Is a 1-CM margin necessary during nephron-sparing surgery for renal cell carcinoma?

OBJECTIVES: To determine whether a 1-cm margin is necessary for cancer control during nephron-sparing surgery (NSS) for renal cell carcinoma (RCC). METHODS: A retrospective review of 67 patients who underwent NSS for RCC between 1990 and 2000 was conducted. The data collected included patient demographics, tumor size and location, histologic type and grade, margin status (positive or negative), and the shortest distance of normal parenchyma (in millimeters) around the tumor in the final pathologic specimen. Recurrence was determined from the clinical follow-up, which included physical examination, ultrasonography or computed tomography, and various laboratory tests. RESULTS: Fifty-five cases were performed open and 12 laparoscopically. The mean follow-up was 60 months (range 5 to 124). The mean tumor size was 3.0 cm (range 0.9 to 11.0). Seven patients were found to have a positive margin; 1 died of metastatic RCC, 1 was alive with systemic recurrence, and 5 had no evidence of disease. Of 11 patients with a negative margin distance of less than 1 mm, 9 were recurrence free, 1 had simultaneous local and pulmonary relapse, and the other had pulmonary recurrence only. The remainder of the study patients (n = 49) had negative margins greater than 1 mm, and all were alive without evidence of disease at the last follow-up. CONCLUSIONS: This review questions the necessity of a 1-cm margin to prevent recurrence after NSS for RCC. Additional studies to determine the optimal margin distance should be conducted.

Bladder rupture after blunt trauma: guidelines for diagnostic imaging.

PURPOSE: The purpose of this study was to establish guidelines for diagnostic imaging for bladder rupture in the blunt trauma victim with multiple injuries, in whom the delay caused by unnecessary testing can hamper the trauma surgeon and threaten outcome. METHODS: We undertook chart review (1995-1999) of patients with blunt trauma and bladder rupture at our four institutions and performed focused literature review of retrospective series. RESULTS: Of our 53 patients identified, all had gross hematuria and 85% had pelvic fracture. Literature review revealed similar rates. CONCLUSION: The classic combination of pelvic fracture and gross hematuria constitutes an absolute indication for immediate cystography in blunt trauma victims. Existing data do not support lower urinary tract imaging in all patients with either pelvic fracture or hematuria alone. Clinical indicators of bladder rupture may be used to identify atypical patients at higher risk. Patients with isolated hematuria and no physical signs of lower urinary tract injury may be spared the morbidity, time, and expense of immediate cystographic evaluation.

Ureteral substitution with a stapled neoureter: a simplified Boari flap.

PURPOSE: We evaluate a new technique that will quickly and easily replace a long segment of ureter by creating a tapered neoureter (Boari flap) with bladder wall and absorbable staples. MATERIALS AND METHODS: A neoureter was created in 14 pigs with native bladder and 75 mm. Polysorb gastrointestinal anastomosis staplers (U. S. Surgical, Norwalk, Connecticut). Urine culture and serum creatinine were obtained before neoureter creation. Neoureter length and time to construct were recorded. At 6 weeks serum creatinine was repeated, and ureteral stent removed with evaluation of the staple lines for stones and residual staples. At 4 months intravenous pyelogram, cystogram and serum creatinine were obtained before necropsy. The bladder, neoureter and kidneys were examined grossly and histologically for hydronephrosis, staples, stones and stenosis. RESULTS: Mean neoureter length was 13.4 cm. and mean time to construct was 15 minutes. Laboratory results were unremarkable. Of the 14 pigs 2 died of pneumonia before stent removal, and at autopsy neither had evidence of hydronephrosis nor anastomotic stricture. In the remaining 12 pigs there was no evidence of residual staples or stone formation with mucosa covering the staple line at cystoscopy and necropsy. Successful neoureter substitution was performed in 9 pigs with no gross or histological changes. There were 3 pigs that had evidence of hydronephrosis with histological findings of chronic pyelonephritis and 2 of them appeared atrophic compared to the contralateral kidney. CONCLUSIONS: Our study demonstrates a new technique for ureteral substitution with bladder and absorbable staples that may be performed quickly and easily. Furthermore, we show that absorbable staples can be safely incorporated into the urinary tract with minimal worry about encrustation or calculus formation.

Correlation of cystoscopic impression with histologic diagnosis of biopsy specimens of the bladder.

