Jon J. Soble

LONG-TERM OUTCOME OF CALICEAL DIVERTICULA FOLLOWING PERCUTANEOUS ENDOSURGICAL MANAGEMENT

PURPOSE We review the morbidity and long-term outcome of percutaneous caliceal diverticulectomy and associated stone extraction. MATERIALS AND METHODS Percutaneous caliceal diverticulectomy was performed in 19 women and 11 men (age range 20 to 58 years), of whom 26 had stones (all 15 mm. or less). The diverticula were located throughout the kidney, including the upper (11 patients), middle (15) and lower (4) calices. Percutaneous caliceal diverticulectomy included 28 direct and 2 indirect accesses (1 via a previously placed nephrostomy tract and 1 due to stones in other areas of the kidney). In all cases the stone was removed and the diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 22 cases. Transdiverticular percutaneous renal and ureteral drainage was maintained from 2 to 7 days until a nephrostogram demonstrated no extravasation. RESULTS The average operating room time and hospital stay were 171 minutes (range 75 to 330) and 4.1 days (range 2 to 7), respectively. Major complications occurred in 6.6% of the cases, requiring 1 blood transfusion and 1 chest tube placement, and minor complications occurred in 13.4%. There was no mortality. Followup for more than 1 year was available in 27 patients. Stone-free rate was 93% with obliteration of the diverticulum in 76% of patients. Overall, 85% of patients are asymptomatic at average followup of 3.5 years (range 1 to 7.3). CONCLUSIONS Direct percutaneous endosurgical management provides a safe, efficacious and durable means of treating stone bearing caliceal diverticula, regardless of stone size or location of the diverticulum.

Laparoscopic Adrenalectomy for Solitary Metachronous Contralateral Adrenal Metastasis from Renal Cell Carcinoma

PURPOSE We report our experience with laparoscopic adrenalectomy for malignant adrenal disease. MATERIALS AND METHODS Between June 1995 and January 1996, 2 patients with a solitary metachronous contralateral adrenal metastasis from renal cell cancer were evaluated. Both patients had undergone radical nephrectomy for localized renal cancer 5 years previously. Laparoscopic transperitoneal adrenalectomy was performed. RESULTS The laparoscopic procedures required 2.5 and 4.3 hours. Hospital stay was 3 and 4 days. The specimens weighed 98 and 81 gm. All surgical margins were free of metastatic clear cell cancer. Both patients were begun on prednisone and fludrocortisone replacement therapy. One patient experienced an increase in creatinine, which has since stabilized at 3.0 mg/dl. Neither patient had recurrent cancer at 11 and 16 months of followup. CONCLUSIONS Laparoscopic adrenalectomy for metastatic renal cell cancer was performed successfully in 2 patients. However, the short-term benefits to the patient of earlier ambulation, decreased pain, minimal incisions and shortened convalescence must be weighted against the as yet unknown long-term (5 years) results.

Comparison of fibrin glue, laser weld, and mechanical suturing device for the laparoscopic closure of ureterotomy in a porcine model

PURPOSE We evaluated fibrin glue, laser welding, and a mechanical suturing device (Endo-Stitch) as alternatives to standard laparoscopic suturing with a free needle. METHODS In 14 pigs, 22 linear proximal ureterotomies were closed laparoscopically with one of 4 different methods: fibrin glue, laser welding, Endo-Stitch suture placement (4-0 polyglactin), and free-needle suture placement (4-0 polyglactin). The ureterotomy was left open in 6 ureters. Acute leakage was tested by instillation of methylene blue. After 12 weeks, the ureters were assessed with radiography, ex-vivo pressure-flow studies, bursting pressures, and histology. RESULTS All alternative closure techniques were more rapid than free-needle suturing, and less frequently allowed acute leakage. Closure with fibrin glue yielded significantly higher flow rates than control, whereas the other closure techniques yielded flow rates similar to that of unclosed ureters. All alternative closure methods demonstrated histological evidence of healing that were superior to free-needle suturing. In multifactorial analysis, leakage at the ureterotomy site was the factor most significantly associated with subsequent poor ex-vivo flow characteristics. CONCLUSIONS All of the alternative laparoscopic ureteral closure methods compared favorably with standard free-needle suturing. Fibrin glue produced better radiographic findings, flow characteristics, and histology, suggesting that it currently has the most promise as an alternative or adjunct to laparoscopic suturing. Development of alternative laparoscopic techniques is ongoing, however, and thus the current state-of-the-art techniques used in this study may well be supplanted by other technologies in the future.

