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Background: Appropriate surgical management of ureteral strictures is dependent on not only the etiology of the stricture but also its location and characteristics. Stricture length and location play a significant role in potential surgical options, yet accurate evaluation of these features is limited. We present a case of a complex ureteral stricture where employment of an endoscopic tool in a novel manner helped to better evaluate the patient and provide more precise counseling in the preoperative setting. Case Presentation: A 65-year-old Caucasian man with a history of nephrolithiasis developed a complex ureteral stricture secondary to his calculus disease and prior instrumentation. His stricture was causing obstruction of his left collecting system and the patient was interested in a reconstructive procedure. We present a novel use for a pre-existing endoscopic tool that helped to more accurately delineate the characteristics of his ureteral stricture and improved preoperative planning. Conclusion: Determination of precise stricture length and location is of utmost importance for preoperative patient counseling and surgical planning. Where more sophisticated calibration technology is not available, use of an angiographic catheter during diagnostic endoscopy can improve preoperative assessment and surgical planning for complex ureteral reconstructive procedures.

Background: Symptomatic ureteral obstruction from a nonurologic metachronous metastatic malignancy is an unusual phenomenon that is underreported in the literature. This potential etiology for ureteral obstruction warrants consideration by the practicing urologist during a comprehensive evaluation as it may alter prognosis and management options for the afflicted patient. Case Presentation: An 80-year-old Caucasian man with a remote history of prostate cancer and colon cancer presented with new unilateral ureteral obstruction characterized by hydronephrosis, acute kidney injury, and right-sided abdominal pain. A high clinical index of suspicion ultimately leads to the diagnosis of metastatic colon cancer on ureteral biopsy specimen. Conclusion: Evaluation of symptomatic ureteral obstruction in a patient with a significant cancer history should include nonurologic malignant obstruction. Diligence in evaluation of the etiology of the ureteral stricture with repeat biopsies should be undertaken if there is clinical concern. Nephroureterectomy should be part of patient counseling for management of long segment malignant ureteral stricture disease.

INTRODUCTION AND OBJECTIVE:Morbidly enlarged prostate (MEP) >400g due to benign prostatic hypertrophy (BPH) can result in significant lower urinary tract symptoms that are refractory to standard me...

INTRODUCTION AND OBJECTIVE:Research suggests that surgeon awareness of surgical supply cost is lacking. We wanted to assess the ability of urologists and their operating room (OR) staff to estimate...

Benign prostatic hypertrophy (BPH) is a common cause of voiding dysfunction. BPH may lead to bladder outlet obstruction and resultant troublesome lower urinary tract symptoms. Initial management of BPH and bladder outlet obstruction is typically conservative. However, when symptoms are severe or refractory to medical therapy or when urinary retention, bladder stone formation, recurrent urinary tract infections, or upper urinary tract deterioration occur, surgical intervention is often necessary. Numerous options are available for surgical management of BPH ranging from simple office-based procedures to transurethral operative procedures and even open and robotic surgeries. This article reviews the current, most commonly used techniques available for surgical management of BPH.

Throughout the past decade, numerous techniques for the treatment of benign prostatic hyperplasia have emerged. Laser therapy, in particular, has gained widespread popularity among urologists. Since its inception in 1996, holmium laser enucleation of the prostate (HoLEP) has been evaluated rigorously in the treatment of glands of all sizes. HoLEP has produced superior relief of bladder outlet obstruction as compared to transurethral resection of the prostate based on urodynamics, and has proved equally as effective as open prostatectomy, for the management of very large glands (>100 cc), with lower morbidity. In addition to HoLEP, several newer but less well-studied laser techniques currently are available. These include photoselective laser vaporization utilizing the potassium-titanyl-phosphate (KTP or “green light”) laser, thulium laser enucleation, and high-power diode laser vaporization. This report reviews the most current literature on laser therapies utilized in the treatment of benign prostatic hyperplasia with regards to safety, outcome, efficiency, and long-term durability.

