Endoscopic Management of Urolithiasis in the Horseshoe Kidney.

OBJECTIVE: To assess the endourologic outcomes of patients diagnosed with a horseshoe kidney (HK) and symptomatic urolithiasis. METHODS: A retrospective review was performed of patients diagnosed with an HK who underwent endoscopic management from 2002 to present. RESULTS: We identified 45 patients with 64 stone-bearing moieties who underwent 56 procedures, of which 31 (69%) were male. Mean age was 49.4 years (23-78) and mean stone size was 1.6 cm (0.2-5.7). Of the 64 moieties, 37 (58%) underwent percutaneous nephrolithotomy (PCNL), 25 (39%) underwent ureteroscopy (URS), and 2 (3%) underwent extracorporal shockwave lithotripsy (SWL). More than one access was utilized in 2 (5.7%) moieties undergoing PCNL. Additional procedures were required in 10 (28.5%) PCNL patients, of which 7 were URS, 2 were secondary PCNL, and 1 sandwich therapy with SWL and PCNL. Stone-free rate by moiety was 81.1% for PCNL, 84% for URS, and 50% for SWL. Postoperative complications occurred in 3 patients in the PCNL group, including readmission for pain and complicated urinary tract infection. With a mean follow-up of 20.5 months (range 0-118 months), stone recurrence was noted in 7 (16%) patients with a total of 11 events. Calcium oxalate was the most common stone type and 20/24 (83%) of patients with metabolic evaluations were found to have at least one abnormality. CONCLUSION: After careful consideration of the anatomy, individuals with HK and symptomatic urolithiasis can be managed safely by a variety of endoscopic approaches with excellent outcomes; however, secondary procedures and recurrence are common.

Simultaneous vs staged treatment of urolithiasis in patients undergoing radical prostatectomy.

AIM: To assess the outcomes of men treated for urolithiasis at the time of radical prostatectomy. METHODS: From 1991 to 2010, 22 patients were retrospectively identified who were treated simultaneously (n = 10) at radical prostatectomy, or (n = 12) within 120 d prior to prostatectomy, for urolithiasis. Clinical characteristics were reviewed including: type of prostatectomy and stone surgery, location and amount of stone burden, perioperative change in hemoglobin and creatinine, stent frequency, total hospital d, stone-free rates, additional stone procedures and complications. Long-term functional outcomes including stress urinary incontinence and bladder neck contracture were reported. Differences between cohorts (simultaneous vs staged treatment) were assessed. RESULTS: Among men undergoing radical prostatectomy, primary stone procedures included 12 ureteroscopy, 6 shock wave lithotripsy, 2 open nephrolithotomy and 2 percutaneous nephrolithotomy. In staged shock wave lithotripsy there were 4 complications and 3 additional procedures vs 1 (P = 0.5) and 0 (P = 0.2) in the simultaneous cohort. Meanwhile in staged ureteroscopy there were 5 complications and 1 additional procedure vs 1 (P = 0.2) and 1 (P = 0.9) in the simultaneous cohort. Additional procedures for residual stones was greater among patients with asymptomatic upper tract calculi 3 (60%) relative to patients with symptomatic stones 2 (13%; P = 0.02). Likewise, patients with proximal or multiple calculi had a greater total hospital days 5.5 vs 4.1 (P = 0.04), additional procedures 6 vs 0 (P = 0.04) and lower stone-free rates 39% vs 89% (P = 0.02) relative to men with distal stones. Finally, there was no difference in the incidence of bladder neck contracture (P = 0.4) or stress urinary incontinence (P = 0.7) between cohorts. CONCLUSION: Ureteroscopic treatment of symptomatic distal urolithiasis at radical prostatectomy appears to be safe and efficacious with a low rate of adverse postoperative outcomes.

The change in upper tract urolithiasis composition, surgical treatments and outcomes of para and quadriplegic patients over time.

