Matched pair analysis of laparoscopic versus open radical nephrectomy for the treatment of T3 renal cell carcinoma.

PURPOSE: The perioperative and oncological outcomes of laparoscopic radical nephrectomy (LRN) for T1-T2 renal cell carcinoma (RCC) are well established. We aim to determine whether LRN is a comparable alternative to open radical nephrectomy (ORN) in the treatment of T3 RCC using a matched pair analysis study design. METHODS: A review of a prospectively collected database at the Western General Hospital, Edinburgh, between 2000 and 2011 was conducted. Patient pairs were matched based on age at operation, gender, histological subgroup, maximal tumour diameter, TNM stage and grade. Patient demographics, operative and post-operative outcomes were compared. Overall, cancer-specific and progression-free survival [overall survival, cancer-specific survival (CSS) and progression-free survival (PFS)] were estimated using the Kaplan-Meier method. RESULTS: From 252 patients with T3 disease, 25 pairs were matched. Patients were of median age 66.2 years, 64 % male. Tumours were all clear cell RCC, were stage pT3a (32 %) or pT3b and had maximal tumour diameters of 8.7 cm for LRN and 10.0 cm for ORN. Estimated blood loss (100 ml LRN; 650 ml ORN, p < 0.001) and length of post-operative hospital stay (4 days LRN: 9 days ORN, p < 0.001) were lower in the LRN group. Operation time and post-operative complication rates were comparable. CSS and PFS were comparable with a mean CSS of 91.3 months for LRN and 88.7 months for ORN. CONCLUSION: This study reports the longest median follow-up in a T3 LRN cohort. In matched patients, LRN has been shown to have a superior perioperative profile to ORN for the treatment of pT3a/b RCC, with no adverse effect on midterm oncological outcomes.

The use of extra-corporeal shockwave lithotripsy for obstructing ureteric stones.

Extracorporeal shock wave lithotripsy (SWL) is a non-invasive treatment for urinary tract stones. This review presents the role of SWL for treating specifically ureteric calculi. The impact of hydronephrosis on SWL success, the use of SWL as emergency treatment (eSWL) for acute ureteric colic, the influence of ureteric stent placement on SWL outcome and the use of medical expulsive therapy to augment SWL success are discussed.

Failure after shockwave lithotripsy: is outcome machine dependent?

AIM: To investigate the issue of shockwave lithotripsy failure by studying the effect of machine crossover to the Technomed Sonolith Vision (TSV) lithotriptor in patients with previously unsuccessfully treated renal stones with the Dornier Compact Delta (DCD). Records were examined for the period between 1998 and 2006. Parameters analysed were: size, multiple/single stones, location, treatments/stone. RESULTS: Seventy-six patients fulfilled the inclusion criteria. Following lithotripsy with the TSV, the stone-free rate (SFR) at 3 months was 56.7%, and the success rate (stone-free and fragments < or = 4 mm, SR) 86.7%. Twenty-two patients had multiple stones and the majority of the stones were located in the lower calyx (59.2%). Mean size was 8.9 mm prior to treatment with the TSV machine (10.2 mm for DCD). Further analysis followed in a subgroup of 42 patients of the same stone size (+/-2 mm) before and after DCD sessions. Mean stone size was 7 mm. The SFR was 61.9% (62.9% vs. 40.9% for single and multiple stones), and the SR was 88.1%. No difference in SFR was found for single or multiple stones in any of the two groups. CONCLUSIONS: The term 'extracorporeal shockwave lithotripsy (ESWL)-resistant stones' needs to be re-examined, as treatment with a different lithotriptor was successful in a group of stones where another machine had failed. Lithotripters with different shock wave characteristics may result in difference in the results of ESWL. Future research in ESWL should focus on stone characteristics and development of machines with the ability to adapt to specific stone features.

Plain radiography still is required in the planning of treatment for urolithiasis.

