Retroperitoneal Laparoscopic Ureterolithotomy for Upper Ureter Stones

We evaluated the role of retroperitoneal laparoscopic ureterolithotomy (RPLU) for upper ureter stones. Between February 1998 and July 2004, 12 patients (10 men and 2 women) underwent RPLU for upper ureter stones (mean size 18.1 mm, range 10-25). RPLU was carried out in 5 patients as a salvage treatment after failed shock wave lithotripsy (SWL) (3) and both of failed SWL and ureteroscopy (URS) (2), and in 7 patients as primary treatment for large impacted stones. Total 6 of 12 cases were converted to open surgery. The reason of open conversion was failure of locating ureter due to severe adhesion in 5 cases and vascular injury in 1 case. In 6 successful cases, mean operation time, mean estimated blood loss, and mean postoperative hospital stay were respectively 109 min (90-120 min), 50 mL (10-100 mL), 4.6 days (2-7 days). There was no serious postoperative complication except for one patient who showed delayed urinary leakage but was cured with conservative management. Our experience suggested that RPLU was not easy to perform simply because it was indicated mainly in ureter stones with severe adhesion or after failed SWL and/or URS. Nevertheless, it can be considered as a primary procedure before open ureterolithotomy.

The Impact of PSA on Pathologic Characteristics in the Radical Prostatectomy with PSA Level of 4-10ng/ml / 대한비뇨기과학회지

PURPOSE: We evaluated the effect of the serum prostate specific antigen (PSA) levels in the range 4.1 to 10.0ng/ml on the pathologic characteristics after a radical prostatectomy. MATERIALS AND METHODS: Between July 1997 and June 2004, 117 men (64 years: 44-75) with an intermittent PSA level underwent radical retropubic prostatectomy. The patients were divided into 6 groups according to the PSA level (4.1-5.0, 5.0-6.1, 6.1-7.0. 7.1-8.0, 8.1-9.0 and 9.1-10.0ng/ml), and compared the age, prostate volume, Gleason score of biopsy specimen and pathologic stage, grade and margin status of prostatectomy specimen between the 6 groups. RESULTS: The mean age, prostate volume and Gleason score of the biopsy were not significantly different between the 6 groups. The pathologic stage and margin status also were not significantly different between the 6 groups. The mean Gleason score was higher in the high PSA group, but this was not statistically significant. When divided into two groups (group with PSA 4.1-7.0 and 7.1-10.0ng/ml), the pathologic stage and margin status were no different. However, the mean Gleason score and the rate of high grade (Gleason score 8-10) prostate cancer were higher in the high PSA group. The mean high grade prostate cancer rates were 22 and 7% in the PSA 7.1-10.0 and 4.1-7.0ng/ml groups, respectively (p=0.019). CONCLUSIONS: A PSA level above 7.0ng/ml in the intermediate group influenced the pathologic grade of the radical prostatectomy. This result suggests that prostate cancer with a PSA level higher than 7.0ng/ml may have a more aggressive feature.

Analysis of Risk Factors for Ileus Following Radical Cystectomy: Is the Prolonged Use of a Nasogastric Tube Necessary? / 대한비뇨기과학회지

PURPOSE: We examined the risk factors for postoperative ileus, and we investigated whether the duration of postoperative nasogastric tube (NGT) use affects the rate of postoperative ileus in patients undergoing radical cystectomy with urinary diversion. MATERIALS AND METHODS: A total of 101 patients underwent radical cystectomy with urinary diversion from 1999 to 2003. We examined the demographic and perioperative variables of patients who developed postoperative ileus and those who did not. We divided the patients into two groups; a group of patients who had the NGT removed within 24 hours and a group of patients who had the NGT removed at first flatus. We compared the two groups for the incidence of ileus and for the clinical variables. RESULTS: Postoperative ileus was observed in 23 patients (23%). The demographic data for both groups were not different in terms of age and the American Society of Anesthesiology (ASA) score. Also, the operative time, estimated blood loss, the type of diversion and the postoperative complication rates were not significantly different for the two groups (p>0.05). However, the risk of postoperative ileus was significantly higher for those patients who took a polyethylene glycol bowel preparation than for those who took a sodium phosphate bowel preparation (40%:18%, p=0.02). No significant difference in the prevalence of ileus was found between the patients whose NGT were removed within 1 days and those patients whose NGT was removed beyond 2 days (25%:22%, p>0.05). CONCLUSIONS: The results of our study suggest that the use of sodium phosphate for bowel preparation may reduce postoperative ileus and that early NGT removal after cystectomy is not correlated with ileus.