Stone disease in patients with spinal cord injury is a source of morbidity and mortality. Previous studies have indicated a decrease in infection-based urolithiasis in recent decades. We aimed to identify changes in stone composition and surgical outcomes in patients with para and quadriplegia over time. A retrospective review of para and quadriplegic patients from 1986 to 2011 who underwent surgical intervention for urolithiasis was performed, identifying 95 patients. The Mantel-Haenszel Chi square test was used to compare change in stone composition over time. The mean patient age was 44.0 years (range 18-88) and treatment included percutaneous nephrolithotomy (PCNL) 40 (42.1 %), ureteroscopy 28 (29.5 %), shock wave lithotripsy (SWL) 26 (27.4 %), and nephrectomy 1 (1 %). Overall stone-free status was found in 47.4 % with 19.0 % requiring a repeat procedure. The median hospital stay for patients undergoing SWL was 2.5 days, ureteroscopy 5 days, and PCNL 6 days. Infection-based stone composition was identified in 23 patients (36.5 %). We evaluated the linear change in percent of each stone component over time and identified increasing components of calcium oxalate dihydrate (p = 0.002) and calcium carbonate (p = 0.009). However, over a period of 25 years, the incidence of infection-based stone did not change (p = 0.57). Para and quadriplegic patients with urolithiasis can be difficult to treat surgically with prolonged hospitalizations, low stone-free status, and often require additional procedures. Despite improvements in antibiotic agents and management of neurogenic bladders, infection-based calculi continue to be a significant source of morbidity to this patient population.

Percutaneous ablation of renal masses measuring 3.0 cm and smaller: comparative local control and complications after radiofrequency ablation and cryoablation.

OBJECTIVE: The purpose of this article is to compare the efficacy and complication rates of percutaneous radiofrequency ablation (RFA) and cryoablation in the treatment of renal masses measuring 3.0 cm and smaller. MATERIALS AND METHODS: A retrospective review was performed of 385 patients with 445 tumors measuring 3.0 cm or smaller treated with thermal ablation from 2000 through 2010. Two hundred fifty-six tumors in 222 patients were treated with RFA (mean [± SD] tumor size, 1.9 ± 0.5 cm), and 189 tumors in 163 patients were treated with cryoablation (mean tumor size, 2.3 ± 0.5 cm). Major complications and efficacy as measured by technical success and local tumor recurrence rates were recorded. RESULTS: There were five (1.1%) technical failures, including one (0.4%) among tumors treated with RFA and four (2.1%) among tumors treated with cryoablation (p = 0.17). Of the 218 tumors treated with RFA and with follow-up beyond 3 months, seven (3.2%) developed local tumor recurrence, at a mean of 2.8 years after treatment (range, 1.2-4.1 years). Of the 145 tumors treated with cryoablation and with follow-up beyond 3 months, four (2.8%) developed local tumor recurrence at a mean of 0.9 years after treatment (range, 0.3-1.6 years). For biopsy-proven renal cell carcinoma, estimated local recurrence-free survival rates at 1, 3, and 5 years after RFA were 100%, 98.1%, and 98.1%, respectively, compared with 97.3%, 90.6%, and 90.6%, respectively, after cryoablation (p = 0.09). Major complications occurred after 4.3% (10/232) of RFAs and 4.5% (8/176) of cryoablation procedures (p = 0.91). CONCLUSION: RFA and cryoablation are both effective in the treatment of renal masses measuring 3 cm or smaller. Major complications with either procedure are infrequent.

Urolithiasis after ileal conduit urinary diversion: a comparison of minimally invasive therapies.