AMMONIUM ACID URATE CALCULI: A REEVALUATION OF RISK FACTORS

PURPOSE We reevaluate the demographic and metabolic risk factors for ammonium acid urate stones. MATERIALS AND METHODS Since 1986, 23 women and 21 men ranging in age from 20 to 81 years (mean 48.7) were treated for stones partly composed of ammonium acid urate. Stone composition ranged from 2 to 60% ammonium acid urate (mean 24.1) of the total stone mass. No patient had a pure ammonium acid urate stone, although 11 (25%) had stones with ammonium acid urate as the predominant crystal. RESULTS In the 44 patients 1 or more potential risk factors for ammonium acid urate were identified. Of the patients 11 (25%) had a history of inflammatory bowel disease with 10 (22.7%) having undergone ileostomy diversion, 6 (13.6%) admitted to a history of significant laxative use or abuse, 18 (40.9%) were morbidly obese, 16 (36.4%) had a history of recurrent urinary tract infections and 9 (20.5%) had a history of recurrent uric acid stones. CONCLUSIONS Patients clearly at risk for stones with an ammonium acid urate component include those with a history of inflammatory bowel disease and ileostomy diversion or laxative abuse. Other factors that may potentially enhance ammonium acid urate stone formation include morbid obesity, recurrent uric acid calculi and recurrent urinary tract infection. A careful history followed by further metabolic evaluation is warranted in these patients.

Pediatric Endopyelotomy: The Washington University Experience

PURPOSE Endopyelotomy has gained acceptance as minimally invasive therapy for ureteropelvic junction obstruction in adults. Its role in the treatment of pediatric ureteropelvic junction obstruction remains controversial. We report our experience with antegrade endopyelotomy for treating pediatric ureteropelvic junction obstruction. MATERIALS AND METHODS A total of 17 patients 3 months to 17 years old underwent endopyelotomy as primary treatment for ureteropelvic junction obstruction (8) and after failed open pyeloplasty with secondary endopyelotomy performed a mean of 12 weeks after open pyeloplasty (9). Standard antegrade percutaneous techniques were used. Electrosurgical incision of the ureteropelvic junction at a posterolateral orientation was done in each case. Internal ureteral stents remained in place for 4 to 6 weeks postoperatively. RESULTS In 5 of the 8 patients (62%) treated primarily the outcome was successful at a mean followup of 38 months (range 25 to 53). Failures occurred at 6 weeks, 3 months. In all 9 patients treated secondarily outcomes were successful at a mean followup of 59 months (range 16 to 110). CONCLUSIONS Endopyelotomy as primary treatment of pediatric ureteropelvic junction obstruction remains controversial but it may be appropriate in select cases. On the other hand, endopyelotomy is safe and effective for pediatric patients in whom open pyeloplasty fails.

Extracorporeal shock-wave lithotripsy of middle ureteral stones: Are ureteral stents necessary?

