Shelly E. Handa

Experience With More Than 1,000 Holmium Laser Prostate Enucleations for Benign Prostatic Hyperplasia

PURPOSE Holmium laser prostate enucleation is a contemporary treatment for benign prostatic hyperplasia. We report our experience with more than 1,000 procedures. MATERIALS AND METHODS From June 1998 to March 2009 we performed 1,065 holmium laser prostate enucleations. After receiving institutional review board approval we retrospectively reviewed the database. Reported short-term, intermediate term and long-term results are 0 to 6, 6 to 12 and greater than 12 months, respectively. RESULTS Bladder stones were present in 50 patients (4.7%) and 87 of the 717 (12.1%) with laboratory studies available had renal insufficiency. Preoperative urinary retention was present in 411 cases (38.7%). Significant preoperative stress and urge incontinence was noted in 8 and 16 patients, respectively. Mean transrectal ultrasound prostate volume was 99.3 gm (range 9 to 391). Mean preoperative American Urological Association symptom score was 20.3 (range 1 to 35) and maximum urinary flow was 8.4 cc per second (range 1.1 to 39.3). Intraoperative or postoperative complications occurred in 24 cases (2.3%). Mean followup was 287 days (range 6 to 3,571). At short-term, intermediate term and long-term followup the mean symptom score was 8.7, 5.9 and 5.3, and maximum urinary flow was 17.9, 19.5 and 22.7 cc per second, respectively. At the most recent followup 3 patients (0.3%) were in urinary retention. One patient with maximum urinary flow 20 cc per second required a second procedure for bleeding prostatic regrowth. Urethral stricture was noted in 9 (0.9%), 11 (1.3%), 4 (1.3%) and 0 patients, and bladder neck contracture was found in 0, 7 (0.8%), 4 (1.3%) and 5 (6.0%) at short-term, intermediate term, long-term and greater than 5-year followup, respectively. At the most recent followup significant stress and urge incontinence was noted in 9 and 6 patients, respectively. CONCLUSIONS Holmium laser prostate enucleation is safe and effective for benign prostatic hyperplasia. The complication rate is low, and incontinence and the need for ancillary procedures are rare for holmium laser prostate enucleation with durable long-term results.

Holmium Laser Enucleation of the Prostate—Outcomes Independent of Prostate Size?

PURPOSE Generally treatment decisions for benign prostatic hyperplasia are based on prostate size and surgeon experience. Prostates greater than 100 gm often require open surgery. However, less invasive options are available. Randomized, controlled trials have demonstrated that holmium laser enucleation of the prostate is a viable and effective treatment for benign prostatic hyperplasia. We examined the outcome of holmium laser enucleation of the prostate based on prostate size. MATERIALS AND METHODS We retrospectively reviewed the records of all patients in our institutional review board approved database who underwent holmium laser enucleation of the prostate from January 1999 to October 2006. Patients were divided into 3 cohorts based on preoperative transrectal ultrasound prostate measurements, including less than 75, 75 to 125 and more than 125 gm. Patients with prostate cancer were excluded from study. Demographic, laboratory, operative, preoperative and postoperative data were obtained. RESULTS As prostate size increased, so did prostate specific antigen, and the urinary retention and enucleation rates. Hospitalization, catheterization, preoperative and postoperative outcomes were similar among the groups. On linear regression the decrease in prostate specific antigen highly correlated with the amount of tissue removed (p <0.0001). The complication rate was similar among the treatment groups. All patients did equally well in terms of postoperative urinary function independent of prostate size. CONCLUSIONS Holmium laser enucleation of the prostate is a safe and effective minimally invasive treatment for benign prostatic hyperplasia. It improved patient prostate specific antigen, American Urological Association symptom score and maximum urinary flow rate independent of the amount of benign prostatic hyperplasia present. Our results demonstrate the advantage of holmium laser enucleation of the prostate to treat all prostates regardless of size with favorable and equivalent outcomes.

