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Urolithiasis, Endourology and Laparoscopy
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Patient and Partner Satisfaction and Long-Term Results After Surgical Treatment for Peyronie’s Disease M. F. USTA, T. J. BIVALACQUA, J. SANABRIA, I. T. KOKSAL, K. MOPARTY AND W. J. HELLSTROM, Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana Urology, 62: 105–109, 2003 OBJECTIVES: To assess the long-term functional outcome, patient and partner satisfaction, and predictive factors for unfavorable results in men treated with a surgical approach for severe Peyronie’s disease. METHODS: Sixty-one patients underwent surgical treatment for Peyronie’s disease between 1997 and 2001 and were retrospectively evaluated. All patients were assessed preoperatively with a detailed sexual and medical history, focused physical examination, and penile duplex ultrasonography. Nineteen patients underwent penile plaque excision/incision and grafting with Tutoplast cadaveric pericardial grafting material (group 1). Penile prosthesis implantation and manual modeling was performed in 31 patients (group 2a), and 11 men were treated with penile prosthesis implantation and pericardial grafting (group 2b). RESULTS: The mean follow-up of the patients was 21.9 ⫹/⫺ 13.6 months (range 12 to 48). Complete penile straightening was achieved in 15 patients (78.9%) in the excision/incision and grafting group. In the 42 men who underwent reconstruction using penile prosthesis implantation (group 2a,b), penile curvature resolved completely in 37 patients (88%). Long-term postoperative residual curvatures greater than 30 degrees occurred in 3 patients (15.7%) and 2 patients (4.8%) in groups 1 and 2a,b, respectively. One penile prosthesis (2.3%) was explanted in the second group for erosion. Patient responses to our questionnaire showed that overall 83.6% of the patients and 76.9% of the partners were satisfied with the surgical result. CONCLUSIONS: According to the results of this long-term, retrospective study, pericardial grafting can be used successfully after plaque excision/incision procedures in men undergoing surgical treatment for severe Peyronie’s disease. In patients with Peyronie’s disease and erectile dysfunction, implantation of a penile prosthesis and correction of the curvature with a graft can provide an acceptable, functionally straight penis without any increased risk of complications compared with penile prosthesis implantation alone. Editorial Comment: This is a long-term functional outcome study of patient and partner satisfaction. It is important because it is optimal to include the partner whenever possible to understand disease outcome. A total of 61 men underwent surgical treatment for Peyronie’s disease. Of the patients 31 underwent penile prosthesis implantation with manual modeling and 19 underwent plaque excision or incision with grafting. Patient responses to questionnaire data show that 84% of patients and 70% of partners were satisfied with the surgical results. This is important information in that irrespective of the procedure or graft material, as long as the postoperative erection demonstrates minimal curvature and there is a good functional and cosmetic result, there appears to be good long-term outcome and satisfaction. These findings are irrespective of whether graft material is used or a penile prosthesis inserted. These data are important to remember as one counsels men for management of Peyronie’s disease. Allen Seftel, M.D.
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Biochemical Profile of Stone-Forming Patients With Diabetes Mellitus C. Y. C. PAK, K. SAKHAEE, O. MOE, G. M. PREMINGER, J. R. POINDEXTER, R. D. PETERSON, P. PIETROW AND W. EKERUO, Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, and Division of Urology, Duke University Medical Center, Durham, North Carolina Urology, 61: 523–527, 2003 Objectives. To test the hypothesis that stone-forming patients with type II diabetes (DM-II) have a high prevalence of uric acid (UA) stones and present with some of the biochemical features of gouty diathesis (GD). Methods. The demographic and initial biochemical data from 59 stone-forming patients with DM-II (serum glucose greater than 126 mg/dL, no insulin therapy, older than 35 years of age) from Dallas, Texas and Durham, North Carolina were retrieved and compared with data from 58 patients with GD and 116 with hyperuricosuric calcium oxalate urolithiasis (HUCU) without DM. Results. UA stones were detected in 33.9% of patients with DM-II compared with 6.2% of stone-forming patients without DM (P ⬍0.001). Despite similar ingestion of alkali, the urinary pH in patients with DM-II and UA stones (n ⫽ 20) was low (pH ⫽ 5.5), as it is in patients with GD, and was significantly lower than in patients with HUCU. The urinary pH in patients with DM-II and calcium stones (n ⫽ 39) was
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intermediate between that in those with DM-II and UA stones and those with HUCU. However, both DM groups had fractional excretion of urate that was not depressed, as it is in those with GD, and was comparable to the value obtained in those with HUCU. The urinary content of undissociated UA was significantly higher, and the saturation of calcium phosphate (brushite) and sodium urate was significantly lower in those with DM-II and UA stones than in those with HUCU. Conclusions. Stone-forming patients with DM-II have a high prevalence of UA stones. Diabetic patients with UA stones share a key feature of those with GD, namely the passage of unusually acid urine, but not the low fractional excretion of urate. Editorial Comment: New knowledge! Among patients with type II diabetes the occurrence of uric acid stones (33.9%) is 5-fold higher than in the general stone forming population. Why? It may all relate to obesity and insulin resistance. In this group of patients with type II diabetes the average body mass index was 34, with a pH of 5.53. The latter could be due to insulin resistance related decreased production of ammonia resulting in a more acid urine. In keeping with this hypothesis the calcium stone forming diabetics had a less acid pH at 5.89. Ralph V. Clayman, M.D. Laparoscopic Evaluation of Indeterminate Renal Cysts: Long-Term Follow-Up J. LIMB, L. SANTIAGO, J. KASWICK AND G. C. BELLMAN, Department of Urology, Kaiser Permanente, Los Angeles, California J Endourol, 16: 79 – 82, 2002 Purpose: We present our long-term follow-up of patients who have undergone laparoscopic evaluation for their indeterminate renal cysts, specifically reporting those patients who were found to have cystic renalcell carcinoma (RCC) and assessing the safety and efficacy of the procedure. Patients and Methods: Fifty-seven patients with indeterminate renal cysts (28 Bosniak category II and 29 Bosniak category III) underwent laparoscopic evaluation between July 1993 and July 2000. A transperitoneal laparoscopic localization and aspiration of the cyst, cytologic analysis, and biopsy of the cyst wall and base were performed. A total of 11 patients were found to have cystic RCC. Patients with malignancy have been followed for a mean of 40 months (range 6 –70 months), and five patients had 5 years or more of follow-up. Results: Eleven patients (19% of the total) were found to have cystic RCC. Three of these patients had Bosniak category II cysts, and eight had category III cysts. All tumors were low grade (I or II), and the stages were T1–2, Nx– 0, M0. There has been no evidence of laparoscopic port site or renal fossa tumor recurrence, local recurrence, or metastatic disease to date in these patients. There is no cancer-specific mortality. Conclusions: Long-term follow-up indicates that laparoscopic evaluation of indeterminate renal cysts is not associated with an increased risk of port site or retroperitoneal or peritoneal recurrence of RCC. It may save a patient from undergoing open surgery and should be considered as a diagnostic option for patients with indeterminate renal cysts. Editorial Comment: This important followup on the laparoscopic evaluation of complex renal cysts corroborates a paradigm shift in the approach to these lesions. Specifically, laparoscopic exploration is “in” and percutaneous cyst aspiration is “out.” While Bosniak II and III lesions have been noted to harbor a renal cell cancer in 24% and 33% of patients, respectively, the usual approach to diagnosing these lesions has been by needle aspiration. However, as the authors nicely indicate in their review, needle aspiration of these lesions has proved to be unreliable due to false-positive as well as false-negative diagnoses. The latter is particularly commonplace, as high as 86%!1 This finding is further supported by the fact that only 1 of the 11 tumor bearing patients had a positive cytology when the cancerous cyst was aspirated intraoperatively! In this report on 57 patients 11% of 28 patients with Bosniak II lesions and 28% of 29 patients with Bosniak III lesions had a cystic cancer found at laparoscopic exploration. In each case the cyst had been opened, thereby raising the concern of possible intraabdominal seeding. At a mean followup of 3.3 years (greater than 5 years in 5 patients) following partial or radical/total nephrectomy there was no metastatic disease, local recurrence or port site seeding. The authors highlight that all of the lesions were low grade and low stage. From their review of the literature it would appear that among these patients the overall risk of recurrence is in the 2% to 2.5% range, with most recurrences being noted within a 5-year time span.2 The bottom line is that laparoscopic exploration for Bosniak II or Bosniak III renal cysts should now be viewed as the primary diagnostic approach to these lesions, supplanting percutaneous cyst aspiration. The only question is whether this needs to be done at the time the lesion is discovered or following a period of observation and documented growth of the lesion. In the former circumstance 67% to 80% of the explorations will be negative. Ralph V. Clayman, M.D. 1. Hayakawa, M., Hatano, T., Tsuji, A., Nakajima, F. and Ogawa, Y.: Patients with renal cysts associated with renal cell carcinoma and the clinical implications of cyst puncture: a study of 223 cases. Urology, 47: 643, 1996
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UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY 2. Hafez, K. S., Novick, A. C. and Campbell, S. C.: Patterns of tumor recurrence and guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. J Urol, 157: 2067, 1997