PURPOSE: We report our experience with ureteroscopy, percutaneous nephrolithotomy and shock wave lithotripsy for symptomatic stone disease in patients with ileal conduit urinary diversion. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients treated with cystectomy and ileal conduit urinary diversion from 1982 to June 2010 in whom urolithiasis subsequently developed. RESULTS: We identified 77 patients with urolithiasis requiring surgical intervention after ileal conduit urinary diversion. Average age at treatment was 62.5 years (range 30 to 82). Mean followup was 7.1 years (range 0.1 to 24.3). The primary therapy mode was percutaneous nephrolithotomy in 48 patients (62.3%), extracorporeal shock wave lithotripsy in 20 (26.0%) and ureteroscopy in 9 (11.6%). Average stone size was greater in the nephrolithotomy group than in the ureteroscopy and lithotripsy groups (2.1 vs 0.9 and 1.0 cm, respectively, p <0.0001). Total complication rates were similar, including 29% for nephrolithotomy, 30% for lithotripsy and 33% for ureteroscopy (p = 0.9). The incidence of stone-free status was greater in the nephrolithotomy cohort than in the ureteroscopy and shock wave lithotripsy cohorts (83.3% vs 33.3% and 30%, respectively, p <0.0001). The re-treatment rate did not significantly differ among the groups with 66.7% of the ureteroscopy group requiring subsequent procedures compared to 29.2% of the nephrolithotomy and 45% of the lithotripsy groups (p = 0.08). The change in the mean preoperative and current calculated glomerular filtration rate did not significantly differ among the 3 treatment groups. CONCLUSIONS: Treatment for urolithiasis in patients with urinary diversion is associated with high re-treatment and complication rates. Percutaneous nephrolithotomy achieves a better stone-free outcome than ureteroscopy or shock wave lithotripsy. However, there is no difference in ancillary procedures or complication rates among the 3 treatment modalities.

Complications following 573 percutaneous renal radiofrequency and cryoablation procedures.

PURPOSE: To review complications related to percutaneous renal tumor ablation. MATERIALS AND METHODS: Prospectively collected data related to renal radiofrequency (RF) ablation and cryoablation procedures performed from May 2000 through November 2010 were reviewed. This included 573 renal ablation procedures performed in 533 patients to treat 633 tumors. A total of 254 RF ablation and 311 cryoablation procedures were performed; eight patients underwent simultaneous RF ablation and cryoablation. The mean age of patients at the time of the procedure was 70 years (range, 24-93 y), and 382 of 573 procedures (67%) were performed in male patients. Complications were recorded according to the Clavien-Dindo classification scheme. Duration of hospitalization was also documented. RESULTS: Of the 573 procedures, 63 produced complications (11.0% overall complication rate). There were 66 reported complications, of which 38 (6.6% of total procedures) were Clavien-Dindo grade II-IV major complications; there were no deaths. Major complication rates did not differ statistically (P = .15) between cryoablation (7.7%; 24 of 311) and RF ablation (4.7%; 12 of 254). Of the complications related to cryoablation, bleeding and hematuria were most common. Bleeding during cryoablation was associated with advanced age, increased tumor size, increased number of cryoprobes, and central position (P < .05). Of those treated with RF ablation, nerve and urothelial injury were most common. Mean hospitalization duration was 1 day for RF ablation and cryoablation. CONCLUSIONS: Complications related to percutaneous renal ablation are infrequent. Recognition of potential complications and associated risk factors can allow optimization of periprocedural care.

Nephrolithiasis in medullary sponge kidney: evaluation of clinical and metabolic features.

OBJECTIVE: Medullary sponge kidney (MSK) is a disorder characterized by tubular dilation of renal collecting ducts and cystic dilation of medullary pyramids that has been associated with stone disease. The significance of nephrolithiasis and the mechanisms by which it occurs are incompletely understood. We describe clinical and metabolic features of nephrolithiasis in a cohort of patients with MSK. METHODS: Records were reviewed of 56 patients, all with radiographic diagnosis of medullary sponge kidney and data collected pertaining to presentation, stone events and recurrences, stone composition, and metabolic profile to perform a descriptive study with median 3.7 years follow-up. RESULTS: Nephrolithiasis was confirmed radiographically in 39/56 patients (69.6%). No patient without evidence of nephrolithiasis developed a stone event, whereas 13/39 (33%) of those with nephrolithiasis developed a recurrent stone event. Stones were composed of calcium oxalate monohydrate, calcium oxalate dihydrate, calcium phosphate apatite, and uric acid. Metabolic profile was obtained for 26 of 39 (67%) stone-forming patients demonstrating abnormalities in 22/26 (84.6%). These included hypercalciuria, 58% (15/26); low urine volume, 35% (9/26); hyperuricosuria, 27% (7/26); hypocitraturia, 19% (5/26); elevated urine sodium, 15% (4/26); and hyperoxaluria, 12% (3/26). CONCLUSION: Many patients with MSK have no evidence of nephrolithiasis. Among those who do, recurrence is common, and metabolic profile and composition are varied as in the general stone-forming population.

