Hann-Chorng Kuo

Extracorporeal shock wave lithotripsy for obstructed proximal ureteral stones : a prospective randomized study comparing in situ, stent bypass and below stone catheter with irrigation strategies

In an attempt to assess the usefulness of a ureteral stent in facilitating disintegration of obstructed proximal ureteral stone with extracorporeal shock wave lithotripsy (ESWL), a prospective randomized study on 120 patients with ultrasonic evidence of hydronephrosis whose stone sizes were greater than 1.0 x 0.6 cm on KUB film and located above the level of L5 were allocated into three distinct treatment strategies: group 1: in situ without stone manipulation; group 2: bypass stones with stent, and group 3: placement of a catheter below stone with continuous saline irrigation. Of 77 patients, 26, 27 and 24 in each group, followed up for a period of 6 months with sufficient data for analysis, the stone-free rates were 76.9, 59.3 and 62.5%, respectively. The average number of shock waves delivered to accomplish a stone-free state were 3,245, 3,250 and 3,880 for individual groups and the comparisons among them were statistically insignificant (ps > 0.1). ESWL retreatment was common, being 33.3, 29.4 and 43.8%, respectively. Hydronephrosis has a major impact on the outcome of ESWL treatment, as more stone-free cases were found in the mildly hydronephrotic category than in the severer counterparts. About 90% of cases who finally were stone-free, passed all their stone fragments within 28 days. Ancillary procedures were needed in 13 (16.9%), 7 received ureterolithotomy, whilst 6 were removed of their stones by ureteroscopy.

Predictive factors for successful surgical outcome of benign prostatic hypertrophy.

Four hundred patients with benign prostatic hypertrophy (BPH) undergoing prostatic surgery were enrolled in this study in order to search for factors predictive of a successful outcome. 139 patients had acute urinary retention and the others had irritative and obstructive voiding symptoms. Preoperative examinations included intravenous urography (IVU), transrectal sonography of the prostate (TRSP), cystometry, uroflowmetry, and urethral pressure profilometry (UPP). Retropubic prostatectomy was undertaken in 16 cases, transurethral resection of the prostate in 335, and transurethral incision of the prostate in 49. In the follow-up period of 3 months to 3 years, a strictly successful result was achieved in 324 patients (81%). 26 patients (6.5%) had a fair result, 30 (7.5%) were stationary, in 18 (4.5%) the symptoms became worse, and 2 (0.5%) died postoperatively. On analysis of the success rate, 9 favorable factors and 9 unfavorable factors were noted. A symptomatic large prostatic adenoma proven by IVU, TRSP, or UPP will imply a higher success rate. Urodynamically obstructive BPH proven by a high voiding pressure and constrictive flow pattern can also predict a satisfactory outcome. The unfavorable factors always come from a small adenoma, uncertain irritative symptoms and detrusor underactivity. Patients with more than 2 unfavorable factors should be investigated carefully before surgery. The presence of 2 favorable factors without an unfavorable factor will usually predict the best surgical outcome.

Application of transrectal sonography in the diagnosis and treatment of female stress urinary incontinence.

One hundred and two women with genuine stress urinary incontinence (SUI) were examined by transrectal sonography and urodynamics. The patients were classified into five types according to their intrinsic and extrinsic continence mechanism defects. Twenty-five patients had a hypermobile bladder neck and urethra (type 1); 31 patients had an incompetent bladder neck and a hypermobile urethra (type 2); 31 patients showed an incompetent urethral sphincter in addition to urethral hypermobility (type 3); 12 patients had a cystocele accompanying incompetent urethral sphincter and hypermobile urethra (type 4); the remaining 3 showed an incompetent urethral sphincter without hypermobility of the urethra (type 5). Whereas the distance from the lower margin of symphysis pubis to the bladder neck (pubovesical ligament; PVL) showed a significant increase in straining state of types 3 and 4, this was not the case in types 1, 2 and 5. There is a significant increase in the posteroinferior rotational of PVL angle on straining compared with resting in types 1, 2, 3, and 4, but not in type 5. The angle on straining also showed an increased tendency from type 1 to 4. The functional degree of SUI showed a significant increase from type 1 to 5. With this classification, the functional class of SUI is thus well correlated with the anatomical defects. The PVL length and the angle of external rotation of this axis are significantly implicated in the severity of SUI.

DDAVP in the Treatment of Nocturnal Enuresis - A Double Blind Cross-Over Study

In order to evaluate the efficacy of desmopressin in the treatment of primary nocturnal enuresis, 34 patients aged from 5 to 24 years (mean 10 ± 4) were enrolled in a double blind cross-over study. One patient was witharawn because of headache after treatment for 2 weeks.The response rates were 91% on drug and 39% off drug for 1 month. During the course of treatment, 22(67%) were dry, 8(24%) improved to ≦3 wet nights and 3(9%) remained wetting ＞4 nights per week. The placebo effect of DDAVP was negligible, but a gradual decline of the effective rete was observed during the follo-up period. A dose of 20 ug was enough to achieve dry in most of the p0atients and an active treatment cours of 8 weeks is adequate to have a high re-sponse rate. Desmopressin is an effective drug in the management of enuresis, especial-ly in the situations that an immediate effect is desirable. When properly used, an ac-ceptable high long-term benefit also can be obtained.

Percutaneous Antegrade Rigid Nephroscopic Extraction of Upper Ureteral Stiones

Treatment of upper ureteric stones can be accomplished by transurethral retrograde ureteroscopic stone extraction, extracorporeal shock wave lithotripsy or by conventional open ureterolithotomy. Percutaneous antegrade rigid nephroscopic treatment of upper ureteral stones provides an alternative especially suitable for laege stones, severe hydronephrosis or impacted stones. Percutaneous antegrade rigid nephroscopic treatment of upper ureteral stones was used here for seven patients. The average operating time was 87 minutes, and the mean hospitalization was 6.8 days. All seven patients were stone free and there were no perioperative or postoperative complications. This method represents a significant advance over standard open surgical procedures for the removal of upper ureteral stones.