Why Oral Calcium Supplements May Reduce Renal Stone Disease: Report of a Clinical Pilot Study C. P. WILLIAMS, D. F. CHILD, P. R. HUDSON, G. K. DAVIES, M. G. DAVIES, R. JOHN, P. S. ANANDARAM AND A. R. DE BOLLA, Departments of Medical Biochemistry, Medicine and Urology, Wrexham Maelor Hospital NHS Trust, Wrexham and Department of Medical Biochemistry, University Hospital of Wales Healthcare NHS Trust, Heath Park, Cardiff, United Kingdom J Clin Pathol, 54: 54 – 62, 2001 Aims—To investigate whether increasing the daily baseline of gut calcium can cause a gradual downregulation of the active intestinal transport of calcium via reduced parathyroid hormone (PTH) mediated activation of vitamin D, and to discuss why such a mechanism might prevent calcium oxalate rich stones. To demonstrate the importance of seasonal effects upon the evaluation of such data. Methods—Within an intensive 24 hour urine collection regimen, daily calcium supplementation (500 mg) was given to five stone formers for a 10 week period during a six month crossover study. In a further population of patients on follow up for previous renal stone disease, observations were made on 1066 24 hour urine samples collected over five years in respect of seasonal effects relevant to the interpretation of the study. Results—In the group of patients on calcium supplements the following results were found. During calcium supplementation, the proportion of urine calcium to oxalate was higher (increased calcium to oxalate molar ratio), the 24 hour urine product of calcium and oxalate did not rise, and urine oxalate was lower during the first six weeks of supplementation. Twenty four hour urine calcium was 10.2% higher than baseline in the final four weeks of the 10 weeks of supplementation. Twenty four hour urine phosphate was 11.4% lower during the first six weeks of supplementation, but then rose while the patients were still on supplementation; renal tubular reabsorption of phosphate (TmP/GFR) mirrored the urine phosphate changes inversely. PTH was higher after stopping supplementation, but 1,25-(OH)2-cholecalciferol changes were not detected. In the 1066 urine samples collected over five years the following results were found. Calcium and oxalate excretion correlated positively and not inversely. Urine calcium and phosphate excretion were 5.5% and 2.5% higher, respectively, in “light” months of the year compared with “dark” months. A post summer decline in both urine calcium and urine phosphate was relevant to the interpretation of the study. Conclusions—Regular calcium supplementation does not raise the product of calcium and oxalate in urine and the proportion of oxalate to calcium is reduced. The underlying mechanisms of the changes seen in phosphate, calcium, and PTH and the observations on 1,25-(OH)2-cholecalciferol are not clear. Observed changes in phosphate could possibly be part of a calcium regulating feedback loop operating over a period of weeks. In evaluating these mechanisms background seasonal effects are important. It is possible that “programming” of the gut mucosa in terms of calcium transport is a major determinant of the relation between calcium and oxalate concentrations in urine and their relative abundance. Increased oral calcium, in association with a reduction of the relative proportion absorbed, may be pertinent to the prevention of calcium oxalate rich stones. Editorial Comment: Unfortunately, the article does not answer the question posed in its title. However, the preliminary data are of interest. First, a modest calcium load (500 mg daily) results in a decrease in urine oxalate with only a mild increase in urine calcium. The calcium oxalate product decreased but did not reach statistical significance in this small study. Again, the authors confirm other articles warning against dietary calcium restriction in the treatment of stone disease. In addition, urine phosphate levels decreased during calcium supplementation. This outcome could favorably influence a decrease in PTH and a reduction in the activation of vitamin D, providing further benefits in the calcium supplemented group. Moreover, the authors noted increased levels of calcium in the urine during the summer (ie “light”) months, which they hypothesize could also impact subsequent stone disease. Finally, they caution against the use of vitamin D supplements, especially in stone formers. Ralph V. Clayman, M.D. Factors Associated With Failure of Extracorporeal Shock-Wave Lithotripsy for Ureteral Stones Using Dornier Lithotripter U/50 Y. S. ANAGI, T. YAGISAWA, M. NANRI, C. KOBAYASHI AND H. TOMA, Department of Urology, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan Int J Urol, 9: 304 –307, 2002 Background: In the present series of 170 patients who underwent extracorporeal shock-wave lithotripsy (SWL) treatment for ureteral stones, the authors determine which patients with ureteral stones had an unsuccessful outcome. Methods: The records of 170 patients with ureteral stones who were treated with SWL using the Dornier
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lithotriptor U/50 (EMSE 140) between January 1998 and December 1999 were retrospectively investigated. One hundred and thirty-one patients were treated with SWL alone (single session, n ⫽ 98; multiple session, n ⫽ 33) and 39 patients required auxiliary treatment due to failure of SWL (33 with transurethral ureterolithotripsy (TUL), one with open lithotomy, and five with residual fragments who were followed up). These two groups were compared using multivariate logistic regression analysis. Results: Lower ureteral stones and stones more than 12 mm in diameter were associated with a poor outcome of SWL. There were no significant differences in age, gender, number of stones, JJ stent placement, and degree of ureteral obstruction due to the stone between the two groups. The odds ratios of lower ureteral stones and stones ⱖ12 mm were 4.18 and 2.57, respectively. Conclusion: Patients with distal ureteral stones and/or stones more than 12 mm in diameter were difficult to treat successfully with SWL. Alternatives such as TUL should possibly be considered as a first-line therapy for these stones. Editorial Comment: Despite significant progress in the understanding of how shock waves fragment calculi and improvements in treatment strategies, we are once again faced with the fact that the newer machines are not as effective as the original Dornier HM-3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia). In this report the overall success rate (ie fragments less than 4 mm) for lithotripsy of distal ureteral stones was only 64% versus success rates of 83% and 79% in the proximal and mid ureter, respectively. From these numbers one can deduct at least another 5% to obtain stone-free rates. Approximately 39% of patients required more than 1 treatment, and the average number of shock waves administered was 3,000 to 5,000. These results, especially in the distal ureter, pale when compared to the HM-3 results of more than a decade ago in the distal ureter—stone-free in more than 90% with re-treatment in fewer than 10% of patients.1 Time is passing and SWL is getting older but not better. Ralph V. Clayman, M.D. 1. Pearle, M. S., Nadler, R., Bercowsky, E., Chen, C., Dunn, M., Figenshau, R. S. et al: Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi. J Urol, 166: 1255, 2001
Impact of Ureteral Stent Diameter on Symptoms and Tolerability E. ERTURK, A. SESSIONS Rochester, New York
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J. V. JOSEPH, Department of Urology, University of Rochester Medical Center,
J Endourol, 17: 59 – 62, 2003 Background and Purpose: Indwelling double-pigtail ureteral stents are frequently associated with debilitating symptoms. A randomized study was performed to evaluate the effect of stent diameter (4.7F v. 6F) on symptoms and tolerability. Patients and Methods: Between February and October 2000, 46 consecutive patients undergoing ureteroscopy for stone disease were randomly assigned to receive either a 4.7F (group I) or a 6F (group II) ureteral stent following the procedure. The patients were asked to leave their stents in place for minimum of 7 days. Pain and irritative urinary symptoms in the two groups were compared according to a scale ranging from 0 (none) to 5 (severe). The two groups were also compared for stone size and location, rigid v. flexible ureteroscopy, anesthesia, stent migration, and ureteral dilation. Results: There were no differences between the groups in terms of pain (P ⫽ 0.28) or irritative symptoms (P ⫽ 0.37). There was a tendency for stents in group I to migrate distally and dislodge more often than those in group II (32% v 10%). Conclusions: When stent insertion following ureteroscopy is deemed necessary, a minimum diameter of 6F is recommended. Lower Ureteric Obstruction: A Complication of Tailed Ureteric Stents M. F. BULTITUDE, P. DASGUPTA, M. CYNK, J. M. GLASS AND R. C. TIPTAFT, Department of Urology, Guy’s and St Thomas’ Hospital, London, United Kingdom BJU Int, 91: 581, 2003 No Abstract Editorial Comment: Stent woes continue. Will a smaller stent cause fewer problems following ureteroscopy for stone disease? Comparison of a 6Fr and a 4.7Fr stent showed no statistical difference in this study with regard to pain or irritative symptoms during a 7-day plus period of stent placement. In addition, the smaller stents had a tendency to migrate distally in 32% of the patients. However, the study was underpowered to detect a difference of 20% to 30% as there were only 46 patients randomized. In addition, the smaller stents were associated with a lower pain score and lower irritative score but, again, this did not achieve statistical significance possibly given the small sample size. In contrast to a smaller stent, earlier work with the 7Fr/3Fr tail stent demonstrated a statistically significant decrease in lower tract irritative symptoms vs a standard 7Fr stent. However, as the article by Bultitude et al shows, this stent should not be used if there is lower ureteral
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pathology or significant trauma during ureteroscopy. In that case report a lower ureteral stricture developed following ureteroscopy. Not surprisingly, this obstruction was unrelieved with a tail stent. Overall, in concert with independent studies by Denstedt, Preminger, Hoskins and others, the best stent to place after ureteroscopy is likely no stent. Ralph V. Clayman, M.D. Use of Fibrin Glue in Percutaneous Nephrolithotomy A. A. MIKHAIL, J. S. KAPTEIN AND G. C. BELLMAN, Department of Urology and Regional Research Laboratory, Kaiser Permanente, Los Angeles, California Urology, 61: 910 –914, 2003 Objectives. To report our experience with the use of fibrin glue during tubeless percutaneous nephrolithotomy. We addressed the safety of this approach and evaluated its use for any clinical benefit with respect to length of hospital stay, bleeding, analgesic usage, and urinary extravasation. Methods. This was a retrospective review of 43 patients who underwent tubeless percutaneous nephrolithotomy. In 20 consecutive patients (one bilateral), percutaneous tracts were injected with 2 to 3 mL of Tissel Vapor Heated sealant at the conclusion of the procedure. The fibrin glue was instilled during simultaneous removal of the percutaneous sheath. These 20 patients were compared with a control group (23 consecutive patients) in which fibrin glue was not used. The length of hospitalization, hematocrit drop, analgesic use, stone burden, operative times, postoperative complications, and any noted computed tomography scan findings were compared. Results. Postoperatively, the average length of hospital stay was less in the experimental than in the control group by 0.71 day (P ⬍0.05). Differences in hematocrit drop between the experimental (6.8%) and control (5.6%) groups were not statistically significant. The total analgesic use was less in the experimental group, but the difference was not statistically significant. No statistical difference was found between the operative times for both groups. Postoperative fevers and wound seroma were noted in the experimental group. No abscesses or any significant changes along the percutaneous tracts were seen on postoperative computed tomography scans. In the control group, no procedure-related complications were noted. Conclusions. The use of fibrin glue is safe in percutaneous nephrolithotomy procedures and additional prospective randomized studies are needed to evaluate for any clinical benefit. Editorial Comment: “Ain’t going to bleed no more, no more.” The authors are to be congratulated on rediscovering the concept of Pfab et al from 1987 of using a surgical pharmaceutical, in this case fibrin glue, to seal the nephrostomy tract after an acute percutaneous stone removal procedure. In this study the authors purposely pulled the nephrostomy sheath out of the collecting system before instilling the glue to try to prevent it from entering the calix or renal pelvis. It is noteworthy that while the difference in the hematocrit between the glued cases and a historical tubeless control group was nil, there was a tendency toward earlier hospital discharge and less analgesic use in the fibrin glue group. Recently, concern has been raised about the fate of fibrin glue in the collecting system. Work by Uribe et al has shown that when placed directly into urine the fibrin glue has a tendency to form a long lasting clot.1 In contrast, gelatin matrix thrombin remains in a particulate suspension. Accordingly, this substance has recently been used to seal the nephrostomy tract acutely after percutaneous stone removal. Early results in 7 patients have been favorable, with no late bleeding or hospital readmissions. The next step, as sagely raised by Cadeddu in the editorial comment following this article, is to embark on a phase III randomized controlled study to see if the benefit outweighs the cost of these hemostatic agents. Ralph V. Clayman, M.D. 1. Uribe, C., Eichel, L., Khonsari, S. et al: What happens to hemostatic agents in contact with urine? An in vitro study. J Endourol, suppl., 17: A42, 2003
