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Objectives: To evaluate the contemporary indications and outcome after partial nephrectomy for renal urothelial cancer. Partial nephrectomy is an established treatment for renal cell cancer but its use for renal urothelial tumors has been studied less extensively., Methods: Records were reviewed for patients undergoing partial nephrectomy for renal urothelial tumors between January 1990 and December 2001. Partial nephrectomy was selected for those with a solitary kidney, chronic renal insufficiency, or bilateral synchronous tumors. Partial nephrectomy was performed according to the principles of partial nephrectomy. Follow-up included ultrasonography, intravenous urography, computed tomography, metastatic workup, and renal function evaluation., Results: This study included 12 patients (12 kidneys, 10 solitary) with a mean age of 68.5 +/- 21 years and a mean follow-up of 40.8 +/- 32 months. The pathologic T stage was Tis in 1 patient, T1 in 3, T2 in 2, and T3 in 6 patients. Of the 12 patients, 6 had negative surgical margins, and 4 of the 12 patients (30%) were tumor free after a mean follow-up of 57.7 months. Of the 6 patients with positive surgical margins (Stage T1 in 2 and T3 in 4), 1 developed recurrence and 3 developed metastasis; 4 died after a mean of 31.3 months. Overall recurrence was seen in 5 (42%) and progression (metastasis) in 6 (50%) patients. Of the 12 patients, 6 were alive, 4 of them were well (mean serum creatinine 1.83 mg/dL) at 62 months of follow-up. Two patients required dialysis. The overall long-term survival rate was 50%., Conclusions: Partial nephrectomy for renal urothelial tumors is feasible and should be considered in a select population. Dialysis or renal replacement can be delayed or avoided in most of these patients, but strict surveillance remains mandatory.

Purpose: Laparoscopic donor nephrectomy (LDN) is an increasingly accepted modality for procuring donor kidneys for transplantation. We analyzed and compared the short and long-term outcomes of living transplant allografts from kidneys procured by laparoscopic or open donor (ODN) technique and managed with a single immunosuppression regimen in each group., Materials and Methods: Records of recipients who underwent living (laparoscopic or open) donor nephrectomy were reviewed from August 1999 to July 2001 for LDN and from January 1994 to December 1999 for ODN. Patients included were on a single immunosuppression regimen particular to each group. Sirolimus, mycophenolate mofetil and prednisone were given to the LDN group, and calcineurin inhibitor (FK-506 or cyclosporine), mycophenolate mofetil and prednisone were given to the ODN group. Excluded from study were patients with prior kidney transplant or patients not receiving immunosuppression as previously described. Also excluded from study were patients lost to followup before 1 year. Data were retrieved retrospectively from case notes or from the transplant database and analyzed using SAS software (SAS Institute, Cary, North Carolina)., Results: A total of 71 patients from the LDN group and 60 patients from the ODN group qualified for the study. Demographic data are comparable in both groups except for the significantly longer followup in the ODN group. Serum creatinine was 2.2 and 1.8 mg/dl at postoperative day 4, 1.3 and 1.3 mg/dl at day 10, and 1.3 and 1.4 mg/dl at 1 month in the LDN and ODN groups, respectively. Time to achieve nadir serum creatinine was 8.7 versus 6.6 days for LDN and ODN groups, respectively (p = not significant). Delayed graft function was noted in 5 of 71 (7%) in the LDN group and 3 of 60 (5%) in the ODN group (p = 0.5). In the LDN group 13 (18%) patients had a serum creatinine of greater than 1.5 mg/dl at postoperative day 30 compared to 6 (10%) in the ODN group (p = 0.06). Mean serum creatinine at 1 year was lower for LDN recipients (p = not significant). But at last followup this difference became statistically significant in favor of LDN. Mean followup was 939 versus 2,046 days for LDN versus ODN, respectively (p <0.0001). Recipient mean hospital stay was 5.2 versus 6.7 days for LDN versus ODN, respectively (p = 0.08). There were 8 of 78 (10.2%) episodes of acute rejection in the LDN group compared to 22% in the ODN group (p = 0.08). The complication rate (ureteral vascular, lymphocele, acute rejection and wound) was 11% in LDN compared to 15% in the ODN group. Long-term graft function, graft survival and patient survival in the LDN group were comparable to the ODN group., Conclusions: Early graft recovery is slower in LDN allografts, although not statistically significant, but long-term function in the LDN group is significantly better compared to the ODN group. Laparoscopic donor kidneys take longer to achieve nadir serum creatinine, but this does not influence long-term outcome and results.

