Peter Aslan

Use of ureteroscopy and holmium:YAG laser in patients with bleeding diatheses

OBJECTIVES To assess the safety and efficacy of ureteroscopy and holmium laser in patients with known bleeding diatheses and upper tract calculi or transitional cell carcinoma (TCC). METHODS Eight patients with stone disease and 1 patient with upper tract TCC were treated ureteroscopically with the holmium laser. The mean age was 58.3 years (range 42 to 74). Six patients were receiving Coumadin, with a mean international normalized ratio (INR) of 2.1 (normal INR less than 1.1). Two patients were thrombocytopenic, and 1 had von Willebrands disease. None of the bleeding diatheses were corrected before surgery. Semirigid or flexible ureteroscopes were used to access the ureter or intrarenal collecting system. The holmium laser was used to fragment calculi or ablate tumor. RESULTS Only 1 patient had a postoperative bleeding complication related to the procedure, involving an episode of oliguria secondary to a small ureteral clot. This cleared without surgical intervention. Another patient developed an episode of epistaxis after administration of ketorolac for pain. Six of 7 patients who underwent laser fragmentation for calculi were stone free on follow-up intravenous urogram at 1 month, and no tumor recurrence was noted in the patient with TCC (follow-up of 4 months). CONCLUSIONS Ureteroscopy allowed excellent access to all regions of the upper tracts, and holmium laser fragmentation of calculi or ablation of tumor was effective in managing each particular problem. Use of the holmium laser with ureteroscopic access provides a safe and acceptable combination for treating upper tract pathology in patients with uncorrected bleeding diatheses. As a result, these patients can avoid added costs of extended hospital stay and risks associated with transfusions.

Role of stone analysis in metabolic evaluation and medical treatment of nephrolithiasis.

BACKGROUND AND PURPOSE Comprehensive metabolic evaluation has become an important aspect of the management of recurrent nephrolithiasis, yet the role of stone analysis is often neglected or perhaps underestimated. The purpose of this study was to determine the role of stone analysis in medical decision making in patients with recurrent nephrolithiasis. MATERIALS AND METHODS We evaluated 100 consecutive stone-forming patients who had undergone compositional stone analysis as well as comprehensive metabolic evaluation at our institution. An analysis of stone composition in relation to metabolic disturbances was performed. Patients were stratified into two groups: calcium and non-calcium stone formers. RESULTS Patients having non-calcium stones were found to have a metabolic analysis reflecting specific metabolic disorders. Alternatively, patients with calcium stones were heterogeneous with regard to metabolic disorders, but there was a significant likelihood of renal tubular acidosis in those patients with calcium phosphate calculi. On the basis of these results, a simplified metabolic evaluation and nonselective medical therapy based on stone composition was formulated to facilitate assessment, management, and monitoring of stone disease. CONCLUSIONS Compositional stone analysis should be an integral part of the metabolic evaluation of patients with nephrolithiasis. Moreover, stone analysis alone may provide guidance for therapeutic treatment and obviate a formal metabolic evaluation.

Transvaginal repair of vesicovaginal fistulas after hysterectomy by vaginal cuff excision

PURPOSE When repairing vesicovaginal fistulas after hysterectomy there is often reluctance to excise totally the fistula tract for fear of enlarging the tissue defect. It has been suggested that consequent tension on suture lines may cause recurrence of an even larger fistula. On the other hand, a basic surgical principle is that scar tissue margins will not heal as quickly or at all compared to fresh viable margins. We reviewed whether our technique of total excision of the fistula tract and vaginal cuff scar provides an efficient cure rate. MATERIALS AND METHODS We retrospectively analyzed the outcomes of 20 women who underwent vaginal cuff excision repairs of a vesicovaginal fistula after total hysterectomy. Women who had complex fistulas and/or prior radiation therapy were excluded from study. RESULTS Of the 20 patients 3 (15%) sustained a bladder lesion that was repaired intraoperatively and 7 (35%) underwent 1 or more attempts at secondary repair. All fistulas were at the vaginal cuff. Mean fistula size was 0.7 cm. (11 women). All repairs were performed as soon as possible after presentation except 2 (10%) that were delayed because of the fistula appearance. The fistula tract was excised totally in all patients. All patients were cured. There were no postoperative complications and no significant or symptomatic vaginal shortening. CONCLUSIONS Transvaginal vaginal cuff excision repair is an effective first attempt cure of vesicovaginal fistulas after hysterectomy. Excision of the fistula tract and vaginal cuff scar enables the surgeon to suture viable tissues in every layer, thereby providing conditions optimal for wound healing. This procedure obviates the need to wait for tissue readiness and to interpose a flap in the majority of patients.