Endoscopic Management of Symptomatic Caliceal Diverticula: A Retrospective Comparison of Percutaneous Nephrolithotripsy and Ureteroscopy B. K. AUGE, R. MUNVER, J. KOURAMBAS, G. E. NEWMAN AND G. M. PREMINGER, Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery and Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina J Endourol, 16: 557–563, 2002 Background and Purpose: A myriad of minimally invasive options exist for managing symptomatic caliceal diverticula, including shockwave lithotripsy, percutaneous surgery, retrograde ureteroscopy, and laparoscopy. Yet no direct comparisons have been made in the literature of the relative treatment efficacy of ureteroscopy (URS) and percutaneous nephrolithotripsy (PNL). A retrospective review of our patients was performed to determine the most appropriate endoscopic management option for patients with symptomatic caliceal diverticula. Patients and Methods: Between November of 1994 and April 2001, 39 patients presented with symptomatic caliceal diverticula, 37 of which contained calculi. Twenty-two patients (56%) underwent PNL, and 17
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patients (44%) were managed by URS. Of the PNL group, 82% required the creation of a neoinfundibulotomy. The stone burden in the PNL group averaged 11.4 ⫻ 12.0 mm and that in the URS group 12.7 ⫻ 13.0 mm (p ⬎0.05). Pain, recurrent urinary tract infections, and nausea and vomiting were the presenting complaints in both subgroups of patients, with pain being by far the most common symptom. The average hospital stay was 2.8 days for the PNL group. All the URS procedures were performed on a same-daysurgery basis. Results, including stone-free, symptom-free, and complication rates, were compared for the two groups. Results: Thirty-five percent of the URS group were symptom free at 6 weeks’ follow-up, with an additional 29% reporting an improvement in pain, whereas 86% of the PNL group was completely symptom free at 6 weeks’ follow-up. Only 19% of the URS group were stone free on follow-up intravenous urography v 78% of those undergoing PNL (three patients failed to return for follow-up imaging). It was not possible to identify the ostium of the stenotic infundibulum in 4 patients (24%) undergoing URS, and 7 patients (41%) eventually went on to PNL with ultimate success. The PNL was statistically better than URS in producing stone-free results for diverticula located in the upper pole and for stones ⬍11 mm (p ⬍0.05). No complications occurred in the URS group; however, complications were identified in four patients after PNL. One patient developed clot urinary retention necessitating Foley catheterization and manual bladder irrigation; one patient experienced significant bleeding necessitating early cessation of the procedure. Two patients sustained intrathoracic complications, one a pneumothorax and the other a pneumohemothorax after supra-11th rib access. Both were managed successfully with tube thoracostomy. Conclusions: Our review clearly suggests an advantage of percutaneous management over ureteroscopy for complex posterior symptomatic caliceal diverticula, although with a slightly increased risk of complications. Therefore, PNL should be considered the primary modality for managing these difficult processes. In cases where the stenotic infundibulum cannot be traversed with a guidewire, creation of a neoinfundibulotomy permitted secure access to the collecting system while providing effective results. Editorial Comment: Caveat emptor: Beware the intoxication of flexible ureteroscopy! In this article on definitive therapy for the stone bearing caliceal diverticulum flexible ureteroscopy turned out to be safe and minimally invasive but also minimally effective. Even for caliceal diverticula involving the upper pole or for stones 10 mm or smaller the percutaneous approach provided a far better stone-free result— 85% vs 36% and 89% vs 30%, respectively. It is noteworthy that symptom-free rate (86% vs 35%), overall stone-free rate (78% vs 19%) and the need for secondary procedures (4% vs 41%) all favored a percutaneous approach. These differences occurred despite attempts to select “anatomically optimal” patients for ureteroscopy. Ralph V. Clayman, M.D. Biochemical Distinction Between Hyperuricosuric Calcium Urolithiasis and Gouty Diathesis C. Y. C. PAK, J. R. POINDEXTER, R. D. PETERSON, J. KOSKA AND K. SAKHAEE, Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas Urology, 60: 789 –794, 2002 Objectives. To determine whether the biochemical presentation and urinary physicochemical environment of patients with hyperuricosuria presenting with calcium stones (hyperuricosuric calcium urolithiasis [HUCU]) differs from those of patients with gouty diathesis (GD) or idiopathic uric acid urolithiasis. Methods. A total of 122 patients with HUCU and 68 patients with GD were identified from our “stone registry” of patients who underwent a full ambulatory evaluation. All patients with HUCU had urinary uric acid greater than 800 mg/day in men and greater than 750 mg/day in women and presented with calcium stones. Those with GD had pure uric acid stones or mixed uric acid-calcium stones and did not have secondary causes of uric acid urolithiasis. Data derived from the fasting serum and 24-hour urine samples collected on a random diet and on a diet restricted in calcium, sodium, and oxalate were compared between the two groups. Results. Compared with patients with HUCU, those with GD had significantly higher serum uric acid and lower urinary uric acid and pH levels (mean value 5.38 and 5.35 on random and restricted diets versus 6.09 and 6.14, respectively). The fractional excretion of urate and the discriminant score of the relationship between urinary pH and the fractional excretion of urate were significantly lower in those with GD than in those with HUCU. Patients with HUCU displayed a greater urinary saturation of sodium urate and calcium oxalate compared with those with GD, and those with GD had a higher urinary content of undissociated uric acid and lower urinary saturation of brushite (calcium phosphate). Conclusions. Patients with HUCU presented with normal urinary pH and hyperuricosuria, accompanied sometimes by hypercalciuria, which produced increased urinary saturation of sodium urate and calcium oxalate. In contrast, those with GD had a low fractional excretion of urate (that contributed to hyperuricemia) and low urinary pH (that led to increased amount of undissociated uric acid). The varying biochemical and physicochemical presentations of the two conditions can be ascribed to overindulgence with purine-rich foods in those with HUCU and underlying primary gout in those with GD. Editorial Comment: The problem for patients with hyperuricosuric calcium urolithiasis is due to purine gluttony. In the recalcitrant patient the only method for stone prevention may be for
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the urologist to resort to the use of allopurinol. In contrast, for the patient with a gouty diathesis the low urine pH leads to uric acid stone formation, possibly based on a problem with ammonia generation in the urine. For this patient the treatment lies in alkalization, usually with a potassium citrate compound. Ralph V. Clayman, M.D. Creation of Ureteropelvic Junction Obstruction and Its Correction by Chemical Glue-Assisted Laparoscopic Dismembered Pyeloplasty A. W. CHIU, C.-H. LIN, S. K. HUAN, C. J. LIU, C.-C. LIN, Y.-L. HUANG, W.-L. LIN, S.-H. HUANG, P.-S. LEE AND C.-N. LIN, Division of Urology, Department of Surgery, and Departments of Medical Research and Pathology, Chi Mei Medical Center, Tainan and Department of Urology, National Yang-Ming University, School of Medicine, MacKay Memorial Hospital and Chang-hua Christian Hospital, Taipei, Taiwan, Republic of China J Endourol, 17: 23–28, 2003 Purpose: We established a porcine model of ureteropelvic junction (UPJ) obstruction using a laparoscopic technique and assessed the outcome of standard suture-assisted and chemical glue-assisted laparoscopic pyeloplasty. Materials and Methods: Female domestic pigs (N ⫽ 20) underwent laparoscopic suture-ligature to create UPJ obstruction. One month later, laparoscopic end-to-end anastomosis was performed to correct the obstruction: with standard suturing techniques in 10 animals and with chemical (cyanoacrylate) glue in the other 10. Postoperative ureteral stents were not used. Four weeks postoperatively, intravenous urography was performed to evaluate the patency of the anastomoses. The UPJ was procured by laparotomy to assess the anastomoses and periureteral fibrosis histologically. Results: The UPJ obstruction was created in an average of 15 ⫾ 6 minutes. There was no early postoperative mortality. Eighteen pigs survived for at least 1 month, and UPJ obstruction developed in 17 (95%). Microscopically, the lumen of the UPJ was partially occluded, measuring an average of 40% ⫾ 5% of normal. After laparoscopic correction, a patent UPJ was found in seven of nine animals treated with traditional sutures. Among the eight animals with chemically glued anastomoses, none had a patent UPJ, and severe periureteral adhesions and intraluminal fibrosis were noted at the pyeloplasty site. Marked ureteral tortuosity was present in six of the eight pigs receiving glue-assisted pyeloplasty but in none of the animals having suture-assisted pyeloplasty. Conclusions: Ureteropelvic junction obstruction was established by laparoscopic suture-ligature in a porcine model with a 95% success rate. Chemical glue-assisted anastomosis was inferior to standard laparoscopic sutures for pyeloplasty to correct the obstruction. Vesicourethral Anastomosis With 2-Octyl Cyanoacrylate Adhesive in an In Vivo Canine Model J. P. GRUMMET, A. J. COSTELLO, D. A. SWANSON, L. C. STEPHENS AND D. M. CROMEENS, Division of Urology, Department of Surgery, University of Melbourne, Melbourne, Australia, and Departments of Urology, and Veterinary Medicine and Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas Urology, 60: 935–938, 2002 Objectives. To evaluate the effectiveness of 2-octyl cyanoacrylate adhesive (OCA) in the formation of vesicourethral anastomoses. Methods. Open total prostatectomy was performed on 12 mongrel hounds. Of these, 8 had a vesicourethral anastomosis formed using OCA (4 with suture support and 4 sutureless). The remaining four anastomoses were conventionally formed using eight interrupted sutures. Acute leakage was tested intraoperatively. Before killing the hounds, the anastomosis of 1 animal in each group was assessed on postoperative days 3, 5, 7, and 14 by radiography. Each anastomotic specimen was then tested for leak pressure and examined histologically. Results. At intraoperative testing, one small leak was found in the sutureless OCA group. All other anastomoses were watertight intraoperatively. Radiographically, two leaks occurred in the OCA group with suture support, three leaks in the sutureless OCA group, and only one small localized leak in the control group. Only one of the eight anastomoses using OCA achieved a physiologic leak pressure greater than 70 mm Hg (one of these, however, could not be tested because of injury at the time the specimen was retrieved). The leak pressures of all four control-group anastomoses were 70 mm Hg or greater. Histologically, no significant differences were found in healing between the control and OCA anastomoses. Conclusions. With or without suture support, OCA appears to be unsuitable for use in forming the large-diameter vesicourethral anastomosis required in radical prostatectomy. Editorial Comment: At present, neither fibrin glue (a sealant) nor a chemical adhesive (cyanoacrylate) works well for tissue reconstruction. The former is not sufficiently strong and the latter creates marked inflammation at the approximated tissue edge. For the time being, basic suturing is the best method to perform laparoscopic pyeloplasty or laparoscopic urethrovesical
