Comparison of general anesthesia and intravenous sedation-analgesia for SWL.

We compared general anesthesia and intravenous sedation-analgesia for SWL on a Dornier HM3 lithotripter with respect to treatment and anesthesia time, X-ray exposure, shockwaves administered, and efficacy. The case records of 49 patients receiving general anesthesia and 118 patients who underwent intravenous sedation-analgesia were examined. Follow-up plain abdominal radiographs were evaluated for residual stones. Treatments accomplished under intravenous sedation-analgesia required less anesthesia time and less SWL time. The amount of fluoroscopy time was increased. The success rate in treating patients with these two types of anesthesia was not significantly different. Intravenous sedation-analgesia is safe and effective for shockwave lithotripsy in the HM3 lithotripter. This technique facilitates more rapid outpatient treatment and has excellent patient tolerance.

A prospective randomized comparison of transurethral resection to visual laser ablation of the prostate for the treatment of benign prostatic hyperplasia.

OBJECTIVES: Transurethral resection of the prostate (TURP) represents the accepted standard of surgical therapy for the management of symptomatic bladder outlet obstruction due to benign prostatic hyperplasia (BPH). However, this is a major operative procedure associated with significant perioperative morbidity. Visual laser ablation of the prostate (VLAP) utilizing a neodymium:yttrium-aluminum-garnet laser represents a new technologic approach to the surgical management of BPH. We compared the relative safety and efficacy of these two surgical approaches in a prospective, randomized trial. METHODS: At 6 investigational sites in the United States, 115 men with symptomatic BPH more than 50 years of age and not in retention, were randomly assigned to undergo either TURP (59 patients) of VLAP (56 patients). VLAP patients received a mean of 10,200 J of energy delivered in a mean of 5.5 intraprostate laser applications. At preoperative baseline, 3 months, 6 months, and 1 year postoperatively, all patients underwent clinical evaluations, including ultrasonic prostatic volume determination, standardized American Urological Association (AUA)-6 symptom score, peak urine flow, postvoid residual urine volume, and quality-of-life assessment. RESULTS: Compared to TURP, the VLAP procedure required less time (23.4 versus 45.2 minutes; P < 0.01) and shorter hospitalization (1.8 versus 3.1 days, P < 0.01). VLAP was associated with a significantly lower rate of serious treatment-related complications compared to TURP (10.7% versus 35.6%; P < 0.01). Only One (2.2%) patient undergoing VLAP experienced a greater than 2.2 g/dL decrease in hemoglobin compared to 40% of TURP patients (P = 0.01). No patient in the VLAP group required blood transfusion compared with 3.4% of those undergoing TURP. Of the 115 patients, clinical outcomes measured at 1 year showed a mean improvement in AUA-6 symptom scores of -9.0 for VLAP compared with -13.3 for TURP (P < 0.04), mean increase in peak urinary flow rate of 5.3 cc/s for VLAP compared with 7.0 cc/s for TURP (P = 0.27), and mean decrease in postvoid residual urine volume of -55.4 cc for VLAP compared with -138.8 cc for TURP (P < 0.01). At 1 year, 78.2% of patients undergoing VLAP indicated that their quality of life was improved compared with 93.0% of patients undergoing TURP (P = 0.03). When compared with TURP, treatment of BPH with VLAP is associated with less hemoglobin decrease, a lower likelihood of serious complication, and requires less procedure time and a shorter hospital stay. Through a 1-year follow-up, VLAP produced significant improvement over baseline in objective and subjective outcome measures. However, for 1-year improvement in AUA-6 symptom score, postvoid residual urine volume, and quality of life, VLAP was less effective than TURP. CONCLUSIONS: In this initial study in the United States, with relatively low-energy laser applications, VLAP did not result in as complete a removal of prostatic tissue as did TURP. Considering the lower morbidity, shorter procedure and hospitalization times, and the degree of effectiveness that was achieved even at the low-energy doses used in this study, VLAP appears to be a viable and safe alternative to standard TURP.

Stryker frame adaptation of the HM3 lithotriptor for treatment of distal ureteral calculi.

Treatment of distal ureteral stones with the Dornier HM3 lithotriptor depends on the localization and positioning of the calculus from a transgluteal approach. We found the Stryker frame gantry modification preferable to the standard gantry for treatment of stones in the distal ureter. We report the use of this gantry adaptation in 22 cases of distal ureteral stones. The calculi were localized in 100% of the cases and were fragmented successfully with 1 treatment in 89%. In no case was the procedure aborted secondary to nonvisualization of the calculus. Failure to disintegrate the stone requiring retreatment occurred in 11% of the cases, and was attributed to stone characteristics and not due to difficulty with visualization or placement of the calculus within the F2 focus. The average fluoroscopic time was 45 seconds. The Stryker frame modification to the standard Dornier HM3 lithotriptor allows for improved visualization and easier localization of distal ureteral calculi compared to the standard gantry.

Penile intraepithelial neoplasia in patients examined for exposure to human papilloma virus.

Female genital malignancies have recently been associated with infection with various types of human papilloma virus. We present 9 cases of penile intraepithelial neoplasia found in men examined for exposure to human papilloma virus. Six of these men had acetowhite lesions and underwent biopsies to confirm the potential presence of condylomata acuminata. The remaining 3 patients had lesions that were visible but whose nature was in doubt. In addition to condylomata acuminata, penile intraepithelial neoplasia may be a consequence of human papilloma virus infection in the male.

Ureterosigmoidostomy and bladder exstrophy: a long-term followup.