The Value of Prostate Specific Antigen Density in the Diagnosis of Prostate Adenocarcinoma / 대한비뇨기과학회지

PURPOSE: Most studies have shown considerable overlap between benign prostatic hyperplasia(BPH) and cancer, using a prostate specific antigen(PSA) cut-off point of 4.0ng/ml. Because of lack of sensitivity and specificity, the value of PSA measurement in the diagnosis of prostate cancer has been questioned. The concept of PSA density(PSAD) was introduced to enhance the specificity of serum PSA. To determine the value of PSAD in the diagnosis of prostate cancer, we investigated whether PSAD-based clinical guidelines could help in the diagnosis of prostate cancer and assist in avoiding a significant number of biopsies. MATERIALS AND METHODS: Retrospective data were analysed from a selected population of 130 patients(mean age 66 years, range 42-86), 54 with histopathologically diagnosed prostate cancer and 76 with BPH. DRE(digital rectal examination) and TRUS(transrectal ultrasonography) were performed and PSA and PSAD were determined for each patient. RESULTS: The median PSA level was 7.0ng/ml(range 0.6-87ng/m1) in the patients with a benign diagnosis and 25.5ng/ml(range 2.2-736ng/m1) in those with malignancies. Also, the median PSAD was 0.18ng/m1/cm3(range 0.02-2.56ng/ml/cm3) in the benign group and 0.75ng/m1/cm3(range 0.06-22.3ng/m1/cm3) in the malignant group. Both PSA and PSAD discriminated BPH from cancer in a whole range of PSA level and were statistically significant. Of the 130 patients, 49(377 %) had a PSA level in the intermediate range(4.0-10.0ng/ml). In these patients, the median PSA was 6.5ng/ml(range 4.2-10ng/m1) In the benign group and 5.2ng/ml(range 4.1-9.8ng/ml) in the malignant group. Also, the median PSAD was 0.16ng/m1/cm3(range 0.07-0.39ng/m1/cm3) in the benign group and 0.17ng/m1/cm3 (range 0.08-0.27ng/m1/cm3) in the malignant group Both PSA and PSAD had no discriminating ability between BPH arid cancer in the Intermediate PSA range(4.0-10.0ng/ml). CONCLUSIONS: PSAD was of no additional value over serum PSA measurement in discriminating BPH from cancer for the population with intermediate PSA levels.

Analysis of the Urinary Stone Components Using Chemical Analysis Method / 대한비뇨기과학회지

We analyzed the composition of urinary stones using chemical analysis method. From 1985 to 1995, 495 urinary calculi were eligible for stone analysis. Forty six per cent of the stones were composed of single chemical component, and pure calcium oxalate stone was the most common type of the stones consisting 34.9% of all stones, followed by 23.8% of mixture of calcium oxalate and calcium phosphate, and 92.7% of the stones had calcium component. Calcium oxalate crystal was found in 82.6% of the stones, calcium phosphate in 50.5%, ammonium magnesium phosphate in 26.7%, uric acid in 11.3% and cystine in 0.4%. Nation-wide extension of this study using chemical analysis will be mandatory for a proper assessment of the stone composition of Koreans and for planning of the proper management strategies for urinary stones in Korea.

Characteristics and Treatment of Steinstrasse after ESWL / 대한비뇨기과학회지

To evaluate the predisposing factors and characteristics of the steinstrasse after ESWL and to suggest the proper management of it, we analyzed 1,144 urolithiasis patients who were managed by ESWL with the second generation lithotripter, Siemens Lithostar, at Seoul National University Hospital from March 1989 to October 1995. Steinstrasse developed in 72 patients with the incidence of 6.3% after ESWL. As the risk factor for developing steinstrasse after ESWL, stone size and volume significantly influenced the development of steinstrasse (p<0.01, by student t-test), and multiple stones induced steinstrasse more frequently than single stones (p<0.05, by chi-square test). Stones located at renal pelvis induced more steinstrasse after ESWL than calyceal stones or ureter stones t<0.05, by chi-square test). Clinically, 61.1% of the patients who developed steinstrasse didn't have any symptoms or upper tract changes. Nineteen steinstrasse (26.4%) were resolved spontaneously without any intervention, with the median duration of 12 days after detection of the steinstrasse. In 51 steinstrasse which was not resolved spontaneously or with severe symptoms, ESWL was performed resulting in successful resolution in 94.1% of the patients. These results suggest that expectancy could be the first line strategy of the management of steinstrasse, and repeated ESWL could be recommended for patients refractory to expectancy and patients with severe symptoms.

