David N. Siegel

Management of Hemorrhagic Complications Associated with Percutaneous Nephrolithotomy

Urologists have witnessed replacement of complex open surgical procedures with minimally invasive therapies over the past quarter century. Nothing personifies this more than an anatrophic nephrolithotomy in the management of kidney stones. The Boyce procedure, once the gold standard for staghorn calculi, is rarely performed. Percutaneous nephrolithotomy (PCNL) has become the gold standard procedure for large renal stones and staghorns. This article will review the hemorrhagic complications that are associated with PCNL and the necessary therapeutic interventions.

Yield of renal arteriography in the evaluation of pediatric hypertension.

Abstract The prevalence of renovascular disease is estimated to be 3%–5% in pediatric patients with hypertension. The utility of non-invasive imaging tests has not been evaluated in children, and renal arteriography remains the diagnostic test of choice. However, there are no established guidelines for the application of this test and information is not available about the likelihood of detecting an abnormality if an arteriogram is performed in children with hypertension. Therefore, we reviewed the yield of renal arteriography in pediatric patients if the test was performed based on the following two criteria: (1) severe hypertension exceeding the 99th percentile for age and sex or (2) failure to control high blood pressure with one antihypertensive drug. During the period 1983–1998, 28 children (mean age 11.7 years) who satisfied one of the above criteria underwent renal arteriography to investigate hypertension. None of the patients were renal transplant recipients. The average duration of hypertension was 11 months and the peak blood pressure was 168/107 mmHg. The renal arteriogram was abnormal in 12 patients (43%). Unilateral renal artery stenosis was the most-common abnormality. When the patients were divided into two groups – those with an abnormal or normal test result – they did not differ in age, sex, or racial distribution. The peak systolic blood pressure was higher in children with an abnormal renal arteriogram (P<0.05). Among those undergoing the arteriogram on the basis of the first criterion, i.e., severe hypertension, 11 of 23 (48%) studies were abnormal. Five children had an arteriogram based on the second criterion – failure to control the blood pressure with one medication – and in 1 patient (20%) the test was abnormal. We conclude that the prevalence of renovascular disease in a population of hypertensive children subjected to renal arteriography is around 40%. Two clinical criteria – namely severe hypertension or failure to control hypertension effectively with one drug – are useful to guide the application of renal arteriography in children with hypertension.

Prostatic Artery Embolization to Treat Lower Urinary Tract Symptoms Related to Benign Prostatic Hyperplasia and Bleeding in Patients with Prostate Cancer: Proceedings from a Multidisciplinary Research Consensus Panel

AUR = acute urinary retention, BOO = bladder outlet obstruction, BPH = benign prostatic hyperplasia, FDA = U.S. Food and Drug Administration, IDE = investigational device exemption, IPSS = International Prostate Symptom Score, LUTS = lower urinary tract symptoms, PAE = prostatic artery embolization, PV = prostate volume, QOL = quality of life, TUMT = transurethral microwave thermotherapy, TURP = transurethral resection of the prostate, RCP = research consensus panel, UTI = urinary tract infection

Efficacy and Morbidity of Therapeutic Renal Embolization in the Spectrum of Urologic Disease

PURPOSE We report the largest series of renal embolizations performed for a variety of indications. PATIENTS AND METHODS A retrospective analysis was performed on embolizations performed in our institution from 1997 to 2002 encompassing 36 patients who underwent 44 procedures. RESULTS Embolization was successful on the first attempt in 87% of the patients. A second embolization was performed in four of the five unsuccessful cases, three successfully, increasing the success rate to 95%. The mean postoperative narcotic use was 27.2 mg of morphine equivalent, and 10 mg or less was required by 45% of the patients. In the 14 patients who had not also undergone a surgical procedure, the mean narcotic use was 21 mg, and 64% required 10 mg or less. Only 15% of the patients developed fever, which resolved within 2 days in all cases. Leukocytosis was seen in 47%. Follow-up creatinine and hypertension information was available in 16 and 18 patients, respectively. After a mean follow-up of 269 days, only one patient had a clinically significant rise in the creatinine concentration. After a mean follow-up of 496 days, two patients had new-onset hypertension. There was no statistically significant difference in the success rate, narcotic use, complications, creatinine concentrations, or the likelihood of fever, leukocytosis, or hypertension according to the indication for embolization or the agent used. Use of a microcatheter was associated with less parenchymal loss, and decreased parenchymal loss was associated with a significant reduction of narcotic use. CONCLUSIONS Renal embolization is a highly effective and well-tolerated procedure in a variety of urologic conditions. The indications and material used did not have a significant effect on the outcome. Reducing parenchymal loss can significantly reduce morbidity.

