Ezekiel H. Landau

Ureteral Bladder Augmentation

Virtually all segments of the gastrointestinal tract have been used successfully in augmentation cystoplasty. The complications inherent in enterocystoplasty are well described. Megaureters subtending effete kidneys (poorly or nonfunctioning) provide a novel and excellent source of augmentation material with urothelium and muscular backing, free of the electrolyte and acid base disturbances, and mucus production that plague enterocystoplasty. Augmentation cystoplasty using detubularized, reconfigured, otherwise disposable megaureter, with or without ipsilateral total or partial nephrectomy, was performed in 16 patients (mean age 8.8 years, range 1 to 25) with inadequate and dysfunctional bladders. Postoperative followup varied between 8 and 38 months (mean 22). The overall renal function and radiographic appearance of the remaining upper tracts have remained stable or improved in all patients. Of the 16 patients 15 require intermittent catheterization and 1 voids spontaneously. Ten patients are continent day and night, 5 have improved continence (4 damp at night and 1 stress incontinence) and 1 has failed to gain continence despite good capacity and compliance. Complete postoperative urodynamic evaluations in 12 of 13 patients show good capacity, low pressure bladders with no instability. Complications occurred in 5 patients, including transient urine extravasation in 2, contralateral ureterovesical obstruction in 2 and Mitrofanoff stomal stenosis in 1. Augmentation ureterocystoplasty combines the benefits common to all enterocystoplasties without adding any of the untoward complications or risks associated with nonurothelial augmentations.

IS THE PEDIATRIC URETER AS EFFICIENT AS THE ADULT URETER IN TRANSPORTING FRAGMENTS FOLLOWING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY FOR RENAL CALCULI LARGER THAN 10 MM.

PURPOSE We determined whether the thin ureter of the young child transports stone fragments after extracorporeal shockwave lithotripsy (ESWL) as efficiently as the adult ureter does. This determination was done by comparing the outcome after lithotripsy of renal stones greater than 10 mm. between young children and adults. MATERIALS AND METHODS Our study group consisted of 38 children 6 months to 6 years old (median 3 years) with renal stones greater than 10 mm. in diameter. This group was further divided into 3 subgroups according to the longest stone diameter on plain abdominal film. There were 21 children with a renal stone diameter of 10 to 15 mm. (subgroup 1), 8, 16 to 20 mm. (subgroup 2) and 9 greater than 20 mm. (subgroup 3). The control group consisted of 38 adults older than 20 years randomly selected from the local ESWL registry. Each adult was matched with a child regarding stone diameter and localization. The control group was similarly divided into subgroups 1a, 2a and 3a. ESWL was performed with the unmodified Dornier HM-3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia). The stone-free rate, complication rate, and need for tubes, including stent or nephrostomy, and greater than 1 ESWL session were compared. RESULTS The stone-free rate was 95% in the study and 78.9% in the control group (p = 0.086). Stone-free rates were 95%, 100% and 89% in subgroups 1, 2 and 3, and 95%, 65% and 56% in subgroups 1a, 2a and 3a, respectively. There were 10 children and 4 adults who underwent greater than 1 ESWL session (p = 0.14). Then there were 10 children and 6 adults who required a tube before ESWL (p = 0.04), and almost all of them were included in subgroups 3 and 3a. Early complications were rare in both the study and control groups. Late complications had included 2 cases of Steinstrasse in the control and none in the study group. CONCLUSIONS The stone-free rate after ESWL for large renal stones is higher in young children compared to adults with matching stone size. Renal stones greater than 20 mm. often require more than 1 ESWL session. The pediatric ureter is at least as efficient as the adult for transporting stone fragments after ESWL.

