Management of renal-vein perforation during a challenging percutaneous nephrolithotomy.

A 54-year-old man with complex urinary anatomy as the result of previous surgery sustained a renal-vein injury during percutaneous nephrolithotomy for a staghorn calculus with a blood loss of 1.5 L. He was managed with antibiotics, bed rest, heparin, and a 28F nephrostomy catheter, which was withdrawn gradually as the tract sealed. This case highlights the importance of early diagnosis of this complication and the possibility of conservative management.

Ureteric catheterization via an ileal conduit: technique and retrieval of a JJ stent.

Retrograde ureteric catheterization of a patient with an ileal conduit is difficult, because guide wires and catheters coil in the conduit. A modified loopogram, using a Foley catheter as a fulcrum through which catheters can be advanced to the ureteric anastomosis, is described. This technique was used to remove a JJ stent, which had been inserted previously across a stricture in one ureter, the stent crossing from one kidney to the other.

Epidemiology of paediatric renal stone disease in the UK.

BACKGROUND: The previous epidemiological study of paediatric nephrolithiasis in Britain was conducted more than 30 years ago. AIMS: To examine the presenting features, predisposing factors, and treatment strategies used in paediatric stones presenting to a British centre over the past five years. METHODS: A total of 121 children presented with a urinary tract renal stone, to one adult and one paediatric centre, over a five year period (1997-2001). All children were reviewed in a dedicated stone clinic and had a full infective and metabolic stone investigative work up. Treatment was assessed by retrospective hospital note review. RESULTS: A metabolic abnormality was found in 44% of children, 30% were classified as infective, and 26% idiopathic. Bilateral stones on presentation occurred in 26% of the metabolic group compared to 12% in the infective/idiopathic group (odds ratio 2.7, 95% CI 1.03 to 7.02). Coexisting urinary tract infection was common (49%) in the metabolic group. Surgically, minimally invasive techniques (lithotripsy, percutaneous nephrolithotomy, and endoscopy) were used in 68% of patients. CONCLUSIONS: There has been a shift in the epidemiology of paediatric renal stone disease in the UK over the past 30 years. Underlying metabolic causes are now the most common but can be masked by coexisting urinary tract infection. Treatment has progressed, especially surgically, with sophisticated minimally invasive techniques now employed. All children with renal stones should have a metabolic screen.

Management of colonic injury following percutaneous nephrolithotomy.

Injury to the colon during percutaneous nephrolithotomy is rare. There are no definitive management guidelines for this injury. We report a case of left-sided colonic injury diagnosed following percutaneous nephrolithotomy and suggest a treatment algorithm.

Does pericapsular lignocaine reduce pain during transrectal ultrasonography-guided biopsy of the prostate?

OBJECTIVE: To evaluate whether injection with pericapsular lignocaine before transrectal ultrasonography (TRUS)-guided biopsy reduces the perceived pain of prostatic biopsy. PATIENTS AND METHODS: The study included 121 patients referred for TRUS-guided biopsy of the prostate; 27 underwent biopsy with no previous injection and 94 were randomized to pericapsular injection with either 1% lignocaine or a placebo (saline). Both patient and operator were unaware of the content of the injection. The injection was delivered under TRUS guidance to the apex of the prostate. Routine sextant biopsies were taken using an 18 G needle in a spring-loaded biopsy gun. A validated pain scale, the NRS11 (0, no pain, to 10, unbearable pain), was used to record the pain of each biopsy. RESULTS: No significant placebo effect was detected between the 'no injection' and the placebo-injection group, with mean (95% confidence interval) pain scores of 3.58 (2.77-4.39) and 4.01 (3.46-4.51), respectively, using the unpaired Student's t-test (P = 0.409). There was a statistically significant lower mean pain score in the lignocaine group, at 2.54 (2.00-3.10), than in the placebo-injection group (P < 0.001). CONCLUSION: Pericapsular injection with 1% lignocaine significantly reduces the perceived pain of TRUS-guided prostatic biopsy.

Anterior prostate cancer: is it more difficult to diagnose?