Percutaneous renal cryoablation: local control at mean 26 months of followup.

PURPOSE: We retrospectively determined the efficacy of percutaneous renal cryoablation based on a mean followup of more than 2 years. MATERIALS AND METHODS: Institutional review board approval was obtained for this Health Insurance Portability and Accountability Act compliant retrospective study. Informed consent was waived. From March 2003 through March 2007, 91 patients with 93 tumors underwent 92 percutaneous cryoablation procedures. Technical success was defined as extension of the ice ball beyond the tumor margin and post-ablation images showing no contrast enhancement in the area encompassing the original tumor within 3 months of the procedure. Local tumor progression was defined as new enhancement in the ablated tumor or an increase in ablated tumor size beyond 3 months after the procedure. Complications were defined using the National Cancer Institute Common Terminology Criteria for Adverse Events v3.0. RESULTS: Mean followup was 26 months (range 5 to 61, SD ±13) and mean tumor size was 3.4 cm (range 1.5 to 7.3, SD ±1.2). Major complications occurred in 6 of 91 patients (7%) or after 8 of 92 (9%) procedures. Technically successful ablation was performed in the treatment of 89 of the 93 (96%) tumors or 87 of the 91 patients (96%). Of the 83 tumors with followup longer than 3 months only a single case (1%) of local tumor progression occurred. Overall local control was achieved in 86 of 91 (95%) patients or 88 of 93 (95%) tumors. CONCLUSIONS: Midterm followup of percutaneous renal cryoablation shows durability of this treatment method with a low incidence of tumor recurrence beyond 3 months.

Percutaneous cryoablation of renal masses >or=3 cm: efficacy and safety in treatment of 108 patients.

PURPOSE: To evaluate our single institution experience with percutaneous cryoablation of renal masses >or=3 cm in diameter for complications and short-term outcomes. PATIENTS AND METHODS: Between March 2003 and February 2009, 108 patients with 110 renal masses >or=3 cm in diameter were treated with percutaneous cryoablation therapy. Technical success of the ablation procedure, complications, and evidence for local tumor recurrence were evaluated for each patient. RESULTS: Average maximal renal tumor diameter was 4.1 cm (range 3.0-8.3 cm; standard deviation 1.1 cm). A single cryoablation procedure was performed for treatment of each patient. A technically successful ablation was achieved for 107 of 110 (97%) tumors. The three technical failures all resulted from incomplete cryoablation of the deepest margin of a centrally located renal tumor. A total of 9 severe adverse events occurred in six patients, resulting in an 8% major complication rate. Two patients in whom major complications developed were part of the group of only four patients for whom ablation was performed for tumors > 7 cm in diameter. There were no procedural-related deaths. No evidence for local tumor recurrence was identified in any patients with follow-up contrast-enhanced CT or MRI obtained 3 months or longer from the time of the ablation. Follow-up in these patients averaged 15 months (range 3-42 mos). CONCLUSION: Percutaneous cryoablation of renal masses >or=3 cm in diameter can be performed with high technical success and low complication rates. Extra scrutiny is needed during cryoablation of central renal masses to make sure the ablation zone extends to include the deepest margin of the tumor. Although our experience is limited, percutaneous cryoablation of renal tumors > 7 cm in diameter may be associated with increased complications. The lack of local renal tumor recurrences seen in this study on short-term follow-up is encouraging, but long-term follow-up remains necessary to ensure treatment durability.

Percutaneous nephrolithotomy for large or multiple upper tract calculi and autosomal dominant polycystic kidney disease.

