The holmium: YAG laser for ureteric stones.

OBJECTIVE: To assess the efficacy of the pulsed holmium: YAG laser for the fragmentation of ureteric stones. PATIENTS AND METHODS: One hundred patients (72 males and 28 females, age range 14 months-85 years) underwent 114 ureteroscopic procedures using either a 7.2 F semi-rigid or 9.5 F flexible ureteroscope. A holmium: YAG laser (Sunrise Technologies. Fremont, Ca, USA) was used for laser lithotripsy at a maximum energy of 1.0 J/pulse at 5 Hz. Most of the stones (46%) were located in the upper third of the ureter. The mean size of the stones was 9 x 8 mm and the mean duration of the procedure was 73 min (including anaesthesia) with a mean hospital stay of 2.7 days. RESULTS: All the stones were accessed successfully using miniaturized endoscopes either retrogradely or antegradely. The holmium laser effectively fragmented all types of stones. Total clearance of all stones fragments was achieved in 87% of cases, with the best results obtained for stones in the lower third of the ureter (96%). The complications attributed directly to the laser included three strictures and three perforations of the ureteric wall. CONCLUSION: The holmium: YAG laser was effective in fragmenting ureteric stones irrespective of their hardness. However, it has the potential to damage the ureteric wall and must be used with caution.

Lower pole heminephrectomy: its role in treating nonfunctioning lower pole segments.

PURPOSE: We assessed the role and long-term outcome of lower pole heminephrectomy in the treatment of nonfunctioning lower renal moieties in children with duplex kidneys. MATERIALS AND METHODS: Between 1979 and 1994, 54 lower pole heminephrectomies were performed in 53 patients 1 to 192 months old (mean age 54) with duplex systems. A total of 15 patients was prenatally diagnosed, while the others presented with a urinary tract infection (36), orchiepididymitis (1) and failure to thrive (1). The surgical technique was essentially similar to that of upper pole heminephrectomy. RESULTS: Operative course was uneventful except for intraoperative bleeding in 5 cases, which necessitated blood transfusion, and a postoperative urinary tract infection in 1. Followup ranged from 3 to 168 months (mean 56.9). Postoperative renograms available in 34 cases showed unchanged differential function in 12 and an ipsilateral 2 to 14% decrease (mean 5.65%) in 22. No late complications were detected except in 1 patient, who had postoperative urinary tract infections and subsequently underwent removal of the ureteral stump. Our series includes 4 patients with solitary ipsilateral upper poles (after the contralateral kidney was removed or nonfunctioning) who had good renal function at long-term followup despite the reduced parenchymal mass. CONCLUSIONS: Based on our experience it seems that lower pole heminephrectomy is the treatment of choice in cases of nonfunctioning dilated lower segments of duplicated kidneys.

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.

Transurethral incision versus transurethral resection of the prostate. A subjective and objective analysis.

A prospective study was undertaken comparing transurethral incision of the prostate (TUIP) with transurethral resection (TURP) in the treatment of 220 patients with urinary obstruction caused by a small, benign prostate. Patients were managed alternately by TUIP and TURP, and their symptoms and urodynamic findings evaluated before and after surgery. Subjectively and objectively, the results were comparable in both groups. Pre- and post-operative complications were significantly less for the TUIPs than the TURPs. TUIP was significantly better than TURP in terms of shorter operating time, duration of hospitalisation and reduced need for transfusion. We recommend TUIP as the operation of choice for the relief of obstruction in the presence of a small, benign prostatic enlargement.