinical documentation. The technology reduced costs and increased the efficiency of our practice considerably.

Holmium laser enucleation of the prostate for prostates of >125 mL.

OBJECTIVE: To examine a group of patients treated with holmium laser enucleation of the prostate (HoLEP) and with the bladder outlet obstructed by an exceptionally large (>125 mL) prostate, as such men are often not considered candidates for endoscopic treatments and historically have required open surgery. PATIENTS AND METHODS: We analysed retrospectively all patients with prostates of > 125 mL on transrectal ultrasonography (TRUS) who underwent HoLEP between January 2000 and January 2005. RESULTS: Eighty-six patients were identified; their mean (range) age was 72.6 (48-90) years and prostate volume 170.2 (125-309) mL. Their mean preoperative prostate-specific antigen (PSA) level was 9.82 ng/mL and preoperative American Urologic Association symptom score (AUA-SS) was 19.6. The mean operative duration and hospital stay were 128.1 min and 26.1 h, respectively. The mean weight of tissue enucleated was 140.2 g. At the 1-month follow-up the mean AUA-SS (63 men) was 8.4 and at 6 months (35 men) it was 6.4. The mean serum PSA level in 48 patients was 0.96 ng/mL, a reduction of 90%. TRUS measurements in 20 patients gave a mean prostate volume of 30.8 mL, a reduction of 82%. At the 1-year follow-up the mean AUA-SS of 22 patients was 5.1. CONCLUSIONS: The present report details the largest series of patients, with the largest mean prostate size, treated by any endoscopic surgical method. HoLEP may be the ideal treatment for men with prostates of > 125 mL with symptoms of bladder outlet obstruction.