Bruce L. McClennan

Optimal Therapy for the Distal Ureteral Stone: Extracorporeal Shock Wave Lithotripsy Versus Ureteroscopy

Extracorporeal shock wave lithotripsy (ESWL not equal to) is the optimal therapy for renal calculi less than 2 cm. in diameter and for proximal ureteral calculi. Controversy continues over the initial approach to distal ureteral calculi (that is below the bony pelvis): in situ ESWL versus ureteroscopy. Since February 1990, 76 distal ureteral calculi were treated at our institution using either in situ ESWL (Dornier HM3 ESWL with a Stryker frame modification in 27 patients or Siemens Lithostar electromagnetic ESWL in 22) or ureteroscopy (27 patients). Patient age and stone size were similar among the groups. All ESWL treatments were performed with the patient under intravenous sedation and on an outpatient basis. Stone-free rates were 96% for the HM3 device, 84% for the Lithostar and 100% for ureteroscopy. Retreatment was required in 3 Lithostar cases (14%) and 1 HM3 case (4%). When compared to ESWL ureteroscopy for distal ureteral stones was more time-consuming, entailed routine placement of a ureteral stent, often required general anesthesia, more often led to hospitalization and doubled the convalescence period. From a cost standpoint, ESWL on an HM3 unit was a few hundred dollars more expensive than ureteroscopy. In summary, we believe that in situ ESWL provides optimal first line therapy for distal ureteral calculi, while ureteroscopy is better reserved as a salvage procedure should ESWL fail.

The Extraperitoneal Approach and Subcutaneous Emphysema are Associated with Greater Absorption of Carbon Dioxide During Laparoscopic Renal Surgery

PURPOSE We investigated the association of carbon dioxide absorption with the approach (transperitoneal versus extraperitoneal) and other factors during laparoscopy. MATERIALS AND METHODS Carbon dioxide elimination during laparoscopic renal surgery was retrospectively calculated in 63 patients. RESULTS Carbon dioxide elimination increased with time. Multiple factorial analysis revealed that subcutaneous emphysema and the extraperitoneal approach were independently associated with a greater increase in carbon dioxide elimination. Pneumothorax and pneumomediastinum were more common during extraperitoneal procedures. CONCLUSIONS Carbon dioxide absorption during laparoscopic renal surgery increases with time, and is greatest in patients treated through an extraperitoneal approach and in those with subcutaneous emphysema. Nonetheless, with attentive ventilatory management adverse sequelae of hypercapnia can be avoided.

Adrenal Involvement from Renal Cell Carcinoma: Predictive Value of Computerized Tomography

Although adrenal involvement from renal cell carcinoma is rare, removal of the adrenal during radical nephrectomy continues to be standard practice. To assess the actual need for adrenalectomy, we elected to evaluate whether malignant involvement of the adrenal gland could be reliably diagnosed preoperatively by a computerized tomogram (CT) of the abdomen. A blinded retrospective review of preoperative abdominal CT in 157 patients with renal cancer revealed an abnormality of the ipsilateral adrenal gland in 38. Histopathology confirmed malignant involvement of the adrenal in 10 patients. Significantly, all 119 adrenal glands judged to be normal on the preoperative CT were confirmed to be uninvolved by the renal cancer on histopathological study. We conclude that abdominal CT is reliable in the preoperative evaluation of the ipsilateral adrenal gland and assessment of its noninvolvement with renal carcinoma. In such cases adrenal sparing nephrectomy may be considered (76% of our patients). None of these 119 patients had either macroscopic or microscopic adrenal involvement. When the adrenal is not identified, displaced or enlarged on CT (24% of our patients) adrenalectomy should be routinely performed as part of radical nephrectomy. Even in this select group adrenal involvement was present in only 26% of the cases.

