Samuel C. Kim

Hand-Assisted Laparoscopic Pyeloplasty and Isthmectomy in a Patient with a Horseshoe Kidney

We report the laparoscopic management of ureteropelvic junction obstruction in a patient with a horseshoe kidney. We believe this to be the first reported case of isthmectomy performed with the Harmonic Scalpel. Follow-up diuretic renal scan and CT revealed improved drainage and separation of the divided horseshoe kidney.

Bladder endometriosis: pertinent clinical images

A 22-year-old woman presented with a recent history of urgency, frequency, and rightsided flank pain. An intravenous urogram obtained at an outside hospital demonstrated a normal-appearing right nephrogram with prompt uptake and excretion and moderate left hydroureteronephrosis with no obvious filling defects or stones (Fig. 1). Abdominal computed tomography performed at our institution demonstrated left hydroureteronephrosis with no identifiable cause. A technetium-99 Mertiatide (MAG-3) diuretic renal scan demonstrated a normal right kidney and moderately impaired perfusion and function with mild hydronephrosis and drainage impairment in the left kidney. The initial urine culture grew more than 100,000 Escherichia coli and, given her right flank discomfort (pain opposite the side of hydronephrosis) and symptoms of cystitis, she was treated with intravenous antimicrobial agents for presumed right pyelonephritis. A voiding cystourethrogram demonstrated no reflux or bladder filling defects. Because of her complex presentation, the patient underwent cystoscopy, which revealed a 3 to 4-cm, edematous, bluish, submucosal tumor in the trigone that obscured both the right and left ureteral orifices (Fig. 2). The mass obscuring the left ureteral orifice was resected, and a left retrograde nephrostogram revealed no intraluminal filling defects. Histologic review of the resected bladder mass was diagnostic for endometriosis with stromal overgrowth (Fig. 3). Bladder endometriosis occurs in approximately 1% of women with endometriosis. Although cyclical gross hematuria is pathognomonic for vesical endometriosis, it is only present in 20% of patients. These images remind us that bladder endometriosis may masquerade as pyelonephritis, renal obstruction, or interstitial cystitis and must not be forgotten in the differential diagnosis.1

Urolithiasis associated with topiramate

OBJECTIVE Topiramate is a sulfamate-substituted monosaccharide anticonvulsant used as adjunctive therapy for intractable refractory seizures. It is report a case of topiramate-induced urolithiasis. CASE REPORT A 35-year-old man presented with acute, right-sided, colicky flank pain. He denied hematuria or dysuria. He was in use of phenytoin, risperidone, phenobarbital, and topiramate. The total daily dose of topiramate was 375 mg. A CT scan showed a 7 x 1 mm curvilinear density at the right ureterovesical junction with proximal hydrouretronephrosis. He was managed with rigid ureteroscopic stone extraction and the calculus metabolic analysis revealed the stone was composed of carbonate apatite (70%), calcium oxalate dihydrate (20%), and calcium oxalate monohydrate (10%). COMMENTS The present case typifies many features of topiramate-induced urolithiasis. Those who care for patients with urinary stone disease should be aware of this association.

EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY OF PANCREATIC DUCT STONES USING THE HEALTHTRONICS LITHOTRON LITHOTRIPTOR AND THE DORNIER HM3 LITHOTRIPSY MACHINE

PURPOSE Pancreatic duct stones, which are most often a result of alcohol induced chronic pancreatitis, can lead to chronic abdominal pain, pseudocysts, and exocrine and endocrine failure of the pancreas. Others have reported success using extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for pancreatic stones. We report our experience with pancreatic ESWL using the LithoTron (Healthtronics, Marietta, Georgia) and HM3 (Dornier) lithotripsy machines. MATERIALS AND METHODS We performed pancreatic ESWL in 23 patients in 4 years, including in 12 with the LithoTron and in 11 with the HM3. After ESWL endoscopic retrograde cholangio-pancreatography (ERCP) was performed in all cases. Stone-free status was defined as no stone fragments visualized or the elimination of all post-ESWL stones by ERCP. RESULTS Stone-free status was documented in 83% and 82% of patients treated with the LithoTron and HM3, respectively, and 2 per group later required open surgical intervention. There were no changes in pancreatic enzymes and no cases of sepsis or fever after ERCP. CONCLUSIONS In association with post-procedure ERCP pancreatic ESWL is an effective and safe procedure that enables patients with obstructing pancreatic duct stones recalcitrant to primary endoscopic extraction to avoid a potentially morbid open procedure. The HM3 and LithoTron have comparable efficacy and safety. This modality is particularly effective for a stone aggregate of less than 20 mm., while a larger stone burden of greater than 20 mm. in aggregate and multiple stones are clear risk factors for treatment failure.

Percutaneous Hepatolithotomy: The Northwestern University Experience

Obstruction of intrahepatic ducts by calculi can lead to abdominal pain, cholestasis, abscesses, and cholangitis. Patients with stones recalcitrant to extraction using endoscopic retrograde cholangiopancreatography (ERCP) have traditionally been referred to a general surgeon for open stone extraction or hepatic lobectomy despite its great potential morbidity. Borrowing techniques, instrumentation, and experience in performing percutaneous nephrolithotomy, we describe our experience with percutaneous hepatolithotomy (PHL), a minimally invasive, safe, and effective alternative to open surgery for recalcitrant biliary stones.

Resection of a posterior pubic symphyseal protuberance using the electrocautery device.

A posterior protuberance of the pubic symphysis can make a radical retropubic prostatectomy difficult. We describe a technique using electrocautery to remove this protuberance, which can be safely and easily performed.