Loss of Elasticity in Dysfunctional Bladders: Urodynamic and Histochemical Correlation

To store adequate volumes of urine at low safe pressures an elastic bladder wall is required. We developed 2 new techniques to measure this ability in our urodynamic laboratory: pressure specific bladder volume, which measures the bladder capacity at a given pressure, and dynamic analysis of bladder compliance. Recently, morphometric and histochemical techniques have been used to determine the relative volume of connective tissue in the bladder wall and to measure the 2 major types (I and III) of collagen within the bladder wall. These methods quantitate 3 parameters of bladder ultrastructure: 1) relative volume of per cent connective tissue, 2) ratio of connective tissue to smooth muscle and 3) ratio of type III to type I collagen. These parameters have been shown to be abnormally elevated in patients with dysfunctional bladders compared to normals. The purpose of the study was to describe the ultrastructural changes that occur in the wall of dysfunctional bladders and to determine the ability of these new urodynamic techniques to detect reliably the clinical effect of these histological changes. The study included 29 consecutive patients with dysfunctional bladders necessitating bladder augmentation. All patients had upper tract changes and/or were incontinent despite treatment with clean intermittent catheterization and pharmacotherapy. Preoperative urodynamic evaluation included measurement of the total bladder capacity, pressure specific bladder volume and dynamic analysis of bladder compliance. Full thickness bladder biopsies were obtained from the dome of the bladders during augmentation. The per cent connective tissue and the ratio of connective tissue to smooth muscle were determined for all patients, and 4 unselected patients from this group had the ratio of type III to type I collagen determined. These histological results were compared to previously established normal values. All 29 patients had a decreased pressure specific bladder volume and dynamic analysis of bladder compliance, whereas 9 had a normal total bladder capacity. The per cent connective tissue was 35.19 +/- 2.84 and ratio of connective tissue to smooth muscle was 0.60 +/- 0.08 compared to normal values of 10.6 +/- 0.020 and 0.131 +/- 0.021, respectively (p < 0.05). Ratio of type III to type I collagen was also significantly elevated in the 4 samples analyzed (30.53 +/- 1.37 versus 24.00 +/- 2.50, p < 0.05). We conclude that poor storage function of poorly compliant bladders is secondary to an alteration in the connective tissue content of the bladder wall. Furthermore, these pathological ultrastructural changes are universally reflected by an abnormally low pressure specific bladder volume and dynamic analysis of bladder compliance. This strong association validates the use of these parameters and suggests that they are urodynamic indicators of a loss of elasticity in bladder wall.

Extracorporeal shock wave lithotripsy is highly effective for ureteral calculi in children.

PURPOSE Treatment of ureteral calculi in the pediatric population represents a unique challenge. Extracorporeal shock wave lithotripsy (ESWL*) and ureteroscopy have been advocated for the treatment of such stones. We present our experience with ESWL monotherapy for ureteral stones in children in the last decade. MATERIALS AND METHODS Between 1989 and 1999 we treated 21 boys and 17 girls with a mean age of 8 years (range 8 months to 14 years) with ureteral stones at our institution. Records were reviewed and analyzed for presentation, metabolic and anatomical anomalies, stone size and location, outcome and complications. Average stone size was 9.5 x 6.5 mm. (range 3 to 32). Stones were in the upper ureter in 17 cases, mid ureter in 2 and lower ureter in 19. All patients underwent ESWL with a Dornier HM3 lithotriptor under general anesthesia. Nephrostomies were placed in an anuric infant with bilateral ureteral obstruction and in 2 patients with nonfunctioning kidneys (4 renal units). Ureteral catheters were used in 15 patients for better identification and localization of the stone during ESWL. The catheters were removed immediately postoperatively. RESULTS Of the patients 31 (81.5%) were free of stones after 1 session of ESWL, 5 (13.1%) after 2 and 1 after 3. One patient underwent ureteroscopy for residual fragments after 2 ESWL sessions. The stone-free rate following 1 ESWL session was 100% for ureteral calculi 10 mm. or smaller regardless of location. Of the 12 patients with stones larger than 10 mm. 8 (67%) were free of stones following 1 ESWL session. The overall success rate of ESWL was 97.3%. No child had postoperative urinary infection or ureteral obstruction. CONCLUSIONS ESWL is an efficient and safe modality for the treatment of pediatric ureteral stones.

Lateral Decubitus Position for Percutaneous Nephrolithotripsy in the Morbidly Obese or Kyphotic Patient

BACKGROUND AND PURPOSE Morbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty. PATIENTS AND METHODS Two morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position. RESULTS An attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously. CONCLUSION We highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.