OBJECTIVES To ascertain whether insertion of a ureteral stent improves the outcome of middle ureteral (overlying the pelvic bone) stones treated with extracorporeal shock-wave lithotripsy (ESWL). METHODS Thirty-three patients with middle ureteral stones were treated with ESWL at our institution between October 1991 and October 1994. Twenty-six patients were available for follow-up; 14 patients were treated with stent bypass, 8 were treated in situ, and 4 patients were treated after percutaneous nephrostomy (PCN). All patients were treated initially on an unmodified Dornier HM-3, and all but 4 patients were treated in the prone position on a modified Stryker frame. Follow-up consisted of a plain abdominal radiograph, intravenous urogram, occasionally a retrograde urogram, and a telephone interview. RESULTS The overall stone-free rate for ESWL alone was 73%, and the efficiency quotient was 69. The stone-free rates after a single treatment for the stent bypass, in situ, and PCN groups were 71%, 63%, and 75%, respectively. Overall, 4% of patients required retreatment, 19% of patients required an auxiliary procedure, and 8% of the patients required hospital or emergency room admissions for renal colic. For stones 10 mm or greater (9), stone-free rates after one treatment for the stent bypass, in situ, and PCN groups were 33%, 33%, and 67%, respectively; for stones less than 10 mm (17), success rates were 82%, 80%, and 100%, respectively. CONCLUSIONS Pretreatment stinting provides no advantage over in situ ESWL for middle ureteral calculi (Fishers exact test, P = 1.0). ESWL is a reasonable initial therapy for middle ureteral stones less than 10 mm.

Ureteral Cell Cultures II: Collagen Production and Response to Pharmacologic Agents

PURPOSE To investigate the in vitro response of ureteral cells to potentially anti-fibrotic agents. MATERIALS AND METHODS Cultured human uroepithelial cells, smooth muscle cells, and myofibroblasts were assayed for proliferation and production of collagen types I and III, with and without the presence of hydrocortisone, colchicine, retinol, verapamil, and D-penicillamine. RESULTS Hydrocortisone stimulated the proliferation of all three cell types and reduced the type I and type III collagen production by myofibroblasts and smooth muscle cells, respectively. Verapamil enhanced the growth of uroepithelial cells and decreased collagen III production by both uroepithelial and smooth muscle cells. D-penicillamine increased the proliferation of uroepithelial and smooth muscle cells, and inhibited collagen type III production by all three cell types. CONCLUSIONS In vitro evidence suggests that hydrocortisone, verapamil, and D-penicillamine have effects that could favorably alter the healing of endoscopic ureteral incisions.

Ureteral cell cultures. I. Characterization and cellular interactions

PURPOSE To further understand the biology of ureteral cells, we studied the growth characteristics and in vitro cellular interactions of human ureteral uroepithelial cells, smooth muscle cells and myofibroblasts. MATERIALS AND METHODS The proliferation, morphology and immunohistochemical characteristics of human ureteral cells grown in vitro were evaluated under varying conditions. RESULTS The growth and morphology of ureteral cells were dependent upon media characteristics, especially the calcium concentration and presence of epidermal growth factor and bovine pituitary extract. Cells demonstrated specific stimulatory interactions via both soluble and insoluble factors. Most important, uroepithelial cells and smooth muscle cells displayed reciprocal enhancement of growth. CONCLUSIONS The favorable interactions between ureteral cell types in vitro have implications for future work involving these cells.

The Unintubated Ureterotomy Endourologically Revisited

PURPOSE The duration of stenting after endoureterotomy is a controversial issue. An even more basic question, however, is whether stent placement is needed at all. We performed a porcine study to address this question. METHODS A unilateral midureteral stricture was created in 20 minipigs. Six weeks later, 15 pigs underwent endoureterotomy. In 10 animals, a 7F ureteral stent was placed for 1 week. Five pigs remained unstented. Three months later, all 20 ureters were studied radiographically and were harvested. RESULTS Three of 5 control animals and 2 of 10 stented animals has strictures. In the unstented study group, all 5 animals had a nonobstructing dilation at the site of endoureterotomy. This was corroborated by a normal furosemide washout renal scan in all 3 animals so tested. CONCLUSIONS The result of unstented endoureterotomy in the porcine model suggests that, after endoureterotomy of secondary midureteral strictures, stenting may be unnecessary.