Stephen Y. Nakada

LOWER POLE I: A PROSPECTIVE RANDOMIZED TRIAL OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AND PERCUTANEOUS NEPHROSTOLITHOTOMY FOR LOWER POLE NEPHROLITHIASIS—INITIAL RESULTS

PURPOSE The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.

A multicenter clinical trial investigating the use of a fluoroscopically controlled cutting balloon catheter for the management of ureteral and ureteropelvic junction obstruction

PURPOSE We assessed the efficacy of a fluoroscopically controlled cutting balloon catheter for the treatment of ureteropelvic junction and ureteral strictures. MATERIALS AND METHODS A multicenter trial was performed that included 66 endopyelotomies and 49 endoureterotomies. To our knowledge this study represents the largest number of patients with ureteropelvic junction obstruction and ureteral strictures tested with this device to date. RESULTS With a mean followup of 7.8 months (range 1 to 17.9) the patency rate was 77% for endopyelotomy, with 72% of the primary and 100% of the secondary ureteropelvic junction obstructions remaining patent. The endoureterotomy patients were followed for an average of 8.7 months (range 1.2 to 17.0), with a patency rate of 55%. CONCLUSIONS A cutting balloon endoscopic incision is effective in the majority of cases, with patency rates for endopyelotomies and endoureterotomies that mirror current endourological reports using other, albeit more time intensive and more invasive, incisional techniques.

Acucise Endopyelotomy: Assessment of Long-term Durability

PURPOSE We evaluated the long-term efficacy of Acucise endopyelotomy. MATERIALS AND METHODS A total of 28 patients with 28 ureteropelvic junction obstructions was reevaluated 2 or more years after Acucise endopyelotomy (mean 32.5 months). Subjective analysis was done with analog pain scales and objective analysis was performed with diuretic renal scintigraphy. RESULTS Subjective followup was available for all 28 patients, and 17 (61%) had a favorable response with 36% totally free of pain and 25% markedly improved. Among 26 patients with objective followup (93%) 21 (81%) had a patient ureteropelvic junction based on a diuretic renal scan with a half-time of less than 10 minutes or a normal Whitaker test. Among all regularly followed patients failure occurred uniformly within 1 year. CONCLUSIONS Acucise endopyelotomy is an effective and durable method for treating ureteropelvic junction obstruction.

Flexible Ureteroscopy: Washington University Experience With the 9.3F and 7.5F Flexible Ureteroscopes

PURPOSE Recent advances in the design of flexible ureteroscopes have resulted in smaller caliber instruments. We review our experience with the smaller flexible ureteroscopes, and compare the efficacy and efficiency of the newer 7.5F to the standard 9.3F flexible instruments. MATERIALS AND METHODS Between January 1991 and 1995, 69 male and 41 female patients (mean age 57 years, range 16 to 91) underwent 116 retrograde flexible ureteroscopic procedures for a variety of diagnostic and therapeutic indications. A 9.3F ureteroscope (group 1) was used in 71 patients and a 7.5F instrument (group 2) was used in 39. RESULTS Patients in group 2 received sedation analgesia significantly more often than those in group 1 (56 versus 35%, p = 0.04). Active dilation of the ureteral orifice was required less often in group 2 (22.5%) than in group 1 (58%, p < or = 0.05). The total success rate for stone management, and diagnosis and/or treatment of an upper urinary tract lesion was 98.3 and 100%, respectively, in group 1, and 90 and 100%, respectively, in group 2 (p = 0.17). Of the 71 patients in group 1, 17 (24%) were treated on an outpatient basis, compared to 14 of 39 (49%) in group 2 (p = 0.16). No intraoperative or postoperative major complications were encountered in either group. Group 2 required less postoperative analgesia (p = 0.05). No ureteral stricture occurred in either group at an average followup of 9.5 months postoperatively (range 2 to 35). CONCLUSIONS For ureteral and renal pathological conditions the 7.5F ureteroscope is as effective as the 9.3F instrument diagnostically and therapeutically. The 7.5F ureteroscope usually can be used with sedation analgesia. Also, the smaller 7.5F ureteroscope is associated with less need for active ureteral dilation, minimal postoperative discomfort and a brief hospital stay.