There is a paucity of information in the contemporary literature that would permit assessment of the urologist's ability to endoscopically discriminate between benign and malignant lesions of the bladder or to predict the grade and stage of papillary neoplasms. This prospective study evaluates the correlation between cystoscopic impression of urothelial lesions and final histologic diagnoses. Sixty-four patients with 68 urothelial abnormalities requiring formal biopsy or endoscopic resection were evaluated prospectively. At the time of endoscopy, treating urologists completed questionnaires documenting the surgeon's endoscopic impression of disease type and extent and performed standard biopsy or resection of all suspicious lesions. Specimens were submitted for routine histopathologic analysis, and the results were correlated with the questionnaire data. Endoscopic evaluation correctly discriminated between dysplastic/malignant and benign/reactive lesions in this study with a sensitivity of 100%, specificity of 100%, and positive and negative predictive values of 100%. Urologists could not readily distinguish between low- and high-grade papillary urothelial lesions and were frequently unable to determine if a tumor was invasive, particularly if the degree of invasion was microscopic. Endoscopic impression at the time of bladder biopsy or resection is accurate and discriminates between the presence and absence of cancer. Endoscopic impression alone is a relatively poor staging tool with respect to extent of invasive disease and must be coupled with careful histopathologic analysis of biopsy material, bimanual examination when appropriate, and axial imaging for complete assessment of a given tumor.

The broken stone basket: configuration and technique for removal.

PURPOSE: We investigated the ease of breakage of endoscopic stone baskets with the holmium:yttrium-aluminum-garnet (YAG) laser and their resultant configuration. More importantly, possible safe methods of retrieval were evaluated. MATERIALS AND METHODS: Endoscopic stone baskets from Bard (Platinum Class 2.4F Flat and 3.0F Helical Wire), Cook (3.2F Captura, 3.2F Atlas, 3.0F N-Circle, 4.5F N-Force), and Microvasive (2.4F Zero Tip, 3.0F Gemini, 3.0F Segura) were broken once using the holmium:YAG laser. The energy (kJ) required to break one of the wires was recorded. Configuration was documented using photographs. Baskets were disassembled and assessed for extraction through a 7F open-ended catheter, an 8F/10F set, and a 20F peel-away sheath. RESULTS: Tipless baskets (N-Circle, Zero Tip) broke the easiest (range 0.02-0.03 kJ). Tipped baskets (Segura, Platinum Class Flat and Helical, Gemini, Captura, N-Force, Atlas) were more resistant, but all broke within the range (0.06-0.78 kJ) typically used for intracorporeal lithotripsy. Broken segments of wire tended to protrude outward, with tipless baskets having less change in configuration than tipped baskets. Tipless baskets could easily be pulled into any of the extracting devices, whereas tipped baskets could not. CONCLUSIONS: Baskets break at typical holmium:YAG intracorporeal lithotripsy energy settings. Tipless baskets break easiest and assume a safer configuration. Tipless baskets are extracted easily through a 7F open-ended catheter, 8F/10F set, or 20F sheath, while tipped baskets are unable to be extracted through any of these.

Laparoscopic nephron-sparing surgery for solid renal masses using the ultrasonic shears.

OBJECTIVES: To report our experience with laparoscopic nephron-sparing surgery (NSS) for solid renal masses. METHODS: Between August 1998 and December 1999, 15 patients with solid renal masses underwent laparoscopic NSS at our institutions. Seven patients underwent a transperitoneal approach and eight a retroperitoneal approach. The kidneys were fully mobilized to allow inspection of all renal parenchyma. The ultrasonic shears were used to divide the renal parenchyma around the tumor in all cases. Renal surface hemostasis was then accomplished by welding a piece of oxidized regenerated cellulose gauze to the transected renal surface with the argon beam coagulator. Tumors were removed intact and sent for analysis of frozen section margin status. RESULTS: Laparoscopic NSS was successfully completed without complications in all patients. The mean tumor size was 2.3 cm (range 0.8 to 3.5), mean operative time was 170 minutes (range 105 to 240), and mean estimated blood loss was 368 mL (range 75 to 1000). The final pathologic finding was renal cell carcinoma in 12 patients and oncocytoma in 3 patients. All final surgical margins were negative. Patients were hospitalized for a mean of 2.6 days (range 2 to 4). CONCLUSIONS: Laparoscopic NSS for small, solid renal masses can be performed safely with a combination of the ultrasonic shears for renal parenchymal transection and argon beam coagulation and oxidized regenerated cellulose gauze for renal surface hemostasis.

