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We reviewed 53 patients with infection stones treated by extracorporeal shock wave lithotripsy (ESWL*) monotherapy to determine the long-term rate free of stones and the stone recurrence rate as correlated with the pre-treatment stone burden and the radiological presence of sand or fragments after the procedure. Long-term followup (mean 26.6 months) was available on 33 patients representing 38 kidneys. Although only 3 kidneys were free of stones immediately after ESWL, 20 were without stones at 3 months and 18 (47%) were stone-free at followup. Of 9 kidneys with fragments of more than 5 mm. after the final treatment 7 (78%) had residual fragments at 3 months and experienced stone progression. Of 9 kidneys with sand remaining 6 (66%) and all 3 kidneys that appeared to be free of stones after ESWL were without stones at followup. The 3-month plain film of the kidneys, ureters and bladder was a reliable indicator of eventual outcome. Of 20 kidneys that were free of stones at 3 months 16 remained without stones. Of 18 kidneys with residual stone particles at 3 months 14 showed disease progression, 2 had stable disease and 2 passed residual sand. Only 1 of 17 patients who were free of stones or had stable stone disease had a positive urine culture at followup. Patients with infection stone fragments 3 months after ESWL monotherapy have a high rate of stone progression (78%) and should undergo further treatment. ESWL monotherapy of infection stones requires close patient followup to assure that all residual fragments have passed and urine remains sterile.

Current knowledge fails to support the notion that adaptive hyperfiltration of the remnant kidney after donor nephrectomy is deleterious. Rather than being maladaptive, hyperfiltration appropriately compensates for the loss of functional renal mass. Accordingly, most kidney donors can be expected to maintain a stable level of renal function without proteinuria or hypertension. Essential to this is proper selection of donors for nephrectomy and exclusion of high risk potential donors, bearing in mind the fact that apparently healthy, asymptomatic relatives of end stage renal disease patients are prone to the same disease processes that inflict the general population and have a higher risk of underlying renal disease.

The documented long-term health of the living related renal donor is a tribute to careful preoperative selection and surgical technique. At our medical center 187 prospective donors were evaluated during a 6-year period and 91 underwent donor nephrectomy. Hypertension, renal artery anomalies and donor indecision were the most common reasons for donor rejection. Recipient health and/or death, or a positive crossmatch after pre-transplant donor specific transfusion were other post-arteriogram reasons not to proceed with transplantation. Women were more likely to undergo nephrectomy than men, and older or heavier donors were more likely to be rejected. Using the transcostal, extrapleural surgical approach for nephrectomy there were no deaths or major complications, and the mean postoperative length of stay was 6.4 days. The average postoperative increase in serum creatinine was 0.33 mg./dl. with an average creatinine at discharge of the patient from the hospital of 1.2 mg./dl. The latter creatinine values varied concordantly with donor age. Only 56% of fully evaluated donors (91 of 159) actually underwent donor nephrectomy. The minimal morbidity sustained by these patients re-emphasizes the importance of careful donor selection.

Evolution of the extracorporeal shock wave lithotripsy technique involves not just second generation technology but operator innovations and experience. Retrospective analysis of the first 512 treatments at a university medical stone unit using the Dornier HM3 lithotriptor was compared to 3 intervals of 100 consecutive treatments during the next 2-year period (1985 to 1987). Patient referral and selection as well as treatment techniques and rates of endourological interventions were analyzed. Patient demographics, stone types and retreatment rates remained constant during 2,500 treatments. However, the use of local anesthesia and internal ureteral stents became increasingly common. Of the 1987 cohort 29% were treated with the patient under local anesthesia, and 23 of the 44 with a stent (52%) received internal ureteral stents. Other treatment trends identified during the study period included increasing number of large (greater than 2 cm.) and multiple stones treated; increasing use of internal and external ureteral catheters before treatment, fewer stents for small, mobile renal calculi and decreasing length of hospital stay (2.7 to 2.1 days) with increasing use of stents before lithotripsy. The increasing average number of shock waves per treatment (1,382 versus 1,580) during the study period can be attributed to the larger proportion of patients with high stone burdens and the impact of an increased number of operators with more varied criteria for endoscopy and treatment end point.

