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The learning curve associated with laparoscopic surgery may be associated with higher patient risk, and in the setting of kidney donation such risk may be unacceptable. We characterize the learning curve for hand-assisted laparoscopic donor nephrectomy in the context of a urology training program, and establish a case volume threshold after which improvements in laparoscopic skill can be demonstrated.

We determined the perioperative course of laparoscopic decortication of renal/adrenal cysts, and the association among cyst location, radiographic assessment and long-term symptom relief.

To determine if local anesthesia decreases discomfort following laparoscopic upper retroperitoneal surgery, we performed a randomized, double-blind, placebo controlled study in which the port sites and hand assist incision were infiltrated with bupivacaine or placebo prior to surgery.

We assess the feasibility, technique, complications and clinical outcomes of retrograde ureteroscopy in patients with orthotopic ileal neobladder.

Foregoing ureteral stents following ureteroscopy for urinary calculi is an evolving practice. Randomized trials support stent omission in select cases though generalizeability is unclear and criteria for stentless ureteroscopy are unknown. Therefore, we sought to identify significant clinical characteristics affecting postoperative morbidity in unstented patients to provide a context for future randomized trials.

We evaluated the effect of previous abdominal surgery on perioperative outcomes in patients undergoing a renal/adrenal laparoscopic procedure via a transperitoneal approach.

We report on endoscopic treatment outcomes for upper tract urothelial carcinoma and identify predictive factors for success.

We compared standard and hand assisted laparoscopic radical nephrectomy for suspected renal cell carcinoma.

A biodegradable cyanoacrylate glue was tested for its ability to close bladder injuries in an established porcine model. Inflammation and encrustation associated with this glue were examined in a rabbit model.

We compared the efficacy of shock wave lithotripsy and ureteroscopy for treatment of distal ureteral calculi.

Laparoscopic nephron sparing surgery has been reported rarely, likely due to technical difficulty when using only laparoscopic instrumentation. Hand assisted techniques may facilitate the procedure in select cases while maintaining the benefits of minimally invasive surgery. We prospectively compared the laparoscopic with selective hand assistance and open surgical approaches to nephron sparing surgery for suspected malignancy.

The technical difficulty of standard laparoscopic live donor nephrectomy has limited its application. Hand assistance, which takes advantage of the incision necessary for organ removal, facilitates laparoscopy without significant impact on patient recovery. We prospectively compared open surgical and hand assisted laparoscopic donor nephrectomy.

In a retrospective review of patients with urinary diversion who presented to our stone center during a 3.5-year period 9 underwent 20 procedures for suspected stone episodes. Eventual outcome was excellent in all but 1 patient. In particular, all attempts at retrograde trans-stomal manipulation were successful. We present our cases, and note the technical considerations and management principles. Frequently, these patients are best served by a combination of percutaneous antegrade, trans-stomal retrograde and/or extracorporeal shock wave lithotripsy.

Augmentation cystoplasy using the gastrointestinal tract has disadvantages related to the intestinal resection and its incorporation into the urinary tract. To preclude both sets of complications, we performed augmentation ureterocystoplasty in a 5½-year-old meningomyelocele patient with urinary incontinence, a low capacity bladder, severe vesicoureteral reflux and a poorly functioning kidney. After nephrectomy the ureter was incised longitudinally, folded over and placed onto the bladder as a patch. Bladder capacity, only 60cc without the contribution from the refluxing upper tract, increased to 200cc 6 months postoperatively. The patient is continent. Augmentation ureterocystoplasty is an option for bladder enlargement that obviates many of the risks associated with enterocystoplasty.

PurposeWe reviewed the results of endoureterotomy for benign ureteral and ureteroenteric strictures to determine efficacy and factors associated with a successful outcome.Materials and MethodsFollowup was available for 69 patients undergoing 77 endoureterotomies. Success was defined as symptomatic improvement and radiographic resolution of obstruction. Kaplan-Meier survival curves were constructed and data were analyzed with a Cox proportional hazards model.ResultsNone of 9 procedures in patients with the ipsilateral kidney contributing less than 25% of total renal function was successful. Among the 38 remaining benign ureteral stricture treatments with ipsilateral function 25% or greater with a median followup of 28.4 months among successful cases the 3-year success rate was 80%. No procedure failed beyond 11 months and there were 25 patients at risk beyond this point. Among the 30 remaining ureteroenteric stricture treatments with ipsilateral function 25% or greater the success rates at 1, 2 and 3 years were 73, 51 and 32%, respectively. Failures were noted during the first 36 months but none occurred later and 5 patients were at risk beyond this point. Overall, complete or tight strictures were less successfully treated. A nonischemic etiology, a stent 12F or greater and injection of triamcinolone into the bed of the incised stricture were associated with better outcome for strictures longer than 1 cm.ConclusionsEndoureterotomy of benign ureteral strictures is associated with an excellent outcome (80% success at 3 years). Endoscopic treatment of ureteroenteric strictures is less successful but still offers a reasonable first step (32% 3-year success rate). For all strictures failure is likely if ipsilateral renal function is poor. For strictures longer than 1 cm. use of a stent 12F or greater and injection of triamcinolone appear to be beneficial.