INCORPORATION OF PATIENT PREFERENCES IN THE TREATMENT OF UPPER URINARY TRACT CALCULI: A DECISION ANALYTICAL VIEW

PURPOSE Patient preferences, or utilities, may be crucial to select an appropriate treatment plan for stone disease. We used decision modeling to understand better patient choices and decision making in the overall management of recurrent nephrolithiasis. MATERIALS AND METHODS We interviewed 180 consecutive patients with active stone disease. Demographic data and historical experiences with calculi were recorded. Patients were presented with 6 hypothetical clinical scenarios and various treatment options. The standard gamble method was used to obtain utility values for each option. RESULTS Nephrectomy had the lowest mean utility value of 0.883. Percutaneous nephrolithotomy for severe, moderate and mild pain had utilities of 0.924, 0.932 and 0.947, respectively. Shock wave lithotripsy for the management of mild pain was the most attractive option (mean utility 0.968). The utility for long-term medical therapy was 0.949, which was between that of percutaneous nephrolithotomy and shock wave lithotripsy for mild pain. Patients with a surgical history of stone removal assigned lower utilities to invasive procedures (nephrectomy, percutaneous nephrolithotomy, p <0.05). As the incidence of spontaneous stone passage increased, a higher utility was given to long-term medical therapy (p <0.05). Patients on medical therapy less than 1 year did not appreciate a significant benefit of medical prophylaxis. However, longer compliance with medical management led patients to perceive increasing benefits of continuing such medical treatment (p <0.05). Patients who had undergone stone removal via endoscopic or open surgery also had a higher preference for medical therapy (p <0.05). CONCLUSIONS Patients who had undergone stone removal wanted to avoid future invasive procedures. They ranked long-term medical therapy below shock wave lithotripsy but above invasive procedures, such as percutaneous nephrolithotomy. Most importantly, patients appreciated the benefits of medical therapy the longer that they complied with specific recommendations. These results support the concept that patients perceive long-term medical therapy to prevent recurrent nephrolithiasis as a desirable treatment option.

RETROGRADE BALLOON CAUTERY INCISION OF URETEROPELVIC JUNCTION OBSTRUCTION

Retrograde balloon endopyelotomy has produced durable success rates of approximately 80% for all patients with UPJ obstruction. Patients with poor renal function, high-grade hydronephrosis, or stricture lengths of more than 2 cm fair worse, and these factors should be considered prior to balloon endopyelotomy. The debate concerning the functional significance of crossing vessels continues. However they are probably more important in terms of the risk of postoperative bleeding than in regards to overall success rates. With the use of endoluminal ultrasound, angiography, or spiral CT, patients with significant size crossing vessels can be identified preoperatively. The retrograde approach to UPJ obstruction using a cutting balloon is a quick and relatively inexpensive (shorter operative time and hospital stay, and no percutaneous nephrostomy) method for accomplishing an endopyelotomy incision. With the development of the 5-F balloon catheter and the use of a 7-F post-endopyelotomy stent, the need to stent the ureter for 7 days prior to the procedure is overcome. In this regard, the entire retrograde endopyelotomy may be performed in a one-step outpatient procedure.

Frequency of Angiomyolipomas Among Echogenic Nonshadowing Renal Masses (> 4 mm) Found at Ultrasound and the Utility of MRI for Diagnosis

OBJECTIVE The purpose of this study is to evaluate what percentage of echogenic nonshadowing renal lesions larger than 4 mm found at ultrasound are angiomyolipomas (AMLs) and to review how to diagnose AMLs, with particular emphasis on the increasing role played by MRI. MATERIALS AND METHODS The study data were obtained at a single institution over a period of 45 months. Although some patients were being reviewed for specific symptoms, such as hematuria, pain, or recurrent urinary tract infections, most of the findings were incidental. Follow-up data on 158 lesions in 132 patients were available. Confirmation of diagnosis was made with follow-up imaging or with histopathologic examination. RESULTS Ninety-eight (62.0%) of the lesions were AMLs, eight (5.1%) were renal cell carcinomas, three (1.9%) were oncocytomas, 17 (10.8%) were artifacts, seven (4.4%) were fat, five (3.2%) were calculi, another eight (5.1%) were scars, and 12 (7.6%) were complicated cysts. The mean age of patients with AML was significantly lower than that of patients without AML (61.71 [SD, 13.25] years vs 68.80 [SD, 17.85] years; p = 0.005). There was a female association with AMLs (p < 0.001). CONCLUSION Echogenic nonshadowing renal lesions larger than 4 mm seen at ultrasound should not be assumed to represent an AML without follow-up because a percentage of renal cell carcinomas will be missed. Although certain ultrasound features can be useful in differentiating an AML from a renal cell carcinoma and CT is frequently diagnostic, an understanding of MRI is important because it can potentially detect lipid-poor AMLs.

SECURED MEDICAL IMAGING OVER THE INTERNET

The Internet has established itself as an affordable, extremely viable and ubiquitous communications network that can be easily accessed from virtually any point in the world. This makes it ideally suited for medical image communications. Issues regarding security and confidentiality of information on the Internet, however, need to be addressed for both occasional, individual users and consistent enterprise-wide users. In addition, the limited bandwidth of most Internet connections must be factored into the development of a realistic usermodel and resulting protocol. Open architecture issues must also be considered so that images can be communicated to recipients who do not have similar programs. Further, application-specific software is required to integrate image acquisition, encryption and transmission into a single, streamlined process. Using Photomailer software provided by PhysiTel Inc., the authors investigated the use of sending secured still images over the Internet. The scope of their investigation covered the use of the Internet for communicating images for consultation, referral, mentoring and education. Photomailer software was used at several local and remote sites. The program was used for both sending and receiving images. It was also used for sending images to recipients who did not have Photomailer, but instead relied on conventional email programs. The results of the investigation demonstrated that using products such as Photomailer, images could be quickly and easily communicated from one location to another via the Internet. In addition, the investigators were able to retrieve images off of their existing email accounts, thereby providing greater flexibility and convenience than other systems which require scheduled transmission of information on dedicated systems. We conclude that Photomailer and similar products may provide a significant benefit and improve communications among colleagues, providing an inexpensive means of sending secured images on the Internet.