Bladder Augmentation: Ureterocystoplasty Versus Ileocystoplasty

The primary advantages of augmentation ureterocystoplasty include the absence of mucus, lack of electrolyte absorption from the augmenting segment and the avoidance of gastrointestinal complications. We tested whether the ureteral patch offers sufficient biomaterial to increase adequately the storage efficiency of dysfunctional bladders. Between April 1989 and November 1992, 8 children with unilaterally dilated and tortuous ureters underwent bladder augmentation using detubularized reconfigured megaureter. Clinical and urodynamic outcomes were compared between these patients and a control group of 8 children matched in age and diagnosis who had undergone ileocystoplasty during the same time. Total bladder capacity, pressure specific bladder volume at pressure less than 30 cm. water, dynamic analysis of bladder compliance, continence and upper tract status were compared between the 2 groups before and after augmentation. Preoperatively, all 16 patients were incontinent with high pressure, small capacity bladders, and all had upper tract changes. Postoperatively, the mean total bladder capacity was 417 ml. in the ureterocystoplasty group and 381 ml. in the ileocystoplasty group (p > 0.05), while the mean pressure specific bladder volume was 413 and 380 ml. (p > 0.05), respectively. Pressure specific bladder volume and dynamic bladder compliance were normal in 7 of 8 patients (87.5%) in the ureterocystoplasty group. All patients in the ileocystoplasty group had normal postoperative urodynamics. We conclude that megaureters subtending effete kidneys may be used to improve the storage function of dysfunctional bladders to the same extent as that achieved with ileum without the complications pursuant to ileocystoplasty, and that the improvement is maintained long term.

Renal Cell Carcinoma: Evaluation of the 1997 TNM System and Recommendations for Follow–Up after Surgery

Objective: We evaluated the tumor recurrence pattern after radical or nephron–sparing surgery for localized renal cell carcinoma. Based on this pattern, we suggest a surveillance protocol after surgery. Methods: The outcome of 200 consecutive patients with localized renal cell carcinoma (RCC) that were operated on between January 1982 and December 1997 was evaluated retrospectively. Radical nephrectomy was performed in 155 patients (77.5%), and nephron–sparing surgery in 45 patients (22.5%). The timing and site of disease recurrence were correlated with parameters of the primary tumor. Results: One hundred and twenty–four patients (62%) had pathological stage T1, 26 (13%) had stage T2, and 50 (25%) had stage T3 (41 stage T3a, 8 stage T3b, and 1 stage T3c). The mean follow–up was 47 months (range 6–169 months). Four patients (3.2%) with stage T1, 6 patients (23%) with T2, and 13 patients (26%) with T3 developed recurrent disease. None of the patients with a stage T1 tumor, smaller than 4 cm, had tumor recurrence. There were no recurrences after nephron–sparing surgery compared to 23 recurrences (14.8%) among patients after radical nephrectomy (p = 0.01). Only 1 patient who underwent pulmonary lobectomy for asymptomatic metastases smaller than 2.5 cm, found by routine chest CT, attained long–term survival. Conclusions: The prognosis of patients after radical nephrectomy for renal cell carcinoma, smaller than 4 cm, is excellent and they do not need radiological follow–up. Patients with larger T1 tumors, 4–7 cm in diameter, or a higher stage should be followed with CT of the chest and abdomen done every 6 months for 5 years and then annually. Following partial nephrectomy of small renal tumors periodic renal ultrasonography should be done to rule out local recurrence in the operated kidney.

Extracorporeal shock wave lithotripsy in prepubertal children: 22-year experience at a single institution with a single lithotriptor.

