Expression of cytokeratin 20 and CD44 protein in upper urinary tract transitional cell carcinoma: cytologic-histologic correlation.

OBJECTIVE: To explore the potential utility of immunostaining for CK20 and CD44 protein isoforms in evaluating cases of upper urinary tract transitional cell carcinoma (UTTCC). STUDY DESIGN: Of 105 consecutive patients diagnosed cytologically with UTTCC, 33 subsequently underwent open surgical procedures. Cytologic samples from these patients retrieved by aspiration and biopsy, and corresponding surgical specimens were graded and staged using World Health Organization/International Society of Urologic Pathologists criteria. Immunostaining for CK20, CD44 standard (CD44s) and CD44v6 isoform (CD44-v6) was performed on all available cytologic and surgical materials. Expression levels and distributions of these markers were correlated semiquantitatively with grade and stage. RESULTS: Cytologically assigned grade correlated with final histologic grade in 19 of 31 cases examined (61%). However, tumor invasion was not accurately assessable in cytologic samples from the majority of these cases. Statistically significant correlations of both increasing tumor grade and stage with abnormal CK20 expression were found. In addition, a significant relationship between focal CD44 isoform expression loss and tumor grade was identified. However, CD44 isoform expression loss did not significantly correlate with increasing tumor stage. CONCLUSION: Although cytologic tumor grading of UTTCC was accurate, invasion could not be adequately assessed. As an adjunct to morphologic analysis, immunostaining for CK20 and CD44 may aid in the clinical evaluation of UTTCC tumor stage and biologic behavior prior to definitive therapy.

Long-term effects of ureteroscopic laser lithotripsy on glomerular filtration rate in the face of mild to moderate renal insufficiency.

BACKGROUND AND PURPOSE: Ureteroscopic laser treatment of calculi in the upper urinary tract was examined in regard to its effect on renal function in the setting of mild renal insufficiency. Percutaneous nephrolithotomy (PCNL) and SWL have been previously shown not to adversely affect the glomerular filtration rate (GFR) in renal insufficiency, but to our knowledge, the effect of ureteroscopic laser lithotripsy on GFR has not been previously reported. PATIENTS AND METHODS: A retrospective review of all cases of ureteroscopic laser lithotripsy at our institution was performed. A total of 18 patients with a baseline serum creatinine of > or = 1.5 mg/dL were found. The mean follow-up after treatment was 18.0 months (range 4-39 months). The change in the reciprocal of serum creatinine was used as an indicator of change in the GFR. Deterioration of 20% was considered significant. RESULTS: The overall mean change in treated patients was a 5.9% improvement. Patients with a preoperative creatinine of < 2.0 mg/dL improved 7.6% and those with creatinine of > or = 2.0 mg/dL increased 3.9%. Other factors such as the size of the stone, location of the stone, and total joules used during treatment were not significant. CONCLUSION: This examination suggests that ureteroscopic laser lithotripsy has no ill effects on renal function in the face of mild to moderate renal insufficiency.

Ureteroscopic surgery for upper tract transitional-cell carcinoma: complications and management.

In some patients with small low-grade transitional-cell carcinoma of the ureter, the lesion can be treated ureteroscopically with the laser or electrocoagulation. Patients must be compliant with lifelong frequent surveillance. Surgical complications such as ureteral perforation and stricture are uncommon. The authors provide advice on technique and on preventing and managing complications.

Experience with endoluminal ultrasonography in the urinary tract.

Ultrasonography has been an invaluable tool in the field of urology for its noninvasiveness, safety, and relatively low cost. However, examination of the ureter with ultrasound is difficult because of the distance of the transducer from the ureter and because of intervening structures such as nonconductive bowel gas. As smaller probes have become available, attempts have been made to apply them to endoluminal use. Endoluminal ultrasonography has been employed in urology to examine the proper placement of injected collagen, diagnose urethral diverticula, diagnose and stage upper tract transitional-cell carcinoma, locate crossing vessels to guide endopyelotomy, diagnose submucosal calculi, and examine the severity and length of ureteral strictures.

Fluoroscopic placement of double-pigtail ureteral stents.

