Evaluation of the impact and need for use of a safety guidewire during ureteroscopy

BACKGROUND AND PURPOSE

The routine use of a "safety" guidewire adjacent to the ureteroscope during upper tract endoscopy is advocated in surgical texts and by many endourologists. Our experience has led us to theorize that a safety guidewire complicates ureteroscopy by providing resistance to introduction of the endoscope and by creating an obstruction to ureteroscopic instrumentation. To examine our theory, we developed a porcine animal model to evaluate the impact of the presence of a safety guidewire and reviewed our clinical experience, which routinely does not use a safety guidewire during ureteroscopy.

PATIENTS AND METHODS

An ex vivo model was created using the excised urinary tract of freshly slaughtered pigs. The forces needed to advance both a semirigid and flexible ureteroscope in the ureter were measured with and without the presence of a 0.035-inch safety guidewire. The clinical records of all patients undergoing ureteroscopy over a 4-year period were reviewed.

RESULTS

On average, an additional 12 and 20 g of force were needed to introduce the semirigid and flexible ureteroscope when a guidewire was present. For the chosen study period, 361 patients underwent ureteroscopic procedures without the placement of a safety guidewire. No patient experienced an intraoperative complication related to the absence of a safety wire.

CONCLUSIONS

The presence of a safety guidewire adjacent to the endoscope inhibits passage of the ureteroscope in an in vitro animal model. Technologic advancements in ureteroscope design and use of the holmium laser lithotrite minimize ureteral trauma and obviate the need for routine use of a safety wire during ureteroscopy.

Granular cell tumor of the urinary bladder with pseudoepitheliomatous hyperplasia and colocalization with adenocarcinoma

Granular cell tumor of the bladder is exceptionally rare, with only 11 cases reported in the published reports. Pseudoepitheliomatous hyperplasia of the overlying squamous epithelium has been observed in non-bladder granular cell tumors. We herein report the first case of bladder granular cell tumor to exhibit pseudoepitheliomatous hyperplasia. This phenomenon is significant as it may potentially lead to difficulty in the distinction between infiltrative squamous cell carcinoma and pseudoepitheliomatous hyperplasia in cases of granular cell tumor of the bladder. This case also represents the first granular cell tumor to demonstrate colocalization with adenocarcinoma of the bladder. Based on our findings and a review of the published reports, management for granular cell tumor of the bladder should involve a course of local resection combined with active surveillance given its typical benign course, albeit with the potential for local recurrence.

Umbilical stomal stenosis: a simple surgical revision technique

Stenosis of stomas sited at the umbilicus presents a surgical challenge. A paucity of literature exists on the surgical management of this problem, despite its relatively frequent occurrence. A simple technique is described, using scar incision and advancement of an umbilical skin flap, to accomplish stomal revision.

Penile paraffinoma: the delayed presentation

The injection of foreign substances into the penis for the purpose of augmentation may result in erectile dysfunction, voiding difficulties, and severe deformity. We report a case of penile paraffinoma in a 71-year-old man that developed nearly 40 years after undergoing a series of penile injections with an unknown substance. Penile paraffinoma can therefore present a diagnostic dilemma given its protracted latency period, after which time the initial injections have faded into distant memory.

Can single dose preoperative intrathecal morphine sulfate provide cost-effective postoperative analgesia and patient satisfaction during radical prostatectomy in the current era of cost containment?

We retrospectively analyzed the analgesic efficacy and surgical outcomes of a single preoperative intrathecal long-acting morphine sulfate injection (0.25-0.5 mg) and postoperative intravenous (i.v.) ketorolac in 62 patients who underwent radical retropubic prostatectomy (RRP). Total postoperative analgesic requirement was documented along with assessment of length of hospital stay, pain control and time for resumption of normal activity. Postoperatively, 45% of patients required only nonsteroidal agents (ketorolac), whereas 55% needed a mean of 13.3 mg of supplemental i.v. morphine sulfate. Mean hospital stay was 2.3+/-0.3 days. Eighty-two per cent of patients felt the length of hospital stay adequate. Ninety-seven per cent of patients were satisfied with anesthesia selected and 95% of patients considered pain control on postoperative days 1 and 2 as effective. All patients resumed to full physical activity by 5.3+/-0.4 weeks after surgery. We conclude that a single preoperative injection of intrathecal morphine sulfate combined with i.v. ketorolac postoperatively results in effective analgesia, diminished supplemental narcotic requirement and high patient satisfaction during radical retropubic prostatectomy.

Signal transduction-mediated regulation of urokinase gene expression in human prostate cancer

Urokinase-type plasminogen activator (u-PA) contributes to tumor progression in prostate cancer (CaP). We have previously shown that u-PA expression is upregulated through the AP-1 and PEA3 sites and repressed by androgen. However, signaling pathways mediating u-PA gene expression in CaP are not delineated. We hypothesized that MAPK pathways mediate u-PA in CaP, and thereby studied specific ERK, JNK, and P38-MAPK pathway mutant constructs and inhibitors in vitro. Human, androgen insensitive CaP PC3 cells stably transfected with the androgen receptor expression vector and vector alone were used. A u-PA promoter CAT vector transiently expressed with dominant negative mutant signaling constructs was studied. All mutants drastically reduced u-PA promoter activity. Furthermore, inhibition of PI3K, an upstream regulator in the JNK/SAPK pathway, decreased u-PA promoter transcription. Collectively, these results show that MAPK pathways ERK, JNK/SAPK, and P38-MAPK represent a significant component in the regulation of u-PA expression in human CaP.