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Benign prostatic hyperplasia (BPH) is common in aging males and is the most common cause of bladder outlet obstruction (BOO) in these patients. Over 80 % of men in their eighth decade have been diagnosed with BPH, and many will require one or more treatments for outflow obstruction throughout their lives. Additional causes of BOO include urethral strictures, lower urinary tract malignancy, and obstructing bladder stones. Diagnosing the cause of lower urinary tract symptoms (LUTS) in male patients may, at times, prove difficult. In patients for whom a diagnosis of BOO is suspected, urodynamic testing may aid in confirming this diagnosis, as well as determining the degree of obstruction. The American Urological Association recommends that urodynamic testing should be considered optional in the evaluation of patients presenting with LUTS suggestive of BOO.

Although more than a decade of experience with laparoscopic radical nephrectomy indicates it is an alternative to open surgery for localized renal-cell carcinoma (RCC), the long-term oncologic effectiveness of this procedure remains to be established.A thorough MEDLINE and PubMed literature research on long-term outcomes of laparoscopic radical nephrectomy was performed, and all pertinent articles were reviewed in detail. This review was formulated on the current cancer indication, the oncologic basis, the oncologic efficacy, and the longterm oncologic effectiveness of the procedure, including laparoscopic cytoreductive nephrectomy, with regard to metastasis, port-site tumor recurrence, and the relation to laparoscopic partial nephrectomy. Furthermore, the authors' previous report on the intermediate-term efficacy of laparoscopic radical nephrectomy was updated.With increasing experience, the indications for laparoscopic radical nephrectomy continue to expand. There were many reports of intermediate-term, two reports of long-term, and our up-to-date outcomes analyzing the management of localized RCC that showed effective cancer control with no statistically significant difference between laparoscopic and open radical nephrectomy in the true 5- and 10-year survival analysis.Long-term data, critical in the evaluation of any treatment for cancer, are currently available with respect to laparoscopic radical nephrectomy for localized RCC.

Our goal was to correlate the size of renal cell carcinoma with tumor stage, nuclear grade, and histologic subtype in patients treated using partial or radical nephrectomy.We retrospectively reviewed 213 consecutive renal cell carcinomas resected at our institution from 1995 through 1999. Three groups of lesions stratified by size (or = 3 cm,3-5 cm,5 cm) were compared with regard to pathologic findings. Statistical significance was assessed using Fisher's exact test.Of 50 lesions 3 cm or smaller, 19 (38%) had extension outside the renal capsule (T3 or T4) and 14 (28%) were a high nuclear grade (Fuhrman grade 3 or 4). Lesions 3 cm or smaller and those greater than 3 cm to 5 cm did not differ statistically with regard to T stage or nuclear grade. Lesions larger than 5 cm showed a statistically higher T stage (p0.001) and nuclear grade (p = 0.001) than the other smaller lesions. More non-clear cell tumors were found in the two groups of smaller lesions (p = 0.105) but without statistical significance. The majority (58%) of the tumors were asymptomatic and had been detected incidentally on cross-sectional imaging. Lesions larger than 5 cm were significantly more likely to be symptomatic (p0.001). Seventy-nine percent of the tumors 3 cm or smaller were incidental, and these lesions did not differ significantly from the symptomatic lesions with regard to stage, grade, or histology.In our study population, renal cell carcinomas up to 3 cm, including asymptomatic lesions, showed a significant incidence of high nuclear grade and tumor extension beyond the renal capsule; these findings support aggressive management of small lesions. Symptomatic status was not an adequate discriminator to guide management. A longitudinal study is necessary to further evaluate the efficacy of current patterns of therapy.

Purpose: Several studies have documented that increased biopsy sampling, that is 6 versus 12 biopsy cores, can detect more prostate cancer. It is unknown whether increased sampling of the prostate will detect a higher number of potentially insignificant tumors.Materials and Methods: We searched the surgical pathology files at The Johns Hopkins Hospital for patients in whom prostate needle biopsy was performed by a single urologist between April 1993 and April 2000, and subsequently underwent radical prostatectomy. Patients who underwent radical prostatectomy and had 8 core biopsies or less between March 1994 and August 1999 were also studied. Clinically significant tumors were defined as those with volume greater than 0.5 cc, Gleason score 7 or greater or nonorgan confined disease.Results: A total of 297 patients with a mean age of 60 years (range 36 to 75) were evaluated. Group 1 consisted of 107 men with 8 core biopsies or less, including 51 with 6, and group 2 comprised 190 men with 9 cores or greater,...

We evaluated the clinical efficacy of laparoscopic versus open radical nephrectomy in patients with clinically localized renal cell carcinoma.Between 1991 and 1999, 67 laparoscopic radical nephrectomies were performed for clinically localized, stages cT1/2 NXMX, pathologically confirmed renal cell carcinoma. During this period 54 patients who underwent open radical nephrectomy with pathologically confirmed stages pT1/2 NXMX disease were also identified. Medical and operative records were retrospectively reviewed and telephone followup was done to assess patient status.In the laparoscopic and open groups average tumor size was 5.1 (range 1 to 13) and 5.4 cm. (range 0.2 to 18), respectively, which was not statistically significant. No patient had laparoscopic port site, wound or renal fossa tumor recurrence in either group. All patients were followed at least 12 months. In the laparoscopic group 2 cancer specific deaths occurred at a mean followup of 35.6 months. In the open group there were 2 cancer specific deaths and 3 cases of disease progression at a mean followup of 44 months. Kaplan-Meier disease-free survival and actuarial survival analysis revealed no significant differences in the laparoscopic and open radical nephrectomy groups. Also, no differences were noted in the complication rate.Laparoscopic radical nephrectomy is an effective alternative for localized renal cell carcinoma when the principles of surgical oncology are maintained. Initial data show shorter patient hospitalization and effective cancer control with no significant difference in survival compared with open radical nephrectomy.

