Peter G. Schulam

Flexible Ureteroscopy and Laser Lithotripsy for Single Intrarenal Stones 2 cm or Greater—Is This the New Frontier?

PURPOSEnPercutaneous nephrolithotomy has been the standard of care for intrarenal calculi greater than 2 cm. Flexible ureteroscopy with holmium laser lithotripsy is a minimally invasive treatment modality that is able to treat large intrarenal calculi with the potential to decrease morbidity, while maintaining a high level of efficacy.nnnMATERIALS AND METHODSnA total of 15 patients with a single intrarenal calculus 2 cm or greater were treated with retrograde ureteroscopic nephrolithotripsy. Lithotripsy was performed with a 7.2Fr flexible ureteroscope and 200 micron laser fiber. The stone-free rate was defined as the absence of any stones in the kidney or residual stone fragments less than 1 mm, which is too small to be extracted with a basket or a grasper. All patients underwent followup ureteroscopy within 15 days after the last procedure and renal ultrasound 30 days after the last treatment.nnnRESULTSnThere were a total of 15 intrarenal calculi 20 to 25 mm (mean 22) in diameter. The mean number of procedures was 2.3 (range 2 to 4). The overall stone-free rate was 93.3%. One patient (6.6%) had a residual 5 mm stone fragment in the lower pole of the kidney, which was followed expectantly for 2 years with no change in size. There were no major complications. There were 3 minor complications (20%), including 1 emergency room visit for fever and pain, and 2 cases of gross hematuria. All cases were performed on an outpatient basis.nnnCONCLUSIONSnIn select patients with a single intrarenal calculus 2 cm or greater small diameter flexible ureteroscopy with holmium laser lithotripsy may represent an alternative therapy to standard percutaneous nephrolithotomy with acceptable efficacy and low morbidity.

Flexible Ureteroscopy and Laser Lithotripsy for Multiple Unilateral Intrarenal Stones

BACKGROUNDnExternal shock wave lithotripsy (ESWL) and percutaneous nephrolithotomy (PNL) have been the standard of care for the treatment of intrarenal calculi.nnnOBJECTIVEnWe sought to determine the safety and efficacy of flexible ureteroscopy and holmium laser lithotripsy for the treatment of multiple intrarenal calculi and further stratify the efficacy by stone burden less than and greater than 20mm.nnnDESIGN, SETTING, AND PARTICIPANTSnPatients with multiple unilateral renal calculi treated between 2000 and 2006 at a single tertiary academic center were retrospectively evaluated.nnnINTERVENTIONnAll patients underwent retrograde flexible ureteroscopy and holmium laser lithotripsy.nnnMEASUREMENTSnStone-free status was determined by ureteroscopy 15 d after the last procedure and was defined as the absence of stones in the kidney or residual fragments <1mm. A renal ultrasound was performed 30 d after the last treatment to confirm the absence of stones and hydronephrosis.nnnRESULTS AND LIMITATIONSnFifty-one patients were identified for a total of 161 intrarenal calculi with a mean stone size per patient of 6.6+/-3mm (range: 2-15). The mean number of stones per patient was 3.1+/-1 (range: 2-6). The mean number of primary procedures was 1.4+/-0.6 (range: 1-3). The overall stone-free rates after one and two procedures were 64.7% and 92.2%, respectively. The stone-free rates for patients with a stone burden greater than and less than 20mm were 85.1% and 100%, respectively. The overall complication rate was 13.6%; 97.6% of cases were performed as outpatient procedures. There are some limitations to this study, however: This is a retrospective review from a single institution, and our results are based on a relatively small sample size.nnnCONCLUSIONSnFor select patients with multiple intrarenal calculi, flexible ureteroscopy with holmium laser lithotripsy may represent an alternative therapy to ESWL or PNL, with acceptable efficacy and low morbidity.

Importance of surgical margins in the management of renal cell carcinoma.

Surgical resection remains the standard treatment for clinically localized renal cell carcinoma. Pathological features of the surgical specimen, including the margin status, play an important part in determining the patients prognosis. Negative surgical margins have traditionally been sought to maximize the efficacy of treatment. Initial concerns that partial nephrectomy might have high local recurrence rates compared with radical nephrectomy have now been minimized as a result of technological advances and refinements in surgical technique. Current concerns in relation to partial nephrectomy include the width of parenchymal tissue that should be removed to avoid positive surgical margins, effects of positive margins on recurrence-free survival, and the use of frozen-section analysis to determine margin status. Size of the surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence, and not all positive surgical margins lead to recurrent disease. Intraoperative frozen-section analysis is not definitive and its value in guiding the surgical management of renal tumors remains to be defined. Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses. Intraoperative use of ultrasound, cold-scissor parenchymal transection, embolization, and hilar clamping to achieve a bloodless operative field with clear visibility, may minimize the risk of positive margins during partial nephrectomy.

Treatment of renal transplant ureterovesical anastomotic strictures using antegrade balloon dilation with or without holmium:YAG laser endoureterotomy.