LONG-TERM OUTCOME OF CALICEAL DIVERTICULA FOLLOWING PERCUTANEOUS ENDOSURGICAL MANAGEMENT

PURPOSE We review the morbidity and long-term outcome of percutaneous caliceal diverticulectomy and associated stone extraction. MATERIALS AND METHODS Percutaneous caliceal diverticulectomy was performed in 19 women and 11 men (age range 20 to 58 years), of whom 26 had stones (all 15 mm. or less). The diverticula were located throughout the kidney, including the upper (11 patients), middle (15) and lower (4) calices. Percutaneous caliceal diverticulectomy included 28 direct and 2 indirect accesses (1 via a previously placed nephrostomy tract and 1 due to stones in other areas of the kidney). In all cases the stone was removed and the diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 22 cases. Transdiverticular percutaneous renal and ureteral drainage was maintained from 2 to 7 days until a nephrostogram demonstrated no extravasation. RESULTS The average operating room time and hospital stay were 171 minutes (range 75 to 330) and 4.1 days (range 2 to 7), respectively. Major complications occurred in 6.6% of the cases, requiring 1 blood transfusion and 1 chest tube placement, and minor complications occurred in 13.4%. There was no mortality. Followup for more than 1 year was available in 27 patients. Stone-free rate was 93% with obliteration of the diverticulum in 76% of patients. Overall, 85% of patients are asymptomatic at average followup of 3.5 years (range 1 to 7.3). CONCLUSIONS Direct percutaneous endosurgical management provides a safe, efficacious and durable means of treating stone bearing caliceal diverticula, regardless of stone size or location of the diverticulum.

Are Excretory Urograms Necessary in Evaluating Women with Urinary Tract Infection

Of 164 excretory urograms obtained from women with a history of recurrent urinary tract infections 88 per cent were perfectly normal. Eleven (6.7 per cent) had minor, normal, anatomic variations. Nine (5.5 per cent) were considered to have positive findings but in no case a significant finding present that required surgical intervention or altered the therapeutic approach. The total cost of the studies to the patients involved was

Computed tomography in the staging of testicular neoplasms.

17,930. Thus, an extremely negative cost-benefit ratio emerged. The routine use of excretory urograms as part of the evaluation of a woman with a urinary tract infection is expensive, unrewarding and has little justification.

Comparison of computed tomography and conventional cystography for detection of traumatic bladder rupture.

Twenty-six patients with primary testicular tumor were evaluated by computed tomography. It was highly accurate in differentiating lymph node metastases from testicular tumors. CT scanning may reveal tumor in lymph nodes not normally opacified during bipedal lymphangiography. It can also be used in treatment planning, follow-up, and in localizing sites of recurrence when serum tumor markers become positive. Some pitfalls of CT are also discussed.

Relative value of computed tomography and ultrasonography in the assessment of renal angiomyolipoma.

Computed tomography (CT) is the method of choice for evaluating patients with blunt abdominal and/or pelvic trauma. However, the sensitivity of CT for detecting bladder ruptures has been questioned. We reviewed both the conventional cystograms and the CT examinations of 25 patients who had both studies as the initial evaluation of blunt abdominal and pelvic trauma in the last 5 years. Five of these 25 patients had bladder ruptures, three extraperitoneal and two intraperitoneal. All five injuries were detected by both CT and conventional cystography. In one patient the conventional cystogram was falsely positive. In this case the correct diagnosis was made by CT, and a repeat cystogram confirmed that no bladder injury was present. Our results indicate that CT, if properly performed, is as sensitive for detection of bladder injuries as conventional cystography.

Computed tomography in malignant endometrial neoplasms

Imaging studies on six patients with known angiomyolipomas were reviewed to determine the contribution of each imaging modality to the preoperative diagnosis. A spectrum of clinical presentations from asymptomatic patients with tuberous sclerosis to acutely ill patients with flank pain and hypotension was included. Findings varied from multiple, small, bilateral intrarenal masses to single larger masses with extrarenal components. Computed tomography (CT) identified fat containing masses in all cases. Ultrasound showed hyperechoic masses in all four cases in which it was utilized. In addition, CT allowed diagnosis of associated hematomas and additional angiornyolipomas not seen on other studies. Ultrasound provided a noninvasive follow-up method without the use of ionizing radiation.

Extracorporeal shock-wave lithotripsy of middle ureteral stones: Are ureteral stents necessary?

Malignant uterine neoplasms are the most common invasive gynecological malignancies. The prognosis depends on the history, the grade, and the stage. Recent reports have stressed that a small percentage of patients with clinically low stage disease have unsuspected metastases. We retrospectively reviewed 61 patients with known malignant uterine neoplasms. In 18 patients with preoperative computed tomographic examinations, these scans detected unsuspected omental metastases in two and pelvic adenopathy in three. There was one false positive and one false negative examination. Computed tomography was superior to the clinical examination in defining the extent of the tumor in five patients. Computed tomography was also helpful in evaluating patients with suspected recurrent disease.