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anastomosis. Parenthetically, fibrin glue should likely not be used after a sutured repair as a “safety” measure. Indeed, its use under these circumstances may harm more than help. Ralph V. Clayman, M.D. Resolution of Ephedrine Stones With Dissolution Therapy N. HOFFMAN, S. M. MCGEE AND J. C. HULBERT, Department of Urologic Surgery, University of Minnesota Medical School and Fairview-University Medical Center, Minneapolis, Minnesota Urology, 61: 1035vi–1035vii, 2003 A patient with a history of ingesting large quantities of an over-the-counter stimulant developed renal calculi that on further analysis, after stone passage, revealed increased amounts of ephedrine. Over the course of 7 months, all of the patient’s ephedrine stones were managed successfully by alkalinization. Similar to previously reported ephedrine calculi, these stones were radiolucent on x-ray imaging, but their course was monitored on serial nonenhanced computed tomography scans. We believe this to be the first reported use of alkaline therapy for the dissolution of renal stones containing ephedrine. Editorial Comment: In this patient stones of 1.0 and 1.5 cm were dissolved with 20 mEq potassium citrate 3 times daily to alkalize the urine. Ephedrine stones, like uric acid stones, are radiolucent and susceptible to dissolution therapy. Ralph V. Clayman, M.D. Retroperitoneoscopic Nephroureterectomy for Transitional Cell Carcinoma of the Renal Pelvis and Ureter: Nagoya Experience Y. YOSHINO, Y. ONO, R. HATTORI, M. GOTOH, O. KAMIHIRA AND S. OHSHIMA, Department of Urology, Nagoya University School of Medicine, Nagoya-shi and Komaki Shimin Hospital, Komaki, Japan Urology, 61: 533–538, 2003 Objectives. To evaluate the efficacy of our new retroperitoneoscopic nephroureterectomy for patients with transitional cell carcinoma of the renal pelvis and ureter, we present the operative procedure and analysis of the clinical outcome of retroperitoneoscopy in 23 patients. Methods. Twenty-three patients with transitional cell carcinoma of the upper urinary tract underwent retroperitoneal laparoscopic nephroureterectomy between February 2000 and February 2002. Patient age ranged from 44 to 83 years (mean 66.7). Each kidney was retroperitoneoscopically dissected en bloc, together with the perirenal fatty tissue, lymph nodes, and/or adrenal gland, without transecting the ureter. The lower ureter was resected with the bladder cuff transected using an ultrasonic scalpel and an endoscopic gastrointestinal automatic stapler. The dissected specimen was removed intact through a 6-cm-long original incision. Results. The mean operating time was 4.8 hours, including 0.7 hours for complete removal of the ureteral end with the bladder cuff. The mean estimated blood loss was 304 mL. The mean time to recovery to normal activity was 18 days. In the mean follow-up period of 15 months, 2 patients died of cancer progression in the sixth postoperative month, 2 died of other causes, and 4 had recurrent transitional cell carcinoma of the bladder after surgery. Conclusions. Our retroperitoneal laparoscopic nephroureterectomy using an endoscopic gastrointestinal automatic stapler is a fast, low-risk, and minimally invasive procedure and might be an alternative to other laparoscopic techniques and open nephroureterectomy. However, long-term follow-up is necessary to confirm the efficacy for patients with transitional cell carcinoma of the renal pelvis and ureter. Editorial Comment: Among 23 patients a successful completely retroperitoneal laparoscopic nephroureterectomy was completed using a 5-port approach. The bladder cuff was removed after first using a 5 mm harmonic scalpel/shears to dissect the detrusor muscle in 3 linear directions along the lowermost portion of the ureter. The bladder cuff was secured with staples. At followup cystoscopy the authors noted no staples in the bladder, and in each case the ureteral tunnel and orifice had been taken. The advantages of this approach would appear to be maintenance of the integrity of the bladder throughout the procedure, a pure retroperitoneoscopic approach and elimination of any transurethral procedure. I would only caution the reader that a quick flexible cystoscopy at the end of the procedure or even during the procedure may be worthwhile to be certain that the entire ipsilateral ureteral tunnel and orifice have been removed. If not, the tunnel can be cystoscopically unroofed until staples are seen. Two final points are that this approach leaves a 4.7 mm cuff of stapled urothelium on the bladder. Recent work by Venkatesh et al has shown that the urothelium between the staples remains viable.1 While no bladder cuff recurrence has been reported in any series using a stapler to secure the cuff, the concern remains. Lastly, this report, as with all other reports in which the stapler has been used to secure the bladder cuff, has likewise shown no occurrence of bladder stones. Ralph V. Clayman, M.D.
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RENAL, URETERAL AND RETROPERITONEAL TUMORS 1. Venkatesh, R., Landman, J., Rehman, J. et al: Viability of cells within the staple lines following laparoscopic bladder stapling in a porcine model. J Endourol, suppl., 17: A4, 2003
UROLOGICAL ONCOLOGY: RENAL, URETERAL AND RETROPERITONEAL TUMORS Prediction of Progression After Radical Nephrectomy for Patients With Clear Cell Renal Cell Carcinoma. A Stratification Tool for Prospective Clinical Trials B. C. LEIBOVICH, M. L. BLUTE, J. C. CHEVILLE, C. M. LOHSE, I. FRANK, E. D. KWON, A. L. WEAVER, A. S. PARKER AND H. ZINCKE, Departments of Urology, Pathology, Health Sciences Research and Immunology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota Cancer, 97: 1663–1671, 2003 BACKGROUND. The objective of the current study was to develop an algorithm to predict progression to metastases after radical nephrectomy for patients with clinically localized renal cell carcinoma (RCC) to allow stratification of patients for potential adjuvant therapy trials. METHODS. The authors identified 1671 sporadic patients with clinically localized, unilateral clear cell RCC who underwent radical nephrectomy between 1970 and 2000. The clinical features examined included age, gender, smoking history, recent onset hypertension, performance status, and presenting symptoms. The pathologic features examined included surgical margins, tumor stage, regional lymph node status, tumor size, nuclear grade, histologic tumor necrosis, sarcomatoid component, cystic architecture, and multifocality. Metastases free survival was estimated using the Kaplan-Meier method. A multivariate Cox proportional hazards regression model was fit to determine associations between the clinical and pathologic features and distant metastases. RESULTS. The median follow-up was 5.4 years (range, 0 –31 years). Metastases occurred in 479 patients at a median of 1.3 years (range, 0 –25 years) after nephrectomy. The estimated metastases free survival rates were 86.9% at 1 year, 77.8% at 3 years, 74.1% at 5 years, 70.8% at 7 years, and 67.1% at 10 years. Multivariate analysis showed that the following features were associated with progression to metastases: tumor stage, regional lymph node status, tumor size, nuclear grade, and histologic tumor necrosis (P ⬍0.001 for all). CONCLUSIONS. In patients with clear cell RCC, tumor stage, regional lymph node status, tumor size, nuclear grade, and histologic tumor necrosis showed statistically significant associations with progression to metastatic RCC. The authors present a scoring algorithm based on these features that can be used to predict disease progression after patients undergo radical nephrectomy for clinically localized clear cell RCC. Editorial Comment: These authors revised their nomogram for the prediction of progression of renal cell carcinoma after nephrectomy for only clear cell renal cell carcinoma. The simple scoring algorithm was constructed to predict the possibility of metastases after nephrectomy. A total of 1,671 patients were included in the study. This algorithm differs from their previous tumor stage, size, grade and necrosis score in that the authors identify the end point as progression to metastatic disease rather than pure survival. The University of California, Los Angeles group (reference 18 in article) and the Memorial Sloan-Kettering group (reference 30 in article) have devised their own prognostic nomograms. This study still uses tumor necrosis as a variable but it is not included in the other systems. Scores are assigned to stage, lymph node status, tumor size, nuclear grade and tumor necrosis. Years to metastasis can then be calculated according to the score. These nomograms may be helpful in deciding adjuvant therapy and followup examinations. Fray F. Marshall, M.D. Differentiation of Subtypes of Renal Cell Carcinoma on Helical CT Scans J. K. KIM, T. K. KIM, H. J. AHN, C. S. KIM, K.-R. KIM AND K.-S. CHO, Department of Radiology, Asan Medical Center, University of Ulsan, Sangpu-gu, Seoul, South Korea AJR Am J Roentgenol, 178: 1499 –1506, 2002 OBJECTIVE. The purpose of our study was to differentiate subtypes of renal cell carcinoma on helical CT scans. MATERIALS AND METHODS. We reviewed CT scans of four subtypes of renal cell carcinoma: 76 conventional (clear cell), 19 papillary, 13 chromophobe, and two collecting duct. Biphasic CT scans (unenhanced, corticomedullary, and excretory phase scans) were obtained in 61 patients, and monophasic CT scans (unenhanced and excretory phase scans) in 49. We compared patient age and sex; tumor size; degree
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Patient and Partner Satisfaction and Long-Term Results After Surgical Treatment for Peyronie’s Disease M. F. USTA, T. J. BIVALACQUA, J. SANABRIA, I. T. KOKSAL, K. MOPARTY AND W. J. HELLSTROM, Department of Urology, Tulane University School of Medicine, New Orleans, Louisiana Urology, 62: 105–109, 2003 OBJECTIVES: To assess the long-term functional outcome, patient and partner satisfaction, and predictive factors for unfavorable results in men treated with a surgical approach for severe Peyronie’s disease. METHODS: Sixty-one patients underwent surgical treatment for Peyronie’s disease between 1997 and 2001 and were retrospectively evaluated. All patients were assessed preoperatively with a detailed sexual and medical history, focused physical examination, and penile duplex ultrasonography. Nineteen patients underwent penile plaque excision/incision and grafting with Tutoplast cadaveric pericardial grafting material (group 1). Penile prosthesis implantation and manual modeling was performed in 31 patients (group 2a), and 11 men were treated with penile prosthesis implantation and pericardial grafting (group 2b). RESULTS: The mean follow-up of the patients was 21.9 ⫹/⫺ 13.6 months (range 12 to 48). Complete penile straightening was achieved in 15 patients (78.9%) in the excision/incision and grafting group. In the 42 men who underwent reconstruction using penile prosthesis implantation (group 2a,b), penile curvature resolved completely in 37 patients (88%). Long-term postoperative residual curvatures greater than 30 degrees occurred in 3 patients (15.7%) and 2 patients (4.8%) in groups 1 and 2a,b, respectively. One penile prosthesis (2.3%) was explanted in the second group for erosion. Patient responses to our questionnaire showed that overall 83.6% of the patients and 76.9% of the partners were satisfied with the surgical result. CONCLUSIONS: According to the results of this long-term, retrospective study, pericardial grafting can be used successfully after plaque excision/incision procedures in men undergoing surgical treatment for severe Peyronie’s disease. In patients with Peyronie’s disease and erectile dysfunction, implantation of a penile prosthesis and correction of the curvature with a graft can provide an acceptable, functionally straight penis without any increased risk of complications compared with penile prosthesis implantation alone. Editorial Comment: This is a long-term functional outcome study of patient and partner satisfaction. It is important because it is optimal to include the partner whenever possible to understand disease outcome. A total of 61 men underwent surgical treatment for Peyronie’s disease. Of the patients 31 underwent penile prosthesis implantation with manual modeling and 19 underwent plaque excision or incision with grafting. Patient responses to questionnaire data show that 84% of patients and 70% of partners were satisfied with the surgical results. This is important information in that irrespective of the procedure or graft material, as long as the postoperative erection demonstrates minimal curvature and there is a good functional and cosmetic result, there appears to be good long-term outcome and satisfaction. These findings are irrespective of whether graft material is used or a penile prosthesis inserted. These data are important to remember as one counsels men for management of Peyronie’s disease. Allen Seftel, M.D.