PurposeTo investigate the in vitro response of ureteral cells to potentially anti-fibrotic agents.Materials and MethodsCultured human uroepithelial cells, smooth muscle cells, and myofibroblasts were assayed for proliferation and production of collagen types I and III, with and without the presence of hydrocortisone, colchicine, retinol, verapamil, and D-penicillamine.ResultsHydrocortisone stimulated the proliferation of all three cell types and reduced the type I and type III collagen production by myofibroblasts and smooth muscle cells, respectively. Verapamil enhanced the growth of uroepithelial cells and decreased collagen III production by both uroepithelial and smooth muscle cells. D-penicillamine increased the proliferation of uroepithelial and smooth muscle cells, and inhibited collagen type III production by all three cell types.ConclusionsIn vitro evidence suggests that hydrocortisone, verapamil, and D-penicillamine have effects that could favorably alter the healing of endoscopic ureteral incisions.

We report our initial experience with hand assisted laparoscopic nephrectomy, and compare it to our results of standard laparoscopic nephrectomy.

We prospectively studied the usefulness of contrast material to facilitate extracorporeal shock wave lithotripsy (ESWL ††Dornier Medical Systems, Inc., Marietta, Georgia.) of ureteral calculi in situ.

We compared prostate specific antigen (PSA) to PSA density for 3 clinical uses: detection of nonpalpable prostate cancer, staging of clinically localized prostate cancer and prediction of PSA detectability following radical prostatectomy. Of 153 men with normal digital rectal examinations undergoing prostate biopsy 25% had prostate cancer. Analysis of receiver operator characteristic curves demonstrated that PSA density predicted the outcome of biopsy significantly better than did PSA (p = 0.0013). Pathological examination of 155 radical prostatectomy specimens revealed that 56% had pathologically uncontained disease. There was no difference between the ability of PSA and PSA density to predict the pathological findings (p = 0.2379). PSA data more than 1 year postoperatively were available in 96 of the 155 prostatectomy patients. Of these men 41% had postoperative PSA levels of 0.1ng./ml. or more. Preoperative PSA and PSA density values were almost identical in the ability to identify these patients (p = 0.6776). While PSA density is superior to PSA for the detection of prostate cancer in patients with a palpably normal prostate, it does not offer any improvement over PSA for staging of prostate cancer or for the prediction of PSA detectability after radical prostatectomy.

PurposeWith the increasing detection of incidental renal lesions, the evaluation and management of solid and cystic renal masses are assuming greater importance in urological practice. A review of the techniques for evaluation and management is presented, with an emphasis on new and evolving procedures, along with recommendations for their selective use.Material and MethodsA MEDLINE computerized reference search and manual bibliographic review were performed to find pertinent peer reviewed articles published since 1985. Meeting abstracts were considered if they provided unique information.ResultsThe primary means of evaluating renal masses is radiography (mainly ultrasonography and computerized tomography), although minimally invasive techniques such as percutaneous biopsy and laparoscopy are useful in selected situations. Nephron sparing surgery, minimally invasive surgery, alternative energy sources and other new techniques are being increasingly applied to the management of solid and cystic renal masses.ConclusionsSimple renal cysts can be defined ultrasonographically but more complicated masses require computerized tomography, other imaging modalities or rarely biopsy. Currently, minimally invasive techniques are commonly applied only to assist in the diagnosis of selected renal lesions and to treat benign simple cysts. The treatment of choice of solid renal masses remains open surgical radical nephrectomy and partial nephrectomy but alternative techniques will likely have a more significant role in the near future.

PurposeUsing spiral computerized tomography (CT) angiography, we sought to evaluate the incidence of a crossing vessel in a group of adults with primary ureteropelvic junction obstruction who had previously undergone successful retrograde endopyelotomy.Materials and MethodsA total of 16 patients who had undergone successful Acucise ‡‡Applied Medical Resources, Laguna Hills, California. balloon incision endopyelotomy for ureteropelvic junction obstruction, all with followup greater than 2 years, underwent a spiral CT angiogram with intravenous contrast material to identify those with a crossing vessel. Contrast enhanced CT was performed with dual phase technique on a Somatom-Plus-S§§Siemens, Iselin, New Jersey. [section] CT scanner using prototype software. After 180-degree linear interpolation of the projection data, transaxial images of the affected kidney were reconstructed. In addition, at the time of the study all patients completed analog followup pain scales and quality of life assessment questionnaires.ResultsAmong the 16 patients 6 (38%) had anterior or posterior crossing vessels based on spiral CT angiography. No patient had both types. By analog pain scale patients had 80% mean improvement in pain (range 63 to 100).ConclusionsIn our series nearly 40% of patients with anterior or posterior crossing vessels had a long-term (greater than 2 years) successful outcome with retrograde endopyelotomy. Endopyelotomy continues to be our initial mode of therapy among adults with primary ureteropelvic junction obstruction. In our opinion the adverse influence of the crossing vessel is not sufficient to justify the added expense of preoperative angiography, spinal CT or endoluminal ultrasound.

