John V. Kryger

OPTIMAL METHOD OF URGENT DECOMPRESSION OF THE COLLECTING SYSTEM FOR OBSTRUCTION AND INFECTION DUE TO URETERAL CALCULI

PURPOSE We compare the efficacy of percutaneous nephrostomy with retrograde ureteral catheterization for renal drainage in cases of obstruction and infection associated with ureteral calculi. MATERIALS AND METHODS We randomized 42 consecutive patients presenting with obstructing ureteral calculi and clinical signs of infection (temperature greater than 38 C and/or white blood count greater than 17,000/mm.3) to drainage with percutaneous nephrostomy or retrograde ureteral catheterization. Preoperative patient and stone characteristics, procedural parameters, clinical outcomes and costs were assessed for each group. RESULTS Urine cultures obtained at drainage were positive in 62.9% of percutaneous nephrostomy and 19.1% of retrograde ureteral catheterization patients. There was no significant difference in the time to treatment between the 2 groups. Procedural and fluoroscopy times were significantly shorter in the retrograde ureteral catheterization (32.7 and 5.1 minutes, respectively) compared with the percutaneous nephrostomy (49.2 and 7.7 minutes, respectively) group. One treatment failure occurred in the percutaneous nephrostomy group, which was successfully salvaged with retrograde ureteral catheterization. Time to normal temperature was 2.3 days in the percutaneous nephrostomy and 2.6 in the retrograde ureteral catheterization group, and time to normal white blood count was 2 days in the percutaneous nephrostomy and 1.7 days in the retrograde ureteral catheterization group (p not significant). Length of stay was 4.5 days in the percutaneous nephrostomy group compared with 3.2 days in the retrograde ureteral catheterization group (p not significant). Cost analysis revealed that retrograde ureteral catheterization was twice as costly as percutaneous nephrostomy. CONCLUSIONS Retrograde ureteral catheterization and percutaneous nephrostomy effectively relieve obstruction and infection due to ureteral calculi. Neither modality demonstrated superiority in promoting a more rapid recovery after drainage. Percutaneous nephrostomy is less costly than retrograde ureteral catheterization. The decision of which mode of drainage to use may be based on logistical factors, surgeon preference and stone characteristics.

OUTCOMES OF CONTEMPORARY PERCUTANEOUS NEPHROSTOLITHOTOMY IN MORBIDLY OBESE PATIENTS

PURPOSE The surgical management of renal and ureteral calculi presents unique challenges in the obese patient. We reviewed our recent experience with percutaneous nephrostolithotomy in patients with a body mass index greater than 30. MATERIALS AND METHODS We reviewed the records of 236 patients undergoing percutaneous nephrostolithotomy between August 1994 and March 1997 at 2 university and affiliated hospitals. Among this group 57 patients had a body mass index greater than 30 (mean plus or minus standard deviation 38.9 +/- 7.4). Renal anomalies were present in 21% of patients and more than half (56%) had co-morbidities in addition to obesity. Staghorn calculi were present in 19 patients (31.7%). In the remaining patients the mean cumulative stone size for single or multiple stones was 14.5 +/- 8.7 mm. Stone-free status after the procedure was determined by plain nephrotomograms or noncontrast computerized tomography. RESULTS A total of 96 procedures were performed on 60 renal units (1.6 procedures per renal unit). Average operative time for the initial procedure was 181.2 +/- 91.4 minutes. Complications occurred in 8 patients (14%) and 5 (8.8%) received a blood transfusion. Average hospital stay was 4.9 +/- 3.1 days. The overall stone-free rate was 88.3%, and stone-free rate for staghorn calculi was 84.2% compared with 90.2% for nonstaghorn calculi. CONCLUSIONS Percutaneous nephrostolithotomy in obese patients yields a stone-free rate that is comparable to that achieved in an unselected patient population. The complication rate, transfusion rate and hospital stay are also similar. Modifications to standard technique and instrumentation are sometimes necessary to perform percutaneous nephrostolithotomy in this group of patients.

Re: Surgical management of urinary incontinence in children with neurogenic sphincteric incompetence.

PURPOSE There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique. MATERIALS AND METHODS A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate. RESULTS Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional voiding and avoidance of bladder augmentation. Revision rates of various procedures were similar but the incidence of complications was highest with the Kropp procedure. Long-term published data were limited in regard to bladder neck sling, reconstruction, injection, suspension and urethral lengthening techniques. CONCLUSIONS Long-term published data support artificial urinary sphincter creation as first line surgical management of neurogenic sphincteric incontinence. Girls who already depend on intermittent catheterization may benefit equally from a sling procedure if successful long-term continence is demonstrated in future studies.