We review the recent literature on pediatric urolithiasis and present up-to-date findings on epidemiology, diagnosis, and medical and surgical management.There are surprisingly few reliable data on pediatric urolithiasis incidence, but widespread anecdotal and single-center reports suggest that more children with stones are being seen. The contamination of Chinese infant formula with melamine caused urolithiasis and other renal problems in hundreds of thousands of infants in the region, underlining the role of environmental factors in urolithiasis. Efforts continue to determine normal metabolic parameters in children, but have been hampered by variations among regions, races, and ethnicities. The Bonn Risk Index may prove to be a useful tool for assessing risk of urolithiasis in children. Children with recurrent urolithiasis are more likely to have detectable metabolic abnormalities. Surgical approaches to urolithiasis in children continue to evolve, with robotic-assisted laparoscopy being perhaps the most significant new technique. Finally, clinicians and radiologists must be aware of the potential for dextranomer/hyaluronic acid (Deflux) implants to mimic distal ureteral stones on computed tomography (CT) scan.Pediatric urolithiasis is an expanding field, due in part to the apparent increase in cases. Research continues, seeking to refine the appropriate diagnostic and therapeutic approaches in these unfortunate children.

To identify changes associated with P-cadherin expression in bladder cancer and evaluate the potential role of such events in determining the clinical outcome and cell behaviour, as the function of P-cadherin in normal epithelium is unknown, as is its potential role in neoplastic progression in different cancers.In all, 536 bladder tumour specimens from 408 patients were assembled in seven tissue microarrays. Paraffin sections from each array were processed for immunohistochemistry to assess the expression of P-cadherin. The expression of P-cadherin was forced using lipofectin, followed by an assessment of migration and invasion potential using standard in vitro assays.The absence of P-cadherin staining was associated with muscle-invasive disease, grade 3 (P0.001) and nodal disease (P = 0.009). Similar results were obtained when considering cytoplasmic and unrestricted localization of P-cadherin (P0.001), except for nodal involvement. The group with cytoplasmic location of P-cadherin showed a shorter cancer-specific survival than the group with membrane location of P-cadherin (P = 0.03). Forced expression of P-cadherin in EJ and UM-UC-3 cells, that constitutively lack P-cadherin expression, resulted in modulation of catenin expression and enhanced migration of EJ and UM-UC-3/P-cadherin transfectants (200%).These results showed that loss of expression, cytoplasmic relocation or unrestricted tissue location of P-cadherin was associated with a poor clinical outcome and prognosis in bladder cancer. From the in vitro work it is evident that P-cadherin plays a role in regulating the migration potential of bladder carcinoma cells.

Strategies for vascular control and limiting warm ischemia time (WIT) vary between institutions for laparoscopic live donor nephrectomy (LLDN). We refined our technique and retrospectively determined whether it safely provides an allograft of comparable quality to published series.Fifty consecutive LLDN between February 2003 and November 2006 were reviewed. Key technical aspects include placing the perfused kidney and transected ureter entirely within an endocatch bag, with the string externalized through an extended lateral port site incision. Vessels are then controlled with clips, or a Satinsky clamp for right sided veins. The extraction incision is completed and the bag immediately withdrawn and placed on ice. WIT ends with perfusion with cold UW solution.The series includes 42 left and 8 right kidneys. 13/50 (26%) demonstrated anatomical complexity (more than one artery, vein and/or ureter). Average operative time was 178 minutes. Average WIT was 128 seconds. Conversion to open surgery occurred in two patients, one to define challenging anatomy, and another for hemorrhage from the renal artery stump. Average blood loss was 76 ml. Average length of stay was 3.6 days. Average recipient creatinine was 1.26 mg/dl at discharge. Delayed graft function occurred in three recipients. ATN/slow normalization of creatinine occurred in four. Graft survival at one year was 96%.The refined technique of LLDN mimics important principles of open donor nephrectomy. Controllable variables which may impact graft function are optimized. WIT is amongst the lowest reported for pure laparoscopy, without increasing complication rates, blood loss, or operative time.