Objectives. To evaluate the influence of isolated, histologically identified capsular incision (CI) (exposure of benign or malignant glands to the inked surgical margin in the setting of organ-confined disease) on disease progression after anatomic radical retropubic prostatectomy (RRP) for clinically localized prostate cancer. Methods. Between March 1993 and September 1999, 4747 men underwent RRP at the Johns Hopkins Hospital; 107 men (2.3%) were diagnosed with CI in otherwise organ-confined disease; 92 (86%) had at least 6 months (mean 30) of follow-up. We matched these CI cases (based on surgeon, age, clinical stage, final pathologic Gleason grade, and preoperative serum prostate-specific antigen level) one-for-one with controls in three additional pathologically defined groups and compared the freedom from disease progression (prostate-specific antigen level greater than 0.2 ng/mL and/or local palpable recurrence) after RRP. Results. The actuarial 3-year likelihood of freedom from disease progression was 87.8% for the CI group, 96.4% for men with organ-confined disease (P = 0.10), 91.3% for men with extraprostatic extension and negative surgical margins (P = 0.99), and 73.9% for men with positive surgical margins resulting from extraprostatic extension (P

Objectives. The techniques for hemostasis after renal tumor excision have limited the widespread application of laparoscopic partial nephrectomy (LPN). To improve hemostasis and aid visualization, we report our experience with a novel radiofrequency coagulation (RFC) technique for LPN. Methods. Ten patients underwent RFC-assisted LPN. The demographic and perioperative data were tabulated. Patients were positioned as for laparoscopic nephrectomy, and laparoscopic ports were placed. The kidney within Gerota’s fascia was mobilized, and the fat overlying the tumor was carefully removed for pathologic evaluation. Under laparoscopic guidance, a radiofrequency probe was percutaneously inserted into the lesion and deployed to coagulate the lesion and a margin of normal parenchyma. Laparoscopic scissors were used to excise the lesion; additional hemostatic maneuvers were used selectively. Results. The mean renal tumor size was 2.1 cm (range 1.0 to 3.2). The median operative time was 170 minutes and the median blood loss was 125 mL. The RFC technique resulted in complete tissue coagulation within the treated volume, thereby facilitating intraoperative visualization, minimizing blood loss, and permitting rapid and controlled tumor resection. The renal architecture was preserved, allowing accurate diagnosis of renal cell carcinoma and angiomyolipoma in 9 and 1 cases, respectively. No perioperative complications occurred. Conclusions. The use of RFC is an effective method to facilitate LPN of both exophytic and endophytic masses. By coagulating a margin of normal parenchyma, the technique minimizes blood loss and improves visualization during LPN. We anticipate this technique will broaden the clinical application for LPN.

Objectives. To establish the safety and efficacy of laparoscopic and laparoscopic-assisted nephroureterectomy. Methods. Since 1993, 25 patients with a minimum of 12 months of follow-up underwent nephroureterectomy using a total laparoscopic or laparoscopic-assisted technique. Four patients had specimen morcellation for tissue removal. All patients had regular follow-up with physical examinations, interval cystoscopy, and radiographs, depending on the metastatic potential of the tumor. Retrospective chart review was performed and assessed for operative time, blood loss, tumor pathologic stage, complications, and outcome. One patient was excluded because of an open conversion due to multiple previous abdominal surgeries and failure to progress. Results. The mean operating time was 329 minutes but decreased with experience. The median hospital stay was 4 days. Tumor stage was directly related to tumor grade. Associated bladder tumors (prior history or recurrent tumors) occurred in 50% of the patients. Ipsilateral ureteral stump site recurrence occurred in 1 patient. Although no port site seeding occurred, 1 patient, whose tumor was discovered histologically after laparoscopic pyeloplasty for presumed benign disease, developed recurrence in the renal fossa and metastatic disease. Two patients developed liver metastasis. Conclusions. Total laparoscopic and laparoscopic-assisted nephroureterectomy are acceptable alternatives to open surgery in the treatment of transitional cell carcinoma of the upper urinary tract. Tumor morcellation did not appear to adversely affect patient outcome. As with open nephroureterectomy, tumor grade is the most important prognostic indicator of local, bladder, and metastatic recurrence. No port site seeding was observed in either the total laparoscopic or laparoscopic-assisted groups.

Purpose The purpose of this work was to define the temporal CT characteristics of hepatic and renal ablation following point-source radioablation utilizing a low energy, photon X-ray source emitted from a miniature probe. Method Twelve mongrel dogs underwent each of three hepatic and two renal point-source radiation ablations. Animals underwent serial, dual phase, spiral CT scans and were killed at 1, 3, and 6 months after treatment. Results Ablative lesions were clearly visible at 1 month following therapy and consistently diminished in size over the 6 months of follow-up. Lesion size tended to be proportional to dose delivered. Both hepatic and renal lesions were low in attenuation with frequent rim enhancement that diminished over time. Hepatic lesions frequently showed transient hepatic attenuation differences (THADs). Lesion size appeared independent of proximity to vessels. Conclusion Following hepatic or renal interstitial radiotherapy, lesions are generated that are similar in CT appearance to those produced by other ablative techniques. The presence of rim or THAD enhancement can be seen early on as part of the normal tissue-healing response.