Purpose: We determined the results of shock wave lithotripsy with a newer electromagnetic lithotriptor and compared them with those in a contemporary series of cases managed by an electrohydraulic lithotriptor using identical treatment and followup criteria at a single center., Materials and Methods: Between 1995 and 1999, 356 patients (375 renal units, 483 upper urinary tract stones) meeting study inclusion criteria were treated with an MFL 5000 electrohydraulic shock wave lithotripsy unit (Dornier Medical Systems, Inc., Marietta, Georgia). From 1999 to 2000, 173 patients (175 renal units; 218 upper urinary tract stones) meeting identical study inclusion criteria were treated using an electromagnetic Modulith SLX shock wave lithotripsy unit (Karl Storz Lithotripsy, Atlanta, Georgia). In each group stone-free results were determined by plain abdominal x-ray and renal ultrasound 1 month after lithotripsy and efficiency quotients were developed. Baseline patient and stone characteristics were compared by the Wilcoxon rank sum and Fisher exact tests. All variables significant at p <0.05 were included in subsequent outcome analysis using multivariate logistic regression., Results: Baseline characteristics were equivalent, including patient age, gender, stone number and location, although patients treated with the electrohydraulic unit had a significantly larger median stone burden (103 versus 71 mm.2, p = 0.015). Multivariate regression analysis demonstrated a higher stone-free rate in the electrohydraulic group (77% versus 67%, p = 0.01) but also a higher rate of total adjunctive measures (56% versus 47%, p = 0.04). Consequently the efficiency quotients were comparable for the electrohydraulic and electromagnetic lithotripsy units (0.45 and 0.42, respectively, p = 0.43)., Conclusions: Electrohydraulic lithotripsy resulted in a higher stone-free rate at 1 month, although it was associated with a higher rate of auxiliary measures. Ultimately the efficiency quotients were equivalent, implying that these 2 contemporary energy sources are acceptable. According to single center treatment and followup criteria they are equally efficacious.

Cystinuria is an inherited defect in renal tubular and intestinal transport of dibasic amino acids that results in elevated urinary excretion of cystine, ornithine, lysine, and arginine. The only clinical manifestation of this disease is the development of urinary tract cystine calculi. Cystinuric patients suffer recurrent stone episodes, requiring an aggressive multi-modal approach to management. This article reviews the results of medical prevention regimens, the role of minimally invasive urologic intervention, and the recent insights into the complex genetic basis for the varied cystinuric phenotypes.

Purpose: We compared the long-term impact on renal function after shock wave lithotripsy, percutaneous nephrolithotomy or the 2 techniques combined in patients with a solitary kidney., Materials and Methods: A total of 45 women and 38 men 15 to 86 years old (mean age 56.1) with a solitary kidney were treated with shock wave lithotripsy (53), percutaneous nephrolithotomy (18) or the 2 techniques combined (12). Before and after treatment serum creatinine, blood pressure and the calculated glomerular filtration rate were determined, and raw and calculated data were compared by the Kruskal-Wallis, Fisher exact and Wilcoxon rank sum tests, and the Spearman correlation coefficient. Followup was 1 to 166.5 months (mean 53.0, median 46.9) overall and statistically equivalent in the 3 treatment arms., Results: Treatment groups were comparable in regard to patient age, sex distribution, weight, blood pressure and pretreatment serum creatinine. There was no significant difference in any evaluated pretreatment or posttreatment parameters and no difference in the change in any parameter after treatment. Stratifying patients to pretreatment serum creatinine less or greater than 2 mg./dl. likewise revealed no significant difference in the impact on long-term renal function. However, pretreatment serum creatinine positively and strongly correlated with a positive change in the glomerular filtration rate after therapy., Conclusions: In this study there was no evidence that any of these 3 treatment modalities resulted in the deterioration of renal function even at long-term followup. This finding implies that shock wave lithotripsy, percutaneous nephrolithotomy and the 2 therapies combined are equally efficacious for preserving renal function when performed in patients with a solitary kidney.

