Clinical Outcomes of Ahmed ClearPath Implantation in Glaucomatous Eyes: A Novel Valveless Glaucoma Drainage Device

PRCIS

Designed with novel features to facilitate implantation and improve safety, the Ahmed ClearPath (ACP) glaucoma drainage device (GDD) provided intraocular pressure (IOP) reduction comparable with other GDDs in eyes with refractory glaucoma in a multicenter retrospective study.

PURPOSE

To present clinical outcomes with a novel valveless GDD (ACP, New World Medical). The 250 and 350 mm2 models feature a contoured plate for optimal globe apposition, anteriorized suture points to facilitate suturing to the globe, and a prethreaded 4-0 polypropylene ripcord suture.

METHODS

This was a multicenter retrospective analysis of eyes with medically and/or surgically uncontrolled glaucoma implanted with the 250 or 350 mm2 ACP either as a standalone procedure or in combination with other procedures. Pre-, intra-, and postoperative data through 6 months were collected.

RESULTS

A total of 104 eyes (100 subjects) received the ACP by 10 US surgeons, 63.5% of which had primary open-angle glaucoma and 62.5% had severe glaucoma. Mean baseline IOP was 26.3 (9.0) mm Hg and mean medication use was 3.9 (1.3). Through 6 months' follow-up, mean IOP ranged from 13.6 to 16.7 mm Hg and mean medication use from 0.9 to 1.9 medications (P<0.0001 at all timepoints for each outcome measure). At 6 months, mean IOP was 13.7 mm Hg (-13.0 mm Hg, 43.0%, P<0.0001) and mean medication use was 1.9 medications per eye (-2.1, 47.7%, P<0.0001). Common adverse events included anterior chamber inflammation (16.3%), hyphema (15.4%), and hypotony (6.7%).

CONCLUSION

The new ACP appears to be safe and efficacious as a standalone procedure or in combination with other procedures for uncontrolled glaucoma, and may be considered as a GDD option for patients in whom its unique design may facilitate the implantation process.

Twenty-Four-Month Outcome of Gonioscopy-Assisted Transluminal Trabeculotomy (GATT) in Eyes With Prior Corneal Transplant Surgery

PURPOSE

Glaucoma is a well-known sequelae of corneal transplant surgery and is a leading cause of visual loss in this patient group. We evaluated the performance and safety of gonioscopy-assisted transluminal trabeculotomy (GATT) in this population.

DESIGN

Noncomparative retrospective case series.

PARTICIPANTS

Consecutive eyes of patients receiving the GATT procedure for uncontrolled intraocular pressure (IOP) following corneal transplant surgery from 2016 to 2019.

METHODS

Retrospective analysis of eyes with a history of prior corneal transplant undergoing GATT at Glaucoma Associates of Texas between 2016 and 2019 was performed. Data included IOP, patient demographics, preoperative and postoperative medications, preoperative and postoperative corneal procedures, complications, and need for reoperation for IOP control.

MAIN OUTCOME MEASURES

IOP reduction and medication use following the procedure.

RESULTS

Thirty-nine eyes of 32 patients with prior corneal transplant surgery underwent a GATT procedure. Prior corneal surgery included penetrating keratoplasty (59.0%), Descemet's stripping endothelial keratoplasty (35.9%), Descemet's membrane endothelial keratoplasty (2.6%), and deep anterior lamellar keratoplasty (2.6%). Patient age ranged from 24 to 94 years (mean 68.0 y) with 44% female and 81% Caucasian. The majority of patients had secondary open angle glaucoma (64.1%). There was a significant reduction in IOP and number of medications at all postoperative time points after censoring patients requiring reoperation to control IOP (P<0.001). At 24 months the pressure decreased from baseline of 30.9±11.5 to 13.9±4.7 mm Hg. Medications decreased from 4.2±1.0 medications at baseline to 0.6±1.0 at 24 months. Visual acuities decreased significantly over the first postsurgical month (all P<0.05), but these recovered at subsequent follow-up visits with 2-Snellen line improvements exceeding losses from month 3 to 36. Seven eyes required reoperation for uncontrolled glaucoma at a median of 8.5 months (range: 1.6 to 16.2 mo) after GATT. The cumulative proportion of eyes undergoing repeat cornea surgery was 2.6%, 2.6%, and 14.3% at 12, 24, and 36 months post-GATT, respectively.

