Herbert M. User

Applications of FloSeal innephron-sparing surgery

Hemostasis can be a challenging problem to control laparoscopically. We advocate the use of FloSeal Matrix. FloSeal can be used in a variety of open and laparoscopic procedures, including laparoscopic or open partial nephrectomy. FloSeal was highly effective in stopping bleeding in a bloody surgical field.

THE EFFICACY AND SAFETY OF SYNCHRONOUS BILATERAL EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY

PURPOSE Bilateral renal calculi have traditionally been managed by staged extracorporeal shock wave lithotripsy (ESWLdagger) due to concern about bilateral obstruction. We evaluated the safety and efficacy of synchronous bilateral ESWL in a large series of patients treated at our institution to determine the safety and efficacy of this controversial technique in what is to our knowledge the largest series to date. MATERIALS AND METHODS We retrospectively evaluated the records of 120 patients with a mean age of 48 years who underwent bilateral synchronous ESWL between 1987 and 1996. Of the patients 71 (59%) were male. Average followup was 21 months. ESWL was performed using a Dornier HM3 lithotriptor in all cases. Intraoperative technique and postoperative factors were analyzed using the Pearson product moment correlation, the 2-tailed t test and multiple regression analysis. RESULTS Mean stone size was 13 and 15 mm. on the left and right sides, respectively. There was an average of 1.7 stones per renal unit. After 1 treatment 72 of the 120 patients (60%) were stone-free bilaterally, while 72% and 73% of left and right renal units, respectively, were also stone-free. Mean creatinine was similar preoperatively and postoperatively (1.46 and 1.41 mg./dl., respectively, p = 0.73). There was 1 or more complications in 18 cases. The majority of complications were minor with no long-term morbidity or death and there was no case of bilateral obstruction or renal failure. Additional procedures were required in 19 patients (16%) due to significant residual stone disease or obstruction during followup. Multiple regression analysis revealed that only patient age, a right ureteral stent and the number of shocks correlated with the complication rate. Stone size and number independently increased the probability of treatment failure and a repeat procedure (p <0.05). Patients with stones 20 mm. or greater were at particularly high risk for treatment failure and additional procedures. A total of 27 of the 35 patients (77%) with residual calculi and 13 of the 19 (68%) requiring additional procedures were in this high risk subgroup. CONCLUSIONS Bilateral synchronous ESWL is safe and effective monotherapy for bilateral urolithiasis. No patient had bilateral obstruction or renal failure and no deterioration of renal function was detected at followup. Knowing which patient populations are at higher risk for failure or complications may guide decision making.

Safety and efficacy of 12-mm radial dilating ports for laparoscopic access

obturator is removed and its depth adjusted under laparoscopic vision. The dilated fascia and crossed-hatch mesh sheath provide a gas-tight fascial seal, and enable stability and minimize slipping in the fascia. We have found stay sutures to be unnecessary. Additional ports may be placed using the same technique under direct laparoscopic vision. At the end of the procedure, the ports are simply removed and the skin closed, as no fascial sutures are used.

OCCULT RETAINED PENILE PROSTHETIC FRAGMENTS IN PERSISTENT UROGENITAL INFECTIONS

Case 1. A 46-year-old black man with a history of T2a pros- tate cancer treated with radical retropubic prostatectomy un- derwent insertion of a penile prosthesis. This prosthesis was removed because of mechanical failure. The patient underwent 2 additional inflatable prosthesis implantations during the next 16 years, both of which explanted secondary to infection. Three months after the most recent explantation he noticed penile swelling and a rash over the scrotum. Evaluation elsewhere included contrast enhanced computerized tomography (CT) of the abdomen/pelvis as well as a skin biopsy. Diagnosis was Schonlein-Henoch purpura associated with a soft tissue phleg- mon of the anterior pelvis. There was no foreign body noted. The patient was referred to us 4 months later with the persistent complaints of intermittent discomfort and swell- ing of the entire penis, scrotum and suprapubic region. Non- enhanced CT of the pelvis using small cuts revealed a small foreign body near the peripheral aspect of the phlegmon in the scrotum (fig. 1). This finding was consistent with a re- tained segment of connecting tubing from a previously re- moved penile prosthesis. Surgical extirpation of the retained connecting tubing and phlegmon resulted in resolution of symptoms. Intraoperative ultrasound confirmed the absence of further retained foreign bodies. Intraoperative cultures yielded only rare Peptostreptococcus, while the gram stains revealed numerous white blood cells and gram positive cocci. Notably, the patient had been on broad-spectrum antibiotics preoperatively. Case 2. A 36-year-old black man with a history of recalci- trant erectile dysfunction underwent insertion of an inflat- able penile prosthesis. Mechanical failure required at- tempted revision and replacement of the prosthesis 1 year later. The new prosthesis became infected 11 months later and was removed. Four years later he underwent difficult reconstruction at a second medical center, which involved placement of a single cylinder into the right proximal crus crossing the midline into the left distal corporeal shaft. Op- erative notes indicated significant fibrotic changes.

Urolithiasis associated with topiramate

OBJECTIVE Topiramate is a sulfamate-substituted monosaccharide anticonvulsant used as adjunctive therapy for intractable refractory seizures. It is report a case of topiramate-induced urolithiasis. CASE REPORT A 35-year-old man presented with acute, right-sided, colicky flank pain. He denied hematuria or dysuria. He was in use of phenytoin, risperidone, phenobarbital, and topiramate. The total daily dose of topiramate was 375 mg. A CT scan showed a 7 x 1 mm curvilinear density at the right ureterovesical junction with proximal hydrouretronephrosis. He was managed with rigid ureteroscopic stone extraction and the calculus metabolic analysis revealed the stone was composed of carbonate apatite (70%), calcium oxalate dihydrate (20%), and calcium oxalate monohydrate (10%). COMMENTS The present case typifies many features of topiramate-induced urolithiasis. Those who care for patients with urinary stone disease should be aware of this association.