One-step percutaneous nephrolithotomy sheath versus standard two-step technique.

OBJECTIVES: Advances in technique and equipment have allowed urologists to perform percutaneous stone removal with increasing efficacy and decreasing complications. The procedure of choice for large renal calculi is percutaneous nephrolithotomy. At our institution, percutaneous access is achieved by a two-step process using either Amplatz dilators or placement of a high-pressure balloon catheter for tract dilation, followed by advancement of a sheath over the balloon. A novel device, the Pathway Access Sheath (PAS) has been developed that allows for balloon tract dilation and percutaneous access sheath placement in one simple step. METHODS: Our study population consisted of 21 patients, who were randomized to one of two arms. Of the 21 patients, 10 underwent standard two-step access using a high-pressure balloon catheter and 11 underwent percutaneous nephrolithotomy using the novel PAS. We compared the insertion time, blood loss, and cost between the two techniques. RESULTS: The average insertion time was shorter in the PAS group (3 minutes) compared with the high-pressure balloon catheter (5 minutes, 42 seconds); a difference that was statistically significant (P <0.01). The estimated blood loss and cost were similar between the two groups. The increased sheath flexibility of the PAS was noted to be an advantage in some patients. CONCLUSIONS: The results of our study have shown that a novel single-step renal access device is safe and efficacious and results in a shorter insertion time for percutaneous nephrolithotomy. Blood loss was less in the PAS group as well, although the difference was not statistically significant. Additional studies will establish whether this device will provide a new standard of obtaining renal access.

Prospective randomized study of various techniques of percutaneous nephrolithotomy.

OBJECTIVES: To compare the modifications of the technique of percutaneous nephrolithotomy (PCN), including "mini-PCN" and tubeless PCN, to establish which technique is associated with the least morbidity and complications. METHODS: We performed a prospective randomized trial to assess the efficacy and morbidity of each method of percutaneous renal access. Standard PCN involved tract dilation to 30F for passage of a 34F working sheath, and our "mini-PCN" involved tract dilation to 22F for passage of a 26F sheath. Tubeless PCN involved the use of a double-J stent for internal drainage without the use of a nephrostomy tube for external drainage at termination of the procedure. Thirty patients (10 patients in each group) were enrolled, and 27 patients completed the study. All three groups were compared with regard to postoperative pain using a validated pain questionnaire comprised of a visual analogue scale and a verbal rating scale. The operative time, estimated blood loss, stone burden, procedure success rate, stone-free rate, length of hospitalization, total procedural cost, and complications were also compared for each technique. RESULTS: The tubeless PCN population required less morphine use, had a decreased length of hospitalization, and had a smaller total procedural cost compared with the other two groups. One complication was noted in both the standard and mini-PCN groups, consisting of renal bleeding requiring a 2 and 3-U blood transfusion in the standard and mini-PCN groups, respectively. CONCLUSIONS: The tubeless technique is associated with the least amount of morbidity and the greatest cost efficiency compared with the other techniques. No overall advantage was found for the mini-PCN versus the standard technique, but the mini-PCN is at a slight disadvantage because of poorer visualization and optics and difficulty with use of the nephroscopic graspers.

Percutaneous management of stones in a patient with sacral agenesis.

We report a case of a patient with sacral agenesis and nephrolithiasis in whom percutaneous nephrostolithotomy was used to treat the stone disease. Sacral agenesis is an uncommon congenital anomaly involving the lower vertebral bodies and is associated with urinary tract dysfunction. Nephrolithiasis in a patient with sacral agenesis poses a problem in access for percutaneous nephrostolithotomy because of the associated presence of renal ectopia. We describe our technique and the special considerations necessary for successful access.

Management of ureteral obstruction secondary to pelvic malignancies.