Purpose: We report the technique of and initial experience with retroperitoneal laparoscopic live donor right nephrectomy for purposes of renal allotransplantation and autotransplantation., Materials and Methods: A total of 5 patients underwent retroperitoneoscopic live donor nephrectomy of the right kidney for autotransplantation in 4 and living related renal donation in 1. Indications for autotransplantation included a large proximal ureteral tumor, a long distal ureteral stricture and 2 cases of the loin pain hematuria syndrome. In all cases a 3-port retroperitoneal laparoscopic approach and a pelvic muscle splitting Gibson incision for kidney extraction were used. In patients undergoing autotransplantation the same incision was used for subsequent transplantation., Results: All procedures were successfully accomplished without technical or surgical complications. Total mean operating time was 5.8 hours and average laparoscopic donor nephrectomy time was 3.1 hours. Mean renal warm ischemia time, including endoscopic cross clamping of the renal artery to ex vivo cold perfusion, was 4 minutes. Average blood loss for the entire procedure was 400 cc. Radionuclide scan on postoperative day 1 confirmed good blood flow and function in all transplanted kidneys. Mean analgesic requirement was 58 mg. fentanyl. Mean hospital stay was 4 days (range 2 to 8), and convalescence was completed in 3 to 4 weeks., Conclusions: In the occasional patient requiring renal autotransplantation live donor nephrectomy can be performed laparoscopically with renal extraction and subsequent transplantation through a single standard extraperitoneal Gibson incision, thus, minimizing the overall operative morbidity. Furthermore, these data demonstrate that live donor nephrectomy of the right kidney can be performed safely using a retroperitoneal approach with an adequate length of the right renal vein obtained for allotransplantation or autotransplantation.

Percutaneous endopyelotomy, introduced over 15 years ago, is a well-established alternative to open operative pyeloplasty for management of ureteropelvic junction (UPJ) obstruction. Although several variations of the technique have been described, the goal in all cases is to develop a full thickness incision though the obstructing proximal uretra that extends out to the peripyeloureteral fat and heals over an internal stent. Though a percutaneous endopyelotomy can be considered for almost any patient with primary or secondary UPJ obstruction, it is particularly valuable in the setting of upper tract stones that can then be managed simultaneously. This article reviews the indications, techniques, and outcomes of percutaneous endopyelotomy.

Advancements in endourology, laparoscopic urology, and interventional radiology continue to influence the contemporary management of renal transplant complications. The successful implementation of these minimally invasive therapies significantly relies on careful patient selection; not all renal transplantation complications are suitable or amenable for this form of management--true for transplant ureteral complications and less so for other potential complications. With such a strategy, renal transplant complications can be managed efficiently and effectively with these minimally invasive modalities to minimize further recipient morbidity while also minimizing potential risk to the recipient and for the renal allograft.

Purpose: We performed a prospective study to determine the incidence and spectrum of metabolic abnormalities predisposing to stone formation in patients with ureteropelvic junction obstruction and renal calculi., Materials and Methods: A total of 47 consecutive patients with congenital ureteropelvic junction obstruction underwent metabolic evaluation of stone risk factors. Of these patients 21 had associated stones (study group), while 26 did not (control group). Logistical regression, Wilcoxon rank sum and Fisher's exact tests were performed to determine whether there was a significant difference between these groups in regard to the presence of metabolic risk factors., Results: Demographically and symptomatically the 2 groups were equivalent except that the study patients were older. The 24-hour urinary excretion of calcium was significantly higher in study than in the control patients (p = 0.007). While the incidence of hypercalciuria and hyperuricosuria was also higher in the study population, these differences were not significant (p = 0.08 and 0.07, respectively)., Conclusions: Metabolic abnormalities predisposing to stone formation are present more frequently in patients with ureteropelvic junction obstruction who have associated stones compared to those who do not. As such, urinary stasis alone does not explain stone formation in these cases. Rather, the local physiological environment of urine likely has a predisposing role. In addition to restoring unobstructed urinary flow, consideration should be given to metabolic evaluation and prophylactic treatment for affected patients.