We assessed patient outcomes using 2 widely different contemporary lithotripters.We performed a consecutive case series study of 355 patients in a large private practice group using a Modulith® SLX electromagnetic lithotripter in 200 patients and a LithoGold LG-380 electrohydraulic lithotripter (TRT, Woodstock, Georgia) in 155. Patients were followed at approximately 2 weeks. All preoperative and postoperative films were reviewed blindly by a dedicated genitourinary radiologist. The stone-free rate was defined as no residual fragments remaining after a single session of shock wave lithotripsy without an ancillary procedure.Patients with multiple stones were excluded from analysis, leaving 76 and 142 treated with electrohydraulic and electromagnetic lithotripsy, respectively. The stone-free rate was similar for the electrohydraulic and electromagnetic lithotripters (29 of 76 patients or 38.2% and 69 of 142 or 48.6%, p = 0.15) with no difference in the stone-free outcome for renal stones (20 of 45 or 44.4% and 33 of 66 or 50%, p = 0.70) or ureteral stones (9 of 31 or 29% and 36 of 76 or 47.4%, respectively, p = 0.08). The percent of stones that did not break was similar for the electrohydraulic and electromagnetic devices (10 of 76 patients or 13.2% and 23 of 142 or 16.2%) and ureteroscopy was the most common ancillary procedure (18 of 22 or 81.8% and 30 of 40 or 75%, respectively). The overall mean number of procedures performed in patients in the 2 groups was similar (1.7 and 1.5, respectively).We present lithotripsy outcomes in the setting of a suburban urology practice. Stone-free rates were modest using shock wave lithotripsy alone but access to ureteroscopy provided satisfactory outcomes overall. Although the acoustic characteristics of the electrohydraulic and electromagnetic lithotripters differ substantially, outcomes with these 2 machines were similar.

INTRODUCTION AND OBJECTIVES: The prostate is composed of approximately 70% glandular elements and 30% fibromuscular stroma. 5-alpha reductase inhibitors (5ARIs) are a commonly prescribed medication for BPH that reduces prostate volume by causing regression of the soft glandular element of the gland resulting in a greater % of the fibromuscular stromal element. HoLEP is an effective treatment for benign prostatic hyperplasia (BPH) that involves removal of the transitional zone. Due to the large volume of tissue accumulated during enucleation, morcellation is required for specimen removal. Enucleation and morcellation times are dependent on a number of factors including prostate volume as well as tissue quality. We hypothesized that patients taking 5ARIs prior to HoLEP may have longer surgeries secondary to a more challenging enucleation and/or morcellation due to the effect of these drugs on prostatic tissue. Factors potentially impacting tissue enucleation and morcellation were analyzed. METHODS: A retrospective single institution analysis of HoLEP patients between 1998 and 2011 was performed. Variables that may impact enucleation and morcellation times were evaluated using univariate and multivariate linear regression models. RESULTS: Overall, of 714 patients who underwent HoLEP, 222 or 31.1% of patients were taking a 5ARI (Table 1). After univariate and multivariate analysis, only the weight of the specimen that was removed was found to be predictive of enucleation and morcellation times (Tables 2 and 3). More specifically, with increasing prostate size there was a statistically significant increase in both enucleation and morcellation times. CONCLUSIONS: On multivariate analysis only specimen weight significantly predicts enucleation and morcellation times. The use of 5ARIs as a predictor of enucleation and/or morcellation times was not found to be statistically significant.