We investigated the association of carbon dioxide absorption with the approach (transperitoneal versus extraperitoneal) and other factors during laparoscopy.

Dog bites to the external male genitalia occur infrequently. We present 4 new cases and review 4 others described préviously. Victims tend to seek medical care quickly. Thus, morbidity is directly related to the severity of the initial wound and delayed infectious complications appear to be minimal. Guidelines for management include irrigation, debridement as necessary, empiric antibiotics, consideration of tetanus and rabies immunization, and primary wound closure or surgical reconstruction. The differences between dog bites and human bites to the genitalia—primarily interval to presentation and subsequent likelihood of infection—are summarized. Measures to prevent dog bites are discussed.

We analyzed retrospectively 127 percutaneous nephrolithotomies performed on 96 patients between 1986 and 1989 to estimate the average total blood loss from the procedure. Blood transfusions and a postoperative decrease in hemoglobin level were combined to estimate total blood loss. The average blood loss for uncomplicated 1-stage single puncture percutaneous nephrolithotomy was 2.8gm./dl. hemoglobin. Factors potentially influencing blood loss were identified. Multiple punctures and/or renal pelvic perforation was associated with a 2-fold greater blood loss. Half of the expected blood loss occurred in patients with a preexisting nephrostomy tract. Calculus morphology, location, composition and length did not affect total blood loss, nor did the number of fragments or stone-containing calices. Other factors, such as puncture site, type of fascial dilation, hypertension, renal insufficiency, infection, previous open renal surgery or previous extracorporeal shock wave lithotripsy, also did not affect total estimated blood loss. During the study years the blood transfusion rate was 23% in all patients and 14% in those with a single puncture uncomplicated by renal pelvic perforation and without a mature nephrostomy tract. The only statistically significant risk factors influencing the likelihood of a blood transfusion were preoperative anemia and total blood loss. Although our current transfusion rate associated with percutaneous nephrolithotomy (4% in nonanemic patients from 1989 to 1992) is much lower, patients must be made aware of the likelihood of blood transfusion, and urologists should recognize the risk factors for blood loss and transfusion.

To evaluate compounds for the long-term inhibition of urinary calculi growth, we applied a newly developed in vitro assay to various metal-ligand complexes. The new experimental model—the preadsorbed calculi growth assay—was based upon the initiation of crystal growth in a metastable solution of calcium and oxalate with uniform granules derived from human renal calculi. Potential inhibitors were first adsorbed onto the surface of the calculi granules, following which the loss of calcium from the seeded metastable solution was monitored as the indicator of calcium oxalate deposition. This assay allowed participation in the reaction by any matrix components present in the human calculi granules and limited the effect of the inhibitors to the calculi surface.

Purpose: We evaluated the efficacy and safety of the Dornier compact lithotriptor for management of renal stones. Materials and Methods: We administered 191 treatments to 169 patients with renal stones on 176 occasions with the patient under combined parental sedation and analgesia. The Dornier Compact lithotriptor is mobile and ultrasound guided, and uses an electromagnetic energy source. Results: A total of 22 patients required a second treatment (13 percent), 123 (72.8 percent) were stone-free, 26 (15.4 percent) had fragments less than 4 mm. large, 16 (9.5 percent) had stone fragments larger than 4 mm. and 4 (2.4 percent) required auxiliary therapy (treatment failures). The side effects were mostly mild to moderate, with nausea and/or vomiting reported in 26 patients (14 percent), colic or pain in 66 (39 percent), ureteral obstruction in 2, steinstrasse in 7 (4 percent) and fever in 1. Our clinical results indicate that extracorporeal shock wave lithotripsy was effective for treatment of stones in the kidney, with a low incidence of complications and adverse effects. The lithotriptor used is much smaller, less expensive and user friendly with no installation requirements, rendering it mobile. Conclusions: The success rate with newer generation devices compares well with results obtained using other stationary and larger versions.