Objectives. To present the preliminary results of renal ablative cryosurgery in selected patients. Methods. Seven patients were treated, all of whom had small peripheral tumors and chose not to undergo partial or radical nephrectomy. Four patients underwent a rib-sparing flank incision; the remaining three underwent laparoscopy. All tumors were biopsied before cryoablation. Intraoperative ultrasound was used to monitor the cryolesion. Results. There were no intraoperative complications. The estimated blood loss averaged 111 mL. To date, 6 of the 7 patients have undergone at least one follow-up computed tomography scan (14.2 months average follow-up); all these scans demonstrated partial resolution of the lesion. Clinically, the patients tolerated the procedure without any renal complications or significant changes in creatinine. Conclusions. This limited clinical trial has demonstrated the feasibility of treating small peripherally located renal tumors with cryosurgery with minimal morbidity and a favorable outcome. Further studies are necessary to determine the long-term efficacy of this treatment modality.

Adhesions from prior extensive open abdominal surgery can make initial transperitoneal access for laparoscopy hazardous. An alternative to open port placement is a retroperitoneal approach to the peritoneal cavity. We describe our retroperitoneal access for transperitoneal laparoscopy and evaluate the success of the subsequent laparoscopic procedure.Eight patients with a history of abdominal surgery have undergone retroperitoneal access to the peritoneum prior to a laparoscopic urologic procedure. With the patient in a lateral decubitus position, the retroperitoneum is entered with a 10-mm Visiport device (US Surgical Corp., Norwalk, CT) along the posterior axillary line. A working space is bluntly created, the peritoneum identified anterior to the colon, and the endoscope passed through a peritoneotomy. The abdomen is then inspected, transperitoneal ports are strategically placed under direct vision, and the intended procedure is commenced.In all cases, retroperitoneal access to the peritoneum and subsequent trocar placement was successful. In five cases, the intended procedure was completed laparoscopically. In a case of bilateral ureterolysis, one side was completed laparoscopically; however, the other required open conversion. In two nephrectomies for xanthogranulomatous pyelonephritis (XGP), open conversion was necessary because of fibrosis.Retroperitoneal access to the peritoneal cavity permits safe and effective port placement when previous abdominal surgery makes initial transabdominal access difficult. However, despite successful access, in patients at risk for extensive perinephric fibrosis (e.g., XGP), a high incidence of open conversion may be expected.

The disadvantages of standard percutaneous nephrolithotomy (PCNL) as compared with ureteroscopy or extracorporeal shock-wave lithotripsy include increased blood loss, greater pain, and longer hospital stay. A 13-Fr "mini-perc" technique using a ureteroscopy sheath for PCNL was developed in an attempt to address these drawbacks. Nine "mini-percs" have been performed in patients aged 40-73 years with stone burdens of < or = 2 cm2. On average, patients had 1.4 stones with a cross-sectional area of 1.5 cm2. The mean total procedure time, estimated blood loss, and hematocrit decrease were 176 min, 83 ml, and 6.6%, respectively. On average, patients used 14 mg of parenteral morphine and stayed 1.7 days in the hospital. There was no procedure-related complication or transfusion. Eight of nine kidneys (89%) were stone-free on early follow-up at a mean of 3.8 weeks. As compared with standard PCNL, the "mini-perc" technique has similar early success rates in selected patients and may offer advantages with respect to hemorrhage, postoperative pain, and shortened hospital stays.

Purpose: We present our experience with laparoscopic pyeloplasty plus pyelolithotomy in patients in whom stones were not the cause of ureteropelvic junction obstruction.Materials and Methods: A transperitoneal approach was used for laparoscopic pyeloplasty and pyelolithotomy in 19 patients (20 renal units). Before ureteropelvic junction repair stones were extracted through a small pyelotomy that was eventually incorporated into the final pyeloplasty incision. Stones in the renal pelvis were removed with rigid graspers under direct laparoscopic vision. A flexible cystoscope introduced through a port was used to extract stones in the calices. The renal pelvis was reconstructed based on the anatomy of the ureteropelvic junction.Results: A median of 1 stone (range 1 to 28) was recovered. In 11, 8 and 1 patients the Anderson-Hynes dismembered pyeloplasty, Y-V plasty and the Heinecke Mickulicz procedure were performed, respectively. At 3 months 2 patients had residual calculi for a procedural stone-free rate of...

We describe our surgical technique for rapid ligation of the renal hilum during transperitoneal laparoscopic nephrectomy. This technique is reliable and provides an efficient method of hilar ligation.

Purpose: Controlled ligation and division of the renal hilum are critical steps during any nephrectomy procedure. The use of the endovascular gastrointestinal anastomosis (GIA) stapling device for control of the renal vessels during laparoscopic nephrectomy has become standard practice. However, malfunction can lead to serious consequences which require emergency conversion to an open procedure. We report our experience with GIA malfunction during laparoscopic nephrectomy.Materials and Methods: From July 1993 to September 1999, 565 patients underwent laparoscopic nephrectomy at 2 institutions for benign and malignant diseases, and for live renal donation. Retrospective chart reviews and primary surgeon interviews were conducted to determine etiology of failure, intraoperative management and possible future prevention.Results: Malfunction occurred in 10 cases (1.7%). In 8 cases the renal vein was involved and malfunctions affected the renal artery in 2. The estimated blood loss ranged from 200 to 1,200 cc....