REVIEW ARTICLE: SURGICAL MANAGEMENT OF URINARY INCONTINENCE IN CHILDREN WITH NEUROGENIC SPHINCTERIC INCOMPETENCE

Purpose:: There are many alternatives for the surgical treatment of children with neurogenic sphincteric incompetence. However, there is no consensus regarding appropriate evaluation and long-term management in these patients. We critically reviewed the literature and compare the outcomes of each technique.Materials and Methods:: A MEDLINE search was performed to select all relevant peer reviewed publications since 1966. In addition, the bibliography of each article was examined for additional published resources. The results of each technique were compared in 7 objective categories, including continence (defined as complete dryness for 4 hours between voidings or catheterizations), the need for intermittent catheterization, effects on bladder compliance, the need for bladder augmentation, upper tract changes, other complications and the revision rate.Results:: Long-term results of artificial urinary sphincter placement were superior and reproducible in terms of continence, preservation of volitional void...

Vaginal mucosal immunization for recurrent urinary tract infection : Extended phase II clinical trial

Many women remain susceptible to ascending urinary tract infections (UTIs) despite the absence of a demonstrable anatomic abnormality [1]. Repeated treatment with antibiotics is often necessary for these women but may lead to adverse reactions and infection with antibiotic-resistant organisms [2]. On the basis of concepts of mucosal immunity in the genitourinary tract [3-5], we have been working to develop an effective mucosally applied vaginal immunogen to help prevent ascending UTIs. After a trial in nonhuman primates, we carried out and reported two previous clinical trials in susceptible women [6-8]. We are now reporting on a clinical trial to extend the time period of protection through use of the same multivalent vaginal immunogen and through immunogen boosts given at 4week intervals.

LONG-TERM RESULTS OF ARTIFICIAL URINARY SPHINCTERS IN CHILDREN ARE INDEPENDENT OF AGE AT IMPLANTATION

PURPOSE The long-term success and efficacy of the artificial urinary sphincter for the management of neurogenic incontinence have been well documented. We evaluated if long-term results were affected by patient age at the time of sphincter placement. MATERIALS AND METHODS A retrospective review of the medical records of patients who underwent artificial urinary sphincter placement and had minimum of 10 years of followup was conducted. All patients with an intact sphincter were interviewed to assess current results. Patients were stratified into groups 1 and 2 if the sphincter was implanted before or after age 11 years, respectively, and the results were compared statistically. RESULTS An artificial urinary sphincter was placed in 45 children at Childrens Hospital of Michigan between October 1978 and August 1986, and medical records and followup were available for 32. Mean followup was 15.4 years. Of the 21 group 1 patients 12 (57%) have an intact sphincter after 26 revisions, and all are dry and 9 (75%) require intermittent catheterization. Of the 11 group 2 patients 7 (64%) have an intact sphincter, and 6 (86%) are dry, 3 (43%) perform intermittent catheterization and 6 required 8 revisions. There was no statistically significant difference in the number of artificial urinary sphincter removals, continence, revision rate, bladder augmentations, complications or upper tract changes. CONCLUSIONS The artificial urinary sphincter is a successful and durable option for the surgical management of neurogenic incontinence. The long-term results appear independent of patient age at the time of sphincter placement.

EFFECTS OF AN ENVIRONMENTAL ENDOCRINE DISRUPTOR ON FETAL DEVELOPMENT, ESTROGEN RECEPTOR alpha AND EPIDERMAL GROWTH FACTOR RECEPTOR EXPRESSION IN THE PORCINE MALE GENITAL TRACT

PURPOSE We studied the effect of a potent reproductive tract toxin, 2,3,7,8-tetrachlorodibenzo-rho-dioxin, on fetal development and expression of estrogen receptor alpha and epidermal growth factor receptor (EGFR) in male swine. MATERIALS AND METHODS Fetal domestic swine and miniswine were injected with 1 microg./kg. dioxin on day 50 of gestation and removed near term (114 days). Germ cell counts were performed on sections of formalin fixed testes. Estrogen receptor a protein, and messenger ribonucleic acid (mRNA) and EGFR mRNA expression were analyzed in frozen tissue using Western blotting and semiquantitative reverse transcriptase polymerase chain reaction. RESULTS Of 15 dioxin exposed male offspring 8 (53%) had genital anomalies, including cryptorchidism in 4, epididymal detachment in 1, epididymal atresia in 1 and vasal dilatation in 3, while 3 of 17 control male swine (18%) had incompletely descended testes (p = 0.06). High intra-abdominal testes were found in 3 of 4 cryptorchid dioxin exposed but no control male swine. Mean germ cell number per tubule was 4.0+/-1.1 and 2.7+/-0.7 in control and dioxin groups, respectively (p = 0.01). Estrogen receptor a protein and mRNA were identified in fetal uterus, testis, gubernaculum and epididymis. Protein levels were 2 to 3-fold higher in dioxin exposed testis, and mRNA levels were significantly lower in gubernaculum and epididymis. EGFR mRNA expression was similar in treated and control testis and epididymis. CONCLUSIONS Preliminary data suggest that dioxin produces cryptorchidism and wolffian duct anomalies in male swine exposed just before mid gestation. Germ cell counts and estrogen receptor alpha mRNA expression in gubernaculum and epididymis were significantly reduced, and estrogen receptor a protein expression in testis appeared to be increased by dioxin exposure. Aberrant regulation of estrogen receptor a expression by dioxin may contribute to reproductive tract anomalies in male fetuses.