PURPOSE: Percutaneous nephrolithotomy is standard therapy for upper tract calculi larger than 2 cm. However, the role of percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease has not been well evaluated. We report our experience with percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients with autosomal dominant polycystic kidney disease and subsequent renal calculi managed by percutaneous nephrolithotomy from October 1981 to the present. RESULTS: We identified 9 patients. Percutaneous nephrolithotomy was performed in 11 kidneys. Flank pain was the presenting symptom in 6 patients. Average stone burden was 2.5 cm (range 1.6 to 3.6). Two access tracts were necessary in 5 kidneys. No intraoperative complications occurred. In 2 kidneys a second stage endoscopic procedure with ultrasonic lithotripsy was required to achieve stone-free status. Nephrostogram 24 hours after the final procedure showed no residual stone fragments in 9 of 11 kidneys (82%). The remaining 2 patients underwent percutaneous basket extraction to render them stone-free. There were no postoperative complications or recurrent stones. No patient required blood transfusion. Mean followup was 2.7 years (range 0.3 to 4). Mean calculated creatinine clearance was stable at 85.6 (range 45.9 to 126.6) and 89.5 mg/dl per minute (range 39.6 to 126.6) preoperatively and at last followup, respectively (p = 0.783). CONCLUSIONS: Autosomal dominant polycystic kidney disease increased operative complexity, the need for multiple percutaneous access tracts and the likelihood of repeat endoscopy. Despite the altered anatomy percutaneous nephrolithotomy was a safe, efficacious approach for autosomal dominant polycystic kidney disease. At last followup there was no stone recurrence and renal function was stable.

Fibroepithelial polyps of the ureter: a single-institutional experience.

OBJECTIVE: Ureteral fibroepithelial polyps (UFP) are rare lesions that may mimic ureteral malignancy, and management is not well defined. We report our experience with the management of UFP. MATERIALS AND METHODS: Between 1945 and 2008, review of our clinical database identified 27 patients who were found to have UFP. Single-pathologist review excluded five patients (three papilloma, one inflammatory pseudopolyp, and one nondiagnostic). Fisher's exact methods were utilized to assess significance of clinical associations. RESULTS: Mean age at diagnosis was 40 years (range 7-73 years) and 68% were male. Mean follow-up was 37 months (range 2-276 months). History of urologic conditions occurred in 13 patients: 7 (32%) urolithiasis, 2 (9%) ureteral stents, 1 (5%) recurrent urinary tract infection, and 3 (14%) ureteropelvic junction obstruction. Mean UFP diameter was 2 cm (range 0.5-4 cm). UFP was more common in the left ureter (68%, 15/22). UFP location within the ureter was proximal in 13 (59%, 15/22), mid in 4 (18%, 4/22), and distal in 4 (18%, 4/22) with multiple UFP along the length of one ureter. Six patients (27%) had multiple UFP. Open surgery, last performed in 1994, was the initial treatment in 10 (45%, 10/22) patients. Endoscopic treatment was performed in 12 (55%, 12/22) patients and was successful in 11. After endoscopic treatment, open surgical treatment was required in 3 patients with ureteral stricture and 1 patient with incomplete polyp resection. UFP reoccurred in 1 patient (1/12) at 26 months and was successfully treated with ureteroscopy. CONCLUSIONS: We conclude that UFP can be successfully managed with endoscopic techniques. Postoperative surveillance is recommended for potential early detection of ureteral stricture or recurrence.

Percutaneous nephrolithotomy success in the transplant kidney.

PURPOSE: Treatment for symptomatic calculi in the transplanted kidney can be problematic. Percutaneous nephrolithotomy has routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We report our experience with percutaneous nephrolithotomy in the transplant kidney. MATERIALS AND METHODS: A retrospective chart review from 1988 to the present was performed of all cases of a renal transplant and subsequent renal calculi treated with percutaneous nephrolithotomy. RESULTS: We identified 13 patients with a renal transplant who underwent percutaneous nephrolithotomy. Presenting symptoms included renal failure in 46.1% of cases, hematuria in 23.1%, urinary tract infection/pyelonephritis in 23.1%, pain in 15.4%, fever in 7.7% and hydronephrosis in 7.7%. Average calculus size was 1.36 cm (range 0.2 to partial staghorn). A single access tract was used in 12 cases and 2 access tracts were used in 1. Ultrasonic lithotripsy was performed in 10 cases, basket extraction was performed in 3 and the 2 techniques were performed in 1. No intraoperative complications occurred. Nephrostogram 24 hours after the procedure demonstrated no residual fragments in 10 patients (76.9%). Repeat endoscopy was required in 3 patients to achieve subsequent stone-free status. Postoperative complications developed in 3 patients, including sepsis, gastrointestinal bleeding and herpes esophagitis, respectively. Mean followup was 5.3 years (range 0.6 to 9). The single stone recurrence was treated with shock wave lithotripsy. Mean creatinine was stable at 2.0 mg/dl (range 0.9 to 3.9) preoperatively to 1.7 mg/dl (range 0.9 to 2.6) at the last visit (p = 0.311). CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone-free status was achieved in all cases. At long-term followup there were few stone recurrences with stable graft function after the procedure.