The recently recognized Xp11 translocation renal cell carcinomas (RCCs), all of which bear gene fusions involving the TFE3 transcription factor gene, comprise at least one-third of pediatric RCC. Only rare adult cases have been reported, without detailed pathologic analysis. We identified and analyzed 28 Xp11 translocation RCC in patients over the age of 20 years. All cases were confirmed by TFE3 immunohistochemistry, a sensitive and specific marker of neoplasms with TFE3 gene fusions, which can be applied to archival material. Three cases were also confirmed genetically. Patients ranged from ages 22 to 78 years, with a strong female predominance (F:M=22:6). These cancers tended to present at advanced stage; 14 of 28 presented at stage 4, whereas lymph nodes were involved by metastatic carcinoma in 11 of 13 cases in which they were resected. Previously not described and distinctive clinical presentations included dense tumor calcifications such that the tumor mimicked renal lithiasis, and obstruction of the renal pelvis promoting extensive obscuring xanthogranulomatous pyelonephritis. Previously unreported morphologic variants included tumor giant cells, fascicles of spindle cells, and a biphasic appearance that simulated the RCC characterized by a t(6;11)(p21;q12) chromosome translocation. One case harbored a novel variant translocation, t(X;3)(p11;q23). Five of 6 patients with 1 or more years of follow-up developed hematogenous metastases, with 2 dying within 1 year of diagnosis. Xp11 translocation RCC can occur in adults, and may be aggressive cancers that require morphologic distinction from clear cell and papillary RCC. Although they may be uncommon on a percentage basis, given the vast predominance of RCC in adults compared with children, adult Xp11 translocation RCC may well outnumber their pediatric counterparts.

Curative surgery in more advanced renal cell carcinoma is limited to solitary metastases or regional disease. Response to systemic immunotherapy continues to be reported; however, most responses are limited and not durable. Only randomized, prospective clinical trials will prove the efficacy of systemic therapy.

We evaluated the concordance between post-digital rectal examination and post-prostate biopsy urine samples using conventional methylation specific polymerase chain reaction analysis of 3 gene promoters in patients with suspected or confirmed prostate cancer.Voided urine specimens were collected from 17 men after 15-second digital rectal examination and again after transrectal ultrasound guided biopsy of the prostate for suspected malignancy or for followup biopsy as part of an expectant management protocol. Urine sediment DNA was isolated and subjected to bisulfite modification. Methylation of GSTP1, EDNRB and APC promoters was determined by conventional methylation specific polymerase chain reaction analysis in post-digital rectal examination and post-biopsy samples, and correlated with clinical information.Prostate cancer was detected on prostate biopsy in 12 of 17 patients (71%). Promoter methylation was detected in post-digital rectal examination urine specimens for GSTP1 (24%), APC (12%) and EDNRB (66%). Promoter methylation was detected in post-biopsy urine specimens for GSTP1 (18%), APC (18%) and EDNRB (77%). The concordance between post-digital rectal examination and post-biopsy urine samples was 94% for GSTP1 and APC, and 82% for EDNRB. Overall 100% of patients with biopsy proven prostate cancer had at least 1 gene methylated in urine vs 60% of those without evidence of prostate cancer on biopsy.Gene analysis using conventional methylation specific polymerase chain reaction is a reliable method for detecting abnormal DNA methylation in voided urine samples obtained following digital rectal examination or prostate needle biopsy. The concordance between post-digital rectal examination and post-biopsy urinary samples for promoter methylation is high (82% to 94%), suggesting that urine collected after digital rectal examination may be used for genetic analysis with results similar to those in post-biopsy urine samples.

This report assesses the long-term oncological efficacy of laparoscopic radical nephrectomy compared with open radical nephrectomy in patients with clinically localized renal cell carcinoma.We analyzed the data from 121 patients who underwent radical nephrectomy between 1991 and 1999 for clinical tumor stage T1/2 N0M0. The medical records of all patients were retrospectively reviewed with emphasis on tumor recurrence and survival. Statistical comparison was performed using Kaplan-Meier analysis.The median followup was 73 months for the laparoscopic group and 80 months for the open group. Of the 67 patients who underwent laparoscopic surgery, 53 survived without any recurrence of disease, 2 are currently alive with metastasis, 2 died of metastatic disease in months 12 and 17, and 10 patients died without any disease recurrence. Laparoscopic port site metastasis did not develop in any patients. Of the 54 who underwent open surgery, 34 survived without any recurrence of disease, 1 currently has metastasis, 6 died of metastasis within 17 to 74 months, and 13 died without any disease recurrence. A comparison of the 5 and 10-year disease-free survival rates of the laparoscopic and open groups revealed no significant differences. In addition, the 5 and 10-year cancer specific and actuarial survival rates were not significantly different.Based on long-term followup, our evaluation confirmed for clinical tumor stage T1/2 N0M0 that laparoscopic radical nephrectomy is oncologically equivalent to open radical nephrectomy.

Positive surgical margins adversely affect biochemical recurrence-free survival after radical retropubic prostatectomy (RRP) for prostate cancer. We retrospectively reviewed a large series of men who underwent RRP at a single academic university urology program to define the change in the incidence of organ confined (OC) disease and positive surgical margin (SM+) during the last 2 decades.Between 1982 and 2001, 9,035 men underwent RRP for clinically localized prostate cancer (T1 to T3a) at a single institution. We compared the incidences of OC disease and SM+ in this population.An increasing proportion of men presented with OC disease over time. The incidence of SM+ in the overall RRP population decreased dramatically over time. However, in men with nonorgan confined disease (pT3), the proportion with SM+ was stable and consistently elevated (22.7% to 27.8%), after the initial decrease from the early 1980s (53%).Widespread early detection programs for prostate cancer resulted in a downward stage migration in men presenting with clinically localized prostate cancer at our institution during the last 2 decades. The decrease in the percentage of men with SM+ was due to the increasing number of men with organ confined disease. These results imply that the decrease in surgical margin rates in the overall RRP population is most likely due to stage migration and improved patient selection, rather than major improvements in surgical technique. The stable percentage of SM+ among men with pT3 disease dictates the need for continued evaluation of surgical technique and the need for effective adjuvant therapy.

