David F. Green

Early Experience with Direct Vision Electrohydraulic Lithotripsy of Ureteral Calculi

Rigid ureteroscopy is now an established technique for the management of ureteral stones. Manipulation of calculi can be done under direct vision using flexible forceps or stone baskets with increased safety and efficacy. We also have used a 5F electrohydraulic lithotripsy electrode to disintegrate stones that were too large to be removed by manipulation. Between October 1982 and January 1984, 36 ureteroscopies were performed for the removal of ureteral stones. In 26 cases (72 per cent) the stone was removed successfully. Electrohydraulic lithotripsy was used successfully to remove the stone in 9 cases (24 per cent) and there were no immediate complications. Followup with excretory urography in 7 of these patients 2 to 18 months after lithotripsy failed to reveal any evidence of long-term complications. We conclude that electrohydraulic lithotripsy under direct vision can be done safely if certain guidelines are adhered to strictly.

Complications of Ureteral Endoscopy

Use of the rigid ureterorenoscope has become widely accepted for the diagnosis of ureteral lesions, and for the removal and disintegration of ureteral calculi. Few complications have been reported. During the last 3 years 128 ureteroscopic procedures were performed for a variety of indications (98 for stone disease). There were 26 complications: 22 minor with no morbidity and 4 major that required surgical correction. Minor complications consisted of asymptomatic ureteral perforations in 6 patients, perforations with urinary extravasation, pain, ileus or fever in 4, migration of the stone into the kidney in 10 and migration of the stone outside the ureter with the calculus left in situ in 2. Major complications included ureteral perforation during basket extraction of an upper ureteral stone, urinoma following perforation and requiring drainage, stenosis of the intramural ureter that was corrected by marsupialization and aseptic necrosis of the ureter that was treated by ileal replacement.

A Comparison of Endoscopic Suspension of the Vesical Neck versus Anterior Urethropexy for the Treatment of Stress Urinary Incontinence

Endoscopic suspension of the vesical neck has been reported to be as effective as anterior urethropexy in the treatment of female stress urinary incontinence. We compared our first 29 patients treated with endoscopic suspension of the vesical neck between 1982 and 1985 to our last 21 patients treated with anterior urethropexy between 1979 and 1985. Both groups were comparable in regard to age, parity, duration of symptoms and previous surgery for stress urinary incontinence. All patients underwent thorough preoperative urodynamic testing. Endoscopic suspension of the vesical neck successfully cured stress urinary incontinence in 26 patients (90 per cent), while anterior urethropexy resolved the incontinence in 20 (95 per cent). Of the 3 failures of endoscopic suspension 2 probably were related to technique or material failure. Hospitalization was reduced for endoscopic suspension versus anterior urethropexy (mean 4.04 versus 6.00 days, respectively). The most common complication after endoscopic suspension of the vesical neck was transient urinary retention (34 per cent). We conclude that endoscopic suspension of the vesical neck is an effective method to treat stress urinary incontinence, and that it also reduces hospital stay and postoperative recovery.

Urodynamic Studies in Patients Undergoing Bladder Replacement Surgery

A high incidence of nocturnal incontinence has been a problem in patients undergoing continent urinary diversion when intact bowel segments are used. Detubularization has been advocated to solve this problem. Fifteen patients underwent continent urinary diversions and 4 underwent bladder augmentation with a variety of intestinal segments. Detubularization of the right colon anastomosed to the urethra was used in the first 3 patients, all of whom experienced nocturnal incontinence. Urodynamic studies showed high pressure contractions of the intestinal pouch of 60 to 100 cm. water pressure after the pouch was filled with 50 to 150 cc fluid. Incorporation of an ileal patch into the detubularized segment of colon was effective in reducing these pressures to 15 to 60 cm. water. This method reduced but did not eliminate the incidence of nocturnal incontinence. It is suggested that other factors may account for this problem.