Radiofrequency ablation of renal tumors in the solitary kidney.

OBJECTIVES: Radiofrequency ablation (RFA) is a minimally invasive therapy aimed at maximal preservation of renal function in the nonsurgical renal mass patient. We evaluate our experience with RFA of renal tumors in the solitary kidney. PATIENTS AND METHODS: A retrospective review of all patients with a solitary kidney treated with RFA for renal mass was performed. Two radiologists reviewed all images. From December 2001 to June 2006, 55 renal tumors were treated with RFA in 30 patients with a solitary kidney. Percutaneous approach was used in 44 tumors (26 patients) and intraoperative open approach in 11 tumors (4 patients). Average mass size was 2.0 cm (1.2-5.4). Biopsy performed prior to ablation in 14 tumors showed renal cell carcinoma in 12 (86%) and was non diagnostic in 2 (14%). RESULTS: There were no major post procedural complications. Initial technical success was noted in 98% of tumors in 97% of patients. Average follow-up with contrast enhanced CT or MRI was 25 months (3-47) in 26 patients (50 tumors) and showed local tumor control in 100%. No difference in preoperative and postoperative calculated creatinine clearance was noted (p = 0.072). There was no difference in systolic (p = 0.102) and diastolic (p = 0.790) blood pressure pre and post ablation. CONCLUSIONS: RFA of renal masses in the solitary kidney appears to be a safe, minimally invasive alternative to open surgical resection in properly selected patients. Local tumor control was achieved with no adverse effects on renal function and blood pressure in this series.

Elective endoscopic management of transitional cell carcinoma first diagnosed in the upper urinary tract.

OBJECTIVE: To report our experience using ureteroscopic or percutaneous management of upper urinary tract (UUT) transitional cell carcinoma (TCC) in patients with no history of bladder TCC. PATIENTS AND METHODS: Between 1983 and 2004 we identified 22 patients who underwent endoscopic management of TCC first diagnosed in the UUT and in the setting of a normal contralateral kidney. We performed a retrospective chart review and conducted outcome analyses. RESULTS: The median (range) age at diagnosis was 64 (37-86) years and the median tumour size was 0.8 (0.3-2.6) cm. The tumour grade was 1, 2, or diagnosed as visual low grade in two (9%), seven (32%), and 13 (59%) patients, respectively; no patient had grade 3 TCC at diagnosis. Tumour stage was Ta or visual Ta in all patients. The median follow-up was 4.9 (0.4-17) years during which 11 (50%) patients developed 21 UUT recurrences and 10 (45%) patients developed bladder TCC. At last follow-up, seven (32%) patients required a nephroureterectomy for recurrent TCC and two (9%) patients died from TCC. Among 13 patients with a diagnosis based on visual inspection only, three recurred with grade 3 invasive TCC during follow-up. No patient with pathological confirmation of low-grade/stage TCC recurred with high-grade or invasive TCC. CONCLUSIONS: Recurrence is common after endoscopic management of UUT-TCC, underscoring the need for strict surveillance. Patients diagnosed visually, without adequate tissue for pathological examination, can recur with high-grade invasive TCC. No patient with pathological confirmation of low-grade TCC developed progressive disease during follow-up.

Long-term outcomes of percutaneous nephrolithotomy compared to shock wave lithotripsy and conservative management.