PURPOSE: Double-pigtail ureteral stent is placed cystoscopically after ureteroscopy. We describe a technique for fluoroscopic placement of ureteral stents and demonstrate its use in a non-randomized prospective study. MATERIALS AND METHODS: Double-pigtail stents were placed either fluoroscopically or cystoscopically in 121 consecutive patients. In the fluoroscopic method, the stent was placed over a guide wire using a stent pusher without the use of cystoscopy. Conversely, stents were placed through the working channel of the cystoscope under vision. The procedure, stent length, width, type, method, ureteral dilation, and use of a retrieval string were noted. RESULTS: A wide range of stent sizes were used. The success with fluoroscopic placement of double-pigtail ureteral stents was 100% (89 of 89 cases). No stents migrated or required replacement. Stents were placed after ureteroscopic laser lithotripsy (53/89) and ureteroscopic tumor treatment (22/89). Cystoscopic visualization was used in 32 additional procedures requiring precise control (15 ureteral strictures and nine retrograde endopyelotomy). CONCLUSIONS: The fluoroscopic placement of ureteral stents is a safe and simple technique with a very high success rate. We have used cystoscopic placement only after incisional procedures such as retrograde endopyelotomy, stricture or ureterotomy.

Surveillance of upper urinary tract transitional cell carcinoma: the role of ureteroscopy, retrograde pyelography, cytology and urinalysis.

PURPOSE: A select group of patients with upper tract transitional cell carcinoma are treated with ureteroscopic resection. We determine the validity and accuracy of urinalysis, bladder cytology, upper tract biopsy/cytology and retrograde pyelography for the detection of recurrent upper tract transitional cell carcinoma compared to endoscopic findings. MATERIALS AND METHODS: Patients with ureteroscopically treated upper tract transitional cell carcinoma were followed with surveillance every 3 to 6 months. Surveillance included urinalysis with dipstick and microscopic examination, bladder cytology, retrograde pyelography read by a urologist and radiologist, and ureteropyeloscopy with cytology and biopsy of suspicious areas. Not all results were available for all surveillance procedures. Measures of sensitivity and specificity for the aforementioned surveillance procedures were determined relative to endoscopic findings that were defined as the standard. Confidence intervals were also estimated. Initially, a generalized estimation equation approach was used to take into account the clustering of repeated testing within patients. The accuracy of each procedure was also calculated. RESULTS: There were 23 patients with previously resected low grade upper tract transitional cell carcinoma who underwent a total of 88 surveillances in 30 months. A total of 56 of 88 (64%) recurrences were detected ureteroscopically, including 11 (12%) associated bladder recurrences. In patients who did not have bladder recurrences urinalysis had a sensitivity of 37.5% but specificity was 85%, while bladder cytology had a sensitivity of 50% and specificity was 100%, and retrograde pyelography read in the endoscopy room revealed a sensitivity of 71.7% and specificity of 84.7%. Ureteroscopic biopsy/cytology had a sensitivity and specificity of 93.4% and 65.2%, respectively. CONCLUSIONS: Our findings indicate that compared to ureteroscopy, urinalysis, bladder cytology, retrograde pyelography and ureteroscopic cytology/biopsy are less valid and accurate in detecting upper tract transitional cell carcinoma recurrences. Based on our data we recommend ureteroscopic evaluation as an essential procedure for the surveillance of patients treated endoscopically for upper tract transitional cell carcinoma.