UNLABELLED: OBJECTIVE; To determine whether anterior prostatic tumours are adequately sampled using the Stamey sextant protocol, as a fifth of prostate cancers are anterior in distribution at radical prostatectomy. MATERIALS AND METHODS: All tumours (62) with an anterior distribution (>or=75% of the tumour anterior to the urethra) on radical prostatectomy whole-mounts, and in which the number and results of the sextant biopsies were available, were extracted from a prostate cancer database. Sixty-one posterior tumours (>or=75% of the malignant tissue posterior to the urethra) and their corresponding sextant biopsies were also retrieved for comparison. The number of biopsy sessions, the number of cores involved and the summated tumour length were recorded, together with the prostate gland weight, the tumour volume and the site of >or=75% of tumour in the superior-inferior axis. RESULTS: Anterior tumours required significantly more biopsy sessions to diagnose prostate cancer than posterior neoplasms (anterior, one set 47; > one set 15; posterior, one set 57; > one set, four, P=0.007). Anterior tumours had fewer cores with tumour involvement and less summated tumour length than had posterior cancers. The mean (sd) number of positive cores was; anterior 1.8 (1.01), posterior 2.50 (1.30) (P=0.001); the summated tumour length was; anterior 5.05 (4.10) mm, posterior 9.25 (7.80) mm (P<0.001). There was no significant difference in gland weight (mean anterior 43.8 g; posterior 48.3 g, P=0.3) or tumour volume (mean anterior 1.85 mL; posterior 1.49 mL, P=0.11) between the groups. There was no significant difference between the incidence of anterior and posterior neoplasms with respect to their position in the superior-inferior axis (P=0.96). CONCLUSIONS: Anterior prostate tumours account for 21% of all prostate cancers. They more often require multiple sets of sextant biopsies for diagnosis, and yield smaller areas of cancer on core biopsies than do posterior tumours in glands of similar weight and tumour volume. If prostate cancer is suspected clinically but biopsies are negative, targeting the anterior gland at subsequent prostatic biopsy should be considered.

The self-expanding metallic ureteric stent in the long-term management of benign ureteric strictures.

OBJECTIVE: To evaluate and assess the long-term complications of using the thermo-expandable, nickel-titanium alloy stent (Memokath 051, Engineers & Doctors A/S, Hornbaek, Denmark) for managing benign ureteric strictures. PATIENTS AND METHODS: Over a 3-year period, 13 Memokath stents were inserted in 11 patients (mean age 58 years, range 35-85) with 12 lower ureteric strictures. The cause of the stricture was benign in all cases, i.e. radiation fibrosis in three, retroperitoneal fibrosis, ischaemic uretero-ileal anastomosis and scarring after ureteroscopy in two each, and diathermy damage, extraluminal endometriosis and stone passage in one each. Four stents were 9 F with proximal expansion to 17 F and the other nine used were 10.5 F with proximal expansion to 20 F. The patients were followed for a mean (range) of 18 (1.5-33) months. RESULTS: No complications or side-effects occurred with nine stents; four stents were removed at a mean (range) of 16.3 (4-33) months. Three of these had become encrusted, two of which had been placed in patients who had either a history of stone disease or recurrent urinary tract infection. The other stent had migrated. CONCLUSION: The Memokath stent appears to have a useful role in managing benign ureteric strictures, but it must be closely monitored in patients who are predisposed to encrustation.

Endopyelotomy in the symptomatic older child.

OBJECTIVE: To evaluate the results of endopyelotomy in children, an established method in adult practice as a treatment for pelvi-ureteric junction (PUJ) obstruction. PATIENTS AND METHODS: Endopyelotomies undertaken between 1992 and 1999 by one surgeon in an established endourology unit were reviewed retrospectively. Children aged > 5 years presenting with pain and obstruction on isotope renography were selected for endopyelotomy. Patients with crossing vessels detectable on spiral computed tomography were treated by open pyeloplasty. Access to the renal pelvis was provided by a uroradiologist. Endopyelotomy was carried out through an Amplatz sheath of (median) 26 F. After applying traction to invaginate the PUJ an incision was made postero-laterally using electrocautery via an 11 F paediatric resectoscope. Stenting was maintained for 6 weeks. In all, 13 patients (median age 10 years, range 5-14) were treated; two had associated calculi. RESULTS: The symptoms resolved and the obstruction was relieved in only six patients, with a median (range) follow-up of 50 (26-68) months. The seven patients in whom endopyelotomy failed, as indicated by persistent pain, proceeded to open pyeloplasty at a median (range) of 4 (1.3-79) months. Of these, two had presented with associated multiple calculi and significant hydronephrosis (one with an associated duplex system) and three had crossing lower pole vessels at open operation. One developed a urinoma after the original endopyelotomy and one had a retained stent fragment removed at the time of pyeloplasty. CONCLUSIONS: Endopyelotomy in the symptomatic child requires a careful preoperative evaluation. Crossing lower pole vessels warrant an open pyeloplasty.