Retrospective review of 298 extracorporeal shock wave lithotripsy (ESWL) treatments was undertaken to determine the factors which influence radiation exposure during ESWL. Fluoroscopy time averaged 160 seconds (3-509), and the average number of spot films taken per patient was 26 (5-68). The average stone burden was 19.3 mm (3-64). Average calculated skin surface radiation exposure was 17.8 R per treatment. Radiation exposure increased with increasing stone burden and patient weight. Stones treated in the ureter resulted in a higher average patient radiation exposure than for renal stones (19 R vs 16 R), even though the average size of these ureteral stones (11.3 mm) was significantly less than the mean. However, type of anesthetic (general or regional) used was not a significant factor. Operator training, experience, and familiarity with radiation physics should significantly decrease the amount of imaging time and consequent patient radiation exposure during ESWL.

Four hundred sixty-seven patients with symptomatic upper urinary tract calculi underwent extracorporeal shock-wave lithotripsy (ESWL) at The New York Hospital-Cornell Medical Center during the first year. Ninety-five percent of stones were completely treated with one ESWL session. An analysis of 300 treatments revealed that the overall stone-free rate (success) three months after treatment was 75%. The stone-free rate for patients with renal pelvic calculi less than or equal to 20 mm in diameter was 91%. Individual patient stone-free rates depended on stone size (burden), position, composition, and quality of disintegration. Two percent of treatments failed to disintegrate the targeted stone. Complications were minimal. Seven percent of treatments were followed by a secondary endoscopic procedure to facilitate complete stone passage, and 23% of treatments were preceded by cystoscopy with ureteral stent placement of manipulation of stones. Combined therapy utilizing percutaneous surgery or multiple sequential ESWL treatments is necessary for complex stones, and ureteroscopy or basket extraction remains the treatment of choice for distal ureteral calculi.

Extracorporeal shock wave lithotripsy (ESWL) currently is performed in selected urologic centers to treat over 80 per cent of patients with symptomatic upper urinary tract calculi. This noninvasive technique utilizing shockwaves to disintegrate stones into sand-sized particles allows the patient to pass the particles with spontaneous urination and replaces most surgery or percutaneous endoscopy for stone removal. However, stone-free success rates must be individualized depending on stone position, stone size, and composition. Lithotripsy of renal stones prior to migration and proximal ureteral stones early in their symptomatic course may alter significantly the incidence of distal ureteral calculi requiring hospitalization, cystoscopy, or ureteroscopy.

Placement of internal ureteral stents before extracorporeal shock wave lithotripsy of large stone burdens has decreased the incidence of post-extracorporeal shock wave lithotripsy colic, secondary endoscopic procedures and prolonged hospital stays. However, indwelling stents have an associated patient morbidity and intolerance. A telephone survey of 50 patients (average stone burden 28 mm.) who were discharged from the hospital after treatment with an indwelling internal polymer stent was performed with a standard questionnaire. Symptoms reported with in situ internal ureteral stents included gross hematuria (42 per cent), fever or chills (20 per cent), and persistent discomfort or pain in the bladder and/or flank (26 to 38 per cent). Of the patients 44 per cent reported moderate to intolerable discomfort that was relieved by removal of the stent. The degree of symptoms was not associated with stent composition, style or length, or the presence of a transurethral string. Five patients had premature migration or dislodgment of the internal stent and 4 reported episodes of obstructive pyelonephritis requiring removal of an impacted stent or endourological intervention. Internal ureteral stents placed before extracorporeal shock wave lithotripsy have an identifiable patient morbidity while indwelling and, therefore, they should be used judiciously according to the stone burden, renal anatomy and body habitus.