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY Biochemical Profile of Stone-Forming Patients With Diabetes Mellitus C. Y. C. PAK, K. SAKHAEE, O. MOE, G. M. PREMINGER, J. R. POINDEXTER, R. D. PETERSON, P. PIETROW AND W. EKERUO, Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas, and Division of Urology, Duke University Medical Center, Durham, North Carolina Urology, 61: 523–527, 2003 Objectives. To test the hypothesis that stone-forming patients with type II diabetes (DM-II) have a high prevalence of uric acid (UA) stones and present with some of the biochemical features of gouty diathesis (GD). Methods. The demographic and initial biochemical data from 59 stone-forming patients with DM-II (serum glucose greater than 126 mg/dL, no insulin therapy, older than 35 years of age) from Dallas, Texas and Durham, North Carolina were retrieved and compared with data from 58 patients with GD and 116 with hyperuricosuric calcium oxalate urolithiasis (HUCU) without DM. Results. UA stones were detected in 33.9% of patients with DM-II compared with 6.2% of stone-forming patients without DM (P ⬍0.001). Despite similar ingestion of alkali, the urinary pH in patients with DM-II and UA stones (n ⫽ 20) was low (pH ⫽ 5.5), as it is in patients with GD, and was significantly lower than in patients with HUCU. The urinary pH in patients with DM-II and calcium stones (n ⫽ 39) was
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intermediate between that in those with DM-II and UA stones and those with HUCU. However, both DM groups had fractional excretion of urate that was not depressed, as it is in those with GD, and was comparable to the value obtained in those with HUCU. The urinary content of undissociated UA was significantly higher, and the saturation of calcium phosphate (brushite) and sodium urate was significantly lower in those with DM-II and UA stones than in those with HUCU. Conclusions. Stone-forming patients with DM-II have a high prevalence of UA stones. Diabetic patients with UA stones share a key feature of those with GD, namely the passage of unusually acid urine, but not the low fractional excretion of urate. Editorial Comment: New knowledge! Among patients with type II diabetes the occurrence of uric acid stones (33.9%) is 5-fold higher than in the general stone forming population. Why? It may all relate to obesity and insulin resistance. In this group of patients with type II diabetes the average body mass index was 34, with a pH of 5.53. The latter could be due to insulin resistance related decreased production of ammonia resulting in a more acid urine. In keeping with this hypothesis the calcium stone forming diabetics had a less acid pH at 5.89. Ralph V. Clayman, M.D. Laparoscopic Evaluation of Indeterminate Renal Cysts: Long-Term Follow-Up J. LIMB, L. SANTIAGO, J. KASWICK AND G. C. BELLMAN, Department of Urology, Kaiser Permanente, Los Angeles, California J Endourol, 16: 79 – 82, 2002 Purpose: We present our long-term follow-up of patients who have undergone laparoscopic evaluation for their indeterminate renal cysts, specifically reporting those patients who were found to have cystic renalcell carcinoma (RCC) and assessing the safety and efficacy of the procedure. Patients and Methods: Fifty-seven patients with indeterminate renal cysts (28 Bosniak category II and 29 Bosniak category III) underwent laparoscopic evaluation between July 1993 and July 2000. A transperitoneal laparoscopic localization and aspiration of the cyst, cytologic analysis, and biopsy of the cyst wall and base were performed. A total of 11 patients were found to have cystic RCC. Patients with malignancy have been followed for a mean of 40 months (range 6 –70 months), and five patients had 5 years or more of follow-up. Results: Eleven patients (19% of the total) were found to have cystic RCC. Three of these patients had Bosniak category II cysts, and eight had category III cysts. All tumors were low grade (I or II), and the stages were T1–2, Nx– 0, M0. There has been no evidence of laparoscopic port site or renal fossa tumor recurrence, local recurrence, or metastatic disease to date in these patients. There is no cancer-specific mortality. Conclusions: Long-term follow-up indicates that laparoscopic evaluation of indeterminate renal cysts is not associated with an increased risk of port site or retroperitoneal or peritoneal recurrence of RCC. It may save a patient from undergoing open surgery and should be considered as a diagnostic option for patients with indeterminate renal cysts. Editorial Comment: This important followup on the laparoscopic evaluation of complex renal cysts corroborates a paradigm shift in the approach to these lesions. Specifically, laparoscopic exploration is “in” and percutaneous cyst aspiration is “out.” While Bosniak II and III lesions have been noted to harbor a renal cell cancer in 24% and 33% of patients, respectively, the usual approach to diagnosing these lesions has been by needle aspiration. However, as the authors nicely indicate in their review, needle aspiration of these lesions has proved to be unreliable due to false-positive as well as false-negative diagnoses. The latter is particularly commonplace, as high as 86%!1 This finding is further supported by the fact that only 1 of the 11 tumor bearing patients had a positive cytology when the cancerous cyst was aspirated intraoperatively! In this report on 57 patients 11% of 28 patients with Bosniak II lesions and 28% of 29 patients with Bosniak III lesions had a cystic cancer found at laparoscopic exploration. In each case the cyst had been opened, thereby raising the concern of possible intraabdominal seeding. At a mean followup of 3.3 years (greater than 5 years in 5 patients) following partial or radical/total nephrectomy there was no metastatic disease, local recurrence or port site seeding. The authors highlight that all of the lesions were low grade and low stage. From their review of the literature it would appear that among these patients the overall risk of recurrence is in the 2% to 2.5% range, with most recurrences being noted within a 5-year time span.2 The bottom line is that laparoscopic exploration for Bosniak II or Bosniak III renal cysts should now be viewed as the primary diagnostic approach to these lesions, supplanting percutaneous cyst aspiration. The only question is whether this needs to be done at the time the lesion is discovered or following a period of observation and documented growth of the lesion. In the former circumstance 67% to 80% of the explorations will be negative. Ralph V. Clayman, M.D. 1. Hayakawa, M., Hatano, T., Tsuji, A., Nakajima, F. and Ogawa, Y.: Patients with renal cysts associated with renal cell carcinoma and the clinical implications of cyst puncture: a study of 223 cases. Urology, 47: 643, 1996
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UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPY 2. Hafez, K. S., Novick, A. C. and Campbell, S. C.: Patterns of tumor recurrence and guidelines for followup after nephron sparing surgery for sporadic renal cell carcinoma. J Urol, 157: 2067, 1997
Why Oral Calcium Supplements May Reduce Renal Stone Disease: Report of a Clinical Pilot Study C. P. WILLIAMS, D. F. CHILD, P. R. HUDSON, G. K. DAVIES, M. G. DAVIES, R. JOHN, P. S. ANANDARAM AND A. R. DE BOLLA, Departments of Medical Biochemistry, Medicine and Urology, Wrexham Maelor Hospital NHS Trust, Wrexham and Department of Medical Biochemistry, University Hospital of Wales Healthcare NHS Trust, Heath Park, Cardiff, United Kingdom J Clin Pathol, 54: 54 – 62, 2001 Aims—To investigate whether increasing the daily baseline of gut calcium can cause a gradual downregulation of the active intestinal transport of calcium via reduced parathyroid hormone (PTH) mediated activation of vitamin D, and to discuss why such a mechanism might prevent calcium oxalate rich stones. To demonstrate the importance of seasonal effects upon the evaluation of such data. Methods—Within an intensive 24 hour urine collection regimen, daily calcium supplementation (500 mg) was given to five stone formers for a 10 week period during a six month crossover study. In a further population of patients on follow up for previous renal stone disease, observations were made on 1066 24 hour urine samples collected over five years in respect of seasonal effects relevant to the interpretation of the study. Results—In the group of patients on calcium supplements the following results were found. During calcium supplementation, the proportion of urine calcium to oxalate was higher (increased calcium to oxalate molar ratio), the 24 hour urine product of calcium and oxalate did not rise, and urine oxalate was lower during the first six weeks of supplementation. Twenty four hour urine calcium was 10.2% higher than baseline in the final four weeks of the 10 weeks of supplementation. Twenty four hour urine phosphate was 11.4% lower during the first six weeks of supplementation, but then rose while the patients were still on supplementation; renal tubular reabsorption of phosphate (TmP/GFR) mirrored the urine phosphate changes inversely. PTH was higher after stopping supplementation, but 1,25-(OH)2-cholecalciferol changes were not detected. In the 1066 urine samples collected over five years the following results were found. Calcium and oxalate excretion correlated positively and not inversely. Urine calcium and phosphate excretion were 5.5% and 2.5% higher, respectively, in “light” months of the year compared with “dark” months. A post summer decline in both urine calcium and urine phosphate was relevant to the interpretation of the study. Conclusions—Regular calcium supplementation does not raise the product of calcium and oxalate in urine and the proportion of oxalate to calcium is reduced. The underlying mechanisms of the changes seen in phosphate, calcium, and PTH and the observations on 1,25-(OH)2-cholecalciferol are not clear. Observed changes in phosphate could possibly be part of a calcium regulating feedback loop operating over a period of weeks. In evaluating these mechanisms background seasonal effects are important. It is possible that “programming” of the gut mucosa in terms of calcium transport is a major determinant of the relation between calcium and oxalate concentrations in urine and their relative abundance. Increased oral calcium, in association with a reduction of the relative proportion absorbed, may be pertinent to the prevention of calcium oxalate rich stones. Editorial Comment: Unfortunately, the article does not answer the question posed in its title. However, the preliminary data are of interest. First, a modest calcium load (500 mg daily) results in a decrease in urine oxalate with only a mild increase in urine calcium. The calcium oxalate product decreased but did not reach statistical significance in this small study. Again, the authors confirm other articles warning against dietary calcium restriction in the treatment of stone disease. In addition, urine phosphate levels decreased during calcium supplementation. This outcome could favorably influence a decrease in PTH and a reduction in the activation of vitamin D, providing further benefits in the calcium supplemented group. Moreover, the authors noted increased levels of calcium in the urine during the summer (ie “light”) months, which they hypothesize could also impact subsequent stone disease. Finally, they caution against the use of vitamin D supplements, especially in stone formers. Ralph V. Clayman, M.D. Factors Associated With Failure of Extracorporeal Shock-Wave Lithotripsy for Ureteral Stones Using Dornier Lithotripter U/50 Y. S. ANAGI, T. YAGISAWA, M. NANRI, C. KOBAYASHI AND H. TOMA, Department of Urology, Kidney Center, Tokyo Women’s Medical University, Tokyo, Japan Int J Urol, 9: 304 –307, 2002 Background: In the present series of 170 patients who underwent extracorporeal shock-wave lithotripsy (SWL) treatment for ureteral stones, the authors determine which patients with ureteral stones had an unsuccessful outcome. Methods: The records of 170 patients with ureteral stones who were treated with SWL using the Dornier
