Management of distal ureter in laparoscopic nephroureterectomy--a comprehensive review of techniques.

Approximately 5% of all urothelial tumors in adults arise from the upper tracts. While the gold standard treatment is open nephroureterectomy, laparoscopic nephroureterectomy is becoming increasingly popular. Oncologic principles dictate that complete excision of the transmural ureter and bladder cuff and avoidance of urine spillage are paramount. This can be challenging laparoscopically and multiple techniques have been described. We review described surgical techniques, published oncologic data, as well as advantages and disadvantages for each technique including open excision, cystoscopic detachment and ligation, laparoscopic stapling, ureteral intussusception, transurethral resection of ureteral orifice (TURUO) and modifications of TURUO. To date, no controlled studies have been performed demonstrating one technique's superiority.

Mannitol extravasation during partial nephrectomy leading to forearm compartment syndrome.

We present the first known complication of forearm compartment syndrome after mannitol infusion during partial nephrectomy. We stress the importance of excellent intravenous catheter access and constant visual monitoring of the intravenous catheter site during and after mannitol infusion as ways to prevent this complication. Prompt recognition of compartment syndrome with appropriate intervention can prevent long-term sequelae.

Angiosarcoma of bladder: long-term survival after multimodal therapy.

Angiosarcoma of the bladder is extremely rare and carries a dismal prognosis because of the uniformly high-grade and aggressive tumor biology of the neoplasm. We report the long-term disease-free survival of 1 patient, treated with multimodal therapy, whom we have previously reported on. Six years after the initial presentation, the patient died, and the postmortem analysis revealed no evidence of residual disease. Our case represents the longest reported survival of a patient with angiosarcoma of the bladder.

Mannitol extravasation during partial nephrectomy leading to forearm compartment syndrome

We present the first known complication of forearm compartment syndrome after mannitol infusion during partial nephrectomy. We stress the importance of excellent intravenous catheter access and constant visual monitoring of the intravenous catheter site during and after mannitol infusion as ways to prevent this complication. Prompt recognition of compartment syndrome with appropriate intervention can prevent long-term sequelae.

Newborn society of fetal urology grade 3 hydronephrosis is equivalent to preserved percentage differential function.

PURPOSE: In newborn hydronephrosis (HN), the level of differential function (%df) measured by diuretic renography (DR) is used to judge the need for pyeloplasty. As DR testing is complex, we sought to determine if grading the level of HN (Society of Fetal Urology grade, SFU Gr) by a simple ultrasound correlates with percentage differential function (%df) and thereby obviates the need to perform DR. MATERIALS AND METHODS: Between 1990 and 2003 our institution prospectively enrolled all cases of fetal HN who showed unilateral newborn SFU Gr HN > or =3. The cases underwent standardized testing. DR was done using the method of Well-Tempered Renography which was then followed by ultrasound (US). The US studies were performed while the hydration induced by DR was in effect. The level of %df was categorized as preserved (> or =40%) or reduced (<40%). Cases were excluded if there was an additional urological abnormality (e.g. ureterocele). RESULTS: There were 71 cases that met our study criteria. The SFU Gr HN was 3 (n=33) or 4 (n=38). Kidneys with SFU Gr 3 HN showed preserved %df (33/33,100%) (mean=50.1+/-3.6) significantly more often than kidneys with SFU Gr 4 HN (27/38, 71%) (mean=42.2+/-13.9) (RR=1.41, 95% CI (1.15-1.72), p<0.001). CONCLUSION: In newborns with a history of fetal HN, the postnatal finding of SFU Gr 3 HN uniformly correlates with preserved %df. Standardized hydration prior to US study is done to assure consistency in measurement of the SFU Gr HN. Determining the duration of the relationship between SFU Gr 3 HN and preserved %df will require prospective, longitudinal studies.

Anaphylactoid reaction after retrograde pyelography despite preoperative steroid preparation.

A 19-year-old woman with a known allergy to iodinated contrast presented with intermittent, gross hematuria of 2 years' duration. The patient was scheduled to undergo cystoscopy with bilateral retrograde pyelography, because this is considered a safe alternative to intravenous pyelography or computed tomography. Because of her contrast allergy, the patient completed a 13-hour steroid preparation before the procedure. However, within minutes of extubation, she developed an anaphylactoid reaction and, despite appropriate management, required reintubation and subsequent transfer to the intensive care unit. The patient was subsequently extubated 8 hours later and recovered completely.

Salvage radiation therapy for prostate specific antigen progression following radical prostatectomy: 10-year outcome estimates.