The lion of the union: the pelvic wound of Joshua Lawrence Chamberlain.

PURPOSE: Major General Joshua Lawrence Chamberlain is a true American hero. His medical history and war wounds provide a rare snapshot of Civil War era medicine. In particular the most devastating injury was a rifle shot through the pelvis rupturing the bladder and urethra. We describe this injury and how it affected his life to provide insight into late 19th century urological care. MATERIALS AND METHODS: All available references, including biographies, letters, surgical reports, military documents and prior medical summaries, were reviewed regarding Chamberlain's urological history. RESULTS: While leading the Union charge to Petersburg, Virginia on June 18, 1864, Chamberlain was struck with a minié ball anteriorly below the right greater trochanter. The ball coursed obliquely upward disrupting the bladder and urethra, and embedded behind the left acetabulum. An unprecedented wound exploration in the field hospital was performed to extract the bullet and "reconnect severed urinary organs." Hope for recovery was nonexistent as urine was seen exiting the lower wound postoperatively. This genitourinary injury required 4 subsequent repairs during Chamberlain's lifetime and ultimately left him with a draining urethrocutaneous fistula at the penoscrotal junction. CONCLUSIONS: Survival from catastrophic Civil War wounds was rare, especially from "gut wounds" which had a mortality rate of greater than 90%. Chamberlain not only survived but thrived with his sense of duty carrying him back to the battlefield and beyond. He was plagued during his life with recurrent cystitis and epididymo-orchitis, which in an era without antibiotics was especially miserable. Urosepsis is listed as the cause of death on his death certificate and whether this was true is debatable. However, even if this wound did not cause his death, it surely contributed to it.

Intraluminal pneumatic lithotripsy for the removal of encrusted urinary catheters.

PURPOSE: Urologists frequently treat patients requiring long-term urinary drainage with a percutaneous nephrostomy tube or ureteral stent. When such tubes are neglected and become encrusted, removal challenges even experienced urologists. We describe a new, minimally invasive technique for safely and rapidly removing encrusted, occluded tubes using the Swiss Lithoclast pneumatic lithotriptor. MATERIALS AND METHODS: Patients presenting with an encrusted urinary catheter were evaluated by excretory urography for renal function and obstruction. Gentle manual extraction of the tube was attempted, followed by traditional extracorporeal shock wave lithotripsy and/or ureteroscopy. When the tube was not extracted, patients were then treated with intraluminal insertion of a pneumatic lithotripsy probe. RESULTS: One patient presented with an encrusted, occluded nephrostomy tube and 2 had an encrusted, occluded, indwelling ureteral stent. None was removed by manual traction. Intraluminal encrustations prevented the pigtail portions of these tubes from uncoiling and removal. In each case a pneumatic lithotripsy probe was inserted into the lumen of the catheter and advanced in a jackhammer-like fashion. This technique resulted in disruption of the intraluminal encrustations and straightening of the tubes so that they were removed in an atraumatic manner. CONCLUSIONS: Intraluminal pneumatic lithotripsy is a safe, easy and rapid technique for removing encrusted urinary catheters. It is unique in that the pneumatic lithotripsy probe functions in an aqueous and nonaqueous environment, and dislodges intraluminal calcifications. We recommend its use as first line treatment for removing encrusted urinary catheters.

Priapism: diagnosis and management.

Recent advances in the understanding of erectile physiology have improved the prompt diagnosis and treatment of priapism. During the initial assessment, the physician must distinguish between the two basic types of priapism--low and high flow--because their associated treatment and prognosis differ. To illustrate the diverse manifestation of priapism, we describe the management of four patients with a history of priapism due to varying causes. In addition, we propose an algorithm that provides a systematic and timely approach to treatment. Resumption of erectile function after a prolonged episode of priapism has traditionally been poor but has improved. Patients must be informed that the long-term sequelae of priapism can be avoided with prompt medical or surgical treatment.

Ureteroscopy: current practice and long-term complications.