PURPOSE: To assess the efficacy of urinary diversion (internal v external) in the management of ureteral obstruction secondary to pelvic malignancies and the patients' quality of life after diversion. PATIENTS AND METHODS: Thirty-seven patients presented with malignant ureteral obstruction secondary to primary neoplasms of the pelvis or metastatic disease of the pelvis and retroperitoneum and underwent urinary diversion. Patients were categorized into two groups according to the success (Group I) or failure (Group II) of internal stent drainage. Successful drainage was defined according to either radiologic study or the serum creatinine concentration in the case of a solitary kidney. "Useful life" was defined as satisfying four criteria: (1) little or no pain; (2) no complications; (3) ability to return home for at least 2 months; and (4) full mental capacity. RESULTS: Of the total patient population, 58% ultimately failed internal diversion. Nearly all (92%) of the cervical cancer patients required external drainage. Complications were seen in 10% of the stented patients and 13% of the patients with a percutaneous nephrostomy tube, but no procedure-related deaths occurred. Useful life was achieved by 84% of all patients. CONCLUSION: Antegrade drainage should be considered initially in patients who are likely to fail internal drainage (i.e., those with cervical cancer). The majority of these patients have a reasonably good quality of life, and intervention is most often warranted.

Assessment of relative tumor burden in patients with clinical T1c prostate cancer treated with either external beam or radical prostatectomy.

The choice between external beam radiation therapy (EBRT) or retropubic radical prostatectomy (RPX) as potentially curative treatment for localized carcinoma of the prostate gland (CaP) has not been delineated in randomized studies. Both treatments are more effective if tumor burden is low. We sought to compare these two treatments in patients who had clinical stage T1c (cT1c) lesions and who were thought to have limited tumor burdens pretreatment. Sixty cT1c patients referred to the Department of Radiation Oncology received 66 Gy in 33 sessions of EBRT to localized prostate ports and 59 cT1c patients had RPX. No neoadjuvant nor early adjuvant therapies were prescribed. Radiotherapy success was defined biochemically as a nonrising prostate-specific antigen (PSA) of +/- 1.5 ng/ml. RPX success required a postoperative PSA that was undetectable (PSA <0.2 ng/ml by the Hybritech or Abbott IMx technics). Analysis for nonrising posttreatment PSA levels was performed using Kaplan-Meier and Cox regression methods. Mantel-Haenszel methods were used to determine odds ratios for treatment groups adjusting for potential confounders. We ultimately assessed the relative tumor burden by histologic examination of the RPX specimens. The two treatment groups, although not randomized, were statistically similar in biopsy Gleason Scores, transrectal ultrasonography calculated gland volumes, number of positive biopsy cores, and estimated amount of cancer identified on initial biopsies. Pathologic stage T3 was identified in 25% of RPX patients. Fifty to 60% of RPX specimens histologically had substantial tumor burden and by inference also the EBRT patients. At a median follow-up (F/U) of 36 months, 76% of RPX patients maintained an undetectable PSA, whereas 62% of EBRT patients had a PSA < 1.5 ng/ml at a median F/U of 29 months. The pretreatment PSA values significantly affected EBRT patients' risk of a rising posttreatment PSA level. Twenty-four months after treatment, RPX patients were 3.7 times more likely to maintain a nonrising PSA level (RPX patients posttreatment PSA < 0.2 ng/ml), than EBRT patients (posttreatment PSA < or = 1.5 ng/ml) (p = 0.006). Sixty-six gray in 33 sessions to localized EBRT ports is not sufficiently aggressive therapy for one third or more of patients with cT1c CaP. RPX alone is insufficient therapy for one fourth of cT1c patients. Analysis of the RPX specimens showed that many cT1c tumors have a significant tumor burden. Selection methodologies to separate out patients who require more than conventional dose or type of radiotherapy or more than RPX as monotherapy are needed. Pretreatment PSA and number of positive biopsies may assist this selection process.

Urinary IL-6 is elevated in patients with urolithiasis.