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

PURPOSE: The standard treatment for upper tract transitional cell carcinoma in patients with a normal contralateral kidney is nephroureterectomy with a bladder cuff or segmental ureterectomy. We evaluate whether ureteroscopic tumor resection with vigilant surveillance is a safe alternative in select patients. MATERIALS AND METHODS: Patients with isolated upper tract filling defects on an excretory urogram and a normal contralateral kidney were diagnosed ureteroscopically with papillary low intermediate grade appearing transitional cell carcinoma. Biopsies of the lesions were obtained, and the tumors were treated with laser ablation or electrofulguration in the same sitting. Patients with cytopathological results of high grade transitional cell carcinoma underwent nephroureterectomy. Surveillance consisted of ureteroscopy every 3 months until tumor-free and ureteroscopy every 6 months thereafter. RESULTS: Between 1989 and 1998, 23 patients with normal creatinine (mean 1.0, range 0.7 to 1.6) underwent ureteroscopic resection of unilateral upper tract transitional cell carcinoma. On initial biopsy 22 tumors were grade 1 or 2 and 1 was grade 2 to 3. After the primary tumor was treated 8 (35%) patients remained tumor-free and 15 (65%) had multiple recurrences, which were treated ureteroscopically. Mean followup was 35 months (range 8 to 103 months). All 23 patients are alive without evidence of disease progression. At last followup 4 patients (17%) had persistent disease, 4 (17%) elected to undergo nephroureterectomy and 15 (65%) are free of ipsilateral disease for a mean duration of 17 months (range 6 to 77). CONCLUSIONS: Ureteroscopic treatment of focal low intermediate grade superficial upper tract transitional cell carcinoma is a safe alternative to nephroureterectomy in select patients when vigilant ureteroscopic followup is used.

Examining the obstructed ureter with intraluminal sonography.

PURPOSE: Intraluminal sonography was used to define, differentiate and direct better treatment of obstructing ureteral lesions. MATERIALS AND METHODS: A total of 63 patients with a history of ureteral obstruction and suspected stricture were accrued for evaluation. All patients underwent retrograde contrast imaging, ureteroscopy and intraluminal sonography as part of a diagnostic algorithm. Specific sonographic criteria to differentiate lesions and stricture types were developed. Associated complicating variables defined on sonography included foreign bodies, submucosal stone fragments, ureteral wall fibrosis, mass lesions and adjacent vasculature. Endoscopic treatment was then performed with ultrasound guidance if technically feasible. RESULTS: A total of 63 ureters were evaluated with the preoperative diagnosis of ureteral stricture disease. All ureters were narrowed on contrast imaging in the segment where a stricture was suspected. On sonography 24 ureters (36%) had wall fibrosis with normal periureteral tissues. In general these strictures did well with endoscopic incision. Of the 67 ureters 13 (19%) were thickened or had edematous walls with normal architecture and without fibrosis. These patients all did well with expectant therapy. In contrast, 7 ureters (10%) were obstructed by segmental retroperitoneal fibrosis which did not respond to minimally invasive therapies. In addition, 8 ureters (12%) were obstructed by ureteral wall scarring and periureteral fibrosis, and required open surgical intervention. Ten ureteral strictures had adjacent vasculature, and endoscopic incisions under ultrasound guidance were directed safely away from these structures without associated morbidity. Calculi, stone fragments and foreign bodies embedded in the ureteral wall with associated inflammation were defined with sonography and responded to endoscopic therapies. The intraluminal sonographic diagnosis of ureteral endometriosis was made in 6 patients with a range of lesions from bright, hyperechoic blood filled cysts to an inhomogeneous fluid filled scar involving the wall and periureteral tissues. Primary ureteral carcinoma was also demonstrated in 2 patients after other diagnostic techniques failed. In 1 of these patients intraluminal sonography directed biopsies diagnosed submucosal tumor. Finally, 1 patient had a small periureteral urinoma on intraluminal sonography which was missed on other imaging studies. CONCLUSIONS: Intraluminal sonography is useful in patients with ureteral obstruction of unclear etiology as well as for selecting patients who may benefit from minimally invasive therapies and safely directing these treatments.

Retrieval capabilities of different stone basket designs in vitro.