A case of transient bladder dysfunction and urinary retention concomitant with herpes genitalis is presented. The protean manifestations of the herpes simplex virus, the similar neurotropic behavior of simplex and zoster, and the neurologic sequelae of the cutaneous simplex eruption are discussed. The possibility of sacral radiculopathy after herpes genitalis must be considered when evaluating acute or episodic neurogenic bladders.

The transcostal extrapleural flank approach to the kidney requires an understanding of thoracic and abdominal wall anatomy to prevent injury to the pleura and subsequent pneumothorax. Isolation of the intercostal neurovascular bundle, division of the lumbodorsal fascia inferior to the rib bed and simultaneous dissection of the diaphragmatic insertion along the superior and posterior aspects of the 12th rib toward the lumbocostal arch are necessary surgical maneuvers before release of the diaphragm, exposure of Gerota's fascia and positioning of a flank retractor. Pneumothorax usually results from attempts to separate the pleura from the diaphragm, dissection within the intercostal space rather than along the diaphragmatic insertions and failure to release the diaphragm fully as far as the lumbocostal arch before placement of the retractor. Precise appreciation of the pericostal anatomy allows the urological surgeon to remain extrapleural during this commonly used flank incision.

Second opinion elective surgery programs provide a mechanism to obtain consultation from a board-certified specialist by patients to whom an elective operation has been recommended. We focus on a second opinion program for urologic cases. Of 931 individuals who received a second opinion for urologic surgery the need was confirmed in 692 (74.3 per cent) and was not confirmed in 239 (25.7 per cent). The most common procedure not confirmed was transurethral resection of the prostate. Common reasons for nonconfirmation were the need for further testing, medication preferable to an operation and symptoms not severe enough to warrant an operation. Of patients confirmed for the need for surgery 28.2 per cent did not undergo an operation, while 33.0 per cent of those not confirmed did.

Renin-mediated hypertension can occur with unilateral renal obstruction and hydronephrosis. Elevated peripheral plasma renin activity and a lateralizing renal vein renin relationship represent a hormonal pattern suspiciously suggestive of a renovascular etiology. We report a case of surgically corrected renin-mediated hypertension secondary to ureteropelvic junction obstruction. Hyperreninemia associated with acute unilateral hydronephrosis probably occurs transiently to initiate chronic hypertension sustained by more complex volume-vasoconstriction abnormalities. The participation of renin in this hypertension seems to be influenced by the duration of the obstruction, the presence or absence of a contralateral normal kidney and other intrarenal factors.

The transcostal extrapleural flank approach to the kidney requires an understanding of the anatomy of the thoracic and abdominal wall to prevent injury to the pleura and subsequent pneumothorax. Isolation of the intercostal neurovascular bundle, division of the lumbodorsal fascia inferior to the rib bed, and simultaneous dissection of the diaphragmatic insertion along the superior and posterior aspect of the twelfth rib toward the lumbocostal arch are necessary surgical maneuvers. This should be done prior to the release of the diaphragm, exposure of Gerota's fascia and positioning of a flank retractor. Pneumothorax usually results from attempts to separate the pleura from the diaphragm, dissection within the intercostal space rather than along the diaphragmatic insertions, and failure to release fully the diaphragm as far as the lumbocostal arch prior to placement of the retractor. Precise appreciation of the pericostal anatomy allows the urologic surgeon to remain in the extrapleural space during this commonly used flank incision.

Stents must be judiciously, not indiscriminately, used prior to lithotripsy to maximize successes. The documented advantages for specific stone burdens and patient types should not be taken as an endorsement for pretreatment stenting on a routine basis. Universal stenting is a costly adjunct to an already costly technology, not to mention the substantial number of patients with stents who report bladder or renal discomfort that is relieved when the stents are removed. Certainly, in some cases, the constant discomfort of bladder irritability and reflex voiding secondary to polymer stents may be more incapacitating than mild colic associated with fragment passage. Complications of internal ureteral stents do occur, so judicious selection of patients for pre-ESWL stenting is advised.