PURPOSE: To evaluate the possible role of cytokines interleukin (IL)-1beta, IL-1alpha and IL-6 in patients with urolithiasis. MATERIALS AND METHODS: Fifty-six patients currently with stone disease, 63 patients with bacterial cystitis, and 66 normal individuals were evaluated for urinary IL-1alpha, IL-1beta and IL-6. Clean catch urine samples were obtained and evaluated for cytokine levels using enzyme immunoassays for the respective cytokines. Statistical analysis of the results was carried out using the Kruskal-Wallis test followed by Newman-Keuls test and the chi-squared test. RESULTS: The patients with stone disease had significant elevations in IL-6 (p value< 10(-7)) relative to normal subjects. The levels of IL-6 in stone patients were lower than those of patients with bacterial cystitis. Neither IL-1beta nor IL-1alpha was elevated in stone patients relative to normals. By contrast, bacterial cystitis patients showed significant elevations in all three cytokines relative to normal subjects. Chi-squared analysis confirmed that stone patients had elevated IL-6 without elevation in either IL-1alpha or IL-1beta relative to normal subjects. CONCLUSIONS: Stone patients show significant elevations in IL-6 without marked increases in either IL-1beta or alpha relative to normal subjects. This elevation in IL-6 is not from infection as is seen in bacterial cystitis subjects. The elevation in IL-6 may be useful in the understanding of the pathogenesis of urolithiasis or as a potential marker for stone disease and we are currently investigating these possibilities.

Laparoscopic management of indeterminate renal cysts.

OBJECTIVES: We present our follow-up of patients with indeterminate renal cysts who were initially evaluated laparoscopically. We specifically address those patients discovered to have cystic renal cell carcinoma by laparoscopy and the incidence of tract seeding, local recurrence, and distant metastases. METHODS: Between July 1993 and September 1997, 35 patients with indeterminate renal cysts were evaluated laparoscopically. Under laparoscopic visualization, the cyst was located and aspirated, the fluid was sent for cytology, and the floor of the cyst was biopsied. The tissue was then evaluated immediately by one of our genitourinary pathologists, and an intraoperative decision was made. Four patients were found to have cystic renal cell carcinoma and underwent partial or radical nephrectomy in the same setting. An additional patient had a delayed partial nephrectomy 10 days after laparoscopy as a result of change in the final pathology reading. The patients with malignancy were followed with chest x-ray, liver function tests, abdominal computed tomography (CT) scans, and physical examination every 3 months for the first year and then every 6 months thereafter. The average follow-up was 20.2 months (range 8 to 30). RESULTS: Of the 35 patients evaluated in this manner, 5 (14%) were found to have cystic renal cell carcinoma. There has been no evidence of local recurrence or metastatic disease to date. Physical examinations, chest x-rays, liver function tests, and abdominal CT scans all remain negative. CONCLUSIONS: Initial laparoscopic evaluation of complex cysts can save the patient from undergoing needless open surgery. Laparoscopic biopsy of cystic renal cell carcinoma followed by open surgery does not seem to increase the incidence of peritoneal seeding, tract recurrence, or distant metastases. Although the preliminary results are very encouraging, long-term follow-up is clearly necessary.

Evaluation of urinary IL-1alpha and IL-1beta in gravid females and patients with bacterial cystitis and microscopic hematuria.

OBJECTIVES: to determine IL-1alpha and IL-1beta levels in patients with bacterial cystitis, microscopic hematuria, and gravid females relative to a control group of normal subjects. METHODS: enzyme immunoassays were used to measure concomitantly urinary IL-1alpha and IL-1beta in clean catch urine samples from normal subjects (n = 31) and study patients (n = 46). All normal subjects and patients underwent urinalysis, urine culture, and urine creatinine level determination. Since the IL-1alpha assay was developed for serum, the utility of the assay for urine specimens was unknown. The key parameters of urine collection, processing and sample storage for IL-1alpha were evaluated in detail. RESULTS: mean values +/- SEM (pg/mg) for IL-1alpha/ Cr and IL-1beta/Cr were control group (0.25 +/- 0.10 and 0.17 +/- 0.06), bacterial cystitis (9.97 +/- 1.15 and 42.45 +/- 1.86), and microscopic hematuria (2.81 +/- 0.65 and 2.82 +/- 0.70). Differences in cytokine levels between the control group and patients with either bacterial cystitis or microscopic hematuria were statistically significant for both IL-1alpha/Cr (P < 0.026; P < 0.007, respectively) and IL-1beta /Cr (P < 0.0004; P < 0.014, respectively). IL-1beta/Cr correlates better with pyuria than IL-1alpha/ Cr (P = 0.02 vs P = 0.44). In gravid females, only IL-1alpha was significantly elevated relative to non-pregnant females (IL-1beta elevation approached statistical significance). Gravid females with positive urine cultures could not be distinguished from those with negative cultures based on either interleukin (P > 0.05). CONCLUSIONS: Significant elevations of IL-1alpha and IL-1beta occur in patients with bacterial cystitis and microscopic hematuria. Correlation between pyuria and cytokine elevation was stronger for IL-1beta than for IL-1alpha. Changes in IL-1alpha may reflect changes in the bladder epithelium rather than in the inflammatory leukocytes. The ability of IL-1alpha and IL-1beta to serve as markers for bacterial cystitis in gravid females is diminished due to high basal levels during pregnancy.