PURPOSE The sophistication of percutaneous nephrolithotomy and ureteroscopy challenges the efficacy of ESWL for urolithiasis in prepubertal patients. We evaluated our long-term experience with ESWL in these patients and determined its efficiency. MATERIALS AND METHODS We retrospectively reviewed the charts of all prepubertal patients who underwent ESWL. We evaluated the need for tubing, the 3-month stone-free rate, the need for additional ESWL, and the effect of stone size and location, and cystinuria on the 3-month stone-free rate. RESULTS Between 1986 and 2008, 119 males and 97 females with a mean age of 6.6 years who had urolithiasis underwent ESWL using the Dornier HM3 lithotriptor. We treated 157 children with renal calculi with an average +/- SD diameter of 14.9 +/- 8.9 mm, of whom 66 (42%) required a tube in the urinary system. The 3-month stone-free rate was 80% and 31 patients (19.7%) needed an additional procedure. Stone location did not affect the stone-free rate but stone size did. We treated 59 patients for ureteral stones with an average stone length of 9.5 +/- 4.8 mm, of whom 41 (69%) required tube insertion. The 3-month stone-free rate was 78% and 13 patients (22%) needed an additional procedure. The 3-month stone-free rate did not depend on stone location or size. The rate was 37.5% in patients with cystinuria and 82.5% in all others (p <0.0001). Six patients (2.8%) had complications. CONCLUSIONS The 3-month stone-free rate after ESWL in prepubertal patients is 80% and 20% of patients require additional procedures. ESWL is most effective for kidney stones less than 11 mm. ESWL has inferior results for cystine stones compared to other calculi. Complications are rare.

SEGMENTAL TESTICULAR INFARCTION DUE TO SICKLE CELL DISEASE

Testicular infarction not associated with torsion is rare and segmental infarction is even more rare. The causes of testicular infarction in adults include trauma, sequela of epididymo-orchitis, polycythemia, hypersensitive angiitis, intimal fibroplasia of the spermatic artery and idiopathic etiology.l.2 In most reported cases the diagnosis of testicular infarction was made several days after the onset of symptoms, and the testis was removed to rule out malignancy. We report a case of segmental infarction of a testis presenting as an acute scrotum in a patient with sickle cell anemia. The clinical and sonographic findings that developed during 18 hours of observation allowed insight into the pathogenesis of large vessel occlusion in patients with sickle cell anemia. CASE REPORT A 27-year-old man with homozygous sickle cell anemia presented to the emergency department with severe pain in the left testicle 6 hours in duration. Previous complications of sickle cell disease included acute chest crisis, splenic infarction, osteomyelitis of the left foot and recurrent hemolytic crises. However, the patient had been free of painful crises for the last 9 years. He was married and the father of l-yearold twins who were born after successful in vitro fertilization. The pain was not accompanied by urinary or gastrointestinal symptoms and there was no history of trauma to the testicles. Physical examination revealed a severely distressed patient with normal vital signs. The left hemiscrotum was slightly swollen, red and tender. It was difficult to differentiate the epididymis from the testis. Urinalysis showed 10 to 20 red blood cells per high power field, hemoglobin was 7.7 gm. (normal 14 to 18) and white blood count was 16,500/mm.3 (normal 4,000 to 10,000). Working diagnosis was testicular torsion and color Doppler ultrasonography was done. Both testes appeared normal in echo texture and arterial blood flow. Analgesics, oxygen supplementation and hydration were administered.

THE SENSITIVITY OF PRESSURE SPECIFIC BLADDER VOLUME VERSUS TOTAL BLADDER CAPACITY AS A MEASURE OF BLADDER STORAGE DYSFUNCTION

Assessment of bladder storage function requires an accurate measure of bladder capacity and pressure. Pressure specific bladder volume is the volume that a bladder can accommodate at a specific pressure. A total of 21 consecutive children with neurogenic bladders who were candidates for bladder augmentation based on standard clinical criteria (upper urinary tract deterioration, incontinence and infection) was studied to determine the efficacy of pressure specific bladder volume as a measure of bladder dysfunction. Urodynamic indexes were compared to previously established nomograms. All 21 patients had bladder volumes at pressures of 30 cm. water or less, which decreased below the 5th percentile as determined by the nomogram. In 7 patients (33%) normal total bladder capacity was achieved at the expense of elevated storage pressures. Pressure specific bladder volume provides a better measure of bladder storage function than total bladder capacity because it relates volume to intravesical pressure, does not rely on a subjective end point to bladder filling, and is objective and reproducible.