Lasers in the upper urinary tract for non-stone disease

Though the most common use for lasers in the genitourinary tract is for urolithiasis, a number of other urologic conditions can be treated with lasers because of their unique ablative, destructive and hemostatic properties. This paper reviews the advantages and disadvantages of laser technology for a number of non-stone indications.     

Intraoperative upper urinary tract cytology examination is a risk factor of upper urinary tract recurrence in patients with non-muscle-invasive bladder cancer

ObjectivesTo evaluate the impact of intraoperative upper urinary tract (UUT) cytology examination in patients with non-muscle-invasive bladder cancer (NMIBC) who had undergone transurethral resection of bladder tumor (TURBT).Materials and methodsWe retrospectively evaluated 414 patients with NMIBC who had undergone transurethral resection of bladder tumor between November 1993 and April 2019. Patients with simultaneous UUT urothelial carcinoma (UC) detected via computed tomography were excluded. Patients were divided into 2 groups: those who had undergone intraoperative bilateral UUT cytology examination via retrograde catheterization (study group) and those who had not (control group). We evaluated the utility of intraoperative UUT cytology examination, comparing surgical outcomes and perioperative complications between the 2 groups. In addition, we evaluated the impact of UUT cytology examination on UUT recurrence using background-adjusted multivariate analysis.ResultsWe obtained 292 UUT urine samples from 146 patients with a median age of 72 years. Of 292 UUT urine samples, 11 (3.7%) were positive and 3 were finally diagnosed as UUT UC. Positive predictive value and false positive rate were 18% and 3.1%, respectively. Operative time for the study group was significantly longer than for the control group. Rate of perioperative complications were not significantly different between the 2 groups. However, in background-adjusted multivariate analysis, intraoperative UUT cytology examination was associated with significantly shorter UUT recurrence-free survival.ConclusionIntraoperative UUT cytology examination may not be recommended as a result of low positive predictive value due to contamination and UUT recurrence risk in patients with NMIBC.     

Value of exfoliative urinary cytology for differentiation between uric acid stone and tumor of upper urinary tract

The differentiation between uric acid stone and epithelial tumor in the upper urinary tract by exfoliative urinary cytology is recommended in the literature. To demonstrate the value of cytologic examination a comparative study was performed in unselected urologic outpatients, patients with stones, and patients with epithelial tumors in the renal pelvis or ureter. The over-all accuracy rate of the cytologic diagnosis was 70 per cent, but the reliability was decreased by about 10 per cent of falsely positive results in patients with stones.     

Synchronous bilateral surgery for calculous disease of the upper urinary tract

Bilateral calculous disease of the upper urinary tract frequently poses great difficulty in therapeutic decisions. Staged or sequential surgery is often recommended, with the side that is more obstructed, infected, or symptomatic operated on first. Despite all the rationalization for sequential surgery, we believe that a simultaneous surgical approach to bilateral calculous disease is feasible and advisable in some situations. On the basis of our experience with nine patients, we have categorized the indications for such surgery. In patients, with bilateral calculous disease for whom surgical intervention on both sides will at some point be necessary, simultaneous single-stage surgery is recommended. This is especially true: (a) with bilateral obstructive calculi; (b) in bilateral calculous disease with acute pyelonephritis when which side is affected is equivocal; (c) when anatomic proximity makes bilateral surgery easier, e.g. in bilateral lower ureteral calculi or bilateral calculi in horseshoe kidneys.     