We report the cases of 17 children between the ages of 3 and 17 years who underwent 19 treatments using extracorporeal shock-wave lithotripsy. Stone size averaged 14.9 mm, with a range of 3 to 25 mm. The number of shock waves delivered averaged 1720, with a range of 600 to 2000. Treatment time averaged 36 minutes, with a range of 15 to 55 minutes. The average length of hospital stay was 2.2 days. In nine of the 19 treatments the kidneys were rendered free of stones. There were no complications.

Acute abdominal pain during pregnancy can be of urologic origin. Hydronephrosis of pregnancy can be complicated by symptomatic renal colic, pyelonephritis, and secondary renal abscess formation. In this report, rupture of a hydronephrotic kidney with retroperitoneal urinoma formation was treated by retroperitoneal drainage and internal ureteral until a term delivery was achieved. However, if severe renal hemorrhage accompanies renal rupture, surgical exploration of the kidney with partial or complete nephrectomy may be necessary.

Shock wave lithotripsy of upper ureteral stones is significantly more successful than ureteroscopy. Successful stone manipulation before ESWL increases the stone-free rate, yet impacted stones disintegrate and pass in the majority of patients. Earlier ESWL treatment of symptomatic ureteral stones will decrease patient morbidity and subsequent complication of distal stone passage. Lithotripsy of small renal stones prior to migration and proximal ureteral stones early in their symptomatic course may significantly alter the incidence of distal ureteral calculi requiring hospitalization, cystoscopy, or ureteral endoscopy. Ureteroscopy will remain the treatment of choice for symptomatic distal ureteral stones.

Sixty-six symptomatic primary stones in the upper ureter were treated using extracorporeal shock wave lithotripsy (ESWL). All patients underwent preprocedural cystoscopy for stone manipulation and 27 of the patients had the stones dislodged proximally. The stone-free success rate for this group of dislodged stones was 93 per cent. Of 39 ureteral stones treated in situ (impacted), 33 patients were rendered stone-free at three months. Three stones in this group failed to disintegrate and required surgical treatment. Complications of ESWL were minimal. ESWL of upper ureteral stones is an effective noninvasive, noncontact method of treatment. Successful stone manipulation increased the stone-free rate, yet impacted stones disintegrated and passed in 85 per cent of treatments. Lithotripsy of small renal stones prior to migration and proximal ureteral stones early in the symptomatic course may significantly alter the incidence of distal ureteral calculi requiring hospitalization, cystoscopy or ureteroscopy.

Cytological diagnosis by fine needle aspiration of the prostate was compared to histological diagnosis by either perineal needle biopsy or transurethral prostatic resection in 110 patients suspected to have prostatic cancer by rectal examination. Of the 94 prostatic aspirations that could be given a definite cytological diagnosis there was histological correlation in 85 (90.4 per cent). The false negative rate was 2.7 per cent for fine needle aspiration and 5.3 per cent for perineal needle biopsy. Inadequate cytological samples occurred mainly at the beginning of the study. There was a 69 per cent correlation in 36 cases in which cytological grading was compared to histological grading. Our results indicate that fine needle aspiration is an easily performed, diagnostically reliable outpatient procedure with minimal complications that also can be used for grading purposes.

Computed tomography (CT) body scanning has specific application to the precise diagnosis of urologic disease. The advantage of visualizing the density of normal and abnormal tissue provides new accuracy in evaluation of renal, retroperitoneal, and pelvic masses. The penetration of the pelvic cavity allows the urologist to assess local, nodal, and skeletal involvement from prostatic and bladder neoplasms in a single diagnostic examination. Cost/efficacy analysis and the role of computed tomography in patient managment must await further review and experience.