INTRODUCTION: Nonenhanced computed tomography (NCT) is recognised as the most sensitive tool in diagnosis of renal tract calculi. However, its role as the sole imaging investigation, for decisions regarding management is less clear. OBJECTIVE: To determine the proportion of new stone patient referrals in which management is altered by interpretation of a plain abdominal kidneys, ureters and bladder (KUB) radiograph in addition to NCT. METHODS: One hundred consecutive new referrals to a national lithotripsy centre were considered prospectively for treatment of renal tract calculi. RESULTS: A significant change in management was undertaken in 17 patients on the basis of KUB findings. Eleven patients had radio-lucent ureteric stones, for which Extracorporeal Shockwave Lithotripsy (ESWL) was consequently not possible and who required endoscopic management. There were six inaccuracies in measurement of size or positioning on NCT. In a further 43 patients it was not possible to confirm management until the KUB was reviewed, although in these cases ESWL or expectant management was still pursued. Thus additional imaging with a KUB was required in order to confirm optimum management in 60 patients. CONCLUSION: Additional plain radiography confers a significant advantage in the planning of treatment for urolithiasis once the diagnosis has been established by NCT because of information it provides regarding radio-opacity as well as stone size and visibility. This information cannot be delivered by NCT alone. We therefore recommend that KUB imaging is performed on all new stone patients referred for treatment.

A single-center experience of the usefulness of caliceal-pelvic height in three different lithotripters.

PURPOSE: Stone-free rates for lower caliceal stones after Extracorporeal Shockwave Lithotripsy (SWL) are persistently poor. As stone-free rates vary with lithotripter type, we have compared the applicability of caliceal-pelvic height (CPH) in the prediction of stone clearance in patients treated with three different lithotripters within one center. PATIENTS AND METHODS: Four hundred seventy adult patients with solitary, radiopaque, lower caliceal stones of size 6 to 10 mm receiving primary SWL between January 1992 and June 2002 were identified. They were treated with one of three lithotriptors: the Wolf Piezolith 2300, the Dornier MPL 9000, and the Dornier Compact Delta. Pretreatment intravenous urograms were reviewed and CPH, the vertical distance from the lowermost point of the calix to the highest point of the lower lip of pelvis, was measured. The primary end-point was stone-free status after 3 months. Adjusted odds ratios (AORs) of different potential predictor variables for the overall results and individual machines were estimated using multiple logistic regression. RESULTS: In the overall analysis, stone size and machine type were the only predictors associated with stone clearance. While smaller stones had better clearance overall, the MPL 9000 appears to have the best performance, followed by the Piezolith 2300. However, after patients were stratified into different machine subgroups, CPH became a significant predictor of stone-free rate for the Piezolith 2300 (AOR = 0.960; 95% CI 0.925, 0.960; P = 0.031), but not the other two machines. CONCLUSIONS: CPH was only useful in the prediction of lower caliceal stone clearance for the Piezolith 2300. Therefore the usefulness of one anatomic factor to assess treatment using one lithotripter may not be extrapolated to other machines.

Matched pair analysis of ureteroscopy vs. shock wave lithotripsy for the treatment of upper ureteric calculi.

There is controversy over whether shock wave lithotripsy (SWL) or ureteroscopy (URS) is the best management of ureteric calculi, especially for stones located in the upper ureter. This study compares URS and SWL management of upper ureteric stones directly for the first time using a different analysis tool, the matched pair analysis study design. This method enables meaningful comparisons to be made on a small number of matched patients, using precise like-for-like matching. Adult patients undergoing primary treatment of solitary radiopaque proximal ureteric stones were identified. Patients with stents, nephrostomies or stones at the pelvi-ureteric junction were excluded. Patients had a minimum of 3 months follow-up. Patients treated by primary URS were matched using four parameters (sex, laterality, stone size and location) to patients treated on a Dornier Compact Delta Lithotriptor. A total of 1479 patients had URS or SWL from which 27 upper ureteric stone matched pairs were identified. Three-month stone free rates were 82% for URS and 89% for SWL (McNemar's test, p=0.625). Re-treatment was required in 11% and 26% following URS and SWL respectively (p=0.219). Forty-one per cent of URS patients required an ancillary treatment, such as stent removal, compared with only 22% of SWL patients (p=0.227). Introduction of a holmium:YAG laser for use with URS improved the stone free rate for URS to 100%. Using a robust like-for-like comparison of similar patients with very similar upper ureteric stones the outcomes following SWL and URS were comparable. Choice of treatment should therefore be based on parameters such as availability of equipment, waiting times and patient preference.