CONCLUSIONS

This case series describes a group of glaucoma patients, with a history of prior corneal surgery, that were safely and successfully treated with GATT. While classically traditional glaucoma surgeries are considered the standard of care for eyes following corneal transplant surgery, GATT should be considered as a reasonable, safe and effective alternative for surgically lowering IOP.

Outcomes of bleb revision with ologen following filtering glaucoma surgery

PURPOSE

This study reports long-term outcomes of bleb revision with ologen™ Collagen Matrix (Aeon Astron Europe BV, the Netherlands) for the surgical management of various bleb-related issues including persistent bleb leaks with or without associated hypotony, bleb dysesthesia, overhanging blebs, or hypotony after filtering glaucoma surgery.

MATERIALS AND METHODS

A retrospective chart review was performed for patients who underwent ologen bleb revision from 2012 to 2019 at Glaucoma Associates of Texas.

RESULTS

The study included 23 eyes of 22 patients undergoing bleb revision with the ologen implant. Mean age was 74.0 ± 11.3 years, 16 (69.6%) were female, and 13 (56.5%) were White. Indications for bleb revision included bleb leak (78.3%), dysesthesia (13.0%), and hypotony from an overfiltering bleb (8.7%). Mean preoperative intraocular pressure was 6.8 ± 4.1 mmHg and the number of medications was 0.3 ± 0.9. Median follow-up was 24 months (range: 12-84 months); all patients had at least 12 months of follow-up. At 1 year, mean intraocular pressure was 10.9 ± 4.6 mmHg on 0.2 ± 0.5 medications, and at last follow-up, mean intraocular pressure was 10.4 ± 3.6 mmHg on 0.3 ± 0.7 medications. Bleb morphology remained low, diffuse, and posterior. One patient developed kissing choroidal effusions requiring surgical drainage with subsequent stabilization of intraocular pressure and bleb function, and three patients required additional surgery due to persistent leaks or bleb failure; there were no other vision-threatening complications.

CONCLUSIONS

Use of the ologen implant during surgical bleb revision is a useful surgical technique that confers long-term improvements in bleb morphology and stability of function.

Early Results of Goniotomy with the Kahook Dual Blade, a Novel Device for the Treatment of Glaucoma

PURPOSE

To report the outcomes of patients who underwent goniotomy with the Kahook Dual Blade (KDB) either as a standalone procedure or in combination with cataract extraction.

PATIENTS AND METHODS

This retrospective chart review included 111 eyes of 90 patients who underwent KDB goniotomy from January to November 2016 at Glaucoma Associates of Texas. KDB goniotomy was combined with cataract surgery in 100 eyes. The main outcome measures were postoperative intraocular pressure (IOP) and number of IOP lowering medications.

RESULTS

Preoperatively, mean IOP was 17.1 ± 4.7 mmHg (range 8-34 mmHg) and mean number of IOP lowering medications was 2.4 ± 1.3 (range 0-6). Postoperatively, mean IOP was 14.9 mmHg, 13.9 mmHg, 14.1 mmHg, 14.4 mmHg, and 14.7 mmHg at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.004). Mean numbers of IOP lowering medications were 0.8, 1.0, 1.0, 1.0, and 1.6 at 1, 3, 6, 9, and 12 months follow-up, respectively (all p <0.001). The cumulative reoperation rates for uncontrolled IOP after KDB were 0%, 1.0%, 2.1%, and 4.6% at 3, 6, 9, and 12 months, respectively. Eyes with a preoperative IOP >21 mmHg were significantly more likely to undergo reoperation (p = 0.038, log-rank test). There were no serious complications at any time point in the follow-up period.

CONCLUSION

The Kahook Dual Blade results in a reduction in IOP and use of glaucoma medications after one year of follow-up. Further prospective studies are needed to fully characterize safety and efficacy.

Endophthalmitis Associated With Glaucoma Drainage Implants

BACKGROUND AND OBJECTIVE

To identify the clinical features, organisms, and treatment outcomes in patients with endophthalmitis associated with glaucoma drainage implants.

PATIENTS AND METHODS

A retrospective noncomparative case series.