The role of percutaneous nephrolithotomy in the management of pediatric renal calculi.

PURPOSE: Minimally invasive techniques for the treatment of urinary calculi in children are recommended due to an increased probability of recurrence. Percutaneous nephrolithotomy is well established in adults but to our knowledge this procedure has not been reported previously in a large series of children. We review our experience with percutaneous nephrolithotomy in children. MATERIALS AND METHODS: From 1987 to 1995 percutaneous nephrolithotomy was performed in 25 children 3 to 16 years old (median age 8). Indications for percutaneous nephrolithotomy were an obstructed kidney in 10 cases, large stone size or staghorn calculus in 8, failed extracorporeal shock wave lithotripsy in 4 and residual stones after open surgery in 3. There were 15 solitary renal, 4 staghorn and 2 upper ureteral stones, and 5 children had multiple renal calculi. RESULTS: Percutaneous nephrolithotomy was performed once in 22 patients, and 2, 3 or 5 times in the remainder. Of the 25 patients 17 (68%) were stone-free at hospital discharge or shortly thereafter following a single session of percutaneous nephrolithotomy. Retained calculi after a single percutaneous nephrolithotomy treatment were much more common with staghorn stones (2 of 4 cases or 50%) and multiple stones (3 of 5 or 60%) compared to solitary renal stones (2 of 15 or 13.3%). With subsequent extracorporeal shock wave lithotripsy or repeat percutaneous nephrolithotomy the stone clearance rate was as high as 92%. At a 2 to 66-month followup (average 23) no late complications were noted. Radioisotope scans available in 10 cases before and after percutaneous nephrolithotomy revealed unchanged differential function and evidence of significant renal scars in only 1. CONCLUSIONS: Percutaneous nephrolithotomy is a suitable and safe procedure for treating renal stones in children.

Ureteric drainage and peristalsis after stenting studied using colour Doppler ultrasound.

OBJECTIVE: To study peristalsis and drainage of the stented ureter under normal physiological conditions. PATIENTS AND METHODS: Fifteen non-obstructed patients with ureteric stents and 15 control subjects (i.e. 45 unstented ureters and 15 stented ureters) had ureteric jets and flow analysed using colour Doppler ultrasound (CDU). Cross-sectional and longitudinal studies were performed. RESULTS: Unstented ureters had forceful ureteric jets at a frequency of 0.5-4 jets/min per ureter. Asymmetry of frequency within subjects was common (1-3 jets/min). Some patent stented ureters had no recordable flow on CDU (four cases, three within the first week of stenting). In the remainder, three types of flow pattern were recorded; weak peristaltic jets were seen in a minority (four of 15), flow around the stent (periprosthetic flow) in 11 of 15 and flow through the lumen (luminal flow) in eight of 15. Jets were only seen late after stenting (> 2 months). The periprosthetic flow was mildly peristaltic in some patients and periprosthetic and jet flow increased relative to luminal flow during peak diuresis. CONCLUSIONS: Passive drainage (periprosthetic and luminal flow) is the principal mode of urine transport in the stented ureter throughout the diuretic response and particularly within a week of stenting. With longer duration of stenting (> 2 months) weak peristaltic activity and active ureteric transport became more evident, notably during peak diuresis. CDU is not reliable for diagnosing obstruction of the stented ureter.

A three centre audit of IVU referrals in patients with asymptomatic microscopic haematuria.

There is considerable debate concerning the investigation of patients with asymptomatic microscopic haematuria. Urine dipstick testing is a sensitive screening test but may be positive in some normal individuals. The present consensus is that urine microscopy should be performed to confirm haematuria prior to further investigation. We have performed a retrospective study to establish whether urine microscopy was used in addition to dipstick testing before a request for intravenous urography (IVU) in three centres. IVU request forms from a District General, a Teaching Hospital and a Uroradiological Referral Centre were audited over a 9-month-period. Patients referred with asymptomatic microscopic haematuria were selected. The case notes and urine microscopy results were reviewed. The date of microscopy and its result and the interval between the result and the IVU request were established. One hundred and two cases have been examined, 17 (16.7%) of which were under the age of 40. Only 37 in total had significant haematuria on microscopy and of these, 32 results (31.4% of all cases) were available before the IVU request. In eight patients there was no evidence that urine microscopy had been performed. Fourteen patients had a urinary tract infection. Our findings show that IVUs are often requested on the basis of dipstick testing alone. Only one third of patients had confirmed significant haematuria at the time of IVU request and in some patients infection had not yet been excluded. Although prompt investigation of microscopic haematuria is important, it is essential that the diagnosis is established by microscopy before an IVU is requested.