The presence of a foreign body in the genitourinary tract represents a urologic challenge that often requires prompt intervention. We describe an endoscopic approach that was used for removal of a foreign body located in the prostatic urethra of a schizophrenic man. A nitinol stone basket was used as an effective means for extraction of a large metal screw from the urethra of this patient.

Rationale and Objectives The purpose of this study was to examine the histologic evolution over time of rabbit skeletal muscle thermally ablated with high-intensity focused ultrasound. The objectives included determining the extent and focality of damage created by this noninvasive, transcutaneous ablative technology. Methods Transcutaneous, thermal ablation with an external focused ultrasound transducer was applied to the paraspinous muscles of 19 rabbits. At varying times, up to 100 days after therapy, single sonications were examined histologically. Results Initially, only subtle staining changes were identified within lesions. In the chronic phase (day 51-100), the muscle was replaced or infiltrated by variable amounts of scar and fat similar to degenerative muscle disorders. Histologic changes were limited to the tissue within the intensity focus of the transducer and were not seen in intervening tissues. Discussion The current study took a systematic approach to study the long term, in vivo histologic effects of single HIFU lesions in a nonregenerative tissue. This experience in muscle tissue will provide a basis for understanding ultrasound effects for clinical applications such as treatment of uterine fibroids, cardiac tissue, and sarcomas.

This article evaluates the safety and efficacy of percutaneous radiofrequency ablation (RFA) delivered by computed tomography (CT) fluoroscopic guidance for the treatment of small, solitary renal lesions in high risk surgical and anesthetic patients. In total, 29 patients with 35 small (≤4 cm) renal lesions underwent a total of 37 CT fluoroscopically guided RFA treatments using a dry RFA technique. Because of medical comorbidities, 26 patients were considered high surgical risk candidates, and 3 patients had von Hippel-Lindau disease. Procedures were performed percutaneously, under intravenous sedation and on an outpatient basis. Renal lesions were monitored on a 3-month basis using precontrast- and postcontrast-enhanced CT imaging to assess for the presence of growth or residual lesion enhancement. Of 37 RFA treatments, 35 (95%) were successfully performed under intravenous sedation and 32 (86%) treatments were performed on an outpatient basis. Over a mean radiographic follow-up period of 9 months, 33 of 35 (94%) renal lesions have required only a single RFA treatment, and 2 patients required a second, successful retreatment for small regions of residual enhancement on follow-up CT imaging. Of 13 renal lesions with a ≥12-month radiographic follow-up interval, 11 (85%) have demonstrated no residual enhancement or growth after RFA. Percutaneous RFA of small, solitary renal lesions is well tolerated in high surgical risk patients. Although early results are encouraging, longer-term follow-up time is necessary to determine the precise role of RFA in this patient population. high resolution video , medium resolution video , low resolution video

Objectives Most adenocarcinomas of the prostate with a Gleason score greater than 8 at radical prostatectomy have extraprostatic extension and a high risk of progression. With prostate-specific antigen screening, we have seen some cases of earlier detected, organ-confined, high-grade adenocarcinoma. Few data are available as to the likelihood of cure in these cases. Methods We reviewed 27 cases of pathologically organ-confined adenocarcinoma with a prostatectomy Gleason score of 8 to 10. To exclude cases with a significant proportion of Gleason pattern 3, we excluded cases of Gleason score 3+5=8 and Gleason score 5+3=8. All cases of Gleason score 8 at radical prostatectomy were Gleason score 4+4. The prognostic value of the clinical parameters (clinical stage, serum prostate-specific antigen level, age) and pathologic factors (biopsy Gleason score, radical prostatectomy Gleason score, prostatectomy tumor volume) were tested to predict postoperative progression. Results The mean age at diagnosis was 59.7 years (range 46 to 69) with preoperative serum prostate-specific antigen levels ranging from 1.4 to 28 ng/mL (mean 7.8). All tumors were classified as pathologic Stage T2N0Mx. Fifteen patients (55.6%) had a Gleason score of 8, 11 patients (40.7%) had a Gleason score of 9, and 1 had a Gleason score of 10 (3.7%). Tumor volumes ranged from 0.02 to 1.44 cm 3 (mean 0.56). Follow-up information was available for all men. The mean follow-up for those without progression was 30.6 months (range 7 to 73) and for those with progression was 23.6 months (range 9 to 44). The 33-month actuarial risk of progression was 32%, with 10 men developing progression during the study. None of the preoperative or postoperative variables predicted progression. Conclusions Even when high-grade tumor is organ confined, it is associated with a relatively unfavorable short-term outcome that is not predictable on the basis of either preoperative clinicopathologic data or postoperative pathologic information obtained from the radical prostatectomy specimen.