Of 158 patients who underwent ureterosigmoidostomy for exstrophy of the bladder from 1925 to 1970, 52 were available for followup by telephone interview. Of these patients 34 still had a functioning ureterosigmoidostomy (30 had complete continence day and night) but 18 required diversion by other methods. All of the patients were believed to be socially well adjusted and leading productive lives. Of the patients surviving 15 or more years after ureterosigmoidostomy 11 per cent had colon cancer. Most of the remaining patients were unaware of the risk of adenocarcinoma engendered by the ureterosigmoidostomy. Patients undergoing ureterosigmoidostomy must be fully informed of all health risks and adequate surveillance programs should be arranged. In selected patients ureterosigmoidostomy remains a useful form of urinary diversion, with excellent continence and good social adaptation.

Parastomal ileal conduit-enteric fistula.

We report an unusual and late complication of ileal conduit urinary diversion. Eight years following stomal revision a fistula occurred between the ileum contained within an occult parastomal hernia and the opening of the ileal conduit.

Intraoperative consultation for the kidney.

Unexpected renal masses, renal anomalies, and trauma to the kidneys or renal vessels discovered at exploratory laparotomy may prompt a surgeon to consult a urologist intraoperatively. The usual principles of urologic management apply in these cases, but the evaluation must be tailored to the intraoperative situation. Except in emergency cases, definitive treatment can be delayed safely until full urologic evaluation is possible.

Digital subtraction angiography for evaluating patients with renal carcinoma.

Intravenous digital subtraction angiography has been performed on 39 patients with renal carcinoma. In 19 patients (group 1) imaging of the renal arteries was done following injection of 40 cc intravenous contrast medium through an antecubital vein. In 20 patients (group 2) 40 cc intravenous contrast medium were injected through a femoral vein and digital subtraction imaging of the inferior vena cava was obtained. In 12 of these patients the renal arteries also were visualized from the same injection of contrast medium. Intra-arterial digital subtraction angiography of the renal arteries also was done in 5 patients in group 2. Intravenous digital subtraction angiography satisfactorily demonstrated main renal arterial anatomy in 29 of 35 patients (83 per cent) over-all but failed to delineate the renal mass in most cases. Excellent visualization of the inferior vena cava was obtained in all 20 patients in group 2. Intraarterial digital subtraction angiography yielded an accurate diagnosis of renal carcinoma in all 5 patients with minimal doses of contrast medium. We conclude that intravenous digital subtraction imaging combined with computerized tomography scanning or ultrasonography yields satisfactory diagnostic and anatomical information for most patients with renal carcinoma.

Excessive antidiuretic hormone secretion after radical cystectomy.

Perioperative plasma antidiuretic hormone (vasopressin) levels were determined in 8 patients undergoing radical cystectomy. Marked elevations of antidiuretic hormone were noted immediately postoperatively in all patients and these levels persisted for 48 hours. Plasma antidiuretic hormone was elevated beyond the physiological levels needed for maintenance of intravascular volume and osmolarity. Excessive antidiuretic hormone secretion is common after radical cystectomy and should be considered in the differential diagnosis of postoperative oliguria in these patients.

Bilateral emphysematous pyelonephritis.

Emphysematous pyelonephritis is a severe infection found almost exclusively in diabetics, characterized by the presence of gas within the renal parenchyma. The diagnosis is established radiographically. An additional case is added to the 52 cases reported in the literature; we believe this is the fifth reported case with bilateral emphysematous pyelonephritis. If appropriate diagnostic studies demonstrate no evidence of either perinephric abscess or urinary obstruction, intensive medical management should be the initial therapy for this condition. Surgical intervention is necessary in patients without prompt response to medical therapy.

Digital subtraction angiography for noninvasive imaging of the renal artery.

Digital subtraction angiography (DSA) is a relatively new radiologic technique for noninvasive imaging of arterial anatomy. DSA has been shown to be effective in defining the renal arteries in patients with known or suspected renovascular disease. DSA is an excellent means of screening for renovascular disease and of following patients with serial studies after surgical revascularization or percutaneous dilatation of renal arterial stenosis. It is excellent for monitoring patients with known renovascular disease.

Initial observations and problems with in vitro predictive assay in genitourinary malignancies.

Recently, techniques have been developed that allow in vitro growth and chemosensitivity testing of human malignancies. We report our initial experience with the clonogenic, or colony-forming, assay as applied to genitourinary malignancies. Over the past two years, 172 specimens of genitourinary tumors were sent for assay. Thirty-three per cent were not plated, either because of insufficient quantity of cells obtained in the sample or because of the low viability percentage as determined by trypan blue exclusion. Forty-seven per cent showed adequate growth for chemosensitivity testing whereas 20 per cent of the samples showed inadequate growth. A major problem was obtaining adequate numbers of viable cells. Several other problems make it difficult to draw clinical correlations from in vitro findings. The method appears promising for several potential applications, but further studies will be needed before the final utility of the methods is defined.

Management of the urethra in men undergoing radical cystectomy for bladder cancer.

The records of 119 men who had undergone radical cystectomy for cancer of the bladder were reviewed for involvement of the urethra at the time of cystectomy and for later recurrence of urethral tumor. Urethral recurrences contributed significantly to the over-all pelvic recurrence rate and were associated with a uniformly poor prognosis. Prophylactic urethrectomy is indicated when pathologic examination reveals multifocal tumors, concurrent upper tract tumors, diffuse carcinoma in situ, involvement of the trigone or prostatic urethra, or positive urethral margin on frozen section. Those patients not undergoing urethrectomy should be followed with periodic urethral wash cytology.