The development of shock-wave lithotripsy was a serendipitous event. Fortunately, the significance of this accidental discovery was not overlooked by the engineers at Dornier and their medical counterparts. There are many components that make up a lithotripter, but the heart of the lithotripter is its energy source. These machines often are categorized by the type of shock-wave generator used, and each type of generator has its own advantages and disadvantages. Unfortunately, no quantitative value of a shock-wave generator can be correlated to its qualitative effect. Interestingly, each type of energy source delivers its shock-wave energy with such distinctiveness that even the crater pattern it leaves in a stone is unique. New technology and ideas have transformed lithotripters in form and function so that they bear little resemblance to the original HM-1 prototype. Ongoing research is attempting to improve ESWL in several different ways, and advances in shock-wave generation, shock-wave measurement, and stone localization should result in even more efficient lithotripsy. The application of the time-reversal process to lithotripsy ultimately may enable lithotripters to track stones and electronically steer shock waves toward the target. Advances like these herald a time when ESWL, fortunately or unfortunately, will become automated completely.

Transitional-cell carcinoma (TCC) of the upper urinary tract has traditionally been managed by nephroureterectomy, whereas nephron-sparing surgery has been reserved for those few patients with solitary kidneys or bilateral lesions. However, with the introduction of improved diagnostic and therapeutic technology, including smaller ureteroscopes and working instruments, and the concomitant ease of surveillance, ureteroscopic treatment of upper-tract urothelial tumors has become a reasonable alternative to open operative intervention in patients requiring conservative management. Furthermore, as preoperative grading and staging have improved, ureteroscopic treatment of upper-tract urothelial tumors is assuming an increasingly important role in the management of some patients who might have otherwise been treated with a nephroureterectomy. The technique of ureteroscopic resection is described in detail.

Purpose: We evaluate the role of contemporary urological intervention in patients with nephrolithiasis associated with autosomal dominant polycystic kidney disease., Materials and Methods: Intervention for upper tract stones associated with autosomal dominant polycystic kidney disease was performed in 5 women and 2 men 29 to 65 years old (mean age 47). Indications for intervention consisted of flank pain in 6 patients and/or hematuria in 2. A total of 12 procedures (mean 1.7 per patient) were performed, including shock wave lithotripsy in 6 patients, percutaneous nephrolithotomy in 2, retrograde endoscopy or manipulation in 3 and extended pyelonephrolithotomy in 1., Results: All patients were rendered stone-free or had only residual "dust." Hospital stay for 5 patients was 1 night or less and there were no complications. Renal function for each patient was stable or improved as measured by serum creatinine., Conclusions: Most patients with autosomal dominant polycystic kidney disease who require intervention for nephrolithiasis can be safely and effectively treated with essentially any or all contemporary, minimally invasive techniques. The choice of intervention can be based primarily on size and location of the upper tract stones rather than the associated presence of polycystic kidneys.