Laparoscopic pyeloplasty was developed as a minimally invasive alternative to an open procedure for the treatment of ureteropelvic junction obstruction. Long-term followup has not yet been reported. We present experience with the first 100 consecutive cases of laparoscopic pyeloplasty performed at our institution.A retrospective review of 100 consecutive laparoscopic pyeloplasties in 99 patients (means age 37.3 years) between August 1993 and January 1999 was performed. All patients had radiographic evidence of obstruction with signs, symptoms or deterioration of renal function. Repair was for primary ureteropelvic junction obstruction in 83 patients and secondary obstruction in 17. The 4 types of repairs performed were Anderson-Hynes dismembered (71 cases), Y-V plasty (20), Heineke-Mirhulicz (8) and Davis intubated ureterotomy (1). Type of repair used was dictated by intraoperative findings. Twenty patients had nonobstructing renal stones and underwent concomitant pyelolithotomy. All patients were assessed for symptoms and radiographic evaluation for anatomical obstruction.Average operating room time was 4.2 hours, which decreased with surgeon experience. Average blood loss was 181 cc and hospital stay was 3.3 days. Two patients required blood transfusion. A crossing vessel was found in 57 patients. With a mean clinical and radiographic followup of 2.7 and 2.2 years, respectively, 96% of the patients were free of obstruction on followup radiographic imaging. Of the patients who underwent concomitant pyelolithotomy, 18 (90%) were stone-free at last followup. All failures occurred within the first postoperative year. There were 12 complications in this series.In experienced hands laparoscopic pyeloplasty is an effective alternative treatment for symptomatic ureteropelvic junction obstruction. The results appear durable and comparable to open pyeloplasty with decreased postoperative morbidity.

Laparoscopic donor nephrectomy is gaining increasing popularity because the procedure helps reduce disincentives to live kidney donation and has increased the live kidney donor pool. The left kidney of the donor is the preferred allograft because the right renal vein is shorter. Similarly, the right renal artery might be foreshortened because it hides behind the inferior vena cava during laparoscopic transperitoneal dissection. There are instances, however, in which it is not practical to take the left kidney due to vascular anomalies or asymmetric function. We describe a novel technique for obtaining greater renal arterial length utilizing laparoscopic interaortocaval dissection.

Objectives. To delineate factors that may predict eventual urinary continence after bladder neck reconstruction (BNR) in the bladder exstrophy population. Methods. The records of 65 patients who underwent all phases of bladder exstrophy reconstruction at our institution between 1975 and 1997 with greater than 1-year follow-up were reviewed and data analyzed. Results. Fifty patients (77%) are continent day and night and voiding per urethra without need for augmentation or intermittent catheterization. Nine (14%) patients have social continence, dry for more than 3 hours during the day. Two patients required continent diversion for continence after failed BNR. Four patients are completely incontinent. The mean age of BNR was 4 years with a mean and median capacity of 93 and 85 cc (range 45 to 175). Analysis of bladder capacity measurements prior to BNR revealed that patients with a bladder capacity greater than 85 cc median capacity at the time of BNR had better outcomes. No correlation was found between the age of BNR and obtaining eventual continence. The mean time to daytime continence was 14 months (range 4 to 21) and the mean time to nighttime continence was 22 months (range 11 to 33). Conclusions. Determinants of continence in the bladder exstrophy population are multifactorial. In our experience, 77% of patients are completely dry, day and night, and 91% can achieve social continence, being dry for at least 3 hours. However, with careful evaluation of bladder capacity and bladder growth, urinary continence may be improved in this population with better patient selection.

Renal cell carcinomas often show varying degrees of necrosis and cystic change. The prognostic importance of necrosis so extensive that only a few tumor cells can be identified is not clear. We gathered clinicopathologic and follow-up data on a group of eight such cases ("type I"). These patients were compared with two other groups of renal cell carcinomas: those with extensive necrosis (50%), yet with readily identifiable tumor ("type II"), and cancers with extensive cystic change not resulting from necrosis, usually multiloculated ("type III"). The groups showed similar demographic characteristics, and within each group there was great variation in tumor size. Conventional (clear cell) histology was more common than papillary morphology in all groups. The type II neoplasms tended to be of higher nuclear grade and pathologic stage than the other groups. While one of six type I patients with follow up progressed 131 months after diagnosis, eight of 20 type II patients showed progression. None of the six type III patients with follow up progressed. We conclude that renal cell carcinomas showing extensive necrosis are capable of aggressive behavior, and patients with these lesions cannot be assured of cure following surgery. Pathologists must be aware of this entity and extensively sample any renal lesion showing extensive necrosis. The tumors showing a greater amount of viable neoplastic cells yet at least 50% necrosis had a higher rate of progression than did the type I patients. The lack of progression of any of the type III cases supports the idea that type III multiloculated cystic renal cell carcinomas may carry a distinctly better prognosis than other forms of renal cell carcinoma.

Introduction. Interest in nephron-sparing surgery has been spurred by the good long-term results of patients treated with partial nephrectomy. Partial nephrectomy entails the complete resection of renal tumor while leaving behind clear surgical margins and maximum functional renal parenchyma. Technical Considerations. We prefer to access the renal tumor by a flank incision. Intraoperative sonography is used to define the operative lesion and to search for multicentric tumors. A vascular clamp is placed on the renal hilum for vascular control. Regional hypothermia protects the kidney during renal ischemia. The perinephric fat is excised in situ with the renal tumor. Tumor base biopsies ensure negative margins. Meticulous dissection and tying of vessels improves hemostasis. Diluted methylene blue is directly injected into the renal pelvis to inspect for any intrarenal leakage. The argon beam coagulator is used routinely, and collagen (Avitene) is placed into the renal defect for hemostasis. The renal parenchyma and Gerota’s fascia are reapproximated anatomically. A small drain is left in place, and the wound is closed in the usual manner. Conclusions. Recent studies continue to report that conservative surgery is as effective as radical nephrectomy for renal cell carcinoma, but the judgments in patient selection and operative management are paramount in determining its success.