Holmium Laser Enucleation of the Prostate for Prostates Larger Than 175 Grams

BACKGROUND AND PURPOSE Open simple prostatectomy has been considered the treatment of choice for symptomatic benign prostatic hyperplasia (BPH) of large prostates because traditional endoscopic techniques have not proven either effective or feasible. We present our experience with holmium laser enucleation of the prostate (HoLEP) for glands >175 cc. METHODS An Institutional Review Board approved prospective database has been maintained since January 1999 for all HoLEP procedures. The database was reviewed retrospectively for patients who underwent HoLEP for BPH with a preoperative transrectal ultrasonography (TRUS) volume of >175 cc. RESULTS From January 1999 to November 2008, we identified 57 patients with a mean pretreatment TRUS volume of 217.8 cc (range 175-391 cc). Preoperative retention was present in 30 patients. Preoperative mean prostate-specific antigen level was 14.6 ng/mL, mean American Urological Association (AUA) symptom index was 19.0, and mean peak flow (Qmax) was 8.2 mL/sec. Mean hospital stay was 26 hours, and postoperative catheterization was 18.5 hours (range 6-96 hrs). All patients were able to void after catheter removal. Mean enucleated tissue weight was 176.4 g (range 48-532.2 g). At 6-month follow-up, AUA symptom index was 6.5, mean PSA level was 0.78 ng/mL, and Qmax was 18.5. During the follow-up period, no patient needed catheterization or had persistent incontinence. CONCLUSIONS Even in the large prostate gland, HoLEP provides a satisfactory outcome with low morbidity. HoLEP is the only endoscopic technique that allows for tissue removal comparable to that of open prostatectomy for such patients.

The Presence of Horseshoe Kidney Does Not Affect the Outcome of Percutaneous Nephrolithotomy

BACKGROUND AND PURPOSE Large or complex calculi within a horseshoe kidney can present a challenge because many cases are associated with other aberrant anatomy. We performed a study to define the outcome of patients with a horseshoe kidney who were treated with percutaneous nephrolithotomy (PNL). PATIENTS AND METHODS From August 1999 to February 2007, 44 PNLs were performed in 35 patients for calculi within a horseshoe kidney. Mean age was 55.4 years. Parameters evaluated to assess the outcomes of PNL included presenting symptoms, stone burden, location of access, stone-free rate, need for secondary intervention, length of stay (LOS), complication rate, stone analysis, and metabolic data. RESULTS The average stone burden per kidney was 2.59 cm (range 1-6.2 cm). Single percutaneous access was used in 97.7%. Location of the access tract was upper pole (82.2%), interpolar (13.4%), and lower pole (4.4 %). Flexible nephroscopy was performed in all patients. The stone-free rate after primary PNL was 84.1%. Second-look nephroscopy was performed in five kidneys. Overall stone-free rate was 93.2%. Average LOS was 1.92 days (range 1-4 d). Overall complication rate was 14.3%. Stone analysis revealed predominantly calcium stones, and metabolic abnormalities were demonstrated in all patients with 24-hour urine studies. CONCLUSIONS PNL is the treatment of choice for large and/or complex stones. The presence of a horseshoe kidney does not affect the outcome of PNL. Upper pole access is usually preferred, and flexible nephroscopy is essential to maximize stone-free rates. SA and metabolic data support the premise that calculus formation is a metabolic event.

