Erich K. Lang

Recanalization of obstructed fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis *

OBJECTIVE To investigate effectiveness and cost of transcervical salpingography and recanalization in the management of infertility caused by tubal occlusion. DESIGN Retrospective analysis of patients investigated with transcervical selective salpingography and, in some instances, treated by transcervical recanalization. SETTING Four hundred patients with hysterosalpingography diagnosis of obstructed fallopian tubes (clinical environment) are investigated. A repeat hysterosalpingogram after administration of a prostaglandin antagonist demonstrated patency of the tubes in 82 patients and selective transcervical salpingography demonstrated patency in an additional 131 patients. INTERVENTION Transcervical tubal recanalization. Of the remaining 187 patients, recanalization by transcervical technique was successful in 145 patients. The underlying etiology for tubal obstruction was salpingitis isthmica nodosa in 62, salpingitis and perisalpingitis in 71, endometriosis in 8, failed surgical anastomosis in 43, and undeterminate cause in 3 patients. Pregnancy was attained in 24 patients, there were 10 minor and 1 major complication. OUTCOME MEASURE Attained and maintained patency of tubes, pregnancy, attendant complications. CONCLUSION A pregnancy rate of 12.8% was attained after transcervical recanalization of obstructed tubes. An attendant increased rate of pregnancy in patients proven patent after selective salpingography, valuable detailed information about proximal and distal tubes after recanalization of the obstructed proximal tube segment, the low rate of complications, and low cost are factors recommending the use of this technique. Moreover, tubal surgery or IVF treatment are not influenced adversely by prior transcervical tubal recanalization and remain an option for patients who failed to attain pregnancy.

Percutaneous nephrostomy as adjunct management in advanced upper urinary tract infection

OBJECTIVES To determine by retrospective review of 315 percutaneous nephrostomies, performed for pyonephrosis, whether this intervention has major clinical advantages. METHODS From 1977 to 1996, under the direct supervision of the senior author of this report (E.K.L.), at seven hospital sites, 315 patients (181 males, 134 females; 17 to 88 years of age) were treated with percutaneous nephrostomy and antibiotic therapy for infected hydronephrosis. RESULTS Additional or disparate pathogens were identified in 116 (36.8%) of 315 patients, leading to a clinically significant change in, or addition of, antibiotics and/or antifungal agents in 84 (73%) of 116. Most notably, we often found a clinically important disparity between the results of cultures obtained from the nephrostomy and those obtained from bladder-urine specimens. CONCLUSIONS This retrospective review confirms previously reported advantages of percutaneous upper urinary tract drainage as a potentially life-saving adjunct in the treatment of pyonephrosis. Several case studies highlight the advantage of this maneuver in difficult cases involving obstruction due to extensive fungus or debris. In particular, our review focuses attention on the clinically important insight that urine cultures from percutaneous nephrostomy drainage often identify pathogens that differ from those detected in concurrent bladder cultures.

Comparison of dynamic and conventional computed tomography, angiography, and ultrasonography in the staging of renal cell carcinoma.

A prospective study was carried out on 22 patients to assess the diagnostic ability to stage renal cell carcinoma by computed tomography, dynamic computed tomography, arteriography, ultrasongraphy, and radionuclide scanning. Dynamic computed tomography remedied the most consequential diagnostic shortcomings of conventional computed tomography and proved the most sensitive, specific, and accurate technique for staging of all types of contiguous extension of renal cell carcinoma. For the identification of bone metastases, radionuclide scintiscanograms were found most accurate and cost‐effective.

Multiphasic helical CT diagnosis of early medullary and papillary necrosis.

