Ureteroscopic treatment of upper tract urinary calculi.

Ureteroscopic treatment of upper urinary tract calculi is continuously evolving. Initial reports were limited to the treatment of distal ureteral stones. These cases had mixed success, and compared to modern ureteroscopy, had significant associated morbidity. The entire urinary tract can now be safely accessed via ureteroscopy almost always. Improvements in ureteroscope technology have certainly made this possible. These advances include smaller steerable scopes and sharper optics and video. The enhanced view of the upper urinary tract in combination with advances in lithotripsy, in particular, the holmium laser, has resulted in increased treatment success and reduced procedure related morbidity. This review describes the advances in ureteroscopic technology and provides data regarding treatment success and associated complications.

Carcinoma in Situ of the Bladder.

Central to the earlier detection and effective treatment of bladder cancer is the understanding of the basic principle that in situ cancer, evolving from epithelial atypia or hyperplasia, is the early phase in the development of invasive bladder cancer. While it may be asymptomatic, irritative bladder symptoms such as frequency, urgency, and dysuria irrespective of bacteriuria are usually evident and should be evaluated with exfoliative urinary cytology to detect the presence of this cancer. Properly collected and skillfully interpreted cytologic examination of the urine is probably the most accurate screening test for this and other important varieties of bladder cancer. Improved technologic features of cystoscopy have aided in the identification of in situ cancer, particularly when multiple random cold biopsy specimens of all quadrants, including the trigone, of the bladder and of the prostatic urethra are employed. Such investigative methods recognize that in situ cancer is a generalized urothelial malignancy that very often involves ureteral, prostatic as well as all bladder mucosa. Despite the pathologic observation that this cancer shows an intense cellular activity, the temporal aspect of its transition from a superficial cancer to an invasive one remains unpredictable, although clearly finite. Treatment is controversial. Radical cystectomy should effect cure if recommended early and before it becomes clinically apparent that the disease is already invasive in some urothelial locations. If the cancer appears to be localized to a relatively small (5 cm) area of the bladder and the patient's symptoms are not excessive, intravesical chemotherapy using such preparations as Thio-tepa, mitomycin, Adriamycin, or epodyl may result in a temporary, sometimes complete, remission.

National High Blood Pressure Education Program (NHBPEP) review paper on complications of shock wave lithotripsy for urinary calculi.

This decade has witnessed dramatic advances in the surgical management of urinary calculi. Today, most stones can be removed by minimally invasive means. In fact, the treatment of choice in 60% to 90% of patients with renal and ureteral calculi that need to be surgically removed is extracorporeal shock wave lithotripsy (ESWL). This article reviews indications for ESWL and discusses deleterious effects of ESWL.

Current surgical approaches to nephrolithiasis.

Shock wave lithotripsy is the cornerstone of the modern management of surgical stone disease and is the procedure of choice for small stones in uncomplicated situations. As complexity increases and as the stone size increases, percutaneous lithotripsy becomes more important. Ureteroscopy is preferable for lower ureteral stones and is useful for many mid and upper ureteral stones. Occasional large, complicated stones, or stones that can be reached no other way, require open surgery. Successful management of a wide variety of patients with urinary calculi requires the recognition that multiple forms of therapy are necessary. Identification of the situations best managed by these different treatments will ensure optimal management of patients with surgical stone disease.

Early experience with percutaneous cholecystolithotomy.

Percutaneous cholecystolithotomy should be added to the list of alternatives to elective open cholecystectomy for the management of patients with gallstones. Our initial experience with percutaneous cholecystolithotomy in 13 patients (7 men and 6 women who ranged in age from 47 to 83 years) demonstrated that the procedure could be accomplished successfully with acceptable morbidity and no mortality. After a mean duration of follow-up of 10.7 months, only one patient had recurrent cholelithiasis. Because of rapid changes in the therapeutic approach to patients with cholelithiasis, percutaneous cholecystolithotomy may seldom be used.

Laparoscopic left adrenalectomy for aldosteronoma: early Mayo Clinic experience.