RESULTS

Of the 13 patients, exposure occurred in eight eyes, including exposure of the tube in four eyes, exposure of the patch graft in three eyes, and exposure of the plate in one eye. In the remaining five eyes, either recent implant placement or conjunctival revision occurred. The most common organism was Staphylococcus epidermidis (five eyes). Intravitreal antibiotics were administered in all eyes, with the exception of one eye (primary evisceration). Removal of the implant was performed in six eyes and evisceration or enucleation was performed in three eyes. Median pre-infection visual acuity was 20/80 (range: 20/30 to hand motion). Visual acuity at last follow-up was no light perception (five eyes), light perception (two eyes), hand motion (one eye), and better than or equal to 20/200 (five eyes).

CONCLUSION

Clinical features associated with endophthalmitis include implant exposure and a history of recent surgery. Staphylococcus epidermidis was the most common isolate. Although removal of the implant was performed in many patients, successful treatment was accomplished in some patients without removal. Visual outcomes were generally poor. [Ophthalmic Surg Lasers Imaging Retina. 2016;47:563-569.].

Topical silver nanoparticles result in improved bleb function by increasing filtration and reducing fibrosis in a rabbit model of filtration surgery

PURPOSE

To compare the effects of silver nanoparticles (AgNPs) and mitomycin C (MMC) on intraocular pressure (IOP) and external, histologic, and immunohistochemical bleb characteristics in a rabbit model of filtration surgery.

METHODS

Filtration surgery with concurrent topical application of either AgNPs or MMC was performed on 14 pigmented Dutch Belted rabbits. IOP and bleb characteristics were compared on postoperative day 1 and at weeks 1 through 6. Hematoxylin and eosin staining and smooth muscle actin (SMA) immunohistochemistry were performed at postoperative week 6.

RESULTS

Average IOP across all time points was reduced 5.8 and 3.8 mm Hg in AgNP- and MMC-treated eyes, respectively. At week 6, IOP was reduced 4.1 and 0.2 mm Hg in AgNP- and MMC-treated eyes, respectively. Blebs were smaller, thicker, and less ischemic in AgNP-treated eyes. AgNP-treated eyes showed less fibrosis and more stromal edema, suggesting increased filtration, and also had fewer SMA-positive myofibroblasts, suggesting reduced bleb contraction. AgNP-treated eyes showed more lymphocytes than MMC-treated eyes. There were few complications in both groups.

CONCLUSIONS

In a rabbit model of filtration surgery, AgNPs are a reasonable alternative to MMC as adjunctive therapy. Compared to MMC, AgNPs result in an improved and sustained reduction of IOP and promote blebs with decreased fibrosis and ischemia as well as increased filtration despite a smaller overall size. This combination may offer an opportunity to promote long-term surgical IOP reduction with an improved complication profile.

The Distribution of PSA Age-Specific Profiles in Healthy Irish Men between 20 and 70

Background. Ireland is estimated to have the highest European incidence rate of prostate cancer (Pca) in 2006 which will increase by 275% by 2025. This study aimed to determine PSA cutoff values in different age groups of healthy male patients without Pca. Methods. 660 men in a pilot men's health programme, aged 18–67, had PSA assayed. Men were grouped into 8 age groups at 5-year intervals: 30–34, 35–39, 40–44, 45–49, 50–54, 55–59, 60–64, and 64–70. Results. Linear regression demonstrates a PSA velocity of 0.024 ng/ml/year. The 95% confidence interval demonstrates a near flat line of PSA values from age 20 to 50 and rises after. When transformed logarithmically, PSA correlates highly with expected values from the normal distribution (0.98). A fractional polynomial quantile regression model was used to predict median and 95th percentile for PSA as follows: 30–34 (0.73, 1.57), 35–39 (0.71, 1.65), 40–44 (0.73, 1.85), 45–49 (0.78, 2.17), 50–54 (0.88, 2.63), 55–59 (1.01, 3.25), 60–64 (1.20, 4.02), and 64–70 (1.43, 4.96). Conclusions. PSA levels are similar to other racial groups but not as high as US Caucasians until 65 years. These data define the predicted PSA for the Irish population and provide a reference for future screening programmes.