Does Intravesical Chemotherapy Prevent Invasive Bladder Cancer

Intravesical chemotherapy has been shown to prolong the interval free of disease and to reduce the tumor recurrence rates in patients with superficial bladder cancer. These observations led us to consider whether a course of intravesical chemotherapy might provide a long-term decrease in the recurrent tumor rate or reduce the incidence of progression to invasive carcinoma. The records of 123 patients entered into a randomized multicenter protocol between 1975 and 1978 were examined. Patients had received a 1-year course of thiotepa or VM26, or transurethral resection alone. Mean followup was 47 months. Patients receiving thiotepa or VM26 had a lower rate of tumor recurrence, expressed as recurrences per 100 patient-months, than those undergoing transurethral resection only (5.25 versus 5.71 versus 7.98) but this was not statistically significant. However, 28 per cent of the controls required therapy besides transurethral resection to control the bladder cancer and 19 per cent died of advanced bladder cancer during followup. Only 15 per cent of the patients undergoing intravesical chemotherapy required therapy other than transurethral resection and only 3 per cent died of advanced carcinoma of the bladder. This finding suggests that intravesical chemotherapy given for 1 year is associated with a significant decrease in the incidence of tumor progression, and provides the justification to conduct future trials with extended followup.

A Phase II Study of Intravesical Mitomycin C in the Treatment of Superficial Bladder Cancer

Twenty-three patients with histologically proven superficial bladder cancer (Tis, Ta, T1) were treated with intravesical instillations of Mitomycin C at a dose of 20 mg in 20 ml of water 3 times weekly for 21 instillations. Seventeen patients (77%) showed complete disappearance of all known disease and a further 4 showed partial responses. In 8 patients toxic effects developed (thrombocytopaenia 1, chemical cystitis 2, skin rash 3, urinary tract infection 2). All resolved rapidly on stopping the treatment but were severe enough in 5 patients to prevent them from receiving a full course of treatment.

Management of the bladder by augmentation ileocecocystoplasty.

Use of cecum and ileum to construct a large capacity, urinary reservoir with provision for easy intermittent catheterization is described. The technique is useful in the management of hypertonic or hyperreflexic vesical dysfunction.

Acute Adrenal Insufficiency as a Complication of Urological Surgery

Acute adrenal insufficiency postoperatively is an uncommon problem and, if unrecognized, it may cause serious morbidity and can be fatal. It can occur as the result of acute bilateral adrenal hemorrhage associated with anticoagulation, inadvertent injury to or removal of a solitary adrenal gland, or postoperative stress in an individual with incipient adrenal insufficiency. Its manifestations, such as fever, tachycardia, hypotension, lethargy, abdominal pain and gastrointestinal dysfunction, mimic the other more common postoperative complications and compound the difficulty in establishing the correct diagnosis. Once the diagnosis is made the condition is readily managed successfully. We report 3 cases of acute adrenal insufficiency occurring after salvage cystectomy, ileal replacement of the ureter and retropubic prostatectomy, which illustrate the salient clinical features, problems in diagnosis and predisposing risk factors. All 3 patients survived once the diagnosis of adrenal insufficiency was made. These cases emphasize the need to be aware of the possibility of this complication to make the correct diagnosis and to institute proper treatment.

Ureteropelvic junction obstruction after percutaneous nephrolithotripsy.

Percutaneous nephrolithotripsy is reported to have few complications. However, we have treated 6 cases of complete ureteropelvic junction obstruction that occurred at a number of centers after percutaneous nephrolithotripsy. In 2 patients stones were impacted at the ureteropelvic junction, 3 had pre-existing stenosis and 1 had had no previous structural abnormality. All stones were less than 2 cm. in size and 5 were removed by ultrasonic disintegration. A nephrostogram after percutaneous nephrolithotripsy showed complete ureteropelvic junction obstruction in 4 cases and partial obstruction that progressed to total obstruction in 6 days in 1. In 1 case the nephrostogram was normal but occlusion was noted 2 weeks later. Initial management consisted of nephrostomy drainage for an average of 3.2 months. One patient was treated successfully with a ureteral stent for 6 weeks after balloon dilation, 1 had unsuccessful balloon dilation and 1 had undergone an unsuccessful endoscopic pyelolysis. Pyeloplasty was successful in 3 cases. In 1 patient 2 attempts at pyeloplasty failed and nephrectomy was performed. In the remaining patient ureterocalycostomy failed and interposition of a small segment of ileum was done. Pre-existing stenosis of the ureteropelvic junction or a stone impacted at the junction probably contributed to the obstruction and stenosis in 5 patients. The passage of ureteral guide wires should be avoided in these patients and impacted stones should be dislodged before endoscopic removal. Extracorporeal shock wave lithotripsy is an option in these cases if the stone can be dislodged or bypassed with a stent. Patients with pre-existing ureteropelvic junction obstruction might be treated best by open nephrolithotomy and pyeloplasty or by percutaneous nephrolithotripsy and endoscopic pyelolysis for ureteropelvic junction narrowing.