OBJECTIVESnTo report our results after antegrade endoscopic treatment of ureteral stenosis with balloon dilation with or without holmium laser endoureterotomy. Ureteral stenosis is the most common long-term urologic complication of renal transplantation.nnnMETHODSnFrom July 2000 to October 2002, 9 renal transplant patients with ureteral obstruction diagnosed by an increase in serum creatinine and radiologic evidence presented for endoscopic treatment. All patients were treated with nephrostomy tube drainage followed by antegrade flexible nephroureteroscopy and balloon dilation of the stricture. Three patients required holmium laser endoureterotomy during the same procedure because of fluoroscopic and endoscopic evidence of persistent stricture. All patients were treated with ureteral stents and nephrostomy tubes postoperatively. The median follow-up was 24 months (range 6 to 32).nnnRESULTSnThe site of stenosis was at the ureterovesical anastomosis in all patients, and the mean stricture length was 0.28 cm. Two patients had previously undergone ureteroneocystostomy for prior ureteral stenosis. Six patients (66%) required only balloon dilation, and 3 patients (33%) also required holmium laser endoureterotomy. The median ureteral stent and nephrostomy tube duration was 40 and 62 days, respectively. The mean serum creatinine level was 2.3 mg/dL at presentation and 1.7 mg/dL at the last follow-up visit. After a median follow-up of 24 months, the ureteral patency and graft function rates were both 100%. No perioperative complications occurred.nnnCONCLUSIONSnBalloon dilation with or without holmium laser endoureterotomy was successful and safe in this group of renal transplant patients with short ureterovesical anastomotic strictures.

Asynchronous, Out-of-Sequence, Transcontinental Chain Kidney Transplantation: A Novel Concept

The organ donor shortage has been the most important hindrance in getting listed patients transplanted. Living kidney donors who are incompatible with their intended recipients are an untapped resource for expanding the donor pool through participation in transplant exchanges. Chain transplantation takes this concept further, with the potential to benefit even more recipients. We describe the first asynchronous, out of sequence transplant chain that was initiated by transcontinental shipment of an altruistic donor kidney 1 week after that recipients incompatible donor had already donated his kidney to the next recipient in the chain. The altruistic donor kidney was transported from New York to Los Angeles and functioned immediately after transplantation. Our modified‐sequence asynchronous transplant chain (MATCH) enabled eight recipients, at four different institutions, to benefit from the generosity of one altruistic donor and warrants further exploration as a promising step toward addressing the organ donor shortage.

Laparoscopic Versus Open Renal Procurement for Pediatric Recipients of Living Donor Renal Transplantation

Despite reports demonstrating the safety of laparoscopic donor nephrectomy (LDN) for pediatric recipients of renal transplants, recent evidence has challenged using LDN for recipients 5 years of age or younger.

Diffusion Tensor Magnetic Resonance Tractography of the Prostate: Feasibility for Mapping Periprostatic Fibers

OBJECTIVEnTo evaluate the feasibility of diffusion tensor imaging (DTI) tractography of the prostate for mapping of periprostatic neurovascular anatomy.nnnMETHODSnEight men with prostate cancer scheduled to undergo nerve-sparing robot-assisted radical prostatectomy (RARP) underwent endorectal multiparametric magnetic resonance imaging (MRI) of the prostate with DTI. Tract mapping was accomplished by positioning spherical regions of interest contiguously along the prostatic capsule at the prostatic apex, midgland, and base.nnnRESULTSnDTI tractography of the prostate effectively visualized periprostatic fiber tract anatomy. There was no significant correlation between total tract number and prostate size, however (Spearmans coefficient = 0.33, P = .42). Variation in tract distribution existed. The total fiber mass was highest in the lower prostate hemisphere at the base of the prostate (mean = 36.9 vs 21.1, P = .0004) and in the upper hemisphere at the apex (mean = 41.6 vs 57.9, P = .006).nnnCONCLUSIONnDTI tractography successfully visualized fiber tracts around the prostate. Gold standard anatomic correlation is needed.

Percutaneous Cystolithotomy for Calculi in Reconstructed Bladders: Initial UCLA Experience