Single-center experience using three shockwave lithotripters with different generator designs in management of urinary calculi.

PURPOSE: We retrospectively reviewed the treatment outcomes of extracorporeal shockwave lithotripsy (SWL) in a single center using either the Wolf Piezolith 2300 (a piezoelectric lithotripter), the Dornier MPL9000 (an electrohydraulic lithotripter), or the Dornier Compact Delta (an electromagnetic lithotripter) from January 1992 to June 2002. PATIENTS AND METHODS: A series of 3123 (1449 Piezolith 2300, 780 MPL9000, and 894 Compact Delta) solitary radiopaque urinary stones of < or =15 mm receiving primary SWL were identified. "Stone free" was defined as the absence of evidence of stone on plain radiography. Treatment outcomes were assessed by the stone-free rate 3 months after one treatment session, the retreatment rate, the auxiliary procedure rate, the complication rate, and the effectiveness quotient (EQ). In order to have a better assessment of the efficacy of individual lithotripters, multiple logistic regression was performed to control various factors affecting treatment outcomes, including lithotripter-type, patients' sex and age, history of previous SWL, the stone characteristics (side, site, and size), and the presence of a stent or nephrostomy tube. RESULTS: There were significant differences in the stone site distribution and mean stone size among the three groups. The overall EQ for the Piezolith 2300, MPL9000, and Compact Delta were 0.345, 0.303, and 0.257, respectively. However, using the multiple logistic regression model, the adjusted odds ratio (AOR) of a patient being stone-free after 3 month for the Piezolith 2300 and MPL9000 (using the Compact Delta as the referent category) were 1.38 (95% CI 1.15, 1.65) and 1.72 (95% CI 1.39, 2.11), respectively. Patients treated using the MPL9000 had significantly less re-treatment (AOR = 0.57; 95% CI 0.48, 0.69) than the other groups. No significant difference in the auxiliary procedure rate and complication rate for the three machines was observed. CONCLUSION: Based on multivariate analysis results, the Dornier MPL9000 had the best treatment outcomes in terms of stone-free rate and re-treatment rate among the three lithotripters.

A teratoid cyst containing nephrogenic tissue in a woman with a horseshoe kidney.

A 21 year old woman presenting with flank pain and vomiting was found to have a cystic lesion associated with a horseshoe kidney. The inner aspect of the cyst wall consisted of connective tissue intermingled with colonic-type epithelium. Within the cyst wall there were multiple foci of immature and incompletely differentiated renal elements, together with fragments of urothelium, smooth muscle, bone, and neuroendocrine tissue. No immature renal blastema were found. This lesion is unique and labelled as a teratoid cyst containing nephrogenic tissue.

An analysis of urinary tract trauma in Scotland: imnpact on management and resource needs.

