Ralph V. Clayman

Malignant Urachal Lesions

Urachal cancers are uncommon malignancies with a location that often permits considerable local extension before they are discovered. The most common histological type is adenocarcinoma, which may produce mucus that is a valuable aid in diagnosis. The presence of stippled calcification in a midline abdominal wall mass is almost pathognomonic for urachal carcinoma. More commonly, however, the symptoms are less specific, such as hematuria and an abdominal mass. Many lesions are visible endoscopically and, thus, the diagnosis can be made preoperatively from a biopsy. Most treatment failures occur because the tumor is not controlled locally by the initial operation and, therefore, we recommend en bloc cystectomy with umbilectomy and pelvic lymphadenectomy unless the tumor is known to be a sarcoma or early stage (I) carcinoma. If these patients are undertreated and there is a local recurrence then the patient usually is not salvageable. Because of the difficulty in identifying the origin of a bladder adenocarcinoma, any tumor on the dome or anterior wall should be approached initially as if it were a urachal tumor.

Percutaneous Nephrolithotomy: Extraction of Renal and Ureteral Calculi from 100 Patients

A percutaneous nephrostomy tract was used as a conduit to the kidney and ureter for extraction of 149 calculi in 100 patients. A variety of grasping and fragmentation techniques under fluoroscopic and endoscopic control were used to extract calculi in 88 per cent of the patients. With experience, operator efficiency and rate of stone extraction increased from 76 per cent early in the series to 91 per cent in the most recent patients, and the incidence of complications decreased from 17 to 5 per cent. Percutaneous removal of upper tract urinary calculi appears to be an appropriate alternative to an open operation in most patients with symptomatic urolithiasis.

Renal Cell Cancer Invading the Inferior Vena Cava: Clinical Review and Anatomical Approach

Renal cell carcinoma invades the inferior vena cava in approximately 5 per cent of the patients. The only effective therapy for intravascular renal cell carcinoma is radical nephrectomy and complete removal of the tumor thrombus. To formulate a reasonable operative approach to intracaval renal cell carcinoma we have reviewed our experience with 6 cases as well as the experience of other investigators. In addition, we studied the collateral circulation of the renal veins as described by various anatomists, and to this information we have added our experience with inferior venacavography and with intraoperative and autopsy dissections. Herein we describe a new preoperative staging system for intravascular renal cell carcinoma. The operative approach to each stage is discussed in detail beneficial intraoperative maneuvers are described and illustrated.

Percutaneous removal of renal and ureteral calculi: experience with 400 cases.

Percutaneous removal of renal and ureteral calculi was performed in 500 patients since 1979. Experience with our first 100 cases enabled us to accumulate a variety of techniques. We report our experience with the subsequent 400 cases. As judged by plain films of the kidneys, ureters and bladder, and renal tomograms without contrast medium we attained a status free of stones in 99 per cent of the patients with renal and 94.5 per cent with ureteral calculi. Intravenous-assisted local anesthesia was used in 94 per cent of the cases. There was no mortality and the incidence of complications was low. Most patients with renal and ureteral calculi can be managed successfully and safely by percutaneous methods with good patient tolerance and minimal convalescence.

Renal vascular complications associated with the percutaneous removal of renal calculi.

Significant immediate and delayed vascular complications occurred in 4 of 140 patients (3 per cent) undergoing percutaneous removal of renal and ureteral calculi. An understanding of renovascular anatomy, use of a safety guide wire and intraoperative availability of an angiographic balloon catheter may help to prevent and to treat bleeding problems.

Flexible Fiberoptic and Rigid-Rod Lens Endoscopy of the Lower Urinary Tract: A Prospective Controlled Comparison

Cystourethroscopy was performed on 80 men by separate examiners with a rigid-rod lens instrument and a flexible fiberoptic choledochonephroscope. Findings with the flexible system were equivalent to or more accurate than those with the rigid endoscope in 94 per cent of the cases. With the flexible instrument the duration of the examination was unchanged, patient comfort was improved, the amount of irrigation fluid was reduced, and patient preparation and positioning were simpler and quicker.

Percutaneous Intrarenal Electrosurgery

A 16F nephroscope with a 5F cutting element was used for percutaneous removal of kidney stones in 10 patients in whom an open operation otherwise would have been necessary. Stone removal was accomplished via percutaneous incision of narrowed infundibula, caliceal diverticula and the ureteropelvic junction. A thorough knowledge of renal vasculature, meticulous care and fluoroscopic control are necessary for successful percutaneous intrarenal electrosurgery.

Tamponade nephrostomy catheter for percutaneous nephrostolithotomy

Hemorrhage from the nephrostomy tract is the most common major complication associated with percutaneous nephrostolithotomy. The tamponade nephrostomy catheter is a new addition to the endourologists instruments; it is expressly designed to achieve immediate tamponade of the nephrostomy tract. The large-diameter, occlusive balloon (36F) is carried on a 14-F nephrostomy tube which is passed over a 5-F ureteral stent. As such, the catheter not only tamponades the nephrostomy tract but effectively drains the renal pelvis, while maintaining ureteral access.

Percutaneous removal of caliceal and other "inaccessible" stones: instruments and techniques.

Percutaneous removal of renal stones is becoming an established procedure, especially for stones lying free in the renal pelvis. However, some renal stones, particularly caliceal stones, are less accessible and require special techniques for removal. We discuss these techniques, which include 1) retrograde pyelography to facilitate a thorough understanding of caliceal anatomy and stone position in 3 dimensions, 2) approaches for accurate placement of a nephrostomy tract for straight-line access to the stone(s), 3) judicious use of percutaneous punctures above the 12th rib and secondary percutaneous tracts, and 4) skilled choice and use of a large variety of cutting, extracting and disintegrating instruments with endoscopic and/or fluoroscopic control. The flexible nephroscope is valuable especially to reach inaccessible areas, although its skilled use requires experience. Flexible endoscopy often is aided by pressure irrigation, an assistant and simultaneous fluoroscopic control.

Total nephroureterectomy with ureteral intussusception and transurethral ureteral detachment and pull-through

We describe a technique for nephroureterectomy that includes ureteral intussusception and transurethral ureteral resection and our method for transurethral ureteral pull-through. These adjuncts permit total nephroureterectomy through a single skin incision and are appropriate in all cases except in patients with known high-grade transitional cell carcinoma of the renal pelvis or ureter. In 18 cases, these techniques have been shown to be reliable, safe, and rapid; in the 14 patients under observation for five years or longer, there have been no local recurrences of tumor.