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lithotriptor U/50 (EMSE 140) between January 1998 and December 1999 were retrospectively investigated. One hundred and thirty-one patients were treated with SWL alone (single session, n ⫽ 98; multiple session, n ⫽ 33) and 39 patients required auxiliary treatment due to failure of SWL (33 with transurethral ureterolithotripsy (TUL), one with open lithotomy, and five with residual fragments who were followed up). These two groups were compared using multivariate logistic regression analysis. Results: Lower ureteral stones and stones more than 12 mm in diameter were associated with a poor outcome of SWL. There were no significant differences in age, gender, number of stones, JJ stent placement, and degree of ureteral obstruction due to the stone between the two groups. The odds ratios of lower ureteral stones and stones ⱖ12 mm were 4.18 and 2.57, respectively. Conclusion: Patients with distal ureteral stones and/or stones more than 12 mm in diameter were difficult to treat successfully with SWL. Alternatives such as TUL should possibly be considered as a first-line therapy for these stones. Editorial Comment: Despite significant progress in the understanding of how shock waves fragment calculi and improvements in treatment strategies, we are once again faced with the fact that the newer machines are not as effective as the original Dornier HM-3 lithotriptor (Dornier Medical Systems, Inc., Marietta, Georgia). In this report the overall success rate (ie fragments less than 4 mm) for lithotripsy of distal ureteral stones was only 64% versus success rates of 83% and 79% in the proximal and mid ureter, respectively. From these numbers one can deduct at least another 5% to obtain stone-free rates. Approximately 39% of patients required more than 1 treatment, and the average number of shock waves administered was 3,000 to 5,000. These results, especially in the distal ureter, pale when compared to the HM-3 results of more than a decade ago in the distal ureter—stone-free in more than 90% with re-treatment in fewer than 10% of patients.1 Time is passing and SWL is getting older but not better. Ralph V. Clayman, M.D. 1. Pearle, M. S., Nadler, R., Bercowsky, E., Chen, C., Dunn, M., Figenshau, R. S. et al: Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi. J Urol, 166: 1255, 2001
Impact of Ureteral Stent Diameter on Symptoms and Tolerability E. ERTURK, A. SESSIONS Rochester, New York
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J. V. JOSEPH, Department of Urology, University of Rochester Medical Center,
J Endourol, 17: 59 – 62, 2003 Background and Purpose: Indwelling double-pigtail ureteral stents are frequently associated with debilitating symptoms. A randomized study was performed to evaluate the effect of stent diameter (4.7F v. 6F) on symptoms and tolerability. Patients and Methods: Between February and October 2000, 46 consecutive patients undergoing ureteroscopy for stone disease were randomly assigned to receive either a 4.7F (group I) or a 6F (group II) ureteral stent following the procedure. The patients were asked to leave their stents in place for minimum of 7 days. Pain and irritative urinary symptoms in the two groups were compared according to a scale ranging from 0 (none) to 5 (severe). The two groups were also compared for stone size and location, rigid v. flexible ureteroscopy, anesthesia, stent migration, and ureteral dilation. Results: There were no differences between the groups in terms of pain (P ⫽ 0.28) or irritative symptoms (P ⫽ 0.37). There was a tendency for stents in group I to migrate distally and dislodge more often than those in group II (32% v 10%). Conclusions: When stent insertion following ureteroscopy is deemed necessary, a minimum diameter of 6F is recommended. Lower Ureteric Obstruction: A Complication of Tailed Ureteric Stents M. F. BULTITUDE, P. DASGUPTA, M. CYNK, J. M. GLASS AND R. C. TIPTAFT, Department of Urology, Guy’s and St Thomas’ Hospital, London, United Kingdom BJU Int, 91: 581, 2003 No Abstract Editorial Comment: Stent woes continue. Will a smaller stent cause fewer problems following ureteroscopy for stone disease? Comparison of a 6Fr and a 4.7Fr stent showed no statistical difference in this study with regard to pain or irritative symptoms during a 7-day plus period of stent placement. In addition, the smaller stents had a tendency to migrate distally in 32% of the patients. However, the study was underpowered to detect a difference of 20% to 30% as there were only 46 patients randomized. In addition, the smaller stents were associated with a lower pain score and lower irritative score but, again, this did not achieve statistical significance possibly given the small sample size. In contrast to a smaller stent, earlier work with the 7Fr/3Fr tail stent demonstrated a statistically significant decrease in lower tract irritative symptoms vs a standard 7Fr stent. However, as the article by Bultitude et al shows, this stent should not be used if there is lower ureteral
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pathology or significant trauma during ureteroscopy. In that case report a lower ureteral stricture developed following ureteroscopy. Not surprisingly, this obstruction was unrelieved with a tail stent. Overall, in concert with independent studies by Denstedt, Preminger, Hoskins and others, the best stent to place after ureteroscopy is likely no stent. Ralph V. Clayman, M.D. Use of Fibrin Glue in Percutaneous Nephrolithotomy A. A. MIKHAIL, J. S. KAPTEIN AND G. C. BELLMAN, Department of Urology and Regional Research Laboratory, Kaiser Permanente, Los Angeles, California Urology, 61: 910 –914, 2003 Objectives. To report our experience with the use of fibrin glue during tubeless percutaneous nephrolithotomy. We addressed the safety of this approach and evaluated its use for any clinical benefit with respect to length of hospital stay, bleeding, analgesic usage, and urinary extravasation. Methods. This was a retrospective review of 43 patients who underwent tubeless percutaneous nephrolithotomy. In 20 consecutive patients (one bilateral), percutaneous tracts were injected with 2 to 3 mL of Tissel Vapor Heated sealant at the conclusion of the procedure. The fibrin glue was instilled during simultaneous removal of the percutaneous sheath. These 20 patients were compared with a control group (23 consecutive patients) in which fibrin glue was not used. The length of hospitalization, hematocrit drop, analgesic use, stone burden, operative times, postoperative complications, and any noted computed tomography scan findings were compared. Results. Postoperatively, the average length of hospital stay was less in the experimental than in the control group by 0.71 day (P ⬍0.05). Differences in hematocrit drop between the experimental (6.8%) and control (5.6%) groups were not statistically significant. The total analgesic use was less in the experimental group, but the difference was not statistically significant. No statistical difference was found between the operative times for both groups. Postoperative fevers and wound seroma were noted in the experimental group. No abscesses or any significant changes along the percutaneous tracts were seen on postoperative computed tomography scans. In the control group, no procedure-related complications were noted. Conclusions. The use of fibrin glue is safe in percutaneous nephrolithotomy procedures and additional prospective randomized studies are needed to evaluate for any clinical benefit. Editorial Comment: “Ain’t going to bleed no more, no more.” The authors are to be congratulated on rediscovering the concept of Pfab et al from 1987 of using a surgical pharmaceutical, in this case fibrin glue, to seal the nephrostomy tract after an acute percutaneous stone removal procedure. In this study the authors purposely pulled the nephrostomy sheath out of the collecting system before instilling the glue to try to prevent it from entering the calix or renal pelvis. It is noteworthy that while the difference in the hematocrit between the glued cases and a historical tubeless control group was nil, there was a tendency toward earlier hospital discharge and less analgesic use in the fibrin glue group. Recently, concern has been raised about the fate of fibrin glue in the collecting system. Work by Uribe et al has shown that when placed directly into urine the fibrin glue has a tendency to form a long lasting clot.1 In contrast, gelatin matrix thrombin remains in a particulate suspension. Accordingly, this substance has recently been used to seal the nephrostomy tract acutely after percutaneous stone removal. Early results in 7 patients have been favorable, with no late bleeding or hospital readmissions. The next step, as sagely raised by Cadeddu in the editorial comment following this article, is to embark on a phase III randomized controlled study to see if the benefit outweighs the cost of these hemostatic agents. Ralph V. Clayman, M.D. 1. Uribe, C., Eichel, L., Khonsari, S. et al: What happens to hemostatic agents in contact with urine? An in vitro study. J Endourol, suppl., 17: A42, 2003
