Increased prevalence and analysis of risk factors for indinavir nephrolithiasis.

PURPOSE: Indinavir is a protease inhibitor used for treating HIV-1. The drug is lithogenic and was thought to cause a 3% incidence of kidney stones. We evaluated a cohort of patients positive for HIV on indinavir to determine the incidence of indinavir nephrolithiasis and identify risk factors for indinavir stone formation. MATERIALS AND METHODS: Our cohort study of the prevalence of indinavir nephrolithiasis included 155 patients with HIV for 5,732 patient-weeks. The same cohort was then used for a retrospective chart review to assess patient age, weight, duration of drug use, time to stone formation, CD4 count, creatinine, alanine transaminase, and urinary pH and specific gravity as risk factors for stone formation. RESULTS: We estimated the cumulative incidence of indinavir stone formation by the Kaplan-Meier product limit estimator method. At 78 weeks 43.2% of patients had stones (95% confidence interval [CI] 0.292 to 0.543). Increasing age was the only variable that was a statistically significant predictor of indinavair urolithiasis (relative risk 0.955, 95% CI 0.918 to 0.993, p = 0.0159). The mean duration plus or minus standard deviation of indinavir use was statistically the same in each group (42.5 +/- 27. 2 and 40.3 +/- 27.1 weeks in those without and with stones, respectively) despite the observed mean time to stone formation of 23.0 +/- 19.8 weeks. CONCLUSIONS: The clinical prevalence of indinavir nephrolithiasis is much greater than initially reported. Nephrolithiasis during indinavir use does not appear to induce patients to withdraw from the drug.

Iatrogenic ureteric injuries: approaches to etiology and management.

Injury to the ureter is a risk of any pelvic or abdominal surgery, including laparoscopy and ureteroscopy. The morbidity associated with such injury may be serious, resulting in increased hospital stay, compromise of the original surgical outcome, secondary invasive interventions, reoperation, potential loss of renal function and deterioration of the patient's quality of life. Management of ureteric injuries, in conjunction with frank and open dialogue with the patient, can lead to an optimal outcome. For ureteral ligation, removal of the suture and assessment of ureteral viability are recommended, with surgical correction if necessary. For partial transection primary closure is suggested over stent placement. For uncomplicated upper- and middle-third ureteral injury ureteroureterostomy is the procedure of choice. For injuries above the pelvic brim several procedures are available: ureteroureterostomy, ureteroileal interposition and nephrectomy. For injuries below the pelvic brim ureteroneocystostomy is recommended with a psoas hitch or Boari bladder flap. To decrease the incidence of iatrogenic ureteral injury, a sound knowledge of abdominal and pelvic anatomy is the best prevention. If the proposed operation is likely to be close to the ureter, the ureter should be identified at the pelvic brim. If the dissection is likely to be difficult, preoperative intravenous pyelography and placement of a ureteral catheter may help in identifying and protecting the ureter.

A vesicouterine fistula caused by catheterization during delivery.

We report a case of a vesicouterine fistula occurring after catheterization during delivery in a women who had two previous Caesarian sections. Fistulae between the bladder and uterus are rare; they have been reported after prolonged and neglected labor 1 and after caesarian section. 2 This case followed catheter penetration of the bladder and thinned cervix during delivery.

Renal cell carcinoma: incidental detection.

The mode of presentation of renal cell carcinoma is changing; in 40% of cases the condition is now found incidentally during the investigation of complaints other than those usually associated with this tumour. Chemotherapy and radiotherapy have not improved the survival of patients with renal cell carcinomas, but, with the introduction of ultrasonography, renal cell carcinomas, including those found incidentally, are being diagnosed earlier than they were a decade ago, resulting in improved survival rates.

Intra-arterial cisplatin for bladder cancer.

Cisplatin (25 to 120 mg. per m.2) was injected into the internal iliac arteries of 33 patients with locally advanced bladder cancer. Of the patients 9 were inevaluable for response to the cisplatin, since they began radiotherapy to the bladder before course 2 of cisplatin as part of a preplanned therapeutic approach. One patient received the treatment as postoperative adjuvant therapy, 1 did not return for followup and 1 with metastatic disease did not undergo repeat cystoscopy. Of 21 evaluable patients 3 (14 per cent) achieved complete remission, 12 (57 per cent) achieved partial remission, 2 (14 per cent) were stable and 4 (19 per cent) failed. The response rate was higher in patients receiving 100 to 120 mg. per m.2 per course than in patients receiving lower doses (all except 1 of whom received 60 or less mg. per m.2 per course) (86 versus 64 per cent) and it was higher in patients without prior radiotherapy or chemotherapy. The response rate in patients with previously untreated invasive transitional cell carcinoma was 88 per cent. Of the 33 patients 21 were alive at last followup, with a median duration of followup of 32 weeks. Toxicity was dose-related and local neurotoxicity was excessive at cisplatin doses of 100 to 120 mg. per m.2. Diabetic patients were particularly prone to have neurotoxicity. Other toxicity generally was not severe and consisted of ototoxicity, nephrotoxicity, myelosuppression, nausea, vomiting and diarrhea. Even elderly patients and patients with cardiac disease tolerated the treatment well. We plan to proceed with further intra-arterial cisplatin studies in which all patients except those more than 80 years old will be treated with an intra-arterial cisplatin dose of 90 mg. per m.2 per course combined with radiotherapy with or without cystectomy.

The role of gonadal venography in the management of the adult with non-palpable undescended testis.

Selective gonadal venography was performed on 9 adult patients with 11 nonpalpable undescended testes. The gonad was accurately localised pre-operatively on 7 occasions. Testicular agenesis was predicted in 2 instances and strongly suggested in 2 others. Four failures were recorded, 2 on the right and 2 on the left. Accurate pre-operative localisation shortened operative time and reduced the extent of the surgical exploration. The demonstration of agenesis of the testis may obviate the need for surgery.

Inaccuracies in angiographic staging of renal cell carcinoma.

In 54 patients with renal cell carcinoma, the angiographic T category of the International Union Against Cancer (UICC) clasification correlated with the histopathologic (P) staging in only 44.4 per cent. Staging of the primary lesion in renal cell carcinoma must be based on the P category and not the angiographic appearances.