OBJECTIVE: To evaluate early results with laparoscopic left adrenalectomy in patients with an aldosteronoma. DESIGN: We retrospectively reviewed the medical records to Mayo patients in whom laparoscopic left adrenalectomy had been attempted for presumed aldosteronoma. MATERIAL AND METHODS: Data on the diagnosis, details about the procedure, occurrence of associated complications, and duration of recovery period were analyzed for all study patients. RESULTS: Of the nine patients who underwent attempted laparoscopic left adrenalectomy, seven had aldosteronoma. In six of the seven patients, the procedure was successful. No preoperative mortality occurred, and morbidity was limited to prolonged ileus in one patient. Of the other five patients with successful results, all tolerated liquids within 24 hours after the procedure. The mean postoperative hospital stay for the six patients with successful laparoscopic procedures was 2.3 days, and four patients were dismissed within 48 hours after the procedure. CONCLUSION: Laparoscopic adrenalectomy is a safe alternative for the management of aldosteronoma of the left adrenal gland.

Isolation of Chlamydia from patients with urethritis.

From October 1973 through August 1974, 335 genitourinary tract specimens from patients with urethritis were inoculated into McCoy's cell cultures for the diagnosis of Chlamydia infections. Of the 45 Chlamydia isolates, 42 were recovered when glass vials rather than plastic microtiter plates were used as cell culture vessels. Herpes simplex virus was isolated 15 times. Bacterial overgrowth occurred 42 times; however, in 20 specimens the contamination was not apparent until after the first subculture. This is the first report of the frequency of Chlamydia infections in patients with urethritis in the Midwest and indicates that these organisms have a significant etiologic role in nongonococcal urethritis in this community.

Percutaneous removal of kidney stones. Preliminary report.

We have performed percutaneous extractions of renal pelvic stones in 15 patients with the use of the Wolf percutaneous universal nephroscope. At one session, with the patient under general anesthesia, a percutaneous tract is dilated to 24 F, and the stone is immediately removed. Fifteen stones have been removed successfully by ultrasonic lithotripsy, basket retrieval, use of a forceps, or a combination of these techniques. Average operating time has been 1 hour and the mean hospitalization time 4 days. The advantages of this technique are that a skin incision of only 1 to 2 cm is required to remove the stone, hospital days are fewer than with open procedures, and postoperative morbidity is minimal. In selected situations, this method represents a significant advance over standard open surgical procedures for removal of renal pelvic stones.

Accuracy of antibody-coated-bacteria test in recurrent urinary tract infections.

Antibody coating of urinary bacteria was compared with results of ureteral catheterization studies in order to localize the site of recurrent urinary tract infections in 32 patients. The antibody-coated-bacteria test reliably detected infections in patients with upper urinary tract infection (16 of 17 patients), but false-positive results occurred frequently in patients with lower urinary tract infection (5 of 15 patients). The antibody-coated-bacteria test appears to be a useful screening test for localization of infection in patients with recurrent urinary tract infections.

Safety of same-day sequential extracorporeal shock wave lithotripsy and dissolution of gallstones by methyl tert-butyl ether in dogs.

Passage of stone fragments after extracorporeal shock wave lithotripsy (ESWL) of gallstones has resulted in biliary colic, duct obstruction, and pancreatitis in some patients. Rapid dissolution of these fragments with methyl tert-butyl ether (MTBE) may prevent such side effects and achieve complete clearance of gallstones within hours rather than several months to a year or longer. This study examines the safety of same-day ESWL fragmentation and MTBE dissolution of surgically implanted human gallstones in 15 dogs. The animals were randomly assigned to one of four treatment groups to assess MTBE absorption from the gallbladder and to observe hematology and chemistry profiles after 0, 400, and 1,200 shock waves from a lithotriptor followed by MTBE dissolution therapy. They were sacrificed either immediately after treatment (12 dogs) or 2 weeks later (3 dogs). The results demonstrated that although ESWL causes moderate trauma to the gallbladder, this did not result in increased MTBE absorption or histologic evidence of mucosal disruption. Blood profiles demonstrated an increase in only the level of aspartate aminotransferase. The three dogs that were sacrificed 2 weeks after the combined treatment had no residual evidence of gallbladder injury or remaining stone material. In all animals, severe injury occurred where shock waves passed through lung or air-filled colon. This study suggests that same-day sequential fragmentation of gallstones by ESWL followed by dissolution of stone fragments with use of MTBE may be associated with only mild to moderate and reversible gallbladder trauma and can rapidly achieve clearance of gallstones.