Contractile Properties of Prostatic Strips in Different Histological Types of Obstructive Benign Prostatic Hypertrophy

Smooth muscle contraction was performed in vitro in thirty-three patients proven to have prostatic obstruction in order to clarify the relationship of the histology and the contractility of the prostatic strips. The mean age was 71 years (59-81), 16 patients presented with dysuria and 17 with urine retention. Phenylephrine (PE) and norepine phrine (NE) (10-7 to 10-4 M) were used as alpha-adrenoceptor stimulation. Prazosin (10-10 to 10-7 M) was used as selective alpha-1 antagonist to inhibit contraction of prostatic strips. The histological examination was classified according to the stoma/gland ratio and the degree of inflammation. The prostatic strips showed a concentration- dependent contraction on PE and NE. There was no significant difference in the contractility on PE and NE between patients with prostatism and retention; nor among the prostates of different size. The contractility showed significant difference in the histology of the prostatic strips: bladder neck smooth muscle ＞ stroma predominant ＞ gland predominant. However, the similarity in histology of the prostatic strips did not correlate well in different parts of the same prostaic gland. The result of this study proves that prostate is rich in alpha-adrenergic receptors with alpha-1 predominant. The histology will affect the contractility of prostatic strips to drugs. However, it should be careful in interpretation of the muscle strip experimental results since great difference might exist in different parts of the prostatic gland.

Treatment Options for Upper Ureteral Calculi: A Comparison between Ureteroscopy and Extracorporeal Shock Wave Lithotripsy

In a series of 210 patients with upper ureteral calculi stratified into 3 groups, each having a specific merit and treatment option, were subjected to analyses. For larger calculi (10 mm × 6 mm) treated with ESWL, the stone free rate (66.2) was apparently inferior to the group having smaller stones (82.9). Ureteroscopic manipulation (URS) previously thought to be inappropriate for proximal ureteral calculi were successful in 64.9% of cases undertaken this procedure. Ninety percent of cases finally rendered the stone free after ESWL has passed out the fragments within 28 days. Open ureterolithotomy was performed in 17 patients (7.7%) as a final solution who were refractory to both nonsurgical procedures. We conclude from the study that smaller proximal ureteral calculi are ideal cases for ESWL and a rate free of stone over 90% is anticipated with only one session of treatment. Larger stones, although much more difficult to achieve satisfactory disintegration solely by in situ ESWL, are best treated primarily with ESWL after retrograde manipulation of the stones into the kidney. URS should be reserved for a second-line consideration and applied as an alternative only after a failing ESWL.

A Modified Non-incision Non-buffer Endoscopic Bladder Neck Suspension for Female Stress Urinary Incontinence - Surgical Technique and Its Mid-term Result

Fifty women underwent a modified endoscopic bladder neck suspension were evaluated 6 to 42 months (mean 23 months) postoperatively. The surgical procedure included: (1) identification of the bladder neck precisely by endoscopy, (2) no vaginal incision and dissection, (3) the bladder neck was suspended along the border of the bladder base, (4) the suspending suture was threaded submucosally without a buffer. However, the successful rate was not satisfactory (cured in 36% and good in 42%) as compared to other reports. Most of the failed cases occurred within the first 12 months postoperatively. Postoperative endosonography demonstrated loss of suspension function in the failed cases. The results in this study demonstrate that the bladder neck suspension without a buffer will not achieve a high cure rate. A helical suture or suspension buffer should be added to prevent cutting through the endopelvic fascia by the suture.

Treatment of Symptomatic Simple Renal Cyst with Ultrasound Guided Percutaneous Aspiration and Minocycline Sclerotherapy: Results and Follow-up

The effectiveness of cyst aspiration and adjuvant instillation of minocycline hydrochloride as a sclerosing agent for the treatment of simple renal cysts was evaluated in a total of 27 patients with 36 cysts. Twenty-one patients (77.8%) reported prompt relief of their flank discomfort immediately after treatment. In an average follow-up period of 16.5 months, 33.3% of the treated cysts had completely disappeared, while another 45.8% were at least 50% diminished in size when followed up by renosonography. Only one-fifth of the cysts were refractory to sclerotherapy, and remained stationary. No treatment associated complication nor malignant transformation was observed in the series, and 14 out of 22 (63.6%) who responded to our questionnaire claimed that their treatments satisfactory. It is suggested that cyst puncture and instillation of minocycline as the initial treatment modality for simple renal cysts because it is a simple, safe and relatively effective method.

Ureteroscopic Manipulation of Ureteral Calculi: Results and Complications

Although extracorporeal shock wave lithotripsy (ESWL) has gained rapid populari-ty to treat urolithiasis at various locations, ureteroscopic stone manipulation (URS-SM) remains the method of choice in managing middle and lower ureteral stones. The suc-cess rates were 75% and 89% respectively for middle and lower ureteral stones. Early complications arising from URS-SM was not uncommon which occurred in 19.7% (25/127) of total cases, nevertheless, the vast majorities (22/25) were minor complica-tions such as small ureteral perforation, urinary tract infection and mucosal laceration. There was no stricture formation in our series observed up to 20 months. The high success rate as well as reduced morbidity and shortened hospital stay attained by URS-SM made it the advocated procedure for the treatment of middle and lower ureteral stones. Whereas, because of frequent backward migration of the stone during ureteroscopy, ESWL is the treatment of choice for upper ureteral stones. (J Urol R.O.C., 2:402-408 1991)