PURPOSE The feasibility of identifying early manifestations of renal papillary necrosis (RPN) and medullary necrosis (RMN) on multiphasic helical CT, leading to prompt treatment for the causative conditions, and its impact on reducing the incidence of late-stage RML and RPN, was investigated. PATIENTS AND METHODS Sixty-eight patients (35 male, 33 female) aged 19 to 88 years were examined by multiphasic helical CT for complaints of microscopic hematuria (N=49), macroscopic hematuria (N=2), bacteriuria (N=45), pyuria (N=10), fever (N=15), and flank pain (N=27). Preenhancement, arterial corticomedullary, parenchymal, and excretory phase scans generated 1.25 to 7-mm-thick slices. Follow-up CTs were performed at 1 month (N=62) and 3 months (N=58). RESULTS While the attenuation coefficients of areas suspect for RMN and RPN were similar on preenhancement CT, they differed substantially on the arterial corticomedullary phase (lesions 55 HU mean; normal medulla 120 HU mean) and parenchymal phase (lesions 58 HU mean, normal medulla 210 HU mean). Investigation for predisposing conditions identified diabetes in 18 patients, upper urinary-tract infections in 48, sickle-cell disease or trait in 17, urinary obstruction in 7, and cirrhosis of the liver in 1. On follow-up examinations, enhancement had normalized in 26 compromised areas of 14 patients at 1 month, and 47 areas (23 patients) at 3 months, remained stationary in 28 patients at 1 month and 9 at 3 months, and progressed in 20 at 1 and 26 at 3 months (P<0.001; Fishers exact test). Patients (N=35) treated for underlying conditions causing ischemia showed reperfusion in 12 cases at 1 month and 20 at 3 months, while of the untreated patients (N=10), none showed reperfusion, and all lesions increased in size. CONCLUSIONS Multiphasic helical CT is recommended for identification of RMN and RPN at a stage when effective treatment of underlying causative conditions can arrest or reverse the process of devascularization and prevent loss of medullary tissue.

Endourologic Management of Malignant Ureteral Strictures

PURPOSE This retrospective analysis assessed the efficacy of balloon dilatation, endoureterotomy, percutaneous ureteroneocystostomy with stenting, and insertion of Wallstents in the management of malignant ureteral strictures with an intact or compromised vascular supply. PATIENTS AND METHODS A series of 127 patients with ureteral strictures secondary to malignancies were assessed after at least 2-year follow-up (range 2-5 years; mean 3.5 years). Balloon dilation (antegrade approach) was applied in 46 patients, endoureterotomy with temporary stenting in 37, percutaneous ureteroneocystostomy with stenting in 34, bougie and stents in 13, and Wallstents in 31. RESULTS Balloon dilatation was successful in only two of four malignant midureteral stenoses with intact vascular supplies and was even less successful (10%) in midureteral strictures with a compromised vascular supply. Endoureterotomy failed in all cases to prevent ureteral obstruction. Percutaneous ureteroneocystostomy achieved patency in 11 of 34 patients (33%) having a compromised ureteral vascular supply. Wallstents were successful in 18 of 31 patients (58%) with stenoses of the pelvic ureter. CONCLUSIONS Percutaneous ureteroneocystostomy with stenting meets the requirement for palliation in patients with obstruction secondary to pelvic neoplasms. Wallstents proved to be most successful when used in the pelvic ureter.

Renal Cell Carcinoma Presenting with Metastases to Pulmonary Hilar Nodes

AbstractMediastinal and hilar renal cell carcinoma metastases are reported in 9 patients, representing an incidence rate of 8 per cent in the series. This observation indicated an ominous prognosis since the mean survival of these patients was only 1.4 months after the discovery of the neoplasm. It is postulated that this poor prognosis is attributable to the size of the primary lesion, with direct extension into retroperitoneal structures and perhaps to an associated exhaustion of immunologic defense mechanisms of the patients. Dissemination from the involved retroperitoneal lymphatics to the thoracic duct and then in retrograde fashion via the bronchomediastinal and paratracheal trunks is advocated as the pathway for this tumor dissemination.

Management of primary and metastatic renal cell carcinoma by transcatheter embolization with iodine 125

The long‐term results of the management of metastatic renal cell carcinoma by a radioactive interstitial implant seated by a transcatheter embolization technique were evaluated in 85 patients at risk at 2 years and 37 at 5 years. The 2‐year survival rate was 33% and the 5‐year survival rate was 32%. Patients with isolated skeletal metastases showed the best survival rate (2‐year survival rate, 69%; 5‐year survival rate, 60%). Isolated pulmonary, other parenchymal, and central nervous system (CNS) metastases showed a lower 2‐year survival rate of 15%. Regardless of the site of metastases and the size of the primary, histologic grade appeared to have a substantial impact on the survival of our patients. The beneficial results of interstitial radiation therapy are attributed to reduction of tumor burden and possibly the stimulation of the host immune response that may initiate remission. The noticeably better results in patients with osseous metastases are attributed to the resolute treatment of all osseous metastases by additional interstitial iodine 125 (125I) infarct implants. Conversely, the poor results in patients with CNS and other parenchymal metastases may be based on the inability to treat such metastases with 125I interstitial infarct implants. In addition to clinical observations of weight gain and the cessation of pain and hematuria if present, remissions are heralded by normalization of the erythrocyte sedimentation rate, disappearance of tumor markers if present, and rise of beta interferon levels. The technique is advocated for the management of inoperable renal cell carcinoma with distant metastases.