OBJECTIVE: We report the incidence, distribution, aetiology and outcome of urological trauma in a unique national database to provide an insight into its contemporary management. PATIENTS AND METHODS: The Scottish Trauma Audit Group prospectively collected data from severe trauma presenting to all major Scottish hospitals. We examined data from 24,666 trauma admissions from 1999 to 2002. Patients who sustained urological injuries were identified and studied in detail. RESULTS: 362 patients had urological injuries, comprising 1.5% of the trauma population, and an incidence of 1 per 45,000 head of adult population per year. Blunt injury (n = 285, 79%) was the main cause of urological trauma. Road traffic accidents were most frequent (197 patients, 54%), followed by assaults (76, 21%) and high falls (45, 12%). Renal injuries were the most common (n = 241, 67%), followed by injuries to the external genitalia (71, 20%), bladder (65, 18%), urethra (16, 4%) and ureter (3, 1%). Only 52 patients (14%) had isolated urological trauma. One hundred and fifty nine out of 310 (51%) urological patients with associated injuries were physiologically compromised on arrival in A&E, compared with only 4/52 (8%) patients with isolated urological trauma. All patients with isolated urological trauma survived, whereas 110/310 (35%) of those with associated injuries died. CONCLUSION: Urological injuries in Scotland mostly result from blunt trauma due to high-energy impacts. Isolated urological injuries are uncommon and all such patients survived. The majority of patients with urological trauma have multiple injuries and require a multi-disciplinary approach. Current urological services appear adequately distributed to cope with contemporary demands of urological trauma.

Comparison of 2 generations of piezoelectric lithotriptors using matched pair analysis.

PURPOSE: The Piezolith 3000 (Richard Wolf, Knittlingen, Germany) is the newest piezoelectric lithotriptor. Using a matched pair analysis model we compared treatment outcomes of this machine with those of an older generation Piezolith 2300 lithotriptor (Richard Wolf). MATERIALS AND METHODS: Patients with solitary, radio-opaque urinary calculi undergoing primary lithotripsy using the Piezolith 3000 were identified. All patients had a 3-month followup. These patients were matched with those from our database treated between 1992 and 1999 with a Piezolith 2300. Patients were initially matched for gender, side and site of the stone. For stones other than those in the lower calix and lower ureter, matching was performed for size in terms of maximum and minimum diameter of the index stone. Additional anatomical factors of caliceal pelvic height and vertical distance of the lower ureteral stone from pubic symphysis were also measured. Thereafter stones with size +/- 1 mm of the index stone were selected and the stone with the best matched anatomical factors was chosen. The initial stone fragmentation rate and stone-free rates at 3 months in the matched pairs were then compared. RESULTS: A total of 25 matched pairs were found between October 2002 and December 2002. There was no statistical difference between the initial fragmentation rate for the Piezolith 3000 (68%) and the Piezolith 2300 (84%, McNemar's test p = 0.388). The stone-free rate at 3 months for the Piezolith 3000 and the Piezolith 2300 were 36% and 48%, respectively, again with no statistical difference (McNemar's test p = 0.581). CONCLUSIONS: Despite significant design changes and technical modifications, the new piezoelectric lithotriptor does not appear to provide a better treatment outcome than the older generation machine.

Laparoscopic nephroureterectomy for upper tract transitional cell carcinoma.

OBJECTIVE: The standard surgical treatment of upper tract TCC remains nephroureterectomy with excision of a cuff of bladder. However, laparoscopic nephroureterectomy (LNU) has been shown to be associated with reduced perioperative morbidity, a shorter hospital stay, and a reduced requirement for transfusion than open nephroureterectomy (ONU). The objective of this article is to review experience and outcome following laparoscopic nephroureterectomy for upper tract TCC. METHOD: A literature search of PubMed (www.ncbi.nlm.nih.gov/PubMed/) was performed and articles reporting technical aspects and outcome of laparoscopic nephroureterectomy for upper tract TCC were reviewed. RESULTS: The published data show that outcomes reported following LNU in terms of cancer control are comparable to ONU, at least in the short to medium term. Despite concerns about port site recurrences there were no incidences of this in the 125 patients undergoing LNU in the reviewed reports. An interesting observation was that a high percentage of the tumours are Grade 2 or 3 when TCC affects the upper tract, unlike TCC of the bladder where the majority of tumours are of low grade and stage. CONCLUSION: Laparoscopic nephroureterectomy is a safe treatment option for patients with upper tract TCC. The shorter hospital stay and faster overall recovery is obviously of benefit to the patient, but importantly the longer-term tumour control appears to be equivalent to that following open nephroureterectomy.