Cost effectiveness of electrohydraulic lithotripsy v Candela pulsed-dye laser in management of the distal ureteral stone.

To compare the efficacy, safety, and cost of the Candela laser lithotripter with those of the electrohydraulic (EHL) lithotripter in the management of distal ureteral stones, 24 patients with obstructing stones were randomized to laser lithotripsy or EHL. Ureteroscopy was performed with a 6.9F ACMI Miniscope under general anesthesia. Twelve patients were treated with laser lithotripsy using the Candela Air-Cooled MDL 2000 LaserTripter System with a 200-micron pulsed-dye laser fiber. Twelve patients were treated with the Herzog Electrohydraulic LithoTripter using the 1.9F fiber. The following issues were studied: stone-free rates, complications (intraoperative, postoperative, and late), and costs of the procedure. No difference was found in the stone-free or complication rates. One patient was found to have hydronephrosis at 6 months secondary to an unrelated proximal ureteral stone. There was no difference in the efficacy of laser lithotripsy and EHL in the management of distal ureteral stones, but EHL was found to be significantly more cost effective: the cost for EHL was +336 per case, whereas, the cost for lasertripsy was +4220 per case, a greater than 10-fold difference.

Holmium:YAG lithotripsy yields smaller fragments than lithoclast, pulsed dye laser or electrohydraulic lithotripsy.

PURPOSE: The mechanism of lithotripsy differs among electrohydraulic lithotripsy, mechanical lithotripsy, pulsed dye lasers and holmium:YAG lithotripsy. It is postulated that fragment size from each of these lithotrites might also differ. This study tests the hypothesis that holmium:YAG lithotripsy yields the smallest fragments among these lithotrites. MATERIALS AND METHODS: We tested 3F electrohydraulic lithotripsy, 2 mm. mechanical lithotripsy, 320 microns pulsed dye lasers and 365 microns. holmium:YAG fiber on stones composed of calcium hydrogen phosphate dihydrate, calcium oxalate monohydrate, cystine, magnesium ammonium phosphate and uric acid. Fragments were dessicated and sorted by size. Fragment size distribution was compared among lithotrites for each composition. RESULTS: Holmium:YAG fragments were significantly smaller on average than fragments from the other lithotrites for all compositions. There were no holmium:YAG fragments greater than 4 mm., whereas there were for the other lithotrites. Holmium:YAG had significantly greater weight of fragments less than 1 mm. compared to the other lithotrites. CONCLUSIONS: Holmium:YAG yields smaller fragments compared to electrohydraulic lithotripsy, mechanical lithotripsy or pulsed dye lasers. These findings imply that fragments from holmium:YAG lithotripsy are more likely to pass without problem compared to the other lithotrites. Furthermore, the significant difference in fragment size adds evidence that holmium:YAG lithotripsy involves vaporization.

Conservative management of colon injury following percutaneous renal surgery.