Objectives: To determine whether a high versus a dependent ureteral insertion significantly affects the outcome of endopyelotomy for management of ureteropelvic junction (UPJ) obstruction., Methods: Sixty patients with UPJ obstruction were treated with an endopyelotomy by way of either an antegrade percutaneous approach (n = 36) or a retrograde hot-wire balloon incision (n = 24). In these 60 patients, the ureteral insertion was high on the renal pelvis in 19 (32%), dependent in 25 (42%), and indeterminate in 16 (26%). Intravenous urography was performed 4 to 6 weeks after stent removal (8 to 12 weeks after endopyelotomy) and then at 6 to 12-month intervals. Success of the procedure was defined as resolution of symptoms and decrease in hydronephrosis compared with pre-endopyelotomy studies., Results: With a follow-up range of 2 to 41 months (mean 10.3), the overall success rate was 80%. This rate was independent of whether the procedure was performed in an antegrade or retrograde fashion. A successful result was achieved in 15 (78.9%) of those with a high insertion, 19 (76%) of those with a dependent insertion, and 14 (87.5%) of those with an equivocal insertion; these differences were not statistically significant (P = 0.72)., Conclusions: The type of ureteral insertion (ie, high versus dependent) had no significant impact on the outcome of endopyelotomy by way of either a percutaneous or retrograde approach. As such, these anatomic variations need not play a role in a decision-making algorithm for contemporary management of UPJ obstruction.

Purpose: We describe a noninvasive radiologic evaluation of a retrocaval ureter using currently available technology., Materials and Methods: Three-dimensional volume-rendered CT and diuretic renography were performed for evaluation of a possible retrocaval ureter., Results: The 3D CT scan definitively diagnosed the retrocaval ureter, while diuretic renography showed no evidence of clinically significant obstruction. No invasive procedures were required., Conclusion: A 3D volume-rendered CT scan in the excretory phase combined with diuretic renography is the radiologic evaluation of choice for patients with a suspected retrocaval ureter, as it is noninvasive yet highly accurate in its anatomic delineation.

Purpose: We determine whether there is a clinically significant difference in the long-term effect on renal function following simultaneous versus staged bilateral extracorporeal shock wave lithotripsy (ESWL)., Materials and Methods: Between July 1986 and October 1995, 360 patients underwent treatment for bilateral renal calculi with ESWL using a Dornier HM-3 lithotriptor. Of the patients 319 had both kidneys treated simultaneously (simultaneous group) and the remaining 41 were treated in a planned, staged fashion (staged group) with the procedures separated by 3 to 20 weeks (mean 6.0). Followup data of at least 1 year were available for 49 men and 30 women (mean age 52.4) in the simultaneous group, and 8 and 12 (mean age 45.1), respectively, in the staged group. Mean stone burden was 0.70 cm.2 on the right and 0.87 on the left side in the simultaneous group, and 1.6 and 1.5, respectively, in the staged group., Results: Patients with at least 1 calculus greater than 0.5 cm.2 treated simultaneously received a mean of 1,386 shock waves to the right and 1,637 to the left side, and the staged group received a mean of 1,802 and 2,094, respectively. Mean serum creatinine was 1.03 mg./dl. before and 1.04 after treatment (normal 0.7 to 1.4 mg./dl.) in the simultaneous group, representing a mean increase of 0.01 at followup of 1.0 to 10.5 years (mean 3.7), and 0.88 and 0.88, respectively, in the staged group, representing a decrease of 0.005 at followup of 1.0 to 7.2 years (mean 3.2). The effects of simultaneous versus staged ESWL on renal function as measured by serum creatinine were not statistically significant using a multiple regression model which controlled for the effects of stone burden, number of shock waves, patient age, pretreatment serum creatinine and length of followup (p = 0.19)., Conclusions: There is no clinically apparent difference in the long-term effect on renal function for patients with bilateral renal calculi treated with ESWL in a simultaneous versus staged fashion.

Cystinuria is an autosomal recessive disorder characterized by a defect in intestinal and renal tubular transport of dibasic amino acids which results in excessive urinary excretion of cystine. Because of the relative insolubility of cystine in urine, patients with this condition are prone to recurrent stone formation. Medical therapy aims both to decrease the urinary concentration of cystine and to increase its solubility. Standard prevention and treatment regimens include hydration, moderate salt and protein restriction, oral alkalinization, and thiol derivatives. Despite aggressive medical management, however, cystinuric patients are likely to suffer frequent recurrent episodes of stones necessitating urologic intervention. Fortunately, the application of safe and efficacious minimally invasive modalities, including advancements in shockwave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy, have obviated open operative intervention in nearly all cases.