We determined whether shock wave lithotripsy of the kidney of pigs with metabolic syndrome would worsen glucose tolerance or increase the risk of diabetes mellitus.Nine-month-old female Ossabaw miniature pigs were fed a hypercaloric atherogenic diet to induce metabolic syndrome. At age 15 months the pigs were treated with 2,000 or 4,000 shock waves (24 kV at 120 shock waves per minute) using an unmodified HM3 lithotripter (Dornier MedTech, Kennesaw, Georgia). Shock waves were targeted to the left kidney upper pole calyx to model treatment that would also expose the pancreatic tail to shock waves. The intravenous glucose tolerance test was done in conscious fasting pigs before lithotripsy, and 1 and 2 months after lithotripsy with blood samples taken for glucose and insulin measurement.Pigs fed the hypercaloric atherogenic diet were obese, dyslipidemic, insulin resistant and glucose intolerant, consistent with metabolic syndrome. Assessments of insulin resistance, glucose tolerance and pancreatic β cell function from fasting plasma glucose and insulin levels, and the glucose and insulin response profile to the intravenous glucose tolerance test were similar before and after lithotripsy.The metabolic syndrome status of pigs treated with shock wave lithotripsy was unchanged 2 months after kidney treatment with 2,000 high amplitude shock waves or overtreatment with 4,000 high amplitude shock waves. These findings do not support a single shock wave lithotripsy treatment of the kidney as a risk factor for the onset of diabetes mellitus.

INTRODUCTION AND OBJECTIVES: In our continuing efforts to determine whether shock wave lithotripsy (SWL) is a risk factor for the development of diabetes mellitus, we treated the kidney of metabolic syndrome (MetS) pigs with a supra-maximal dose of shock waves (SWs) and assessed the SWL effect on the glucose-insulin kinetic response to an intravenous glucose tolerance test (IVGTT). METHODS: Adult female Ossabaw pigs (9-month-old) were fed an excess calorie atherogenic diet to induce MetS. At 15 months of age, the MetS pigs underwent SWL treatment (4000 SWs, 24 kV at 120 SWs/min using the HM-3 lithotripter; n 7). SWs were targeted to the upper pole calyx of the left kidney because of its close association with the tail of the pancreas?a segment rich in insulin containing -cells. IVGTTs were performed on conscious, fasting MetS pigs before SWL and at 1-month and 2-months post-SWL with frequent blood samples taken for glucose and insulin measurement. RESULTS: Pigs fed an excess calorie atherogenic diet developed features of MetS: obesity, dyslipidemia, insulin resistance and glucose intolerance. Fasting levels of plasma glucose and insulin, as well as their response profile to IVGTTs, were similar before and after SWL. Estimates of insulin resistance, glucose tolerance and pancreatic beta cell function derived from the glucose-insulin kinetics calculated from IVGTTs were not significantly altered following SWL. CONCLUSIONS: The pig?s MetS status was unchanged following overtreatment of the kidney with 4000 high-energy SWs. These findings do not support a single session of SWL in MetS patients as a risk factor for the onset of diabetes mellitus?at least in the short-term.

Calyceal diverticula are congenital, non-secretory, urothelium-lined cavities within the kidney. They communicate with the collecting system via narrow infundibula and fill retrogradely with urine. Some diverticuli remain asymptomatic over time, while others cause flank pain, hematuria, and recurrent urinary tract infections or develop calculi. While asymptomatic diverticula can be managed conservatively, symptomatic or stone-containing diverticula should be treated. Due to the development of minimally invasive methods for the treatment of symptomatic diverticula, open surgical techniques such as unroofing, marsupialization, and open diverticulectomy have become obsolete. Currently available minimally invasive techniques for treating calyceal diverticula include extracorporeal shock wave lithotripsy (ESWL), ureteroscopy, laparoscopy, and percutaneous nephrolithotomy (PNL). ESWL does not lead to adequate stone-free rates and does not allow for simultaneous ablation of the diverticular cavity. Ureteroscopy is an acceptable form of treatment for upper or mid pole diverticula and involves incision or balloon dilation of the diverticular neck followed by stone removal and obliteration of the diverticular cavity, if possible. This technique is difficult to perform in lower pole lesions due to the limited flexion capabilities of flexible ureteroscopes, and may not be possible in the case of diverticula with very small ostia. Laparoscopy is generally reserved for anteriorly located diverticula with minimal surrounding parenchyma. This technique is successful in experienced hands, but operative times are often substantially longer than with other modalities. PNL provides the highest stone-free, symptom resolution, and diverticular resolution rates but can pose a significant challenge to urologists owing to the small working space within the diverticular cavity and the difficulty associated with safely maintaining wire access. Additionally, the majority of diverticula are located in the upper pole, and pleural complications such as hydro- or hemothorax associated with supracostal, upper pole access are of significant concern. Here we describe a single stage, infracostal approach for the percutaneous management of symptomatic calyceal diverticula.