No specific cause is identified in most cases of chronic orchialgia. Nonsurgical therapies, including management at a chronic pain clinic, are generally recommended. Only when multiple conservative measures fail are patients offered surgical intervention, such as orchiectomy. We evaluate laparoscopic testicular denervation as an organ preserving and minimally invasive surgical alternative.Since 1993, 9 patients with chronic orchialgia have undergone transperitoneal laparoscopic testicular denervation after nonsurgical modalities failed. Using 1, 10 mm. and 1 or 2, 5 mm. ports, the gonadal vessels were isolated circumferentially and divided cephalad to the vas deferens and its vasculature. Preoperative treatment modalities, morbidity and outcome were documented. A cord block provided temporary relief in all 9 patients. Analog scales were used to assess long-term pain relief (0 no pain to 100 worst pain) and activity levels (0 bedrest to 100 no restrictions).Average symptom duration before laparoscopic testicular denervation was 4.1 years. Of 9 patients 8 had undergone prior scrotal surgery. Failed nonsurgical modalities included anti-inflammatory drugs in 7 patients, antibiotics in 6, pain clinic consultations in 4 and antidepressant medications in 2. Mean pain score decreased from 69.4 (range 35 to 90) preoperatively to 30.6 at a mean followup of 25.1 months. Excluding the 2 cases that had no pain relief (less than 10-point reduction), average pain score decreased from 69 to 19 postoperatively (mean reduction 71%). Activity levels improved in all cases. There were no significant complications, including testis atrophy. One patient who had no pain relief underwent subsequent hydrocelectomy for pain, which also failed.Laparoscopic testicular denervation can provide significant long-term pain relief and appears to be a reasonable alternative in select cases with chronic orchialgia refractory to medical therapy. Larger series and prospective evaluations are necessary.

To evaluate renal cryosurgery by studying the feasibility of laparoscopic delivery and the radiographic characteristics and histopathologic effects in a porcine model using different freeze cycles. On the basis of the results, a clinical trial of laparoscopic cryosurgical ablation in select patients with clinical stage T1 renal tumors was started.Twelve kidneys from six farm pigs underwent cryosurgery. Each kidney was treated with two freeze cycles to -180 degrees C. Six kidneys were retroperitonealized, and six were not. An abdominal CT scan was performed at various times to evaluate for the presence of urinoma or hematoma and to monitor lesion changes. Organs were harvested at times ranging from 24 hours to 13 weeks. Radiographic and histopathologic changes were recorded for each time period. Eight patients with small (average 2-cm) exophytic renal masses underwent laparoscopic biopsy and cryosurgical ablation using a 3- or 4.8-mm probe (Cryomedical Sciences Inc., Rockville, MD) for one 15-minute or two 5-minute freeze cycles to a temperature of -180 degrees C to extend the ice ball at least 7 mm beyond the tumor margin.Dense adhesions between the bowel and cryoablated renal tissue were encountered in all non-retroperitonealized kidneys, but no fistula formation was present. The retroperitonealized kidneys had minimal adhesion formation. None of the animals developed a urinary fistula. At 24 hours and 1 week, CT scanning demonstrated an enhancement defect corresponding to the region of the ice ball with no urinoma or hematoma. At 13 weeks, only a nonenhancing cortical defect was seen. At immediate harvest, hemorrhage was noted in the area of the ice ball with a sharp demarcation at the edge of the freeze zone. At 1 week, four distinct zones were seen: central necrosis, inflammatory infiltrate, hemorrhage, and fibrosis with regeneration. At 13 weeks, the necrotic tissue had been replaced with a circumscribed area of fibrosis. There were no intraoperative or postoperative complications in the eight patients. The estimated blood loss was 140 mL, and the mean hospital stay was 3.5 days. At a mean clinical follow-up of 7.7 (range 1-18) months and radiographic follow-up of 5 months; there have been no tumor recurrences or significant changes in the serum creatinine concentration. At 24 hours, there was an enhancement defect in the area of the ice ball. The CT images at 13 weeks showed a nonenhancing cortical defect in the area of the ice ball.Cryosurgery can be readily delivered laparoscopically, creating a discrete lesion at the time of treatment that appears to be consistent over time. In the animal studies, complete tissue necrosis developed in the freeze zone, followed by reabsorption, and by 13 weeks, fibrous tissue had replaced the defect. In the animal and human trials, there were no operative complications, urinomas, hematomas, or bowel or urinary fistulas. Follow-up imaging in human trials revealed a persistent nonenhancing defect in the area of the freeze zone. Long-term clinical follow-up will be necessary to determine the cancer-free survival rate.