Reconstructive surgery of obstructive disease of the upper urinary tract

Efficacy of reconstructive surgery for the obstructive disease of the upper urinary tract was evaluated. Reconstructive surgery was performed in 75 units of the urinary drainage system of 72 patients between July, 1977 and December, 1987. 44 patients were male and 28 were female. The patients ranged in age 1 to 71, mean +/- S.D. being 43 +/- 14 years old. Original diseases were postoperative scar, scar due to the calculi, injury, retroperitoneal fibrosis, ureteritis, tuberculosis, amyloidosis and multiple ureteral diverticulum. The surgery consisted of ureterocalicostomy, renal descensus, descent of right renal vein, uretero-ureterostomy, ureteroneocystostomy (to the dome of the bladder), psoas bladder hitch and renal autotransplantation. Renal autotransplantation was chosen instead of ileal substitution to preserve the continuity of the urinary drainage system, when the upper urinary tract was extensively damaged. The obstructive change of the upper urinary tract improved or disappeared in 66 of 75 units. However, it persisted in 9 units, which were treated with ureterocalicostomy (wrong technics; in 4 units), ureteroureterostomy (wrong choice of the procedure; in 4 units) and autotransplantation (cessation of anti tbc drugs; in 1 unit). In 3 of these 9 units, additional reconstructive surgery was necessary. One patient who was treated with autotransplantation, died of massive bleeding from rupture of arterial anastomosis on 14th postoperative day. No other life-threatening complications were observed. Deterioration of the renal function was observed in two severely damaged kidneys which were performed autotransplantation, although the obstructive change of their urinary tract completely disappeared.(ABSTRACT TRUNCATED AT 250 WORDS)     

Calculus disease of upper urinary tract in San Francisco Chinese

Acute calculus disease of the upper urinary tract was studied retrospectively (1974–1978) in San Francisco Chinese and Caucasians. The Chinese population of San Francisco represents approximately 10 per cent of the total population. Yet the incidence of upper tract calculus among Chinese was found to be about twice that among Caucasians (as judged by admission at three major hospitals, one of them with Chinese patients only). The stones which develop in Chinese people are predominantly of mixed calcium and uric acid (45 per cent) and pure uric acid (15 per cent). This finding suggests that the origin of recurrent calculus disease is related to high intake of purines inherent in the Chinese diet, inducing hyperuricosuria.     

Ureteral access for upper urinary tract disease: the access sheath.

Ureteral access with the flexible ureteroscope remains a challenge for the urologist. The routine use of a newly developed, site-specific ureteral access sheath facilitates entry into the ureter for fragmentation and basket extraction of ureteral and renal calculi. The step-by-step technique of ureteral access with the Access Sheath is described.     

Flexible nephroscopy for upper urinary tract pathology

Flexible nephroscopy was introduced in the Urological Department of Saint John Emergency Clinical Hospital in 2002 and rapidly became a routine procedure. During September 2002-October 2006, flexible nephroscopy was performed in 113 patients for: lithiasis (107 cases), uretero-pelvic junction stenosis (3 cases), caliceal diverticulum (1 case), caliceal urothelial tumors (2 cases). In all cases a 24F flexible nephroscope was used. The energy sources consisted in an electrohydraulic lithotripsy device or Ho:YAG/Nd:YAG lasers. The success rate in patients with lithiasis was 94.4%. Antegrade endopyelotomy was successfully performed in all 3 cases. Evaluation at 6, 12 and 18 months revealed a normal pyelocaliceal system in 2 cases and a significant reduction of hydronephrosis in the third one. In the patient with caliceal diverticulum, evaluation at 6 and 12 months described a large communication with the pyelocaliceal system and no lithiasis recurrence. No recurrences occurred in the patients with conservatively treated caliceal urothelial tumors. Minor complications were encountered in 7% of the cases. Flexible nephroscopy decreases the necessity for multiple access trajects, supracostal access trajects or multiple procedures, thus reducing the morbidity associated with percutaneous interventions.     

上尿路结石的急诊ESWL治疗

报告８４例上尿路结石患者经急诊ＥＳＷＬ后效果满意，结石一次治疗粉碎率为１００％，结石一周内排净率为１００％。９例急性无尿患者经急诊ＥＳＷＬ后均在１～１２ｈ内迅速排尿，肾功能得已恢复。５６例急性肾绞痛患者经急诊ＥＳＷＬ后绞痛解除，结石排净。１９例输尿管结石在输尿管镜取石过程中将结石推入肾脏后即行ＥＳＷＬ均获一次治疗成功。急诊ＥＳＷＬ是治疗尿石症引起的急性无尿、急性肾绞痛等患者的简单、有效方法之一，能获得立竿见影之效果。     