OBJECTIVES: Colon injury during percutaneous renal surgery is rare and can result in significant morbidity. Our objective was threefold: (1) to identify risk factors for colon injuries; (2) to optimize prevention of such injuries; and (3) to devise a treatment strategy for optimal management of such colon injuries. METHODS: Between July 1990 and July 1995, all percutaneous renal procedures performed at three kidney stone centers were reviewed (Kaiser Permanente Medical Center, Los Angeles; Hospital of the Good Samaritan, Los Angeles; and University of California at San Francisco). In addition, a review of the pertinent literature was performed. RESULTS: Five patients who suffered colon injuries during percutaneous renal surgery were identified. All had undergone percutaneous nephrolithotomy, and all injuries were extraperitoneal. Mean age was 31 years (range 17 to 52). Three patients were considered lean, and the other two were of average body habitus. Four of 5 patients were male. Three injuries occurred on the left side and two on the right. Recognition of colon injury occurred postoperatively in 4 patients and intraoperatively in 1 patient. Presenting signs and symptoms included fever, fecaluria, abdominal pain, and leukocytosis. CONCLUSIONS: High risk patients for colon injuries are young, lean males with minimal retroperitoneal fat, in whom a retrorenal colon is more likely. High risk patients should be accessed with a more superior and medial puncture. Retroperitoneal colon injuries can be successfully managed conservatively with early recognition and appropriate drainage of the urinary and intestinal tracts. A treatment algorithm is presented.

Tubeless percutaneous renal surgery.

PURPOSE: We challenge the requirement for routine placement of a nephrostomy tube following percutaneous renal surgery. MATERIALS AND METHODS: A total of 50 patients underwent tubeless percutaneous renal procedures consisting of nephrolithotripsy, endopyelotomy, and stone extraction plus endopyelotomy performed during the same setting. In the initial 30 patients a Double-J* stent and a Councill nephrostomy tube were placed at the end of the procedure. The Councill catheter was removed 2 to 3 hours postoperatively. The subsequent 20 patients received only a Double-J stent with no Councill catheter. This study group was compared to a control group of 50 age, sex and procedure matched patients who had previously undergone standard percutaneous renal procedures with routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, interval to return to normal activities and cost of treatment were compared between the 2 groups. RESULTS: All 50 tubeless percutaneous procedures were performed successfully without significant complications. In the initial 15 patients postoperative renal ultrasound demonstrated no urinoma. Hospitalization was 0.6 days for the study group and 4.6 days for the controls (p = 0.0001). Average parenteral or intramuscular analgesia requirements were 11.58 and 36.06 mg. morphine sulfate, respectively (p = 0.0001), with patients requiring oral analgesia for 5.9 and 11.7 days, respectively (p = 0.0001). Patients in the study group returned to normal activities within 17.85 days versus 26.6 days for the controls (p = 0.0004). The costs of the procedures were $1,638 and $3,750 (129% greater), respectively, for a cost saving of $2,112 per case. CONCLUSIONS: Tubeless percutaneous renal surgery is a safe procedure and offers numerous advantages over routine placement of a nephrostomy tube. The hospitalization, analgesia requirements, return to normal activities as well as cost are significantly less with this new technique.

"Tubeless" percutaneous surgery: a new advance in the technique of percutaneous renal surgery.

We describe our modification of the technique of traditional percutaneous renal surgery called "tubeless" percutaneous renal surgery. Fifty patients have now undergone percutaneous renal procedures without the use of a postoperative nephrostomy tube consisting of percutaneous nephrolithotripsy, percutaneous endopyelotomy, and both percutaneous stone extraction and endopyelotomy in the same setting. Our current modification of standard percutaneous surgical technique includes the placement of an internal ureteral catheter with primary closure of the access site using hemostatic skin sutures. The study group was compared to a control group of 50 patients who were age, sex and procedure matched who had undergone standard percutaneous renal procedures previously with routine placement of postoperative nephrostomy tubes. The incidence of complications, analgesia requirements, length of hospitalization, time of return to normal activities, and cost of treatment were compared between the two groups. All tubeless percutaneous procedures were successfully performed without significant complications. The initial 15 patients had postoperative renal ultrasounds demonstrating no urinoma. Hospital stay, analgesia requirements, and the patient's ability to return to normal activities were statistically significantly decreased in the patient group studied. The cost of a "tubeless" procedure was $1,638 compared with $3,750 (129% greater) for traditional percutaneous surgery (cost saving of $2,112/case). Tubeless percutaneous renal surgery is a safe procedure and offers advantages over the routine placement of a nephrostomy tube. The hospitalization period, analgesia requirements, return to normal activities, and cost are significantly less with this new technique.