BACKGROUND AND OBJECTIVE: Several designs of endoscopic stone retrieval baskets are available. Each instrument has special characteristics which can be employed in different locations with different techniques and various effects. In this study, we compared the retrieval capability of five basket designs in two in vitro models. MATERIALS AND METHODS: The five baskets were a flat wire (Segura), Parachute, N-0-tip, and two helical designs. The ability of the baskets to retrieve beads of 4, 6, and 8 mm was compared in two models. Each size was used individually, and four beads of the 4-mm size were also studied. In the first model, single and multiple beads were placed in a cylindrical plastic tube to mimic removal of the stone from the ureter. In single-bead retrieval trials, the basket was opened beyond the bead and withdrawn, whereas with multiple beads, the basket was opened beyond, withdrawn, and closed. Bead engagement and removal was considered a successful retrieval. Three repetitions were performed for each basket and each bead size. In the second model, similar beads were placed in a round-bottom test tube to simulate a stone within a calix. The basket was opened at the base of the tube and closed. The number of beads removed was noted for three repetitions for each basket. RESULTS: All baskets were able to retrieve the 4-, 6-, and 8-mm beads from the cylinder, with the exception of the four-wire helical basket, which failed in two of the three retrieval attempts for the 4- and 6-mm beads, and the double-helical basket, which failed in two of the three retrieval attempts for the 4-mm bead. When four beads 4 mm in size were used, the Parachute and double-helical baskets retrieved all of them within two trials and the N-0-tip and four-wire helical baskets within three trials. The Segura basket failed all trials. In the test tube model, all baskets failed to remove any beads with the exception of the N-0-tip, which was successful in removing a single bead with each positioning. CONCLUSIONS: In these in vitro models, it was apparent that the design of the basket affects its ability to retrieve calculi in different situations.

Management of upper urinary tract calculi with ureteroscopic techniques.

OBJECTIVES: To evaluate our experience in treating 155 patients with upper urinary tract calculi ureteroscopically. The treatment of urinary calculi has remained the most frequent application of ureteroscopy. Miniaturization of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. METHODS: Ureteroscopic stone treatment was attempted in 155 patients with upper urinary tract calculi between November 1995 and March 1997. Fifty-nine (38.1%) patients had renal calculi, 82 (52.9%) ureteral, and 14 (9%) had both renal and ureteral calculi. Both semirigid and flexible ureteroscopes were used for treatment (rigid alone in 21 [13.5%], flexible in 64 [41.3%], and both rigid and flexible in 70 [45.2%] patients). Lithotripsy was required in 122 (79%) of the patients. The holmium:yttrium-aluminum-garnet laser was used in 113 (92.6%) of these patients. RESULTS: All patients with ureteral calculi (29 proximal, 19 mid, and 34 distal) were successfully cleared after one endoscopic procedure except for 1 patient with a proximal ureteral calculus who had a 4-mm residual fragment in the kidney. Of the 59 patients with renal calculi, 47 (79.7%) were totally clear of stones 1 month after treatment. The remaining 12 (20.3%) patients had evidence of residual calculi 3 to 4 mm or less in diameter. In patients with combined renal and ureteral calculi, 1 1 of 14 (78.6%) were rendered stone free. The remaining 3 (21.4%) patients had evidence of residual calculi 4 mm in diameter. Overall, 95% of the patients were treated in an outpatient setting. Morbidity was low, with no evidence of stricture. CONCLUSIONS: Ureteroscopy and laser lithotripsy in experienced hands are a safe and reliable method for the treatment of ureteral and even intrarenal calculi.

Three-dimensional endoluminal ultrasonography of the ureter.

Endoluminal ultrasonography has been useful in demonstrating the ureteral and periureteral anatomy. Devices now available give cross-sectional images. A computer program is available to reconstruct these images into three-dimensional (3D) representations. Endoureteral sonography was performed using 6.2F endoluminal ultrasound catheters connected to a dedicated ultrasound unit giving cross-sectional images. The images along the segment in the study were collected by advancing the catheter to the most proximal portion and pulling it in antegrade fashion through the segment with a step-pulling device. The images were collected on videotape and reconstructed into 3D representations using a dedicated 3D computer system (Lis 6000-A). Anatomic features studied included ureteral strictures, obstructed ureteropelvic junction, ureteral neoplasms, and the ureterovesical junction. In each case, additional information and appreciation of the structure could be obtained with the 3D reconstruction. Endoluminal ultrasonography has provided an additional dimension to imaging of the ureter. Three-dimensional reconstruction of these images can give additional information regarding the longitudinal appearance of ureteral segments without the need for development of new ultrasound transducers. It can offer appreciation of anatomic features not evident with two-dimensional imaging alone.