Endoscopic Management of Symptomatic Caliceal Diverticula: A Retrospective Comparison of Percutaneous Nephrolithotripsy and Ureteroscopy B. K. AUGE, R. MUNVER, J. KOURAMBAS, G. E. NEWMAN AND G. M. PREMINGER, Comprehensive Kidney Stone Center, Division of Urology, Department of Surgery and Division of Interventional Radiology, Department of Radiology, Duke University Medical Center, Durham, North Carolina J Endourol, 16: 557–563, 2002 Background and Purpose: A myriad of minimally invasive options exist for managing symptomatic caliceal diverticula, including shockwave lithotripsy, percutaneous surgery, retrograde ureteroscopy, and laparoscopy. Yet no direct comparisons have been made in the literature of the relative treatment efficacy of ureteroscopy (URS) and percutaneous nephrolithotripsy (PNL). A retrospective review of our patients was performed to determine the most appropriate endoscopic management option for patients with symptomatic caliceal diverticula. Patients and Methods: Between November of 1994 and April 2001, 39 patients presented with symptomatic caliceal diverticula, 37 of which contained calculi. Twenty-two patients (56%) underwent PNL, and 17
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patients (44%) were managed by URS. Of the PNL group, 82% required the creation of a neoinfundibulotomy. The stone burden in the PNL group averaged 11.4 ⫻ 12.0 mm and that in the URS group 12.7 ⫻ 13.0 mm (p ⬎0.05). Pain, recurrent urinary tract infections, and nausea and vomiting were the presenting complaints in both subgroups of patients, with pain being by far the most common symptom. The average hospital stay was 2.8 days for the PNL group. All the URS procedures were performed on a same-daysurgery basis. Results, including stone-free, symptom-free, and complication rates, were compared for the two groups. Results: Thirty-five percent of the URS group were symptom free at 6 weeks’ follow-up, with an additional 29% reporting an improvement in pain, whereas 86% of the PNL group was completely symptom free at 6 weeks’ follow-up. Only 19% of the URS group were stone free on follow-up intravenous urography v 78% of those undergoing PNL (three patients failed to return for follow-up imaging). It was not possible to identify the ostium of the stenotic infundibulum in 4 patients (24%) undergoing URS, and 7 patients (41%) eventually went on to PNL with ultimate success. The PNL was statistically better than URS in producing stone-free results for diverticula located in the upper pole and for stones ⬍11 mm (p ⬍0.05). No complications occurred in the URS group; however, complications were identified in four patients after PNL. One patient developed clot urinary retention necessitating Foley catheterization and manual bladder irrigation; one patient experienced significant bleeding necessitating early cessation of the procedure. Two patients sustained intrathoracic complications, one a pneumothorax and the other a pneumohemothorax after supra-11th rib access. Both were managed successfully with tube thoracostomy. Conclusions: Our review clearly suggests an advantage of percutaneous management over ureteroscopy for complex posterior symptomatic caliceal diverticula, although with a slightly increased risk of complications. Therefore, PNL should be considered the primary modality for managing these difficult processes. In cases where the stenotic infundibulum cannot be traversed with a guidewire, creation of a neoinfundibulotomy permitted secure access to the collecting system while providing effective results. Editorial Comment: Caveat emptor: Beware the intoxication of flexible ureteroscopy! In this article on definitive therapy for the stone bearing caliceal diverticulum flexible ureteroscopy turned out to be safe and minimally invasive but also minimally effective. Even for caliceal diverticula involving the upper pole or for stones 10 mm or smaller the percutaneous approach provided a far better stone-free result— 85% vs 36% and 89% vs 30%, respectively. It is noteworthy that symptom-free rate (86% vs 35%), overall stone-free rate (78% vs 19%) and the need for secondary procedures (4% vs 41%) all favored a percutaneous approach. These differences occurred despite attempts to select “anatomically optimal” patients for ureteroscopy. Ralph V. Clayman, M.D. Biochemical Distinction Between Hyperuricosuric Calcium Urolithiasis and Gouty Diathesis C. Y. C. PAK, J. R. POINDEXTER, R. D. PETERSON, J. KOSKA AND K. SAKHAEE, Center for Mineral Metabolism and Clinical Research, University of Texas Southwestern Medical Center, Dallas, Texas Urology, 60: 789 –794, 2002 Objectives. To determine whether the biochemical presentation and urinary physicochemical environment of patients with hyperuricosuria presenting with calcium stones (hyperuricosuric calcium urolithiasis [HUCU]) differs from those of patients with gouty diathesis (GD) or idiopathic uric acid urolithiasis. Methods. A total of 122 patients with HUCU and 68 patients with GD were identified from our “stone registry” of patients who underwent a full ambulatory evaluation. All patients with HUCU had urinary uric acid greater than 800 mg/day in men and greater than 750 mg/day in women and presented with calcium stones. Those with GD had pure uric acid stones or mixed uric acid-calcium stones and did not have secondary causes of uric acid urolithiasis. Data derived from the fasting serum and 24-hour urine samples collected on a random diet and on a diet restricted in calcium, sodium, and oxalate were compared between the two groups. Results. Compared with patients with HUCU, those with GD had significantly higher serum uric acid and lower urinary uric acid and pH levels (mean value 5.38 and 5.35 on random and restricted diets versus 6.09 and 6.14, respectively). The fractional excretion of urate and the discriminant score of the relationship between urinary pH and the fractional excretion of urate were significantly lower in those with GD than in those with HUCU. Patients with HUCU displayed a greater urinary saturation of sodium urate and calcium oxalate compared with those with GD, and those with GD had a higher urinary content of undissociated uric acid and lower urinary saturation of brushite (calcium phosphate). Conclusions. Patients with HUCU presented with normal urinary pH and hyperuricosuria, accompanied sometimes by hypercalciuria, which produced increased urinary saturation of sodium urate and calcium oxalate. In contrast, those with GD had a low fractional excretion of urate (that contributed to hyperuricemia) and low urinary pH (that led to increased amount of undissociated uric acid). The varying biochemical and physicochemical presentations of the two conditions can be ascribed to overindulgence with purine-rich foods in those with HUCU and underlying primary gout in those with GD. Editorial Comment: The problem for patients with hyperuricosuric calcium urolithiasis is due to purine gluttony. In the recalcitrant patient the only method for stone prevention may be for
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the urologist to resort to the use of allopurinol. In contrast, for the patient with a gouty diathesis the low urine pH leads to uric acid stone formation, possibly based on a problem with ammonia generation in the urine. For this patient the treatment lies in alkalization, usually with a potassium citrate compound. Ralph V. Clayman, M.D. Creation of Ureteropelvic Junction Obstruction and Its Correction by Chemical Glue-Assisted Laparoscopic Dismembered Pyeloplasty A. W. CHIU, C.-H. LIN, S. K. HUAN, C. J. LIU, C.-C. LIN, Y.-L. HUANG, W.-L. LIN, S.-H. HUANG, P.-S. LEE AND C.-N. LIN, Division of Urology, Department of Surgery, and Departments of Medical Research and Pathology, Chi Mei Medical Center, Tainan and Department of Urology, National Yang-Ming University, School of Medicine, MacKay Memorial Hospital and Chang-hua Christian Hospital, Taipei, Taiwan, Republic of China J Endourol, 17: 23–28, 2003 Purpose: We established a porcine model of ureteropelvic junction (UPJ) obstruction using a laparoscopic technique and assessed the outcome of standard suture-assisted and chemical glue-assisted laparoscopic pyeloplasty. Materials and Methods: Female domestic pigs (N ⫽ 20) underwent laparoscopic suture-ligature to create UPJ obstruction. One month later, laparoscopic end-to-end anastomosis was performed to correct the obstruction: with standard suturing techniques in 10 animals and with chemical (cyanoacrylate) glue in the other 10. Postoperative ureteral stents were not used. Four weeks postoperatively, intravenous urography was performed to evaluate the patency of the anastomoses. The UPJ was procured by laparotomy to assess the anastomoses and periureteral fibrosis histologically. Results: The UPJ obstruction was created in an average of 15 ⫾ 6 minutes. There was no early postoperative mortality. Eighteen pigs survived for at least 1 month, and UPJ obstruction developed in 17 (95%). Microscopically, the lumen of the UPJ was partially occluded, measuring an average of 40% ⫾ 5% of normal. After laparoscopic correction, a patent UPJ was found in seven of nine animals treated with traditional sutures. Among the eight animals with chemically glued anastomoses, none had a patent UPJ, and severe periureteral adhesions and intraluminal fibrosis were noted at the pyeloplasty site. Marked ureteral tortuosity was present in six of the eight pigs receiving glue-assisted pyeloplasty but in none of the animals having suture-assisted pyeloplasty. Conclusions: Ureteropelvic junction obstruction was established by laparoscopic suture-ligature in a porcine model with a 95% success rate. Chemical glue-assisted anastomosis was inferior to standard laparoscopic sutures for pyeloplasty to correct the obstruction. Vesicourethral Anastomosis With 2-Octyl Cyanoacrylate Adhesive in an In Vivo Canine Model J. P. GRUMMET, A. J. COSTELLO, D. A. SWANSON, L. C. STEPHENS AND D. M. CROMEENS, Division of Urology, Department of Surgery, University of Melbourne, Melbourne, Australia, and Departments of Urology, and Veterinary Medicine and Surgery, University of Texas M. D. Anderson Cancer Center, Houston, Texas Urology, 60: 935–938, 2002 Objectives. To evaluate the effectiveness of 2-octyl cyanoacrylate adhesive (OCA) in the formation of vesicourethral anastomoses. Methods. Open total prostatectomy was performed on 12 mongrel hounds. Of these, 8 had a vesicourethral anastomosis formed using OCA (4 with suture support and 4 sutureless). The remaining four anastomoses were conventionally formed using eight interrupted sutures. Acute leakage was tested intraoperatively. Before killing the hounds, the anastomosis of 1 animal in each group was assessed on postoperative days 3, 5, 7, and 14 by radiography. Each anastomotic specimen was then tested for leak pressure and examined histologically. Results. At intraoperative testing, one small leak was found in the sutureless OCA group. All other anastomoses were watertight intraoperatively. Radiographically, two leaks occurred in the OCA group with suture support, three leaks in the sutureless OCA group, and only one small localized leak in the control group. Only one of the eight anastomoses using OCA achieved a physiologic leak pressure greater than 70 mm Hg (one of these, however, could not be tested because of injury at the time the specimen was retrieved). The leak pressures of all four control-group anastomoses were 70 mm Hg or greater. Histologically, no significant differences were found in healing between the control and OCA anastomoses. Conclusions. With or without suture support, OCA appears to be unsuitable for use in forming the large-diameter vesicourethral anastomosis required in radical prostatectomy. Editorial Comment: At present, neither fibrin glue (a sealant) nor a chemical adhesive (cyanoacrylate) works well for tissue reconstruction. The former is not sufficiently strong and the latter creates marked inflammation at the approximated tissue edge. For the time being, basic suturing is the best method to perform laparoscopic pyeloplasty or laparoscopic urethrovesical