Roentgenologic assessment of medullary cysts

ENAL R CYSTIC DISEASE comprises a heterogeneous group of disorders on the basis of associated phenomena.2p3 As with other categories, the etiologic entities considered in the group of medullary cysts are attributable to various developmental, heritable, and acquired disorders united by the common denominator of cyst formation in the medulla. 218 The principal entities are : medullary cystic disease or nephronophthisis; meduilary sponge kidney; simple cysts, inflammatory or pyelogenic cysts, and cystic-necrotic tumors located in the medulla; and pyelogenic cysts resultant from medullary necrosis.* Simple cysts, inflammatory or pyelogenic cysts, and cystic-necrotic tumors located in the medulla are identical in pathophysiology and histologic appearance to their more common peer group located in the cortex. Medullary cystic disease, medullary sponge kidney, and pyelogenic cysts secondary to medullary or papillary necrosis, however, are entities specific and exclusive to the renal medulla.

Multiphasic helical CT criteria for differentiation of recurrent neoplasm and desmoplastic reaction after laparoscopic resection of renal mass lesions.

BACKGROUND AND PURPOSE Differentiation of recurrent neoplasm and desmoplastic reaction following laparoscopic resection of renal mass lesions poses a problem. The usefulness of multiphasic helical CT-generated criteria based on enhancement and morphologic characteristics was investigated. PATIENTS AND METHODS The findings in 5 female and 12 male patients aged 29 to 68 years having renal-cell carcinoma (11-38 mm; N = 15) or solitary angiomyolipomas (N = 2) treated by laparoscopic resection (N = 15) or open segmental surgery (N = 2) were analyzed. Multiphasic helical CT was performed in the preenhancement, arterial corticomedullary, parenchymal, and excretory phases generating 2.5- to 7-mm slices. RESULTS Both recurrent neoplasms showed median postcontrast enhancement of 119 HU in the arterial corticomedullary phase; the median enhancement of desmoplastic masses was 48 HU. In the parenchymal and excretory phase, recurrent neoplasms showed progressive loss of enhancement, whereas desmoplastic lesions sustained enhancement at about the same level. Recurrent neoplasms presented a defined mass with characteristic spiculation, whereas desmoplastic reaction was characterized by an ill-defined mass with spidery projections extending to abutting fat and residual fascial planes. On 2- to 3-month follow-up scans, recurrent neoplasms showed progressive increases in size and desmoplastic reaction a sharp decrease. CONCLUSION Enhancement of the mass at the operative site on arterial corticomedullary-phase CT to >90 HU strongly suggests recurrent renal-cell carcinoma, while progressive decrease in size on 1- to 3-month follow-up CT suggests a desmoplastic reaction.

Traumatic Lesions of the Ureter

The protected location of the ureter makes injury rather uncommon. Although the incidence of surgically induced injuries to the urinary tract is low, iatrogenic trauma is the leading cause of ureteral injuries (Table 2.1) (Brubacker and Wilbanks 1991; Dowling et al. 1986; Bright and Peters 1977). The majority of iatrogenic ureteral injuries occur during gynecologic surgery, with more than half occurring during simple hysterectomy for benign disease (Brubacker and Wilbanks 1991; Zinman et al. 1978). Urinary tract surgery is responsible for about 30% of the injuries; abdominal surgical procedures such as abdominal perineal resection, pelvic tumor surgery, lyses of adhesions, aortic bypass surgery, and orthopedic and neurosurgical procedures account for the remaining relatively small group of ureteral injuries. Penetrating and blunt trauma are responsible for a small number of ureteral injuries but pose major management problems because there are often associated injuries to other structures (Guerriero 1989).