Ureterolysis for Extrinsic Ureteral Obstruction: A Comparison of Laparoscopic and Open Surgical Techniques

PURPOSE We evaluated the role of laparoscopy in the management of extrinsic ureteral obstruction due to benign retroperitoneal fibrosis or ovarian pathology. The results of laparoscopic ureterolysis were compared to those of a contemporary series of open ureterolysis performed for the same pathological conditions. MATERIALS AND METHODS We compared 6 patients undergoing unilateral laparoscopic ureterolysis for extrinsic ureteral obstruction to 7 undergoing open unilateral ureterolysis for similar pathological conditions. Patient demographic, operative, and early and late postoperative data were collected. RESULTS Laparoscopic ureterolysis was associated with less intraoperative blood loss and need for parenteral pain medications, and significantly shorter hospital stay and convalescence than open surgery. Although there were no intraoperative or postoperative complications in the laparoscopy group, 1 patient in the open surgery group had an intraoperative ureteral avulsion and 4 had minor postoperative complications (blood transfusion, ileus and/or wound cellulitis). Operative time was longer in the laparoscopy group (255 versus 232 minutes). Subjective followup with an analog pain scale and/or telephone interview showed improvement in all patients in the laparoscopy group and all 6 contacted in the open surgery group. Likewise, excretory urography and/or renal scan showed improved renal function and relief of obstruction in all patients. CONCLUSIONS Laparoscopic unilateral ureterolysis for extrinsic ureteral obstruction is a less morbid, yet equally effective procedure with several clinical advantages over conventional open surgical ureterolysis.

Intracorporeal Electrohydraulic Lithotripsy of Ureteral and Renal Calculi Using Small Caliber (1.9F) Electrohydraulic Lithotripsy Probes

PURPOSE The development of 1.9F or smaller electrohydraulic lithotripsy probes has facilitated the use of this form of lithotripsy via miniature rigid and flexible ureteroscopes. We report our experience with ureteroscopic intracorporeal lithotripsy using 1.9F electrohydraulic lithotripsy probes. MATERIALS AND METHODS A total of 45 patients (32 ureteral and 57 renal calculi) underwent retrograde rigid (microscopic to 6F short) or flexible (7.5 and 9.4F) ureteroscopy with electrohydraulic lithotripsy using 1.9F electrohydraulic lithotripsy probes. In 17 patients (38%) there were 37 lower pole caliceal calculi (41%). Stone size ranged from 3 to 30 mm. (mean 8.5). RESULTS Electrohydraulic lithotripsy resulted in successful fragmentation (that is 2 mm. or smaller fragments) in 98% of patients overall. It was successful after failure of HM-3 extracorporeal shock wave lithotripsy in 10 patients and after failed lithotripsy with the 140 mJ. tunable dye laser in 7. Electrohydraulic lithotripsy resulted in successful fragmentation of 94% of lower pole caliceal stones. No intraoperative complications and no significant ureteral or renal mucosal damage were noted. Fever developed postoperatively in 2 patients (4.4%) with negative urine cultures. Postoperatively an indwelling stent was placed for 2 weeks or less in 71% of patients and no stents were placed due to preoperative stenting in 29%. Average hospital stay was 0.8 days (range 0 to 4). Followup imaging in 38 patients (84%) at a mean of 8.7 months (range 2 to 28) revealed stone-free rates of 92% overall and 87% in patients with lower pole renal calculi. No patient had a ureteral or infundibular stricture postoperatively. CONCLUSIONS The development of 1.9F or smaller electrohydraulic lithotripsy probes provides the urologist with a safe, highly effective and inexpensive method for performing intracorporeal lithotripsy throughout the entire upper urinary tract via rigid or flexible ureteroscopes. Furthermore, for the ureteroscopic treatment of lower pole renal calculi electrohydraulic lithotripsy is the only form of intracorporeal lithotripsy sufficiently malleable to allow routine access.

Comparison of fibrin glue, laser weld, and mechanical suturing device for the laparoscopic closure of ureterotomy in a porcine model

PURPOSE We evaluated fibrin glue, laser welding, and a mechanical suturing device (Endo-Stitch) as alternatives to standard laparoscopic suturing with a free needle. METHODS In 14 pigs, 22 linear proximal ureterotomies were closed laparoscopically with one of 4 different methods: fibrin glue, laser welding, Endo-Stitch suture placement (4-0 polyglactin), and free-needle suture placement (4-0 polyglactin). The ureterotomy was left open in 6 ureters. Acute leakage was tested by instillation of methylene blue. After 12 weeks, the ureters were assessed with radiography, ex-vivo pressure-flow studies, bursting pressures, and histology. RESULTS All alternative closure techniques were more rapid than free-needle suturing, and less frequently allowed acute leakage. Closure with fibrin glue yielded significantly higher flow rates than control, whereas the other closure techniques yielded flow rates similar to that of unclosed ureters. All alternative closure methods demonstrated histological evidence of healing that were superior to free-needle suturing. In multifactorial analysis, leakage at the ureterotomy site was the factor most significantly associated with subsequent poor ex-vivo flow characteristics. CONCLUSIONS All of the alternative laparoscopic ureteral closure methods compared favorably with standard free-needle suturing. Fibrin glue produced better radiographic findings, flow characteristics, and histology, suggesting that it currently has the most promise as an alternative or adjunct to laparoscopic suturing. Development of alternative laparoscopic techniques is ongoing, however, and thus the current state-of-the-art techniques used in this study may well be supplanted by other technologies in the future.

