Donald P. Griffith

Report of the United States Cooperative Study of Extracorporeal Shock Wave Lithotripsy

Extracorporeal shock wave lithotripsy effectively fragments urinary calculi in the upper urinary tract and upper ureter. These fragments pass completely by 3 months in 77.4 per cent of the patients with single stones. Risk of obstruction, increased postoperative pain, need for additional urological operations and retained fragments are low for stones less than 1 cm. in size. As the number of stones treated or single stone size increases above 1 cm. the risk for these factors increases. Adjunctive urological surgical management is required in 9 per cent of the patients preoperatively and 8 per cent postoperatively. Only 0.6 per cent of the patients require some type of open operation to resolve the stone problems after extracorporeal shock wave lithotripsy. Hemorrhage, obstruction by fragments, severe pain and urinary infection all constitute known complications and require careful urological management of all patients. Hospitalization averages 2 days after treatment and patients usually return to work within a few days after they are discharged from the hospital.

Transperitoneal Endosurgical Lymphadenectomy in Patients with Localized Prostate Cancer

The main appeal of radiotherapy for carcinoma of the prostate lies in the low morbidity and good subsequent quality of life. The handicap of this approach is the absence of adequate staging through pelvic lymphadenectomy. A new operation with minimal morbidity for the patient is presented and described in detail: endosurgical (laparoscopic) pelvic lymphadenectomy. This operation can be performed on an outpatient basis and is extremely well tolerated by the patient. The results of the first 12 consecutive cases indicate that, with experience, the procedure can be performed within a reasonable time limit (90 to 205 minutes) and that the number of lymph nodes removed (right and left obturator fossae mean 7.6 and 7.1, respectively) is adequate. Endosurgical lymphadenectomy adds only minimal morbidity to the radiotherapeutic treatment of prostatic cancer but permits more accurate staging and, therefore, counseling of the patients.

Acetohydroxamic acid: clinical studies of a urease inhibitor in patients with staghorn renal calculi.

The hydrolysis of urea by the bacterial enzyme urease pathologically increase urinary ammonia, bicarbonate, carconate and alkalinity. These factors contribute to the formation of urinary stones and to the virulence of bacteria. Acetohydroxamic acid, a potent inhibitor of urease, has been administered to 23 patients with staghorn renal calculi and urea-splitting urinary infection. Urinary ammonia and alkalinity has been reduced in every patient. A dose of 1.0 gm. acetohydroxamic acid daily has been well tolerated and effective for 2 to 12 months, even in patients with impaired renal function.

The Use of Alloplastic Biomaterials in Bladder Substitution

The complexity of a total alloplastic prosthetic bladder is evident when one considers the fact that total alloplastic hearts have been applied clinically, although to a limited extent, for several years, whereas prosthetic bladders are still at the investigational stage in animals. 1 The ideal alloplastic bladder should be easy to implant surgically; preserve renal function; provide adequate urinary storage; allow volitional, complete evacuation of urine; be biocompatible; be resistant to extraluminal infection; be tolerant of intraluminal infection; deter intraluminal infection; discharge urine per urethram, and be mechanical reliable 2

The Role of Silicone Ureteral Stents in Extracorporeal Shock Wave Lithotripsy of Large Renal Calculi

Between November 1984 and December 1985 extracorporeal shock wave lithotripsy was used to treat 1,645 kidneys at our institution. A total of 646 kidneys with stone burden greater than 14 mm. was evaluated with regard to the impact of silicone ureteral stents in post-extracorporeal shock wave lithotripsy morbidity. Our results indicate that small stones were pulverized and eliminated with minimum morbidity. Larger stones frequently were associated with post-treatment ureteral obstruction by sand and fragments. Of 283 kidneys with stone burden exceeding 25 mm. pretreatment placement of silicone ureteral stents reduced complications from 26 to 7 per cent and auxiliary procedure rates from 15 to 6 per cent. Silicone ureteral stents protect the kidney from ureteral obstruction, and allow for safe and effective extracorporeal shock wave lithotripsy of large renal calculi.

Controlled Inversion Therapy: an Adjunct to the Elimination of Gravity-Dependent Fragments Following Extracorporeal Shock Wave Lithotripsy

The retention of passable stone debris is the primary shortcoming of extracorporeal shock wave lithotripsy. Residual stone debris is located almost universally in gravity-dependent caudal calices. Our findings suggest that multiple sessions of controlled inversion therapy could have a beneficial role in the postoperative management of this select group of patients.

Adjunctive chemotherapy of infection-induced staghorn calculi.

Bacteria induce urinary crystallization of struvite and carbonate-apatite as a by-product of ureolysis by urease. Eradication of infection and/or inhibition of urease with acetohydroxamic acid for 5 to 30 months retarded stone growth and brought about partial or complete dissolution of stones in 9 patients. Long-term chemotherapy with antimicrobial agents that achieve sterile urine or acetohydroxamic acid in those patients with recalcitrant infection lessens the risk of recurrent calculogenesis.

Generation of Formaldehyde from Methenamine: Effect of pH and Concentration, and Antibacterial Effect

Using an in vitro system that simulates the dynamics of the urinary tract, we have shown that concentrations of formaldehyde ≥ 25 μg/ml can be achieved in urine containing ≥ 0.6 mg of methenamine per ml at pH ≤ 5.7 or ≥ 1 mg/ml at pH ≤ 5.85. Exposure to this concentration of formaldehyde for 2 h produced a measurable antibacterial effect. These studies suggest that an effective bacteriostatic level of formaldehyde is likely to be achieved with currently used dosages of methenamine when the urine pH is less than 5.7 to 5.85.

Effect of Ammonium on Bacterial Adherence to Bladder Transitional Epithelium

The virulence of urease-producing bacteria depends on the ability of urease to degrade urea into ammonia and thereby to alkalinize the urine. Infections caused by urease-producing organisms such as Proteus mirabilis are particularly difficult to manage clinically. We have shown that the layer of glycosaminoglycans at the bladder surface protects against infection by blocking the adherence of bacteria to the epithelium. To determine whether urease-producing urinary pathogens owe their virulence in part to an ability to inactivate the protective effect of the glycosaminoglycan layer, we tested the ability of ammonium chloride to alter bacterial adherence to the normal vesical mucosa. We used an in vivo adherence assay that we have described previously in rabbits. Control animals received sodium chloride adjusted to the same pH as the ammonium chloride. We found that 0.25 M ammonium chloride significantly increases bacterial adherence to normal vesical mucosa as compared to adherence in controls receiving 0.25 M sodium chloride (p less than 0.05). These data suggest that urease plays a hitherto undescribed role in bacterial virulence by altering the antiadherence activity of the glycosaminoglycan layer present at the transitional cell surface.

Pica/Burden: A Staging System for Upper Tract Urinary Stones

A staging system is proposed to stratify upper urinary tract stones by their complexity, location and burden. Burden is defined as the sum of the longest axial diameter of all stones. The kidney is divided into 3 cavities (pelvis, branches or infundibula and calices). The ureter is defined according to 4 segments (upper, middle, lower and juxtavesical). Special descriptors (sand, match heads and fragments) are defined. The use of a scoring diagram allows for a concise description of the complexity and burden of stone in each renal and ureteral cavity. The system facilitates computerized stratification of upper tract stones.