An audit of 2273 ureteroscopies--a focus on intra-operative complications to justify proactive management of ureteric calculi

BACKGROUND

At the national Stone Centre we have adopted a proactive management approach involving early ureteroscopy for ureteric calculi. As the efficacy of ureteroscopy is known this study focuses on the low intra-operative complication rate as justification for a proactive management protocol.

PATIENTS AND METHODS

A retrospective study (1987-1997) identified 1936 patients undergoing 2273 ureteroscopies. A database was created from inpatient hospital records. The male to female ratio was 3 to 1, age range was 25 to 84 years.

RESULTS

Twenty-three patients (1%) had an intra-operative complication during ureteroscopy. Immediate ureteric JJ stenting was performed in 16 cases with ureteric injury. Two cases underwent percutaneous drainage and delayed antegrade ureteric stenting, ureteroscopy was terminated because of poor visibility. Five patients (0.22%) underwent open surgery for: ureteric perforation (n = 2); Dormia basket ureteric avulsion (n = 1); impacted Dormia basket and stone (n = 1); and impacted balloon dilator and stone (n = l). Ureteroscopic complications were not related to the level of ureteric calculus.

CONCLUSION

A protocol of proactive management of ureteric calculi facilitates rapid turnover of large patient numbers. This approach is supported by the low intra-operative complication rate, most of which can be managed by further endoscopic procedures. In the event of corrective open surgery a favourable outcome has resulted.

Ten rural women living with fibromyalgia tell it like it is

The purpose of this qualitative study was to gain an understanding of the personal experiences of 10 rural women dealing with fibromyalgia based on the theoretical frameworks of adaptation to chronic illness and social support. The data were gathered from a nursing intervention that provided computer-based peer support and encouragement. The women described themes of pain, fatigue, depression, and sleep disturbances; expressed views on the experience of rural isolation; and shared positive philosophies of dealing with this disease. With this understanding, professionals and significant others can compassionately respond to the needs of sufferers of fibromyalgia.

Rupture of the male membranous urethra

BACKGROUND

Management of traumatic rupture of the male membranous urethra remains controversial. Long-term morbidity can include urinary incontinence, urethral stricture and erectile dysfunction.

AIMS

To review management and outcome of urethral rupture to improve treatment protocols.

METHODS

A retrospective study of 47 patients presenting with traumatic urethral rupture over 25 years was performed.

RESULTS

All patients underwent emergency suprapubic catheterisation, 32 patients had open surgical realignment at 1-2 weeks; 78% of whom developed strictures. Ten patients unsuitable for early repair underwent delayed transabdominal transpubic urethroplasty at three months: 40% of whom developed strictures. Five patients with partial rupture were managed by cystoscopy and urethral catheter. Erectile dysfunction correlated to initial injury rather than treatment.

CONCLUSIONS

If the patient is stable and requires emergency laparotomy for other abdominal injuries, he should have immediate realignment of the urethra. Early realignment of the urethra at laparotomy at 1-2 weeks can be combined with orthopaedic fixation of pelvic fractures. Patients who remain unstable due to associated injuries should have delayed urethroplasty at three months.

Epididymectomy in the management of intrascrotal disease: a critical reappraisal

OBJECTIVE

To assess the outcome of epididymectomy as a method of treating epididymal pathology.

PATIENTS AND METHODS

Forty-one patients who underwent epididymectomy between 1990 and 1995 were analysed retrospectively; their clinical records were reviewed and their satisfaction with the outcome and relief of symptoms assessed using a questionnaire and/or telephone interview.

RESULTS

Twenty-nine patients with pain were subdivided into three categories depending on the indication for epididymectomy, i.e. post-vasectomy epididymal engorgement (eight patients), complex cystic disease (11) or 'chronic epididymitis' (10). The outcome was satisfactory in 27 of the 29 patients. The best results were obtained in the group who underwent epididymectomy after vasectomy, where seven of eight improved after the procedure. Those with chronic epididymitis had the least favourable outcome, with only seven reporting any improvement in symptoms.

CONCLUSIONS

Epididymectomy has a valuable role in the management of epididymal pathology in appropriately selected patients.