A retrospective analysis of 156 rigid ureteroscopic stone procedures in 145 patients revealed successful manipulation in 90%. The stone-free rate after adjunctive procedures was 95%. Access was achieved without balloon dilation in all but 18 patients. There were 24 perforations, occurring in 31% of proximal, 8% of mid ureteral and 8% of distal stone manipulations. Of the evaluable patients 63% underwent radiographic assessment for stricture disease, 75% at 6 months or more after the procedure. The stricture rate was 3.5% in all patients and 5.9% in patients with perforations. Of 37 patients evaluated for vesicoureteral reflux only 1 had reflux. Questionnaire followup was obtained for 74% of the patients (mean followup 2.6 years) and 32% felt normal within 3 days. Postoperative symptoms included flank pain (13%), renal colic (12%), pelvic discomfort (30%) and Double-J††Medical Engineering Corp., New York, New York.stent related complaints (49%). Of the patients 15% have reported recurrent stones. Ureteroscopy is effective and well tolerated, and it has minimal long-term complications.

PurposeWe review the morbidity and long-term outcome of percutaneous caliceal diverticulectomy and associated stone extraction.Materials and MethodsPercutaneous caliceal diverticulectomy was performed in 19 women and 11 men (age range 20 to 58 years), of whom 26 had stones (all 15 mm. or less). The diverticula were located throughout the kidney, including the upper (11 patients), middle (15) and lower (4) calices. Percutaneous caliceal diverticulectomy included 28 direct and 2 indirect accesses (1 via a previously placed nephrostomy tract and 1 due to stones in other areas of the kidney). In all cases the stone was removed and the diverticular neck was incised or dilated. Fulguration of the diverticular walls was performed in 22 cases. Transdiverticular percutaneous renal and ureteral drainage was maintained from 2 to 7 days until a nephrostogram demonstrated no extravasation.ResultsThe average operating room time and hospital stay were 171 minutes (range 75 to 330) and 4.1 days (range 2 to 7), respectively. Major complications occurred in 6.6% of the cases, requiring 1 blood transfusion and 1 chest tube placement, and minor complications occurred in 13.4%. There was no mortality. Followup for more than 1 year was available in 27 patients. Stone-free rate was 93% with obliteration of the diverticulum in 76% of patients. Overall, 85% of patients are asymptomatic at average followup of 3.5 years (range 1 to 7.3).ConclusionsDirect percutaneous endosurgical management provides a safe, efficacious and durable means of treating stone bearing caliceal diverticula, regardless of stone size or location of the diverticulum.

We evaluated the safety and efficacy of ex vivo ureteroscopy (ExURS) as a means of rendering the donated kidney stone-free at live donor renal transplantation.

Ureteroscopic management is a viable option for lower pole calculi less than 2 cm. Recently a technique was described to displace the calculus into a more accessible calix using a nitinol basket or grasper before lithotripsy. We compared the efficacy and safety of this technique with in situ treatment of small and intermediate lower pole calculi.

To determine the impact of temporary vascular occlusion on patient outcome after surgery for renal trauma, we reviewed the records of 30 patients managed since 1977 whose injuries represented 17% of a total of 181 injuries in 175 patients. Reconstruction was judged to be adequate in 25 patients, while the remaining 5 underwent immediate nephrectomy. Compared with patients whose renal injuries did not require temporary occlusion, these 30 were more likely to have renovascular trauma, shock at presentation and higher transfusion requirements. Postoperatively, of 20 patients renal imaging (9) and radionuclide scanning (11) demonstrated preservation of significant renal parenchyma or function in 18 (90%). Although complications were more common in patients whose renal injuries required temporary vascular occlusion, only 2 were related to the renal injury or its method of repair (urinary extravasation in 1 patient and azotemia in 1 with bilateral injury).

We report a case of tuberculous epididymo-orchitis diagnosed by fine needle aspiration. The history of pelvic tuberculosis in the sexual partner suggests the possibility of female-to-male venereal transmission.

Victims of human bites to the penis often do not seek timely medical attention and dangerous progression of infection may ensue. We present 5 cases, 1 of which evolved into necrotizing fasciitis of the lower abdomen. Recommendations for management of these wounds include aggressive local wound care, empiric antibiotics and careful observation for necrotizing complications.

A young, otherwise healthy man was hospitalized with clinical findings of acute retroperitoneal hemorrhage. Radiographic evaluation suggested a large bleeding renal mass that was thought to be renal cell carcinoma. Radical nephrectomy was performed after angio-embolization. Final pathological diagnosis was grade III transitional cell carcinoma of the renal pelvis invading the renal parenchyma. Distal ureterectomy was subsequently performed 12 days after nephrectomy. Preoperative or intraoperative diagnosis of transitional cell carcinoma would have spared our patient the morbidity of a delayed second procedure. Transitional cell carcinoma of the renal pelvis should be considered in the differential diagnosis of acute retroperitoneal hemorrhage.