Transurethral microwave thermotherapy for prostatism: early Mayo Foundation experience.

As part of a multicenter investigative trial, transurethral microwave thermotherapy of the prostate was used in 60 men with symptomatic benign prostatic hypertrophy. A single office treatment on the Prostatron, a device that provides concurrent microwave heating of the prostate and conductive cooling of the urethra, was well tolerated and caused no major adverse events. Symptomatic improvement, especially the decrease in nocturia and urgency, was dramatic, and urinary flow was improved at 6 weeks. Continued follow-up suggests that further improvement will be achieved and that transurethral microwave thermotherapy has a role in the treatment of benign prostatic hypertrophy.

Surgical management of urinary calculi.

Shock wave lithotripsy is the cornerstone of the modern management of urinary calculi and is the preferred treatment for most small renal stones. Percutaneous lithotripsy is preferred for large stones and in combination with ESWL for staghorn calculi. Upper ureteral stones should be pushed back to the kidney for ESWL, if possible; otherwise they should be treated in situ. Lower ureteral stones are preferentially managed with ureteroscopy, but ESWL may also be used. A variety of methods of power lithotripsy are available: ultrasound, electrohydraulic lithotripsy, and pulsed dye laser lithotripsy. Only 1% to 2% of stone patients require open surgery; it is an important judgment to identify these patients to avoid inappropriate use of newer techniques in cases where success is unlikely. It is apparent that modern management of the patient with a urinary calculus requires access to all methods of stone removal. The surgeon and internist should not forget that the goal is to remove the stone safely, efficaciously, and economically.

Primary hyperparathyroidism and urolithiasis: concomitant surgical management.

Urolithiasis occurs in about 20% of patients undergoing cervical exploration for primary hyperparathyroidism. A small number of these patients may require surgical removal of the renal stones because of either obstruction or infection. The traditional surgical modalities for stone removal have been replaced by extracorporeal shock-wave lithotripsy, ureteroscopic stone removal, and percutaneous lithotripsy. During the period 1980 through January 1989, 22 patients underwent combined cervical exploration for primary hyperparathyroidism and treatment of renal or ureteral stones with a single general anesthetic at our institution. This study demonstrates that this approach can be performed safely with a high success rate and negligible morbidity and that this approach may have cost-effective implications.

Ureteral endometriosis diagnosed at ureteroscopy.

BACKGROUND: Intrinsic ureteral endometriosis is rare. Early detection and treatment is extremely important to preserve renal function. CASE: A 37-year-old woman with right flank pain was diagnosed with a polypoid lesion at excretory urogram. The polyp was removed under ureteroscopy and was found to be endometriosis. Subsequent exploratory laparotomy and ureterolysis failed to document other foci of endometriosis. Resection of the ureter was not needed. She received medroxyprogesterone for 6 months, and a ureteral stent was left in place for 3 months postoperatively. Excretory urogram showed no obstruction 6 months postoperatively. CONCLUSION: This appears to be the first reported case of ureteral endometriosis documented initially at ureteroscopy. Prompt treatment may relieve symptoms and preserve renal function. Resection of the ureter may be avoided in some patients.

A symptomatic testicular cyst in a patient with von Hippel-Lindau disease.

Von Hippel-Lindau disease (VHL) is an autosomal-dominant condition that often involves cystic changes within many organs, including the epididymis. However, no previous report of a patient with VHL and a benign intratesticular cyst has been published. We report on a 28-year-old man with otherwise stable VHL who presented with a symptomatic 3-cm intratesticular benign cyst. The cyst was successfully treated by partial orchiectomy.