Profile of the Brushite Stone Former

PURPOSE The incidence of brushite stones has increased during the last 3 decades and we report our experience with brushite stone formers. MATERIALS AND METHODS From 1996 to 2008 we identified 82 patients with brushite urinary calculi. After institutional review board approval a review of our prospectively collected database was performed. RESULTS There were 54 (65.9%) male and 28 (34.1%) female stone formers. Mean age was 44 years (range 4 to 84). Prior stone events were reported by 69 (84.1%) patients with 54 (78.3%) having received shock wave lithotripsy. Bilateral calculi were present in 28 (34.1%) patients. Mean stone area was 29.2 mm(2) (range 2 to 130). Surgery was performed in 80 patients including 63 (76.8%) percutaneous nephrolithotomy, 8 (9.8%) ureteroscopy, 3 (3.7%) shock wave lithotripsy, and 6 (7.3%) ureteroscopy and percutaneous nephrolithotomy. After primary and secondary procedures 76 (92.7%) patients were rendered stone-free. Metabolic urine studies were available in 45 patients. All patients demonstrated 1 or more abnormalities, with hypercalciuria (greater than 250 mg daily for women and greater than 275 mg daily for men) in 38 (80.9%), urine pH greater than 6.2 in 29 (61.7%), urine volume less than 2 l in 27 (57.4%), hypocitraturia (less than 320 mg daily) in 22 (46.8%), hyperuricosuria (greater than 750 mg daily in women, greater than 800 mg daily in men) in 8 (17%) and hyperoxaluria (greater than 32 mg daily in women and greater than 43 mg daily in men) in 5 (10.6%). Recurrent stone events occurred in 31 (37.8%) patients at a mean of 33 (range 2 to 118) months from treatment. CONCLUSIONS Brushite stone formers are a treatment challenge. Almost a third will present with bilateral stones and the stone burden is sizeable. Nearly 80% of patients report having prior shock wave lithotripsy and recurrent stone events occurred approximately 3 years after treatment. All patients with brushite stones in this cohort had an underlying metabolic abnormality and specifically brushite stones should be heralded as a marker for hypercalciuria. Based on these data we recommend all brushite stone formers undergo 24-hour urine studies and have close long-term followup.

In idiopathic calcium oxalate stone-formers, unattached stones show evidence of having originated as attached stones on Randall’s plaque

Study Type – Diagnostic (exploratory cohort)
Level of Evidence 2b

Brushite stone disease as a consequence of lithotripsy

The incidence of calcium phosphate (CaP) stone disease has increased over the last three decades; specifically, brushite stones have been diagnosed and treated more frequently than in previous years. Brushite is a unique form of CaP, which in certain patients can form into large symptomatic stones. Treatment of brushite stones can be difficult since the stones are resistant to shock wave and ultrasonic lithotripsy, and often require ballistic fragmentation. Patients suffering from brushite stone disease are less likely to be rendered stone free after surgical intervention and often experience stone recurrence despite maximal medical intervention. Studies have demonstrated an association between brushite stone disease and shock wave lithotripsy (SWL) treatment. Some have theorized that many brushite stone formers started as routine calcium oxalate (CaOx) stone formers who sustained an injury to the nephron (such as SWL). The injury to the nephron leads to failure of urine acidification and eventual brushite stone formation. We explore the association between brushite stone disease and iatrogenic transformation of CaOx stone disease to brushite by reviewing the current literature.

Renal Functional Effects of Multiple-Tract Percutaneous Access

INTRODUCTION Percutaneous nephrolithotomy (PCNL) can involve establishing more than one access into the urinary collecting system. The present study examined whether multiple percutaneous accesses results in a more severe reduction in renal function than that after single-percutaneous access. METHODS Adult female pigs were anesthetized, and percutaneous access to the left urinary collecting system was achieved by puncturing the lower pole calyx (single-tract access, n = 16) or serially puncturing the lower pole, interpolar region, and upper pole calyces [multiple (three)-tract access, n = 11]. Renal function measurements included glomerular filtration rate and effective renal plasma flow, and were taken immediately before and 1.5 and 4.5 hours after percutaneous access. We also examined glomerular function in a group of adult patients with normal preoperative serum creatinine (Cr) levels (<or=1.4 mg/dL) who underwent either unilateral single-tract PCNL (23 patients) or unilateral multiple (two)-tract PCNL (10 patients). Access tracts were dilated to 30F with a NephroMax balloon dilator system in animal and human patients. RESULTS Single- and multiple-tract percutaneous access procedures in pigs resulted in a similar renal functional response; both glomerular filtration rate and effective renal plasma flow significantly declined by approximately 60% immediately after access and remained depressed throughout the experimental observation period. A retrospective analysis of patients with normal serum Crs (<or=1.4 mg/dL) who underwent single- or multiple-tract PCNL demonstrated that the procedures produced similar and significant increases in serum Cr on postoperative day 1 (0.33 +/- 0.09 [standard error of mean] mg/dL and 0.39 +/- 0.11 mg/dL, respectively) and day 2 (0.33 +/- 0.09 mg/dL and 0.25 +/- 0.09 mg/dL, respectively). CONCLUSIONS Multiple-tract access does not lead to a more severe reduction in renal function than single-tract access; that is, the acute renal hemodynamic response to PCNL appears independent of the number of access tracts.