The mechanisms by which urinary calculi develop in humans are not entirely understood. In the 1930s, Randall described white plaques on the papillae of cadaveric kidneys from patients with calculi and postulated that this was the site of stone formation in all stone formers. His theory was not well received and for many years was abandoned. It is now known that in certain subsets of stone formers (idiopathic calcium oxalate stone formers), stone formation does occur by overgrowth on Randall’s plaque. However, many other types of stone formers do not demonstrate evidence of classic Randall’s plaque and must therefore possess a different mechanism for stone formation. Careful endoscopic assessment and renal tissue biopsies from unique stone-forming patients (i.e., those with cystinuria, primary hyperparathyroidism, renal tubular acidosis, and primary hyperoxaluria) has revealed evidence of crystalline plugging within dilated ducts of Bellini with associated inflammation and cell injury. These findings are not identified in idiopathic calcium oxalate stone formers and lead one to believe that alternate pathways to the development of nephrolithiasis must be at play. In this chapter we review the composition and anatomic location of Randall’s plaque as well as describe the stone-plaque interface and mechanism of stone overgrowth. Additionally, we review the specific endoscopic and histologic abnormalities in stone-forming patients with cystinuria, brushite stone disease, gastric bypass, ileostomy, primary hyperparathyroidism, renal tubular acidosis, and primary hyperoxaluria and propose potential mechanisms for stone formation.

Noncontrast computed tomography (CT) is commonly utilized after percutaneous nephrolithotomy (PNL) to assess stone-free (SF) status. In addition to assessing SF status, CT is useful in the recognition of complications after PNL. We characterized complications demonstrated by postoperative CT scan and compared hospital re-admission rates based on whether or not CT was performed.We retrospectively reviewed records of 1032 consecutive patients from April 1999 to June 2010. Patients were divided into two cohorts based on whether they had a CT within 24 hours of PNL. Demographic data, CT findings, and need for re-admission for complication management were assessed.Nine hundred fifty-seven patients (92.7%) underwent post-PNL CT. CT-diagnosed complications were perinephric hematoma in 41 (4.3%; 2 requiring embolization and 9 necessitating transfusion), pleural effusion in 25 (2.6%; 10 requiring intervention), colon perforation in 2 (0.2%), and splenic injury in 2 (0.2%). Of patients with postoperative complications, 33% required intervention. Among patients with a CT, 6 (0.6%) were readmitted despite negative postoperative CT (four perinephric hematomas, one calyceal-pleural fistula, and one pseudoaneurysm). The sensitivity of CT for diagnosing complications was 92.7%. Seventy-five patients (7.3%) did not undergo CT post-PNL. Of these, four (5.33%) were readmitted: three for perinephric hematomas and one for ureteral clot obstruction. Patients undergoing post-PNL CT were less likely to be readmitted because of missed complications (p=0.02).Serious post-PNL complications are uncommon, but their prompt diagnosis and treatment is imperative. In addition to identifying residual stones, CT is useful in diagnosing postoperative complications. Postoperative CT could potentially be considered for all patients undergoing PNL, particularly in complex cases such as patients with anatomical abnormalities (renal anatomic abnormality or retrorenal colon), patients requiring upper pole access (risk of thoracic, hepatic, and splenic complications), and patients requiring multisite access (higher risk of perinephric hematoma or need for transfusion).