Laparoscopic and renal sparing approaches to tumours of the ureter and kidney.

Until recently, malignancies of the kidney and ureter were managed with open radical surgery. Over the last decade the urologic community has adopted the skill of laparoscopic surgery for the treatment of these tumours. Parenchymal sparing procedures have become the standard of care in the treatment of selected patients with renal and ureteral tumours and many of these surgical procedures can be performed laparoscopically or ureteroscopically. Due partly to necessity and partly to the advancement of technology, renal and ureteral sparing procedures have become commonplace for definitive treatment and palliation of these tumours. The morbidity of such procedures is significantly less than for open surgery and the future of urologic minimally invasive surgery appears secure. This review article is aimed at updating the reader in the most recent advances in these techniques.

Laparoscopic radical nephrectomy.

Laparoscopic radical nephrectomy has gained in popularity as an accepted treatment modality for localized renal cell carcinoma at many centers worldwide. Laparoscopic radical nephrectomy may be performed via a transperitoneal or retroperitoneal approach. Mostly, the transperitoneal approach is used. Current indications for laparoscopic radical nephrectomy include patients with T(1)-T(3a)N(0)M(0) renal tumors. Herein, transperitoneal as well as retroperitoneal laparoscopic approaches are described. Surgical outcomes and complications from published series are reviewed with comparison to open surgery. Special related concerns as oncologic principles, organ retrieval, lymphadenectomy, and concomitant adrenalectomy are addressed. In conclusion, laparoscopic radical nephrectomy is now established with considerable advantages; decreased postoperative morbidity, decreased analgesic requirements, improved cosmesis, shorter hospital stay and convalescence. Although no long-term follow-up is available, short and intermediate follow-up results confirm the effectiveness of laparoscopic radical nephrectomy.

Ischemia-reperfusion injury after relief of ureteral obstruction: an animal study.

BACKGROUND AND PURPOSE: The complex series of pathophysiologic alterations associated with obstruction nephropathy includes renal ischemia. Free-radical production follows relief of obstruction. We sought to determine whether free radicals caused additional reduction in blood flow after relief of obstruction. MATERIALS AND METHODS: In White-Landrace pigs, the left ureter was divided 6 cm distal to the ureteropelvic junction, and a nephrostomy tube was passed into the renal pelvis and exteriorized. A catheter was placed in the renal vein and exteriorized. Mean renal blood flow was measured before manipulation and during and after 6 hours of obstruction in animals receiving (N = 7) or not receiving (N = 7) allopurinol. The control groups were not subjected to ureteral obstruction and received (N = 7) or did not receive (N = 7) allopurinol. Free radicals in venous blood were measured by the Fox-1 assay for lipid peroxidation. RESULTS: After obstruction, renal blood flow declined significantly by the sixth hour (-28.73% +/- 1.81). The increase after relief of obstruction was only temporary, and by the third hour, the blood flow was again reduced (-20.14% +/- 2.67). Free radical production was significantly increased, with a peak of +24.63% being found 60 minutes after relief of obstruction. Allopurinol prevented free radical production after relief of obstruction and was associated with a return of blood flow to baseline values. CONCLUSION: Free radicals contribute to renal blood flow reduction after relief of ureteral obstruction. Functional impairment may be preventable by free radical blockade, but further studies are required to confirm this hypothesis.

Virtual endoscopy in urology.

Recent years have seen notable advances in virtual reality technology and increased interest in potential medical applications. Computed tomography and magnetic resonance imaging data sets, historically viewed as axial images, may now be used to construct a virtual reality endoscopic image, and navigator software systems allow the operator to 'fly' through the urinary tract. Technological evolution has improved the quality of reconstruction, as this is dependent on the software and data set, allowing virtual reality to begin to challenge endoscopic evaluation. This review describes the evolution of virtual reality in urology and the milestones of its current clinical use. Applications may become widespread in the diagnostic evaluation of common urological symptoms, the planning of surgery and the training of future urologists.