A 28-year-old man with ulcerative colitis presented with a 2-month history of persistent purulent drainage from the glans penis. Symptoms began with the appearance of a small pustule on the glans followed by spontaneous drainage that was associated with tenderness and induration. Computerized tomography and magnetic resonance imaging conducted elsewhere were unremarkable except for colonic wall thickening consistent with a prior diagnosis of ulcerative colitis. Gram and acid-fast stains, and fungal, and aerobic and anaerobic bacterial cultures were negative. The patient recalled a history of intermittent fevers, pain, swelling and purulent drainage from the glans despite treatment with broadspectrum intravenous and oral antibiotics. In addition to medical management, he had previously undergone 3 separate incision and drainage procedures for a suspected penile abscess. Physical examination revealed purulent drainage from incision sites made in the glans 2 weeks previously (fig. 1). Erythema, induration and multiple pustules were also present on the glans. Gross examination of the penile shaft, scrotal skin and rectum was unremarkable. No other cutaneous lesions were noted. The patient had a fever of 102F, and complete blood count demonstrated mild leukocytosis (white blood count 14,300, normal 4,500 to 11,000). Other laboratory data were unremarkable, and repeat bacterial and fungal cultures remained negative. Biopsy of the ulcerative glans lesion showed acanthosis of the epidermis with extensive fibrinoid necrosis and neutrophilic infiltration (fig. 2). There was no evidence of bacteria or fungus using additional stains. These clinical and histological findings were consistent with a diagnosis of pyoderma gangrenosum. Within 24 hours following initiation of oral prednisone the patient was afebrile and the glans drainage had decreased significantly. The patient was discharged from the hospital on a regimen of oral prednisone, and at 1-week followup the wounds had healed dramatically, with resolution of the purulent drainage. Accepted for publication December 6, 2002. * Financial interest and/or other relationship with Transurgical.

A 70-year-old man presented with gross hematuria. Computerized tomography revealed left hydronephrosis. History was significant for recurrent grade 1, Ta transitional cell carcinoma and the patient had undergone right distal ureterectomy, transurethral resection of the bladder and intravesical bacillus Calmette-Guerin therapy. Initial evaluation with cystoscopy and bilateral retrograde pyelograms revealed multiple bladder tumors, several small filling defects in the right ureter and a large filling defect in the left ureter overlying the iliac vessels (fig. 1). Transurethral resection of the bladder was performed and the ureteral tumors were biopsied. All tumors demonstrated low grade and stage disease. An ureteroscopic approach was initially chosen. The 3 small tumors on the right side were treated with holmium laser ablation. However, on the left side endoscopy revealed a 3.5 cm. tumor overlying the iliac vessels and a second 1.0 cm. proximal tumor, which affected a total ureteral length of more than 4.0 cm. After 2 sessions, it was clear that the tumor burden was excessive and a nonureteroscopic approach would be necessary. Right nephroureterectomy was not considered due to the bilateral nature of the disease and the low potential for progression. Bladder capacity was only 300 cc and deemed insufficient for a large bladder (Boari) flap. After consideration of multiple options, including distal ureterectomy with transureteroureterostomy, ileal interposition and autotransplantation, the patient elected to proceed with laparoscopic assisted autotransplantation. A transperitoneal laparoscopic nephrectomy was performed using 3 trocars (12, 10 and 5 mm.) with division of the ureter just above the ureteral tumors. The kidney was removed through a separate 6 cm. umbilical incision with a Accepted for publication December 15, 2000.

Although most renal biopsies are done percutaneously, patients with large body habitus require biopsy under direct vision. 1 Laparoscopic biopsy is an attractive alternative with reduced patient morbidity compared to an open approach. 2 In the morbidly obese patient excessive body and perirenal adipose tissue obscure usual anatomic landmarks, making trocar placement and kidney localization challenging. We describe the use of intraoperative ultrasonography in the guidance of retroperitoneal laparoscopic renal biopsy in the obese patient. METHOD A 40-year-old man, 160 cm. tall and weighing 170.5 kg., was referred by the nephrologist for laparoscopic renal biopsy to evaluate the cause of a nephrotic syndrome. He was placed in the right flank position and secured to the operating table. The standard anatomic landmarks were not palpable, making standard trocar placement hazardous. Transcutaneous ultrasonography was used to identify the 12th rib and iliac crest where an incision was made in the midaxillary line (fig. 1). A Visiport* device was introduced into the retroperitoneum under direct vision. The ultrasound probe was moved to the right upper quadrant. Using the liver as an acoustical window, transverse imaging simultaneously localized the tip of the device and the kidney (fig. 2, A). The Visiport device was guided using realtime imaging to the lateral aspect of the kidney, while simultaneously activating the blade, ensuring incision through Gerota’s fascia (fig. 2, B). The device was removed, the retroperitoneum was insufflated to 10 mm. Hg and blunt dissection with the laparoscope was performed to create a working space. A second 5 mm. trocar was placed in the anterior axillary line at the 12th rib under direct vision. The incision in Gerota’s fascia was identified and, using minimal blunt dissection, the lateral aspect of the lower pole of kidney was located 15 minutes after skin incision. Laparoscopic cup 5 mm. biopsy forceps were used to obtain 2 cortical biopsy specimens. The biopsy site was fulgurated with an argon beam laser and packed with oxidized cellulose after adequate hemostasis was confirmed and the gas was evacuated. Total procedure time was 40 minutes with minimal blood loss. The patient was discharged home within 24 hours.

Crossed renal ectopia is a rare congenital malformation. We report a case of renal cell carcinoma in a 51-year-old man with right-to-left crossed fused renal ectopia. The patient was treated with ultrasound-guided laparoscopic heminephrectomy. Postoperative three-dimensional computed tomography showed normal perfusion of the remaining part of the kidney, with good excretion of contrast from both units of the cross-fused kidney.

Two variants of renal angiomyolipoma (AML)—classic and epithelioid—have been described. Although the epithelioid variant has been reported to demonstrate an aggressive clinical behavior, classic AML is usually benign. Herein, we report a case of a 42-year-old asymptomatic woman with a lipomatous variant of renal AML associated with an inferior vena cava thrombus managed with radical nephrectomy and caval thrombectomy.