Results of a 2-Year Multicenter Trial of Endoscopic Treatment of Vesicoureteral Reflux With Synthetic Calcium Hydroxyapatite

PURPOSE With no FDA approved material available for endoscopic treatment of vesicoureteral reflux, in 2001 we began a prospective multicenter trial of synthetic calcium hydroxyapatite as a subureteral bulking agent in children with traditional indications for surgical repair. MATERIALS AND METHODS A total of 98 patients (155 ureters) with grades II to IV reflux were enrolled at 10 sites in the United States to obtain 86 patients with completed protocol end points at 3 months. Of the 86 patients 74 underwent renal and bladder ultrasonography, blood count and serum chemistry analysis, and VCUG at 1 year. A total of 46 patients (47%) completed 2-year study end points, including VCUG. RESULTS At 1 and 2 years 24 of the 74 patients (32%) were cured. Ureteral cure rates were 46% and 40% at 1 and 2 years, respectively. With 35 patients treated and 85% compliance with the required 2-year VCUG the primary center achieved 2-year cure rates of 66% of patients and 72% of ureters. CONCLUSIONS Synthetic calcium hydroxyapatite is a safe, durable and effective material for endoscopic treatment of VUR. Increased experience with the injection of synthetic calcium hydroxyapatite yields improved results.

A SIMPLIFIED TECHNIQUE OF UPPER POLE HEMINEPHRECTOMY FOR DUPLEX KIDNEY

PURPOSE We describe a simplified technique of upper pole heminephrectomy in cases of duplex kidney. MATERIALS AND METHODS The upper pole collecting system is entered and the upper pole is excised. The vascular supply to the upper pole is then easily identified and divided. The upper pole ureter is dissected below the lower pole vessels and distal ureteral dissection is completed. We performed the technique in 11 girls and 3 boys with a mean age of 1. 8 years who had poor or nonfunctioning upper moieties of duplicated kidneys. The diagnosis was ectopic ureter in 11 cases and ureterocele with duplication in 3. RESULTS Mean surgical time was 95 minutes. Blood loss was not clinically significant in any patient and mean hospitalization was 2.7 days. The only postoperative complication was atelectasis, which resolved promptly with medical treatment. There was no injury to the lower pole ureter or vascular pedicle. CONCLUSIONS Our technique enables reliable and safe excision of upper pole renal tissue with the maximal preservation of functioning lower pole parenchyma. The chance of inadvertent entry into the lower pole collecting system is significantly decreased since the demarcation of the upper and lower moieties is clearly identifiable. In addition, the avoidance of initial, potentially cumbersome hilar dissection minimizes the risk of injury to the lower pole ureter and vascular supply. This technique may be performed rapidly and requires only brief hospitalization postoperatively.

University of Wisconsin experience using the Doli S lithotriptor

OBJECTIVES To present our initial results using the Dornier Doli S lithotriptor with the 220 electromagnetic shock wave emitter to treat urinary calculi. At present, there is no published report of the efficacy of this instrument in service in the United States. METHODS We retrospectively reviewed the outcome of shock wave lithotripsy in 270 consecutive patients with solitary renal and/or ureteral stones treated from September 1998 to October 2001 with the Dornier Doli S lithotriptor. Data were collected with respect to stone size, location, and fragmentation. RESULTS Of the 270 patients treated, 204 had renal stones and 66 had ureteral stones. All patients had solitary stones. The renal stones averaged 9.7 mm in size (range 4 to 26). The ureteral stones averaged 7.8 mm (range 4 to 17). Of the renal stones, 51% were located in the renal pelvis, with 18%, 5%, and 25% located in the upper, middle, and lower poles, respectively. Of the ureteral stones, 68% were located in the proximal ureter, with 14% and 18% in the mid and distal ureter, respectively. In the renal group, 176 (86%) of 204 patients achieved clinical success. Of these patients, 148 were stone free (73%) and 28 had residual fragments less than 4 mm in size (14%). In the ureteral group, 52 (79%) of 66 patients achieved clinical success. Of these patients, 50 were stone free (76%) and 2 (3%) patients had fragments less than 4 mm in size. Thirteen (6%) of 204 patients in the renal group required retreatment. Four (6%) of 62 patients in the ureteral group required retreatment. Of the patients in whom treatment failed and who had stone analysis, 16 (76%) of 21 had stones composed of predominantly calcium oxalate monohydrate. Four patients developed steinstrasse. Two were treated with retrograde stent placement, and the other two with placement of percutaneous nephrostomy. One patient developed a known perinephric hematoma but did not require a blood transfusion. CONCLUSIONS Shock wave lithotripsy using the Doli S in appropriately selected patients is an effective instrument for treating urinary calculi throughout the urinary tract.