PURPOSE: Percutaneous nephrolithotomy is successful at achieving stone-free status but long-term safety data are lacking. We report our long-term experience with percutaneous nephrolithotomy and compare these results with other treatment modalities. MATERIALS AND METHODS: We identified 87 patients treated with percutaneous nephrolithotomy from 1983 to 1984 who continue to receive care at our institution. Retrospective chart review was performed. Long-term results were compared to those of a group of 288 patients with stones treated nonsurgically (controls) and a group of 288 patients treated with shock wave lithotripsy followed for 19 years. RESULTS: Average followup was 19.2 years (range 12.7 to 23.0). After percutaneous nephrolithotomy new onset renal insufficiency was noted in 9 patients (10.6%), hypertension in 29 (34.1%), diabetes mellitus in 20 (23.5%) and ureteropelvic junction obstruction in 3 (3.5%). Stone recurrence occurred in 32 patients (36.8%). Recurrent stone events were associated with residual fragments after percutaneous nephrolithotomy (p = 0.049). Compared to shock wave lithotripsy there were no significant differences in the development of renal insufficiency, hypertension or diabetes mellitus. Stone recurrence was more common following shock wave lithotripsy (53.5%) compared to percutaneous nephrolithotomy (p = 0.033). Compared to controls there were no significant differences in the development of renal insufficiency or hypertension. On univariate analysis percutaneous nephrolithotomy was associated with the development of diabetes mellitus (p <0.001) but this association did not persist in multivariate analysis. CONCLUSIONS: At 19 years of followup stone recurrences were less frequent following percutaneous nephrolithotomy compared to shock wave lithotripsy. Recurrent stone events were associated with residual fragments after percutaneous nephrolithotomy. Percutaneous nephrolithotomy was not associated with the development of adverse medical conditions compared to shock wave lithotripsy or conservatively managed stone cases.

Endoscopic management of upper tract transitional cell carcinoma in patients with normal contralateral kidneys.

OBJECTIVES: We report our experience using ureteroscopic or percutaneous management of upper tract transitional cell carcinoma (TCC) in elective situations. METHODS: Between 1983 and 2004 we identified 83 patients who underwent endoscopic management of upper tract TCC in the setting of a normal contralateral kidney. We performed a retrospective chart review and conducted outcome analyses. RESULTS: Median age at diagnosis was 71 years (range, 37 to 90 years) and median tumor size was 0.8 cm (range, 0.2 to 3.0 cm). Grade 3 tumors were present in 8 patients (10%), whereas the remaining 75 (90%) patients were grade 1 or 2 or diagnosed as visual low grade. Tumor stage was Ta or visual Ta in 78 patients (94%). Median follow-up was 4.6 years (range, 0.4 to 17 years) during which 46 patients (55%) developed 76 upper tract recurrences and 37 patients (45%) developed a recurrence in the bladder. At last follow-up, 27 patients (33%) required a nephroureterectomy and 9 patients (11%) died from TCC. Patients with high-grade (risk ratio, 9.8; P = 0.001) and non-Ta stage tumors (risk ratio, 5.7; P = 0.003) were at significant risk of death from disease. Among 43 patients with a diagnosis based on visual inspection only, 9 (21%) developed grade 3 TCC during follow-up. CONCLUSIONS: Our results underscore the need for strict surveillance after endoscopic management of upper tract TCC. Recurrence is common and nearly one-third of patients in this cohort eventually required nephroureterectomy. Patients with a visual diagnosis, without adequate tissue for pathologic analysis, can experience recurrence of high-grade invasive TCC.

Imperative indications for conservative management of upper tract transitional cell carcinoma.