Ureteroscopic treatment of ureteropelvic junction obstruction.

PURPOSE: Endopyelotomy has increasingly become well accepted as the optimal management for primary and secondary ureteropelvic junction obstruction. We report our experience with ureteroscopic endopyelotomy guided by endoluminal ultrasound. MATERIALS AND METHODS: Ureteroscopic endopyelotomy was attempted in 27 patients with primary and 10 with secondary ureteropelvic junction obstruction. Retrograde pyelogram and endoluminal ultrasound were performed at the start of the procedure in all patients. Based on sonographic findings 5 patients were not considered candidates for the procedure. The remaining 13 men and 19 women were treated ureteroscopically with a rigid ureteroscope in 5 (15.6%), flexible in 20 (62.5%), and rigid and flexible in 7 (21.9%) patients. Stents were placed postoperatively for 6 to 10 weeks. The patients were followed for a mean duration of 10 months. RESULTS: The procedure was completed in all patients. Average operating time was 95 minutes including the time for imaging. Sonographic localization guided the site of incision in all patients and changed therapy in 5. It identified crossing vessels in 10 patients (31%), septum denoting high insertion in 5 (15.5%) and both in 7 (22%). Preoperative stenting was not required in any patient. Morbidity was low with no patients requiring transfusion and no evidence of ureteral strictures. Success, defined as pain-free with resolution of obstruction on diuretic renal scan, was achieved in 28 of the 32 patients (87.5%). CONCLUSIONS: Ureteroscopic endopyelotomy is a safe and effective treatment for most cases of ureteropelvic junction obstruction. Endoluminal ultrasonography of the obstructed ureteropelvic junction has gained a major role in defining which patient to treat and in directing endoluminal incisions to minimize the risk of injury to adjacent vessels. There is a higher failure rate when vessels are present.

Ureteroscopic laser treatment of upper urinary tract tumors.

OBJECTIVE: To summarize the present status of ureteroscopic laser treatment of upper urinary tract tumors. SUMMARY AND BACKGROUND DATA: Small diameter rigid and flexible ureteroscopes can provide convenient access to the upper urinary tract. The small diameter of the instruments and the working channels are ideally suited for the placement of laser fibers as an intraluminal ablative technique. METHODS: The authors reviewed the literature and their own experience with laser treatment of upper tract tumors for the description of instruments, techniques, and the results achieved. RESULTS: At least 12 reports have presented the results after using lasers for treating upper tract tumors. The Nd:YAG laser has been used in most series but more recently, the holmium:YAG laser has become available. Each laser has particular advantages and each can be delivered along the same low water content quartz fibers. Less scarring with stricture formation has been reported after use of the laser versus electrofulguration. Among the series reported, local recurrences occurred in 33% of patients with renal pelvic tumors or ureteral tumors. In the authors' experience, the holmium:YAG laser was most frequently used and the combination of holmium and Nd:YAG was nearly as common. The Nd:YAG was used alone in less than 10% of patients. CONCLUSIONS: The ureteroscopic treatment of upper tract transitional cell carcinoma is a reasonable alternative to surgical removal in many patients. It provides a major advantage in patients with specific indications for conservative therapy and may be a reasonable elective therapy in others with small, low grade, tumors. The holmium laser alone or in combination with the Nd:YAG laser has become our primary mode of therapy.

Ureteroscopic and radiographic imaging of the upper urinary tract.

Direct endoscopic viewing of the upper urinary tract offers multiple benefits, including recognition and diagnosis, and also permits unsurpassed accuracy in positioning working instruments for biopsy and treatment. We have demonstrated the normal and abnormal endoscopic findings within the upper urinary tract in patients who were treated ureteroscopically for numerous indications, including calculi, filling defects, or ureteral obstruction. Small (7 to 7.5F) rigid and flexible ureteroscopes were employed in all patients. Selected endoscopic images of the subject lesions were photographed using a 35-mm camera with an endoscopic zoom lens and ISO-400 film. Endoscopic findings are illustrated in 13 patients, with case summaries in 11. Selected radiographic and endoscopic images show the essential features in each case and demonstrate the value of ureteroscopic examination.