PURPOSE: We evaluated men treated with salvage radiation therapy for increasing serum prostate specific antigen (PSA) following radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: We retrospectively reviewed the records of 3,478 consecutive men who underwent radical retropubic prostatectomy (RRP) between 1983 and 2003, as performed by a single surgeon. A total of 307 men received salvage radiation therapy for persistently increased or increasing PSA after RRP. We compared perioperative and peri-radiotherapy clinicopathological parameters in men who achieved an undetectable PSA level after radiation therapy (responders) vs those who did not (nonresponders). We then evaluated the durability of the PSA response. RESULTS: Median time from RRP to PSA progression was 23 months (range 1 to 129). Median followup from RRP was 104 months (range 7 to 225). Median followup from salvage radiotherapy was 56 months (range 0 to 188). Of 223 men with sufficient followup information 162 (73%) subsequently had undetectable PSA (less than 0.3 ng/ml) in response to salvage radiation therapy. There was no significant difference between responders and nonresponders in the distribution of clinical and pathological tumor stages, age at RRP, surgical margin status, and the interval between RRP and salvage radiation therapy. A Gleason score of 8 to 10 was more prevalent in nonresponders than responders (28% vs 13%). Median PSA at salvage radiation therapy was 1.2 ng/ml in nonresponders vs 0.7 ng/ml in responders. Actuarial 5 and 10-year progression-free (PSA less than 0.3 ng/ml) survival probabilities in all 223 men following salvage radiation therapy were 40% (95% CI 32 to 48) and 25% (95% CI 15 to 36), respectively. Actuarial 5 and 10-year biochemical progression-free survival estimates following salvage radiation therapy in responders only were 55% (95% CI 45 to 64) and 35% (95% CI 21 to 49), respectively. Only seminal vesicle invasion was significantly associated with progression-free survival following radiation therapy on multivariate analysis. CONCLUSIONS: An undetectable PSA level following salvage radiation therapy is more frequently achieved in men with lower pre-radiation serum PSA and those without seminal vesicle or lymph node involvement. Overall approximately a fourth of men with PSA evidence of cancer progression following RRP had a durable response 10 years after the initiation of salvage radiation therapy in the protocols used in this patient cohort.

Efficacy and safety of the Healthtronics LithoTron lithotripter.

PURPOSE: To evaluate our experience with the LithoTron lithotripter (Healthtronics, Atlanta, GA), a dry portable system that utilizes a spark-gap electrode as an energy source. PATIENTS AND METHODS: We prospectively evaluated the first 312 treatments performed on 199 men and 99 women with an average age of 43.5 years (range 4 months-80 years), over a 25-month period between May 1999 and June 2001. Of the 468 stones treated, 136 were located in the ureter, 52 in the renal pelvis or ureteropelvic junction, and 230 in the kidney; the sites of 50 were not specified in our database. The average stone size was 8.0 mm (range 1-40 mm). Follow-up included a plain (KUB) film, CT scan, or intravenous urogram (IVU) and was available for 256 patients. "Stone free" was defined as no fragments visible on postoperative images. The mean radiographic follow-up was 74 days (range 0-866 days). Data collection was initially done manually by data sheets, but a Web-based medical database application was developed in order to enter, store, retrieve, and analyze the data more efficiently. RESULTS: The average number of shocks delivered per renal unit was 2689 at 25.8 kV. Seventy-five percent of the procedures were performed with intravenous sedation. Two thirds (169/256) of the patients were rendered stone free with one treatment. According to size, 71% (209/294) of stones <1 cm, 57% (39/68) of stones between 1.0 and 1.5 cm, and 22% (8/36) of stones >1.5 cm were eliminated. There were 23 patients who required further treatment; from the available data, 18 of them are currently stone free. Perioperative complications occurred in 6 patients (2%). No patient had worsening renal function or new-onset hypertension. The effectiveness quotient was 59.3%. CONCLUSION: The LithoTron lithotripter is satisfactory for stones <1 cm.

Urolithiasis associated with topiramate

OBJECTIVE: Topiramate is a sulfamate-substituted monosaccharide anticonvulsant used as adjunctive therapy for intractable refractory seizures. It is report a case of topiramate-induced urolithiasis. CASE REPORT: A 35-year-old man presented with acute, right-sided, colicky flank pain. He denied hematuria or dysuria. He was in use of phenytoin, risperidone, phenobarbital, and topiramate. The total daily dose of topiramate was 375 mg. A CT scan showed a 7 x 1 mm curvilinear density at the right ureterovesical junction with proximal hydrouretronephrosis. He was managed with rigid ureteroscopic stone extraction and the calculus metabolic analysis revealed the stone was composed of carbonate apatite (70 percent), calcium oxalate dihydrate (20 percent), and calcium oxalate monohydrate (10 percent). COMMENTS: The present case typifies many features of topiramate-induced urolithiasis. Those who care for patients with urinary stone disease should be aware of this association.

Urolithiasis associated with topiramate.

OBJECTIVE: Topiramate is a sulfamate-substituted monosaccharide anticonvulsant used as adjunctive therapy for intractable refractory seizures. It is report a case of topiramate-induced urolithiasis. CASE REPORT: A 35-year-old man presented with acute, right-sided, colicky flank pain. He denied hematuria or dysuria. He was in use of phenytoin, risperidone, phenobarbital, and topiramate. The total daily dose of topiramate was 375 mg. A CT scan showed a 7 x 1 mm curvilinear density at the right ureterovesical junction with proximal hydrouretronephrosis. He was managed with rigid ureteroscopic stone extraction and the calculus metabolic analysis revealed the stone was composed of carbonate apatite (70%), calcium oxalate dihydrate (20%), and calcium oxalate monohydrate (10%). COMMENTS: The present case typifies many features of topiramate-induced urolithiasis. Those who care for patients with urinary stone disease should be aware of this association.