Angiographic Findings of Primary Versus Salvage Varicoceles Treated with Selective Gonadal Vein Embolization: An Explanation for Surgical Treatment Failure

BACKGROUND AND PURPOSE Gonadal vein angioembolization is a successful means of primary and salvage treatment for symptomatic varicoceles. We aim to investigate angiographic findings during embolization of primary varicoceles vs those with failed surgical ligation. PATIENTS AND METHODS Between 1992 and 2010, 106 cases referred to our interventional radiologists for primary or salvage varicocelectomy were reviewed. These patients underwent venography and gonadal vein embolization using a combination of embolization coils and vascular plugs. All images were reviewed by an interventional radiologist to determine the anatomic etiology of the varicocele. Primary and salvage embolization cohorts were compared using t test and chi-square analyses for continuous and categorical variables, respectively. Angiographic parameters were analyzed using univariate and multivariable regression models to determine significance in predicting primary vs salvage status. RESULTS Of the 106 patients, 46 patients (57 testicles) underwent primary and 60 patients (62 testicles) underwent salvage embolization. The salvage cohort of patients was younger (P<0.001) and comprised more solely left-sided pathology (P=0.002). An equivalent number of gonadal vein divisions and proportion of patent gonadal veins was found. However, there was a significantly higher proportion (27.8% vs 6.7%) of inguinal collateral vessels and combined presence of inguinal and retroperitoneal collateral veins (8.5% vs 2.1%) identified in the cohort undergoing embolization after failed surgical varicocelectomy. Presence of inguinal collaterals (P=0.008) as well as presence of both inguinal and retroperitoneal collaterals (P=0.038) on multivariable regression analysis revealed both as independent prognosticators of salvage status. CONCLUSION Recurrence after surgical varicocelectomy is associated with increased inguinal collaterals. The pitfall presented by this anatomic variant to surgical ligation may be successfully managed with selective gonadal vein embolization.

Embolization of an Aberrant Right Subclavian Artery Aneurysm with Amplatzer Vascular Plug without Bypass

Aberrant right subclavian artery (ARSA) aneurysms are rare, but the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. Open surgical repair of ARSA aneurysms usually requires thoracotomy and aortic grafting, which can be contraindicated in high-risk patients with multiple comorbidities. Endovascular repair of ARSA aneurysms has been reported, with or without adjunctive surgical bypass. We report a case of an 80-year-old woman resenting with an asymptomatic 4 cm ARSA aneurysm who underwent a completely endovascular treatment of the aneurysm using an Amplatzer vascular plug II (St. Jude Medical Inc., St. Paul, MN).

Percutaneous cholecystolithotomy: a case for fulguration of the gallbladder wall.

Percutaneous cholecystolithotomy (PC) has been described previously as an alternative to laparoscopic cholecystectomy in high-risk patients and in those with adherent gallbladders that are not amenable for laparoscopic cholecystectomy. However, it is associated with a high (41%) recurrence of cholelithiasis due to intact gallbladder mucosa. In this paper, we describe a case of PC with fulguration of the gallbladder mucosa to scar and defunctionalize the mucosa and thus prevent recurrence of stones. After 12 months of follow-up, the patient remains asymptomatic.

Asymptomatic Intrahepatic Portosystemic Venous Shunt: To Treat or Not To Treat?

Intrahepatic portosystemic venous shunts (IPSVSs) are rare vascular malformations. They can be asymptomatic or present with various symptoms including encephalopathy. We present two cases of IPSVS, one involving a patient presenting with altered mental status and the other discovered incidentally. While there is no question that patients presenting with symptomatic IPSVS should undergo definitive treatment, there is no consensus regarding elective therapy for asymptomatic lesions.

Skin-to-tumor Distance Predicts Treatment Failure of T1A Renal Cell Carcinoma Following Percutaneous Cryoablation

OBJECTIVE To determine the impact of skin-to-tumor (STT) distance on the risk for treatment failure following percutaneous cryoablation (PCA). METHODS We retrospectively reviewed patients who underwent PCA with documented T1a recurrent renal cell carcinoma (RCC) at 2 academic centers between 2005 and 2015. Patient demographics, tumor characteristics, and perioperative and postoperative course variables were collected. Additionally, we measured the STT distance by averaging the distance from the skin to the center of the tumor at 0°, 45°, and 90° on preoperative computed tomography imaging. RESULTS We identified 86 patients with documented T1a RCC. The mean age at the time of surgery was 69 years (range: 37-91 years), and the mean tumor size was 2.7 cm (range: 1.0-4.0 cm). With a mean follow-up of 24 months (range: 3-63 months), 11 (12.8%) treatment failures occurred. Patients with treatment failure had significantly higher mean STT distance than those without: 11.0 cm (range: 6.3-20.1 cm) compared to 8.4 cm (range: 4.4-15.2 cm), respectively (P = .002). STT distance was an independent predictor of treatment failure (odds ratio: 1.32, 95% confidence interval: 1.04-1.69, P = .029). STT distance greater than 10 cm had a fourfold increased risk of tumor treatment failure (odds ratio: 4.43, 95% confidence interval: 1.19-16.39, P = .018). Tumor size, R.E.N.A.L. Nephrometry score, and number of cryoprobes placed were not associated with treatment failure. CONCLUSION STT, an easily measured preoperative variable, may inform the risk of RCC treatment failure following PCA.

Selective Arterial Prostatic Embolization (SAPE) for the Treatment of Lower Urinary Tract Symptoms in the Setting of Benign Prostatic Hyperplasia: A Brief Review

Tel: 212-241-9955 Benign prostatic hyperplasia (BPH) is a common condition related to aging that can lead to a cluster of chronic symptoms collectively known as lower urinary tract symptoms (LUTS), including urinary frequency, urinary urgency, nocturia, hematuria, and decreased urinary stream. It is estimated that BPH affects 75% of men in the United States by age 70, with more than