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anastomosis. Parenthetically, fibrin glue should likely not be used after a sutured repair as a “safety” measure. Indeed, its use under these circumstances may harm more than help. Ralph V. Clayman, M.D. Resolution of Ephedrine Stones With Dissolution Therapy N. HOFFMAN, S. M. MCGEE AND J. C. HULBERT, Department of Urologic Surgery, University of Minnesota Medical School and Fairview-University Medical Center, Minneapolis, Minnesota Urology, 61: 1035vi–1035vii, 2003 A patient with a history of ingesting large quantities of an over-the-counter stimulant developed renal calculi that on further analysis, after stone passage, revealed increased amounts of ephedrine. Over the course of 7 months, all of the patient’s ephedrine stones were managed successfully by alkalinization. Similar to previously reported ephedrine calculi, these stones were radiolucent on x-ray imaging, but their course was monitored on serial nonenhanced computed tomography scans. We believe this to be the first reported use of alkaline therapy for the dissolution of renal stones containing ephedrine. Editorial Comment: In this patient stones of 1.0 and 1.5 cm were dissolved with 20 mEq potassium citrate 3 times daily to alkalize the urine. Ephedrine stones, like uric acid stones, are radiolucent and susceptible to dissolution therapy. Ralph V. Clayman, M.D. Retroperitoneoscopic Nephroureterectomy for Transitional Cell Carcinoma of the Renal Pelvis and Ureter: Nagoya Experience Y. YOSHINO, Y. ONO, R. HATTORI, M. GOTOH, O. KAMIHIRA AND S. OHSHIMA, Department of Urology, Nagoya University School of Medicine, Nagoya-shi and Komaki Shimin Hospital, Komaki, Japan Urology, 61: 533–538, 2003 Objectives. To evaluate the efficacy of our new retroperitoneoscopic nephroureterectomy for patients with transitional cell carcinoma of the renal pelvis and ureter, we present the operative procedure and analysis of the clinical outcome of retroperitoneoscopy in 23 patients. Methods. Twenty-three patients with transitional cell carcinoma of the upper urinary tract underwent retroperitoneal laparoscopic nephroureterectomy between February 2000 and February 2002. Patient age ranged from 44 to 83 years (mean 66.7). Each kidney was retroperitoneoscopically dissected en bloc, together with the perirenal fatty tissue, lymph nodes, and/or adrenal gland, without transecting the ureter. The lower ureter was resected with the bladder cuff transected using an ultrasonic scalpel and an endoscopic gastrointestinal automatic stapler. The dissected specimen was removed intact through a 6-cm-long original incision. Results. The mean operating time was 4.8 hours, including 0.7 hours for complete removal of the ureteral end with the bladder cuff. The mean estimated blood loss was 304 mL. The mean time to recovery to normal activity was 18 days. In the mean follow-up period of 15 months, 2 patients died of cancer progression in the sixth postoperative month, 2 died of other causes, and 4 had recurrent transitional cell carcinoma of the bladder after surgery. Conclusions. Our retroperitoneal laparoscopic nephroureterectomy using an endoscopic gastrointestinal automatic stapler is a fast, low-risk, and minimally invasive procedure and might be an alternative to other laparoscopic techniques and open nephroureterectomy. However, long-term follow-up is necessary to confirm the efficacy for patients with transitional cell carcinoma of the renal pelvis and ureter. Editorial Comment: Among 23 patients a successful completely retroperitoneal laparoscopic nephroureterectomy was completed using a 5-port approach. The bladder cuff was removed after first using a 5 mm harmonic scalpel/shears to dissect the detrusor muscle in 3 linear directions along the lowermost portion of the ureter. The bladder cuff was secured with staples. At followup cystoscopy the authors noted no staples in the bladder, and in each case the ureteral tunnel and orifice had been taken. The advantages of this approach would appear to be maintenance of the integrity of the bladder throughout the procedure, a pure retroperitoneoscopic approach and elimination of any transurethral procedure. I would only caution the reader that a quick flexible cystoscopy at the end of the procedure or even during the procedure may be worthwhile to be certain that the entire ipsilateral ureteral tunnel and orifice have been removed. If not, the tunnel can be cystoscopically unroofed until staples are seen. Two final points are that this approach leaves a 4.7 mm cuff of stapled urothelium on the bladder. Recent work by Venkatesh et al has shown that the urothelium between the staples remains viable.1 While no bladder cuff recurrence has been reported in any series using a stapler to secure the cuff, the concern remains. Lastly, this report, as with all other reports in which the stapler has been used to secure the bladder cuff, has likewise shown no occurrence of bladder stones. Ralph V. Clayman, M.D.
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RENAL, URETERAL AND RETROPERITONEAL TUMORS 1. Venkatesh, R., Landman, J., Rehman, J. et al: Viability of cells within the staple lines following laparoscopic bladder stapling in a porcine model. J Endourol, suppl., 17: A4, 2003
UROLOGICAL ONCOLOGY: RENAL, URETERAL AND RETROPERITONEAL TUMORS Prediction of Progression After Radical Nephrectomy for Patients With Clear Cell Renal Cell Carcinoma. A Stratification Tool for Prospective Clinical Trials B. C. LEIBOVICH, M. L. BLUTE, J. C. CHEVILLE, C. M. LOHSE, I. FRANK, E. D. KWON, A. L. WEAVER, A. S. PARKER AND H. ZINCKE, Departments of Urology, Pathology, Health Sciences Research and Immunology, Mayo Medical School and Mayo Clinic, Rochester, Minnesota Cancer, 97: 1663–1671, 2003 BACKGROUND. The objective of the current study was to develop an algorithm to predict progression to metastases after radical nephrectomy for patients with clinically localized renal cell carcinoma (RCC) to allow stratification of patients for potential adjuvant therapy trials. METHODS. The authors identified 1671 sporadic patients with clinically localized, unilateral clear cell RCC who underwent radical nephrectomy between 1970 and 2000. The clinical features examined included age, gender, smoking history, recent onset hypertension, performance status, and presenting symptoms. The pathologic features examined included surgical margins, tumor stage, regional lymph node status, tumor size, nuclear grade, histologic tumor necrosis, sarcomatoid component, cystic architecture, and multifocality. Metastases free survival was estimated using the Kaplan-Meier method. A multivariate Cox proportional hazards regression model was fit to determine associations between the clinical and pathologic features and distant metastases. RESULTS. The median follow-up was 5.4 years (range, 0 –31 years). Metastases occurred in 479 patients at a median of 1.3 years (range, 0 –25 years) after nephrectomy. The estimated metastases free survival rates were 86.9% at 1 year, 77.8% at 3 years, 74.1% at 5 years, 70.8% at 7 years, and 67.1% at 10 years. Multivariate analysis showed that the following features were associated with progression to metastases: tumor stage, regional lymph node status, tumor size, nuclear grade, and histologic tumor necrosis (P ⬍0.001 for all). CONCLUSIONS. In patients with clear cell RCC, tumor stage, regional lymph node status, tumor size, nuclear grade, and histologic tumor necrosis showed statistically significant associations with progression to metastatic RCC. The authors present a scoring algorithm based on these features that can be used to predict disease progression after patients undergo radical nephrectomy for clinically localized clear cell RCC. Editorial Comment: These authors revised their nomogram for the prediction of progression of renal cell carcinoma after nephrectomy for only clear cell renal cell carcinoma. The simple scoring algorithm was constructed to predict the possibility of metastases after nephrectomy. A total of 1,671 patients were included in the study. This algorithm differs from their previous tumor stage, size, grade and necrosis score in that the authors identify the end point as progression to metastatic disease rather than pure survival. The University of California, Los Angeles group (reference 18 in article) and the Memorial Sloan-Kettering group (reference 30 in article) have devised their own prognostic nomograms. This study still uses tumor necrosis as a variable but it is not included in the other systems. Scores are assigned to stage, lymph node status, tumor size, nuclear grade and tumor necrosis. Years to metastasis can then be calculated according to the score. These nomograms may be helpful in deciding adjuvant therapy and followup examinations. Fray F. Marshall, M.D. Differentiation of Subtypes of Renal Cell Carcinoma on Helical CT Scans J. K. KIM, T. K. KIM, H. J. AHN, C. S. KIM, K.-R. KIM AND K.-S. CHO, Department of Radiology, Asan Medical Center, University of Ulsan, Sangpu-gu, Seoul, South Korea AJR Am J Roentgenol, 178: 1499 –1506, 2002 OBJECTIVE. The purpose of our study was to differentiate subtypes of renal cell carcinoma on helical CT scans. MATERIALS AND METHODS. We reviewed CT scans of four subtypes of renal cell carcinoma: 76 conventional (clear cell), 19 papillary, 13 chromophobe, and two collecting duct. Biphasic CT scans (unenhanced, corticomedullary, and excretory phase scans) were obtained in 61 patients, and monophasic CT scans (unenhanced and excretory phase scans) in 49. We compared patient age and sex; tumor size; degree