The role of FISH and cytology in upper urinary tract surveillance after radical cystectomy for bladder cancer

ObjectivesCytology and fluorescence in situ hybridization (FISH) (Urovysion) assay are often used during upper urinary tract surveillance in patients following radical cystectomy with urinary diversion, without much available data regarding efficacy in this population. Here, we evaluate the value of FISH and cytology in detecting upper tract recurrence in the face of a urinary diversion.Materials and methodsA review of our cystectomy database revealed 270 patients who had at least one FISH and/or cytology assay performed during surveillance after radical cystectomy. Workup included upper tract imaging in all patients and upper tract endoscopy as indicated. A total of 163 FISH assays and 474 urinary cytology examinations were included in the analysis. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of FISH and cytology were assessed.ResultsTen patients (3.4%) developed upper tract recurrence after a median follow-up time of 31 months (2–202). All but 1 patient presented either with gross hematuria or positive finding on imaging; 6 had positive FISH and cytology, and 2 had positive cytology only (no FISH done). For detection of upper tract recurrence, sensitivity, specificity, PPV, and NPV of cytology were 80.0%, 85.6%, 10.7%, and 99.5%, respectively; and that for FISH were 85.7%, 86.5%, 23.1%, and 99.2%, respectively.ConclusionsThe FISH assay and urinary cytology both demonstrate high rates of false positivity and are useful mainly for their negative predictive ability in patients with a urinary diversion. Unless prospective trials show otherwise, both—or at least the more expensive test—can be omitted from surveillance strategies.     

Therapeutic management of upper urinary tract stone disease in 172 subjects

Three hundred one patients with recurrent renal calculi were studied: 129 patients received no treatment, and 172 received either bendrofluazide (90) or allopurinol (82). The renal stone recurrence rate was assessed over a five-year period, and it was noted that the incidence of recurrence was significantly lower in patients receiving either bendrofluazide or allopurinol. In male patients there was no difference in recurrence rates in those receiving the different drugs, but female patients receiving allopurinol had a significantly lower five-year recurrence rate when compared with those receiving bendrofluazide.     

Bacteriology of upper urinary tract stones

Extensive cultures of stones and urine were performed in 215 patients who underwent an operation for upper urinary tract calculi. Microorganisms could be cultured from the stone in 1 of every 3 patients. Despite the extended culture technique urease-producing microorganisms could be cultured from the stone in only 48% of the patients with calculi that contained magnesium ammonium phosphate. This finding suggests that an infection with urease-producing microorganisms is not obligatory for the formation of this type of stone. Of the patients with calcium oxalate phosphate stones 32% had positive stone cultures, which distinguished them from patients with pure calcium oxalate stones, only 8% of whom had a positive stone culture (p less than 0.001).     

Inverted papilloma of upper urinary tract

Two new cases of inverted urothelial papilloma in the upper urinary tract are described and added to the 22 cases previously reported in the literature. In both cases inverted papilloma was localized beneath macroscopic normal surface, and in one of the cases the changes were found scattered widely in the upper urinary tract. The possible etiology and the symptomatology are discussed, and the need for follow-up of these patients is emphasized.     

Recurrence of upper urinary tract calculi

Treatment of upper urinary tract stones has changed greatly. The recurrence of calculi after the discharge was studied in the 634 patients with urolithiasis admitted to our department during the 9 years up to the end of 1984. The recurrence rate in the 325 cases followed for more than 3 months after the disappearance of the original stones, was 15.6% after 2 years, 27.6% after 5 year and 51.4% after 8 years. In recurrent stone formers, the rate of recurrence thereafter was greater than that of primary stone formers. The growth of calculi was rapid in the renal stone former concomitant with urinary tract infection together with a past history of renal surgery. In relation to the composition of the stone, uric acid calculi tended to recur more often than calculi composed of other substances. In view of recurrence, pyelolithotomy is preferred to renal parenchymal incision.