PURPOSE: We report our experience with patients with imperative indications for endoscopic treatment for upper tract transitional cell carcinoma. MATERIALS AND METHODS: Between 1983 and 2004 we identified 37 patients with a solitary kidney, bilateral disease or preoperative creatinine greater than 2.0 mg/dl who underwent endoscopic treatment for localized upper tract transitional cell carcinoma. A retrospective chart review was performed. RESULTS: Of the 37 patients 32 had a solitary kidney, 3 had bilateral disease and 2 had preoperative creatinine greater than 2.0 mg/dl. Median age at diagnosis was 75 years (range 56 to 88). Bladder cytology was positive or atypical in 15 of 31 patients (48%). Tumors were grade 1 to 3 in 2, 13 and 7 patients, respectively, and diagnosed visually in 15. At a median followup of 2.7 years for survivors 23 patients (62%) had a total of 56 upper tract transitional cell carcinoma recurrences. Grade and stage progression occurred in 3 and 3 patients, respectively. Ten of the 23 patients who experienced upper tract recurrence died of transitional cell carcinoma. Overall kidney preservation was achieved in 24 of the 32 patients (75%) with a solitary kidney. At last followup 24 patients had died, including 11 (29.7%) of transitional cell carcinoma, at a median of 2.9 years. Cancer specific survival at 5 years for this cohort was 49.3%. CONCLUSIONS: Our results indicate that upper tract tumor recurrence occurs in a majority of patients with imperative indications for endoscopic treatment, underscoring the need for frequent surveillance. While most kidneys can be preserved, cancer specific death is common.

Endoscopic management of upper tract urothelial carcinoma in patients with a history of bladder urothelial carcinoma.

PURPOSE: Endoscopic management of renal pelvis and ureteral urothelial carcinoma is gaining acceptance as a conservative treatment modality. Patients with a history of bladder urothelial carcinoma are at high risk for upper tract recurrence. We evaluate the role of endoscopic management of upper tract urothelial carcinoma in patients with a history of primary bladder urothelial carcinoma. MATERIALS AND METHODS: We retrospectively reviewed 90 patients with a history of primary bladder urothelial carcinoma who underwent endoscopic treatment of localized upper tract urothelial carcinoma between 1983 and 2004. RESULTS: Median patient age at diagnosis was 73 years (range 50 to 90). A total of 13 (14.4%) patients previously underwent cystectomy. With a median followup of 4.3 years (range 0.1 to 17), 105 upper tract urothelial carcinoma recurrences developed in 55 patients at a mean of 0.6 years (range 22 days to 5.9 years). Of these recurrences 76 were amenable to endoscopic management while 29 required nephroureterectomy. In 38 patients there were 91 bladder recurrences. At last followup 48 patients died, 17 of urothelial carcinoma at a median of 3.4 years (range 1 to 10). Cancer specific survival at 5 years for this cohort was 71.2%. Risk of death from urothelial carcinoma was significantly associated with stage (RR 3.23) and grade (RR 4.05) of upper tract urothelial carcinoma, imperative indication (RR 4.30), and treatment of bladder urothelial carcinoma with cystectomy (RR 3.34). CONCLUSIONS: Endoscopic management of upper tract urothelial carcinoma in patients with primary bladder urothelial carcinoma demonstrates a significant local recurrence rate. Furthermore, 5-year cancer specific survival is low. These patients represent a high risk cohort requiring strict ureteroscopic followup after endoscopic management is instituted.

Percutaneous cryoablation of large renal masses: technical feasibility and short-term outcome.

OBJECTIVE: This retrospective study was performed to assess the feasibility, safety, and short-term outcome of percutaneous cryoablation of large solid renal tumors. MATERIALS AND METHODS: We reviewed 40 percutaneous cryoablation procedures performed on 40 patients with renal tumors 3 cm in diameter or larger. All patients underwent cryoablation with CT monitoring. Technical success was defined by extension of the ice ball beyond the tumor margin and postablation imaging findings of no contrast enhancement in the area encompassing the original tumor. Complications meeting grade 3 of the National Cancer Institute Common Terminology Criteria for Adverse Events were recorded. RESULTS: Mean +/- SD tumor diameter was 4.2 +/- 1.1 cm (range, 3.0-7.2 cm). Technical success was achieved in 38 (95%) of 40 cryoablation procedures. There was one grade 3 adverse event (3% rate of significant complications). Follow-up images obtained 3 months or longer (mean, 9 +/- 6 months; range, 3-22 months) after ablation were available for 26 (65%) of the 40 patients. No local tumor recurrence or tumor progression was found. CONCLUSION: Percutaneous cryoablation of renal tumors measuring 3 cm or larger is technically feasible and relatively safe. Short-term follow-up results are encouraging, although long-term follow-up is necessary to assess true treatment efficacy.