Nephrocalcinosis: re-defined in the era of endourology

Nephrocalcinosis generally refers to the presence of calcium salts within renal tissue, but this term is also used radiologically in diagnostic imaging in disease states that also produce renal stones, so that it is not always clear whether it is tissue calcifications or urinary calculi that give rise to the characteristic appearance of the kidney on x-ray or computed tomography (CT). Recent advances in endoscopic imaging now allow the visual distinction between stones and papillary nephrocalcinosis, and intrarenal endoscopy can also verify the complete removal of urinary stones, so that subsequent radiographic appearance can be confidently attributed to nephrocalcinosis. This report shows exemplary cases of primary hyperparathyroidism, type I distal renal tubular acidosis, medullary sponge kidney, and common calcium oxalate stone formation. In the first three cases—all being conditions commonly associated with nephrocalcinosis—it is shown that the majority of calcifications seen by radiograph may actually be stones. In common calcium oxalate stones formers, it is shown that Randall’s plaque can appear as a small calculus on CT scan, even when calyces are known to be completely clear of stones. In the current era with the use of non-contrast CT for the diagnosis of nephrolithiasis, the finding of calcifications in close association with the renal papillae is common. Distinguishing nephrolithiasis from nephrocalcinosis requires direct visual inspection of the papillae and so the diagnosis of nephrocalcinosis is essentially an endoscopic, not radiologic, diagnosis.

Changing composition of renal calculi in patients with musculoskeletal anomalies.

BACKGROUND AND PURPOSE Calculi from patients with musculoskeletal (MS) anomalies who are largely immobile and prone to urinary infections have been traditionally composed primarily of struvite and carbonate apatite. Because of substantial improvements in the care of these patients in recent decades, stone etiology may have shifted from infectious to metabolic. We assessed the composition of renal calculi and metabolic characteristics in a contemporary cohort of patients with MS anomalies who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS Retrospective analysis of patients who underwent PCNL between April 1999 and June 2009 and had follow-up 24-hour urine studies was performed. Patients with MS anomalies included spinal cord injury, myelomeningocele, muscular dystrophy, multiple sclerosis, cerebral palsy, or other clinical syndromes causing kyphoscoliosis and contractures. RESULTS Our cohort included 33 patients with MS anomalies and 334 consecutive patients as a control group who underwent PCNL and had metabolic workup. Stones were infectious in etiology in 18.4% and 6.2% in MS and control groups, respectively. Thus, most patients harbored stones of metabolic origin. Metabolic stones in the MS group were composed of 52.7% hydroxyapatite, 10.5% calcium oxalate, 7.9% brushite, 2.6% uric acid, 0% cystine, and 7.9% other. Metabolic stones in the control group were 50.5% calcium oxalate, 16.4% hydroxyapatite, 11.5% brushite, 10.8% uric acid, 4.3% cystine, and 0.3% other. Mean 24-hour urine values for patients with metabolic stones in MS/control groups were volume 2.18/1.87 L/d, pH 6.78/6.05, calcium to creatinine ratio 220/151 mg/g, and oxalate 44.8/39.5 mg/d. CONCLUSIONS Although patients with MS anomalies are traditionally thought to harbor infection-related calculi, most will be found to have calculi of metabolic etiology. The incidence of calcium phosphate stones is high in this group of patients, perhaps reflecting their high urinary pH.