Ketorolac effectively inhibits ureteral contractility in vitro.

INTRODUCTION: The use of ketorolac in the management of painful symptoms associated with urinary stones is well supported in the literature; however, the gastric and renal adverse effects limit the dose and duration of administration. As a nonselective cyclooxygenase inhibitor, ketorolac can act locally to help control renal colic by inhibiting smooth muscle contractions and inflammation. We sought to confirm ketorolac's inhibition of ureteral contractility and determine a dose response relationship to identify an effectiveness range. MATERIALS AND METHODS: Porcine ureter strips attached to force displacement transducers were suspended in organ tissue baths that contained aerated Krebs buffer. Tissues equilibrated for 1 hour, and a spontaneous contractility rate was established. Tissues were incubated with a concentration-response curve of ketorolac (0.1 nM-10 microM) for 90 minutes and compared with indomethacin (1 muM) and dimethyl sulfoxide (DMSO) 0.1%. Contractility rates were recorded on a polygraph and analyzed for changes over exposure time. RESULTS: Ketorolac inhibition of ureteral contractility was dose dependent. At 90 minutes, the average percent decrease from the spontaneous contraction rate for 0.1 nM ketorolac was 18.2%; 1 nM, 34.3%; 10 nM, 56.0%; 100 nM, 69.9%; 1 microM, 88.7%; and 10 microM, 98.3%. Ureteral contractility was significantly reduced by 1 microM ketorolac (39.0%; P = 0.016) at 15 minutes when compared with DMSO. In addition, 1 microM ketorolac was not significantly different at any time point from any of the higher doses studied. CONCLUSION: Ketorolac inhibition of stretch-induced ureteral contractility is concentration-dependent between 1 nM and 1 microM. Local administration of ketorolac at these doses may be useful during the management of stones while at the same time limiting the risk for adverse effects.

Single center preliminary experience with hand-assisted laparoscopic resection of isolated renal cell carcinoma fossa recurrences.

OBJECTIVES: Solitary metastasis to the renal fossa after radical nephrectomy for renal cell carcinoma is uncommon. We report the first series on hand-assisted laparoscopic excision for renal cell carcinoma fossa recurrences. METHODS: We performed a retrospective review of patients who underwent hand-assisted laparoscopic excision of renal cell carcinoma fossa recurrence. Patients with distant metastasis or local lymph node or adrenal metastasis were excluded from analysis. We collected data on patient and tumor characteristics, nephrectomy and fossa mass excision procedures, and postoperative outcomes. RESULTS: Between 2001 and 2007, 5 patients underwent laparoscopic resection of a renal fossa recurrence. Mean time to recurrence after radical nephrectomy was 23 months (range, 5 to 46 months) and mean size of the renal fossa mass was 6 cm (range, 4.2 to 9.5 cm). The average operative time was 232 minutes (range, 150 to 300 minutes) and average estimated blood loss was 175 mL (range, 25 to 400 mL). One patient required conversion to open surgery. There were no postoperative complications and mean hospital stay was 4 days. With mean follow-up of 43 months, the cancer-specific and disease-free survival rates were 60% and 20%, respectively. Of the 4 patients who underwent complete resection, 2 died from metastatic disease at 13 and 56 months, 1 continues to have progressive metastatic disease at 69 months, and 1 remains free of any clinical evidence of metastatic disease or recurrence at 37 months. One patient who underwent incomplete resection as a result of inferior vena cava invasion continues to have progressive local and distant metastatic disease at 40-month follow-up. CONCLUSIONS: Hand-assisted laparoscopic excision of renal fossa recurrence after radical nephrectomy appears to be safe and effective for carefully selected patients.

Treatment selection and outcomes: renal calculi.

This article summarizes the history of how renal stones have been treated over the centuries and reviews current treatments and outcomes for renal stones. The authors provide an algorithm based on available outcome data for shock wave lithotripsy, ureteroscopy, and percutaneous nephrolithotomy.

Management of ischemic priapism with high-dose intracavernosal phenylephrine: from bench to bedside.