Laser division of intraluminal sutures.

Neodymium:YAG and holmium:YAG lasers were used to remove intraluminal sutures from three patients. In two, the suture was in the bladder and had served as a nidus for stone formation. In the other, the suture was in the ureter. An in vitro study showed that the Nd:YAG laser could divide all types of suture readily, whereas the Ho:YAG laser could divide all materials except Gortex. These cases illustrate another application for lasers.

Upper urinary tract inverted papillomas.

Inverted papilloma is a rare, benign tumor. Only 33 cases to date have been reported to have occurred in the upper urinary tract. These lesions have a male predominance, are difficult to diagnose, and are associated with urothelial malignancy. Because transitional cell carcinoma can present even 8 years after surgery and in other sites within the urinary system, careful follow-up is essential. This article adds 2 new cases and 1 follow-up of a previously reported case from 1990.

Treatment of biliary calculi using holmium: yttrium aluminum garnet laser.

BACKGROUND: The holmium: yttrium aluminum garnet laser (Ho: YAG) has been shown to be effective and safe for the treatment of urinary calculi. Its effectiveness for the treatment of biliary calculi was investigated. METHODS: Endoscopic Ho: YAG lithotripsy of biliary stones was performed 7 times in 4 patients. Two patients had biliary duct calculi, and the other two patients had gall bladder calculi. All patients had multiple calculi that ranged in size from 4 mm to 5 cm. All procedures were performed percutaneously under intravenous sedation and local anesthesia. Rigid and flexible endoscopes were used to access the biliary calculi. Postoperative cholangiograms were performed on all patients. RESULTS: All calculi were successfully fragmented with the Ho: YAG laser. The most common settings on the laser were 1.0 J and 10 Hz. Average total laser energy used was 12.24 kJ. Two patients required multiple procedures for the resolution of the biliary calculi. No vascular or biliary injuries were encountered. Three patients were free of biliary calculi on their postoperative cholangiogram. One patient with multiple gallbladder stones refused further treatment after two percutaneous procedures. CONCLUSION: The holmium: yttrium aluminum garnet laser can be used safely and effectively in the endoscopic treatment of biliary calculi. This treatment maybe a suitable option in patients who are not candidates for more invasive procedures.

Ureteroscopic evaluation and treatment of chronic unilateral hematuria.

PURPOSE: Chronic unilateral hematuria constitutes a difficult problem of diagnosis and treatment. We evaluated 23 patients with unilateral renal hematuria to determine the cause of bleeding and to evaluate ureteroscopic treatment. MATERIALS AND METHODS: A total of 23 patients with chronic unilateral hematuria were evaluated ureteroscopically during a 2-year period. Semirigid and flexible ureteroscopes were used to evaluate all patients. Dilation of the ureterovesical junction was required in only 1 patient. RESULTS: The entire ureter and intrarenal collecting system were inspected in all patients. Discrete lesions comprised hemangioma in 7, minute venous rupture in 3, small papillary tumor in 3 and calculus in 2 patients which were treated successfully. Nonspecific lesions comprised submucosal erythema in 2 patients and abnormal papillary tip in 1 which were treated successfully as well. In the remaining 5 patients no lesions were detected. In all treated patients hematuria resolved with no recurrence during a mean followup of 8 months (range 4 to 18). CONCLUSIONS: Ureteroscopy is an important diagnostic and therapeutic procedure for patients with chronic unilateral hematuria.

Ureteroscopic retrograde endopyelotomy.

With improvements in technology, we continue to seek new surgical techniques to approach old surgical issues. Antegrade percutaneous endopyelotomy has become the most common first-line approach to treatment of ureteropelvic junction obstruction, however, it is now possible to treat this condition successfully through a retrograde ureteroscopic approach. By combining the latest small ureteroscopes with the technology of endoluminal ultrasound, it is possible to treat this disease in a single setting without the complications of ureteral strictures or significant postoperative hemorrhage, thereby eliminating the need for a nephrostomy tube and dramatically reducing the morbidity of the procedure.