Calculi from patients with musculoskeletal (MS) anomalies who are largely immobile and prone to urinary infections have been traditionally composed primarily of struvite and carbonate apatite. Because of substantial improvements in the care of these patients in recent decades, stone etiology may have shifted from infectious to metabolic. We assessed the composition of renal calculi and metabolic characteristics in a contemporary cohort of patients with MS anomalies who underwent percutaneous nephrolithotomy (PCNL).Retrospective analysis of patients who underwent PCNL between April 1999 and June 2009 and had follow-up 24-hour urine studies was performed. Patients with MS anomalies included spinal cord injury, myelomeningocele, muscular dystrophy, multiple sclerosis, cerebral palsy, or other clinical syndromes causing kyphoscoliosis and contractures.Our cohort included 33 patients with MS anomalies and 334 consecutive patients as a control group who underwent PCNL and had metabolic workup. Stones were infectious in etiology in 18.4% and 6.2% in MS and control groups, respectively. Thus, most patients harbored stones of metabolic origin. Metabolic stones in the MS group were composed of 52.7% hydroxyapatite, 10.5% calcium oxalate, 7.9% brushite, 2.6% uric acid, 0% cystine, and 7.9% other. Metabolic stones in the control group were 50.5% calcium oxalate, 16.4% hydroxyapatite, 11.5% brushite, 10.8% uric acid, 4.3% cystine, and 0.3% other. Mean 24-hour urine values for patients with metabolic stones in MS/control groups were volume 2.18/1.87 L/d, pH 6.78/6.05, calcium to creatinine ratio 220/151 mg/g, and oxalate 44.8/39.5 mg/d.Although patients with MS anomalies are traditionally thought to harbor infection-related calculi, most will be found to have calculi of metabolic etiology. The incidence of calcium phosphate stones is high in this group of patients, perhaps reflecting their high urinary pH.

Numerous imaging modalities are available for the evaluation of patients with renal stone disease. The study of choice is dependent on the clinical scenario and the indication for imaging. Additional factors such as patient age and pregnancy status will influence the radiographic study that is chosen. Currently available technologies for the evaluation of urolithiasis include plain abdominal radiography, ultrasound, intravenous pyelogram, computed tomography, and magnetic resonance imaging. This article reviews the indications, advantages, and disadvantages of each study in the evaluation of patients with known or suspected stone disease.

Holmium laser enucleation of the prostate is an endoscopic alternative for the treatment of symptomatic benign prostatic hyperplasia for men with prostates of any size. Holmium laser enucleation of the prostate is superior to other modalities for the treatment of benign prostatic hyperplasia. We present the most current literature on this procedure.In the 18-month span of this review, there have been a number of articles published on holmium laser enucleation of the prostate. These studies assessed the safety, efficacy, and durability of this procedure. Among these is the largest study to date providing supporting evidence to the long-term efficacy and safety of holmium laser enucleation of the prostate. Other studies provide compelling evidence to suggest that holmium laser enucleation of the prostate can be used in prostates of any size and can provide long-term durable outcomes.Holmium laser enucleation of the prostate represents an effective, well tolerated, and durable procedure to relieve bladder outlet obstruction due to benign prostatic hyperplasia. Holmium laser enucleation of the prostate is a minimally invasive approach which accomplishes complete adenoma removal and, as such, provides unique advantages over other surgical treatments for men with benign prostatic hyperplasia.

OBJECTIVE To identify the frequency of change in the expression and localization of p120ctn in bladder tumours and its association with clinical outcomes, and to investigate the potential role of p120ctn in the migratory and invasive behaviour of bladder carcinoma cells. MATERIALS AND METHODS In all, 425 superficial tumour specimens (Ta, Tis and T1) and 305 invasive (T2–T4) tumour specimens from 534 patients were assembled in 10 tissue microarrays. P120ctn immunostaining was scored for intensity and cellular localization and correlated with clinical variables and survival analysis. Knockdown of p120ctn was achieved using small-interference RNA (siRNA) followed by the assessment of migration and invasion behaviour in standard in vitro assays. RESULTS The expression levels of p120 catenin inversely correlated with pathological tumour stage (P