PURPOSEnFollowing bladder augmentation, patients are at significant risk for bladder calculi. We present our experience with a minimally invasive treatment approach using endoscopically assisted percutaneous cystolithotomy.nnnMATERIALS AND METHODSnA retrospective chart review identified 74 patients who underwent percutaneous cystolithotomy following bladder augmentation between 2002 and 2009. Cystogram was performed to determine the ideal location for percutaneous bladder access and a guidewire was inserted in the bladder through a bile needle. A balloon dilator was used to place a 30Fr sheath. Rigid cystoscopy with a 26Fr nephroscope allowed stone treatment by basketing and ultrasonic lithotripsy. A suprapubic 22Fr catheter was then placed. Patients were seen on postoperative day 14 and abdominal ultrasound was performed. If no significant residual calculi were visualized, the suprapubic tube was removed.nnnRESULTSnMean +/- SD patient age at operation was 20 +/- 10.7 months (range 4 to 40). Mean +/- SD time between bladder augmentation and percutaneous cystolithotomy was 4.8 +/- 2.05 years. Of the patients 38 (51%) were male and 36 (49%) were female. Mean +/- SD number of stones per patient was 4.6 +/- 7.8 (range 1 to 60). Ultrasonic lithotripsy was performed in 49 cases (66%). In 25 cases (34%) only stone basketing was performed. A total of 70 patients (95%) were stone-free on abdominal plain film at 14 days. Of the procedures 24 (32%) were performed on an outpatient basis and 50 were performed on an inpatient basis with a mean +/- SD hospital stay of 1.3 +/- 2.7 days (range 1 to 21). There were 9 minor complications noted (12%).nnnCONCLUSIONSnEndoscopic percutaneous cystolithotomy offers a safe and effective treatment option for bladder calculi in reconstructed bladders and is the preferred method at our institution.

Splenosis Presenting as a Right Suprarenal Retroperitoneal Mass

CASE REPORT A 52-year-old man was referred for evaluation o fa5c m. mass in the right suprarenal position, which was 3 cm. in diameter in 1996, as well as a contrast enhancing 1.5 cm. mass in the lower pole of the right native kidney. History was remarkable for a motor vehicle accident when the patient was 16 years old, which resulted in splenectomy and left nephrectomy performed via laparotomy using a chevron incision. Progressive renal failure and acquired cystic disease of the native right kidney subsequently developed, and in 1999 the patient underwent a cadaveric renal transplant. During a routine followup examination microscopic hematuria was noted, which prompted a hematuria evaluation. Ultrasound revealed a suprarenal mass and a solid renal mass on the right side. Magnetic resonance imaging (MRI) showe da6c m. suprarenal mass adjacent and posterior to the right adrenal gland (fig. 1). The mass was intermediate to dark on T1 and T2-weighted images. MRI also demonstrated the 1.5 cm. contrast enhancing lesion in the lower pole of the right kidney. Functional evaluation revealed no evidence of abnormal hormonal production. After an extensive discussion of surgical options, the patient expressed an interest in a laparoscopic approach, realizing that he would be at increased risk for conversion. A transperitoneal laparoscopic approach was used, and we were able to complete the nephrectomy portion of the case. However, the case was converted to an open approach through a thoracoabdominal incision when it was discovered that the suprarenal mass was densely adherent to the liver at its superior margin in the region of the retrohepatic vena cava. The mass had a distinct venous drainage system that consisted of 1 vein draining into the inferior vena cava. The arterial supply was less distinct. The patient recovered uneventfully and was discharged home on postoperative day 5. Pathological evaluation of the suprarenal mass revealed mature splenic tissue with no malignancy (fig. 2). The splenic tissue had a distinct capsule and

Improved functional deflection with a dual-deflection flexible ureteroscope.

PURPOSEnTo compare the maximal active deflection capabilities of a newly designed dual-deflection ureteroscope with those of a standard flexible ureteroscope.nnnMATERIALS AND METHODSnThe dual-deflection ureteroscope is similar in design to single-deflection ureteroscopes with the addition of a second, more proximal unidirectional deflection point, which is controlled with the index finger on the contralateral side of the instrument. We evaluated the maximal deflection angles achieved with this ureteroscope with no inserted devices as well as with 200-, 365-, and 550-microm laser fibers and a 3F Nitinol wire basket in the working port. We compared these angles with those obtained with the Dur-8 single-deflection ureteroscope.nnnRESULTSnThe dual-deflection ureteroscope allowed a superior maximum active deflection angle of 234.3 degrees with an empty working channel compared with only 143 degrees for the standard single-deflection ureteroscope. Instruments in the working channel dampened the active deflection of both ureteroscopes. The average maximum upward angles achievable with the single-deflection ureteroscope with the 200-, 365-, and 550-microm laser fibers and the 3F basket were 115.3 degrees, 92 degrees, 46.6 degrees, and 123.3 degrees, respectively. The average deflection angles with the dual-deflection endoscope deflected at the distal point were similar to those obtained with the single-deflection ureteroscope. In contrast, the average maximum deflection angles obtained with the dual-deflection endoscope deflected at both points with a 200-, 365-, and 550-microm laser fiber and a 3F basket in the working channel were 211 degrees, 183.3 degrees, 109 degrees, and 224 degrees, respectively. The degree of dampening by larger instruments was greater in the single-deflection than the dual-deflection ureteroscope.nnnCONCLUSIONSnThe double-deflection ureteroscope can achieve superior active deflection compared with a standard ureteroscope. The second active angle allows the use of larger instruments in the working port with a smaller impact on overall deflection. The double-deflection ureteroscope should be beneficial in the management of difficult-to-treat lower-pole renal calculi and may allow some patients who would have required percutaneous nephrolithotomy to undergo ureteroscopic management of their stone disease.