Influence of technique of percutaneous tract creation on incidence of renal hemorrhage.

PURPOSE: Renal hemorrhage is one of the most common and worrisome complications of percutaneous renal surgery. We studied the incidence of renal hemorrhage and transfusion rates in patients undergoing balloon or Amplatz fascial dilation of the nephrostomy tract. MATERIALS AND METHODS: Medical records of 143 patients who underwent 150 percutaneous renal procedures, including percutaneous nephrolithotomy, antegrade endopyelotomy and percutaneous treatment of stones in caliceal diverticula, were reviewed. The nephrostomy tract was dilated with balloon (50 patients) or Amplatz sequential (100) dilators. Perioperative decreases in hemoglobin level and blood transfusion rates were compared between the 2 groups. RESULTS: Of the 100 patients undergoing percutaneous renal Amplatz dilation 25 (25%) required a blood transfusion, compared to only 5 of 50 (10%) undergoing balloon dilation. The difference in the transfusion rates between the 2 groups was statistically significant (p = 0.048). CONCLUSIONS: Improvements in the technique of percutaneous renal surgery have decreased the morbidity associated with these procedures. In our study use of balloon tract dilators led to less renal hemorrhage and lower transfusion rates compared to Amplatz dilation. Additionally, balloon dilation appears to be more rapid and avoids renal movement away from the surgeon, which occasionally occurs during Amplatz dilation.

Massive hemorrhage from renal vein injury during percutaneous renal surgery: endourological management.

PURPOSE: Although minor venous injuries respond to simple maneuvers, major venous injuries pose a significant therapeutic problem and may be under diagnosed. We present our experience with major injury to the renal vein during percutaneous renal surgery. MATERIALS AND METHODS: Four patients had massive hemorrhage during percutaneous renal surgery associated with major injury to the renal vein, and 3 also had renal insufficiency. All 4 patients and 1 additional patient with renal insufficiency and massive hemorrhage from an arteriovenous fistula following percutaneous renal surgery were treated nonoperatively with a selectively positioned and inflated Council balloon catheter. RESULTS: Hemorrhage was controlled and renal function was unaffected in all 5 patients. CONCLUSIONS: Renal vein injuries can be associated with massive hemorrhage. Patients with major vascular injuries from percutaneous renal surgery and concomitant renal insufficiency can be treated without open exploration or angiographic embolization using a Council balloon catheter.

Ureteral stents: impact of diameter and composition on patient symptoms.

We prospectively analyzed three types of ureteral stents to determine the effects of diameter and composition on a patient's symptoms. Twenty stents were placed consecutively in each of the three study groups for the treatment of ureteral obstruction, prior to SWL, or following ureteroscopy: Group I = 6F Percuflex stent, Group II = 6F HydroPlus stent, and Group III = 4.8F HydroPlus stent. All stents were removed in clinic 7 to 10 days after placement. At this time, a confidential questionnaire was completed by the patient addressing the symptoms associated with the indwelling catheter. The 6F hydrogel-coated stents were somewhat easier to insert, especially in high-grade obstructions. Occasional difficulty in seeing the 4.8F stent during fluoroscopy was noted. No statistically significant difference in any of the irritative voiding symptoms-dysuria (P = 0.7998), urgency (P = 0.0928), frequency (P = 0.2646), nocturia (P = 0.2855), hematuria (P = 0.9417), pain (P = 0.4524), or incontinence (P = 0.4524)-was demonstrated. Differences in stent diameter and composition do not appear to affect symptoms. We prefer the hydrogel-coated 6F stent, as it offers advantages in ease of placement and radiographic visibility without increased symptoms.