Long-term outcome after percutaneous treatment of transitional cell carcinoma of the renal pelvis.

PURPOSE: The application of conservative surgery has been established in the treatment of transitional cell tumors of the renal pelvis. We reviewed retrospectively the long-term outcome after percutaneous treatment of select patients referred to a tertiary center with transitional cell tumors of the renal pelvis. MATERIALS AND METHODS: We studied 28 patients referred with a presumptive diagnosis of transitional cell carcinoma of the renal pelvis based on filling defects noted on excretory urograms. At percutaneous endoscopy tumor was resected in 26 patients, while no tumor was found in 2. All 19 men and 7 women smoked, and mean age at presentation was 65 years. Of the patients 18 presented with hematuria and 6 had bilateral upper tract tumors. After percutaneous resection, the access tract was irradiated either with iridium wire in 12 patients or a commercial high dose rate radiation delivery system in 12. Thiotepa was instilled into the nephrostomy tube without brachytherapy in 1 patient and 1 received no adjuvant treatment in all. All patients were followed by excretory urography and urine cytology. Cystoscopy and retrograde pyelography were performed when technically possible. RESULTS: After percutaneous tumor resection 6 patients (23%) had local recurrence in the treated renal pelvis, including 3 at 44, 55 and 60 months, respectively. Further conservative treatment was initially possible in 4 of these patients but ultimately only 2 (both of whom had late recurrences) retained the treated kidney. Of the 11 patients with recurrence elsewhere in the urinary tract the bladder was invariably involved (11), while synchronous or metachronous ureteral recurrence was less common (3). Nine patients remained free of any urothelial recurrence in the upper or lower tract. No patient had recurrent tumor in the nephrostomy tract. Of the patients 7 suffered from procedure-related complications, including 1 who had a persistent urinary fistula that failed to heal after brachytherapy and required nephroureterectomy. There have been 6 deaths during followup, of which 2 were disease related. The 3-year estimated local recurrence-free survival rate was 86% (95% confidence interval 63 to 95%), cause-specific survival rate 91% (95% confidence interval 67 to 98%) and overall survival rate 78% (95% confidence interval 55 to 90%). Differences in recurrence-free survival, comparing those with recurrence in the treated renal pelvis or elsewhere in the urothelium and those remaining disease-free, did not translate to a significant overall survival difference (p < 0.5) between these groups. CONCLUSIONS: Our results suggest that the combination of percutaneous local resection and tract irradiation offers an effective long-term alternative to radical extirpation in the management of select patients with superficial transitional cell carcinoma confined to the renal pelvis. When the postoperative nephrostogram demonstrates a leaking renal pelvis, tract irradiation should not be given.

Nephrostomy track brachytherapy following percutaneous resection of transitional cell carcinoma of the renal pelvis.

Percutaneous nephrostomy can be used to resect transitional cell carcinoma (TCC) from the renal pelvis, to avoid nephrectomy in selected patients. This procedure carries a potential risk of tumour seeding along the nephrostomy track, which it is our policy to irradiate prophylactically. A total of 25 procedures on 23 patients have been carried out since 1982. The 18 males and five females had a median age of 64 years (range 46-81) at the time of treatment. Of the ten patients with only one functioning kidney, nine had undergone contralateral nephroureterectomy, seven for TCC, one for a non-functioning kidney, and one for renal tuberculosis; one patient had received radical radiotherapy for an inoperable contralateral renal tumour. The other 13 patients had asked for a conservative treatment approach to be adopted. From 1982-1989, low dose rate 192Ir wire was used in 13 patients to deliver a median dose of 45 Gy (range 40-50) to the full length of the track at the surface of nephrostomy tube. Since 1989, we have used a high dose rate (HDR) 192Ir microSelectron to treat 12 patients with a single fraction of 10-12 Gy, including two who had undergone previously 192Ir wire track irradiation of the same kidney. One patient required a nephroureterectomy after developing a non-healing renal pelvis leak following combined modality treatment. Otherwise, no early or late radiation-related morbidity has been seen, and no nephrostomy track recurrences have occurred during a median follow-up of 5 years (range 1-9). The HDR microSelection has enabled us to deliver this treatment quickly and simply during the standard postoperative stay in hospital following percutaneous nephrostomy.