Efficacy of a new endoureterotomy balloon for the treatment of benign ureteral strictures using the porcine model.

OBJECTIVES: Endoureterotomy and balloon dilation are techniques that have shown promise as treatment modalities for benign ureteral stricture disease. In this animal investigation, the results of a new endoureterotomy balloon that simultaneously incises and dilates the ureteral stricture via a retrograde approach are discussed. METHODS: Using the female pig model, 9 subjects with benign ureteral strictures were treated: 7 with the endoureterotomy balloon and 2 with balloon dilation only. RESULTS: Success based on radiologic parameters and Whitaker testing was obtained in 5 of the 7 animals treated by endoureterotomy. In both animals treated by balloon dilation only, recurrent ureteral stricture disease developed. CONCLUSIONS: This preliminary investigation suggests that this new device may be an effective treatment for benign ureteral stricture disease and that the further study in clinical trials is warranted.

Percutaneous ultrasonic lithotripsy.

Ultrasonic lithotripsy employed with a percutaneous nephroscope is a safe, controlled method of removal of renal and ureteral stones using the techniques described herein. A success rate of 95 to 98 per cent should be achievable.

Branched, struvite calculus and clear cell carcinoma in same kidney. Rare condition with significant implications for management.

The concomitant existence of a branched (partial staghorn) calculus and clear cell carcinoma (hypernephroma) in the same kidney is rare. Herein, we report the eighth such case in the world literature, and to our knowledge, the first patient with a parenchymal tumor identified preoperatively. In all of the previous 7 cases, the calculus was managed with open renal exploration, and only at the time of surgery was the incidental renal cell carcinoma identified; the surgical procedure was modified accordingly. With open surgery no longer the cornerstone of therapy for renal calculi, it is imperative that the kidney be evaluated in a meticulous and compulsive manner prior to extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PNL). The finding of a coexisting renal cell carcinoma will radically alter the patient's treatment.

Metaphase analysis of metanephric adenoma reveals chromosome Y loss with chromosome 7 and 17 gain.

A 61-year-old man underwent wedge excision of a 3-cm right renal metanephric adenoma. This recently recognized tumor has been considered benign, although no genetic studies have been reported. Metaphase analysis demonstrated a 47,X,-Y,+7,+17 karyotype. These results are consistent with a clonal neoplastic disorder.

Long-term follow-up of endoscopically treated upper urinary tract transitional cell carcinoma.

OBJECTIVES: This report focuses on the long-term follow-up of patients with endoscopically treated upper tract transitional cell carcinoma (TCC) to determine the effectiveness of endoscopic therapy. METHODS: From May 1983 to April 1994, 44 patients with TCC of the upper urinary tract underwent conservative endourologic treatment with either electrocautery fulguration or neodymium:yttrium-aluminum-garnet laser at our institution. The mean follow-up period was 5 years (range, 3 months to 11 years). RESULTS: Renal pelvic tumor sizes ranged from 0.4 to 4.0 cm (mean, 1.5) and ureteral tumors from 0.2 to 1.0 cm (mean, 0.5). The majority of tumors were of pathologic grade 3 or less, and all were Stage T2 or less. Seventeen of 44 patients (38.6%) had local tumor recurrence (mean time to recurrence, 12.8 months; range 1.5 to 64). Mean recurrence time was 7.3 months for renal pelvic tumors and 17.8 months for ureteral tumors. Nineteen of 44 patients (43.2%) developed bladder tumors. The overall 5-year disease-free rate was 57%. No recurrent tumor was shown to have increased in grade, and one recurrent tumor was proved to have progressed in stage. Six patients (14%) ultimately required a nephroureterectomy for recurrence. There were no major complications as a result of endoscopic therapy. Six patients (14%) died of the effects of metastatic TCC, 5 of whom had known muscle invasive bladder TCC. CONCLUSIONS: Endourologic techniques and the conservative treatment of upper urinary tract TCC is an evolving field and can be safely and effectively used as a first-line treatment for upper tract TCC in selected patients.