Laparoscopic nephropexy: Washington University experience.

PURPOSE We evaluated the efficacy of laparoscopic nephropexy for symptomatic nephroptosis. MATERIALS AND METHODS We performed laparoscopic right nephropexy in 6 patients who presented with symptomatic nephroptosis documented by radiographic studies and/or renal scans. In the first patient Gerotas fascia was secured to the peritoneal reflection of the line of Toldt using tacking clips. In the subsequent 5 patients the lateral border of the kidney was sutured to the overlying fascia of the quadratus lumborum muscle using an intracorporeal suturing technique. Additionally, the superior edge of the incised infrahepatic triangular ligament was sutured to the anterior mid portion of the renal capsule, thereby creating a vertical and horizontal means of fixation. RESULTS Laparoscopic right nephropexy was successful in all 6 patients. Average operative time was 4 hours. All patients resumed oral intake during postoperative day 1. Average parenteral analgesia requirement postoperatively was 42.7 mg. morphine. Hospital stay averaged 2.5 days and patients returned to usual activities an average of 2.5 weeks postoperatively. Postoperative imaging studies confirmed a decrease in or resolution of nephroptosis in all patients. All patients remained asymptomatic for an average of 11 months (range 2 to 30). CONCLUSIONS Laparoscopic nephropexy appears to be a feasible treatment option for patients with symptomatic, documented nephroptosis. The procedure can be accomplished safely and effectively with satisfactory anatomical and clinical results.

Long-Term Outcome of Flexible Ureterorenoscopy in the Diagnosis and Treatment of Lateralizing Essential Hematuria

PURPOSE We identified the long-term outcome of ureterorenoscopic diagnosis and treatment of patients with lateralizing essential hematuria. MATERIALS AND METHODS We reviewed retrospectively 17 patients with lateralizing essential hematuria treated with flexible ureterorenoscopy (15) or flexible percutaneous nephroscopy (2) with or without biopsy and electrocoagulation. Followup was longer than 24 months (average 60, range 24 to 116) in all patients. RESULTS At followup 9 of the 17 patients (59%) were cured and 7 (41%) had recurrent bleeding. Discrete lesions occurred in 11 patients (64%), who were treated with electrocoagulation with 9 (82%) cured. All 3 patients (18%) with diffuse lesions had recurrent bleeding as did 2 of 3 (66%, 18% overall) with negative examinations. CONCLUSIONS Ureterorenoscopy is an effective means of diagnosis and treatment of lateralizing essential hematuria. The majority of patients with lateralizing hematuria will have a discrete lesion that will respond to ureterorenoscopic electrocoagulation in the long-term. However, if the lesions are diffuse or the diagnostic examination is unreliable recurrent bleeding is likely.

Subcutaneous urinary diversion utilizing a nephrovesical stent: A superior alternative to long-term external drainage?

OBJECTIVES The use of external percutaneous nephrostomy drainage in patients with end-stage ureteral obstruction in whom ureteral stenting has failed presents significant compromises in the patients quality of life. Toward this end, we present the initial experience in the United States with an intracorporeal nephrovesical stent. METHODS We performed successful subcutaneous urinary diversion in 2 patients with malignant, metastatic periureteral obstruction. Both patients had previously been managed with a chronic percutaneous nephrostomy that was both painful and inconvenient. The nephrovesical stent was inserted utilizing percutaneous access to both the kidney and bladder followed by creation of a subcutaneous tunnel between the two sites. RESULTS The nephrovesical stents are patent at 6 and 9 weeks postoperatively and both patients have had their nephrostomy tubes removed. Both patients have noted a marked improvement in their overall comfort and quality of life since the stent has been in place. CONCLUSIONS Subcutaneous urinary diversion with a nephrovesical stent provides effective urinary drainage and may improve the quality of life of patients with malignant metastatic ureteral obstruction. Further long-term studies are needed.