Ureteroscopic Manipulation for Ureteral Calculi: Comparison with ESWL / 대한비뇨기과학회지

Ureteroscopy has been used widely to remove ureteral calculi, especially distal ureter stones. Also extracorporeal shock wave lithotripsy (ESWL) has widened its applicability to ureter stones including distal ureter stones. In this study we tried to evaluate the exact role of ureteroscopic manipulation to get rid of ureter stones in the era of ESWL. Success rates and complications of 111 ureteroscopic stone removal procedures performed from December 1986 to May 1995 and those of another 369 patients managed with ESWL from May 1989 to May 1995 were analyzed. Success was defined as complete removal of the stones or residual stones less than 2 mm, immediate postoperatively in ureteroscopic manipulation and 2 weeks after ESWL. The success rate of the ureteroscopic manipulation was 38.9% (7/18), 46.2% (6/13) and 67.5% (54/80) in upper, middle and lower ureter stones, respectively. According to the size of the stone, success rate was 72.4% (21/29), 63.5% (40/63) and 14.3% (9/63) when it was less than 5 mm, 6 to 10 mm and larger than 10 mm. So the overall immediate postoperative success rate of ureteroscopic stone removal was 60.4%, and in another 8.9% of the patients the residual fragmented stones were expelled spontaneously in one month after the procedure. Complications were found in 9.9% of the procedures, including 5 mucosal avulsions and 2 ureteral strictures Success rate of the single session of ESWL was 64% without any differences regardless of the location of the stones in ureter, and it increased up to 88% when another 2 more sessions were tried. Success rate of the single session of ESWL according to the size of the stone was 91.7% (22/24), 67.9% (144/215) and 53.89S (70/130) in stones less than 5 mm, 6 to 10 mm and more than 10 mm, respectively. Complications were found in 3.4% of the patients, including 1.7% of steinstrasse and 1.4% of severe nausea and vomiting. From these observations we can conclude that it seems to be mandatory to renovate the indications of the ureteroscopic stone removal procedures in the era of ESWL.

In Situ Extracorporeal Shock Wave Lithotripsy for Ureteral Calculi: Investigation of the Factors Influencing on Stone Fragmentation and the Appropriate Session for Changing Treatment Modality / 대한비뇨기과학회지

To determine the factors influencing on stone fragmentation and the appropriate session for changing treatment modality of ureteral calculi refractory to in situ ESWL, we analyzed 369 patients with ureteral calculi primarily treated by second-generation lithotripter, Siemens Lithostar from March,1989 to December, 1993. The results obtained were as follows: 1.Three hundred and forty two(92.7%) of the total 369 patients were ultimately free of stones by repetitive performance of in situ ESWL ranging from the first session to the tenth session. 2. The cumulative stone-free rates of the first, second and third session were 64%, 81% and 88%, respectively, and the increment of cumulative stone-free rate thereafter with further repeated in situ ESWL was minimal(p0.05). 4. According to the size of stone, the cumulative stone-free rate at third session was 100%, 90%, 87%, 70%, 67%, 50% in stones less than 5 mm, 6-10 mm, 11-15 mm, 16-20 mm, 21-25 mm and above 25 mm, respectively(p<0.001). 5. According to the radio-opacity of stone, the cumulative stone-free rate at third session was 96% in stones with minimal opacity, 94% with moderate opacity and 70% in highly opaque stones(p<0.001). 6. According to the degree of ureteral obstruction due to stone, the cumulative stone-free rate at third session was l00% without ureteral obstruction, 80% with mild, 57% with moderate, 67% with severe ureteral obstruction, and it was 50% in patients with non-visualization of the kidney(p<0.05). From these observations, it could be concluded that the factors influencing on stone fragmentation were the size of calculi, radio-opacity and the degree of ureteral obstruction, whereas the location of the ureteral calculi did not influence on the cumulative success rate of repetitive in situ ESWL. Also, it is preferable to restrict the repetitive sessions of in situ ESWL within third session in patients with the ureteral calculi refractory to in situ ESWL, and early change of surgery would be retreatment modality either to ureteroscopic manipulation or to open commended if there are risk factors listed above.

The Value of Radionuclide Bone Scan in Renal Cell Carcinoma / 대한비뇨기과학회지

The need for routine radionuclide bone scan as part of the preoperative metastatic work-up in patients with renal cell carcinoma has been debated by several investigators more than 10 years. To investigate the value of radionuclide bone scan, radionuclide bone scans were performed preoperatively as part of staging procedures in 79 patients of 91 patients with renal cell carcinoma from 1989 to 1994. We analyzed the findings of bone scan according to the clinical and laboratory variables. When hot uptake was detected on the preoperative bone scan, it was interpreted positive if there was no history of trauma or absence of bone and joint disease such as degenerative Joint disease or arthritis. The bone scans were positive in 21 cases ( 26.6%) and negative in 58 cases (73.4%). The bone scans were neither correlated with the clinical variables such as incidentaloma, age of the patient, performance status, bone pain, the size of the tumor, T category of the tumor, thrombosis of renal vein or IVC, lymph node metastasis and extraskeletal metastasis nor with laboratory variables such as serum alkaline phosphatase, hemoglobin, serum calcium and ESR. We also analyzed positive scan according to the number of bony lesions. There was no correlation between the number of lesions on bone scan and clinica1 and laboratory variables. In conclusion, there was no clinical and laboratory parameters predicting positivity of bone scan. This suggests that all patients with renal cell carcinoma should be staged routinely with preoperative bone scan as the part of the initial clinical work up.