PURPOSE: We compared a current cohort of patients who underwent ureteroscopy to a cohort from the early 1980s to determine changes in success, indications and long-term complications of the procedure. MATERIALS AND METHODS: A chart review was performed of 194 patients who underwent 209 ureteroscopic procedures at our institution during 1992. This group was then statistically compared to 317 patients who underwent 346 ureteroscopies between 1982 and 1985. RESULTS: The current indications for ureteroscopy were calculus extraction (67% of the cases), diagnosis (28%) and stent manipulation (5%). These indications differed from those of the early series, in which 84% of all ureteroscopies were performed for calculus extraction and 16% for diagnosis. Overall ureteroscopic success rate increased from 86 to 96% (p < 0.001). Success of stone extraction improved from 89 to 95% (p = 0.08, distal success rate 95 to 97% and proximal success rate 72 to 77%). Success of diagnostic inspections increased from 73 to 98% (p < 0.001). In the early series failure was usually due to inability to traverse the ureter (54% of the cases), while currently failure is due almost exclusively to impassable ureteral strictures (63%). The overall complication rate decreased from 20 to 12% (p = 0.01) and the rate of significant complications decreased from 6.6 to 1.5% (p < 0.05). Clinical followup (mean 36 months) for all patients and radiological followup (mean 9.8 months) for 67% of eligible patients detected only 1 ureteral stricture. The remaining patients were asymptomatic after the ureteroscopic procedure. CONCLUSIONS: Improvements in ureteroscope design, accessories and technique have led to a significant increase in the success of diagnostic and therapeutic ureteroscopy while decreasing morbidity. Outpatient ureteroscopic stone extraction, particularly for distal ureteral calculi, is almost uniformly successful with low morbidity. The long-term complication rate of ureteroscopy is 0.5%.

Transurethral enzymatic ablation of the prostate: canine model.

OBJECTIVES: The purpose of this study was to investigate the toxicity and potential usefulness of transurethral prostatic injection of a collagenase-based solution in treating benign prostatic hyperplasia in dogs. METHODS: The injected solution contained collagenase, hyaluronidase, Triton X-100, and gentamicin. Twenty-one dogs were randomly divided into three groups for transurethral prostatic needle injection: two treatment groups were observed for 6 and 12 weeks and a control group was observed for 12 weeks. Laboratory studies, clinical monitoring, and complete postmortem examination were performed in all animals. RESULTS: Gross hematuria was noted in all dogs for a mean of 4 days after injection. No significant postoperative morbidity was noted. There were no significant differences in the values of laboratory tests among the three groups except for a mean increase in serum level of aspartate transaminase for treatment groups on postoperative day 1; this resolved by postoperative day 7. Histologically, all treated prostates had stromal atrophy and cystic acinar dilation involving about 30% of the gland without extraprostatic extension of these changes. The urethra, bladder, rectum, testicles, kidney, liver, and lungs were normal and intact in all animals. CONCLUSIONS: Transurethral injection of this enzyme solution creates a predictable, favorable histologic response in the canine prostate. The procedure appears safe and warrants further investigation for treatment of human benign prostatic hyperplasia.

Renal oncocytoma: magnetic resonance imaging characteristics.

PURPOSE: We investigated the magnetic resonance imaging (MRI) appearance of renal oncocytomas. MATERIALS AND METHODS: Between 1985 and 1993, 11 patients at our institution underwent MRI of the kidneys and were subsequently diagnosed with renal oncocytoma. Patient charts and MRI were reviewed. RESULTS: Of 11 T1-weighted images 8 showed a mass with decreased signal intensity compared to renal cortex and 3 of 6 T2-weighted images revealed masses with increased intensity. In addition, 5 tumors were surrounded by a well defined capsule, 3 demonstrated a central stellate architecture and 1 contained an area of central decreased signal, all of which corresponded pathologically to scar. These MRI findings differ somewhat from those of renal cell carcinoma, which typically show intermediate to high signal intensity compared to renal cortex on T1 and T2-weighted pulse sequences and usually contain evidence of either hemorrhage or necrosis. CONCLUSIONS: A low intensity homogeneous mass on T1-weighted images, which appears as increased intensity on T2-weighted images, the presence of a capsule, central scar or stellate pattern and the absence of either hemorrhage or necrosis suggest oncocytoma. It is in the evaluation of patients with a solitary kidney, poor renal function, advanced age or a small easily resectable renal mass when MRI may help diagnose an oncocytoma and, thus, allow renal sparing surgery. The optimal MRI to evaluate renal masses should include T1-weighted spin echo images and without gadolinium, T2-weighted images and gradient recalled echo images.