INTRODUCTION: Ischemic priapism is associated with cavernosal acidosis, which decreases the efficacy of adrenergic agonists. We determined the effect of acidosis on ligand dissociation from adrenergic receptors and assessed the efficacy of high-dose phenylephrine in treating patients with acute ischemic priapism. METHODS: Dissociation rates of [3H]prazosin were determined at pH 7.2 and 6.9 in membrane preparations of rabbit penile cavernosal tissue. Vital signs were recorded from patients before injection, and at 1 minute and 5 minutes after injection of high-dose phenylephrine (1,000 mg q 5 minutes) for 17 consecutive cases of iatrogenic ischemic priapism that occurred after vascular assessment. We also provide two case reports of prolonged ischemic priapism successfully managed with high-dose phenylephrine. RESULTS: Dissociation rates of [3H]prazosin were greater at pH 6.9 (K (-1) = 0.23/minute) than at pH 7.2 (K (-1) = 0.10/minute), suggesting decreased receptor affinity at acidic pH. Intracavernosal therapy with high-dose phenylephrine (mean dose 2,059 +/- 807 microg) was 100% effective with no adverse events or significant changes in vital signs. In addition, two patients with ischemic priapism for > or =36 hours were successfully treated with high-dose intracavernosal phenylephrine (mean dose 45,000 microg) without any adverse event. Both patients are currently potent. CONCLUSIONS: Acidic pH may decrease the binding affinity of adrenergic ligands to their receptors. Phenylephrine at doses higher than previously reported may be necessary to overcome this decreased affinity in acidosis associated with ischemic priapism. High-dose intracavernosal phenylephrine administration is safe and effective in the management of ischemic priapism. Continuous cardiovascular monitoring is advised.

Energy ablative techniques for treatment of small renal tumors.

PURPOSE OF REVIEW: The success of partial nephrectomy for the treatment of small renal cancers has led to the development of energy ablative technologies, which are less invasive alternatives for performing nephron-sparing surgery. Currently, cryoablation and radiofrequency ablation are the two most reported technologies. Both technologies use very different means to cause cellular injury. Additionally, three newer technologies, high-frequency ultrasound ablation, laser interstitial therapy, and microwave therapy are emerging in the literature. RECENT FINDINGS: Three- and 4-year data for cryoablation and radiofrequency ablation are now becoming available. On the basis of these studies, it is clear that ablative technologies can be effective treatments for select small renal tumors. It is also evident that both percutaneous and laparoscopic approaches offer minimal morbidity. SUMMARY: As long-term (5 years and greater) outcome data for ablative technologies accumulate, we are likely to see an increase in clinical reports, including more patients who may be candidates for extirpative surgery. Technology will advance, leading to smaller probes with larger treatment zones, making it possible to treat larger tumors and potentially even tumors in the advanced disease state.

Laparoscopic ureterolysis for benign and malignant conditions.

Ureteral obstruction secondary to extrinsic compression is uncommon. Extrinsic compression results from both benign and malignant conditions of the retroperitoneum. In certain patients, laparoscopic ureterolysis is a minimally invasive alternative to the open approach. To date, the largest numbers of patients have undergone this procedure for idiopathic retroperitoneal fibrosis. Select patients with ureteral obstruction following cancer chemotherapy or radiotherapy may also be candidates for laparoscopic ureterolysis, although experience is limited. This article reviews the current indications, technique, and results of laparoscopic ureterolysis for both benign and malignant conditions. Further long-term studies are required to define its role.

Three-chamber priapism in a patient with primary epithelioid hemangioendothelioma of penis.

A 58-year-old man presented with a 6-month history of painful progressive penile firmness, initially diagnosed as Peyronie's disease. Penile fibrosis involved the entire corpora cavernosa and spongiosum, making it consistent with three-chamber priapism. Cavernosal biopsies revealed epithelioid hemangioendothelioma, and the metastatic workup found hepatic and pulmonary lesions. The patient was treated with paclitaxel, but eventually died of cancer progression. Early infiltrative vascular malignancies of the penis may be indistinguishable from Peyronie's disease. A review of published reports revealed that penile masses associated with progressive growth, obstructive urinary symptoms, dysuria, or painful erections might warrant further evaluation with biopsies.