The role of orchiectomy in the management of postpubertal cryptorchidism

PURPOSE

Owing to the risk of future malignancy, many postpubertal male subjects presenting with unilateral cryptorchidism undergo orchiectomy rather than orchiopexy. We examined the incidence of spermatogenesis and carcinogenesis in whole orchiectomy specimens removed from postpubertal cryptorchid male subjects. We review the concept that orchiectomy is justifiable in these patients.

MATERIALS AND METHODS

A total of 52 patients with postpubertal cryptorchidism (unilateral in 48, bilateral in 4) were retrospectively analyzed from 1984. Patient age ranged from 15 to 66 years (mean 26). Six patients presented with primary infertility (unilateral in 3, bilateral in 3). The undescended testicles were palpable in 32 cases (62%). All patients underwent unilateral orchiectomy and whole specimens were examined histologically.

RESULTS

Histology showed normal spermatogenesis in only 1 orchiectomy specimen, while 15 had maturation arrest, 6 testicular agenesis and 30 seminiferous tubular atrophy and/or Sertoli-cell-only syndrome with no spermatogenesis. The location of the undescended testis was the superficial inguinal pouch in 32 cases, inguinal canal in 6 and inside the deep ring in 8. Absent spermatogenesis was significantly associated with a high level of maldescent and with increasing age. Two patients (4%) had carcinoma in situ of the testicle. Torsion of an undescended testicle occurred in 1 patient (2%).

CONCLUSIONS

This analysis of cryptorchid testes in postpubertal male subjects confirms that the majority cannot contribute to fertility, have significant malignant potential and may undergo torsion. Therefore, orchiectomy remains the treatment of choice for the majority of postpubertal male subjects presenting with unilateral cryptorchidism.

Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility

OBJECTIVES AND METHODS

The effects of double pigtail ureteric catheters (JJS) and percutaneous nephrostomies (PN) on ureteric motility and artificial stone transit was assessed in 12 dogs. Each animal underwent bilateral nephrostomies and an artificial stone insertion into each upper ureter (n = 20). A 4-Fr JJS was inserted on one side (group 1) while a PN was left on the contralateral side (group 2). In 4 stone-only 'control' ureters (group 3), the PN was sealed after 72 h. Stone passage was assessed by plain x-rays. Pelvic and ureteric motility was assessed prior to stone insertion and again at 2 weeks.

RESULTS

In group 1, only 1 of 8 stones (12.5%) passed completely. Four reached the midureter, 3 remained static. Six of 8 stones (75%) in group 2 passed completely. Two stones remained in the distal ureter. All 4 stones (100%) in group 3 passed by day 3 postoperatively. At laparotomy the J-stented ureters were dilated and both pelvic and ureteric contractions were diminished. Ureteric diameter was normal on the PN side. The ureters contracted with normal amplitude, but diminished rate of contraction above the stones in the ureters with residual calculi (n = 2), and in the 6 ureters from which spontaneous stone passage had occurred. A similar pattern was found in the 4 group 3 ureters.

CONCLUSIONS

Double J stents are associated with ureteric dilatation, diminished peristalsis and impaired stone passage. APN preserves ureteric peristalsis and facilitates stone passage. In the initial phase, raised hydrostatic pressure appears to the most important factor determining stone passage.

Incidentally detected renal cell carcinoma: pathological features, survival trends and implications for treatment

OBJECTIVES

To compare treatment outcomes in symptomatic and incidental renal cell carcinoma (RCC) with specific interest in the role of radical nephrectomy.

PATIENTS AND METHODS

The records of 189 patients with a clinical diagnosis of RCC were reviewed. The mode of presentation, tumour size, grade and stage at presentation were correlated with final outcome, as measured by the disease-free and overall survival of the patients.

RESULTS

The rate of incidental detection was 15%; incidental tumours were of a lower stage and patients with incidentally detected tumours had a significantly longer disease-free and overall survival than had those with symptomatic tumours (P < 0.05).

CONCLUSIONS

The increased detection of incidental tumours should further improve survival in RCC. We continue to advocate radical nephrectomy for incidentally detected tumours, as it offers the best outcome and simplifies the follow-up.

The fate of the defunctioned bladder following supravesical urinary diversion

OBJECTIVE

To determine the nature, incidence and severity of bladder complications after supravesical urinary diversion without cystectomy and to identify preventative risk factors.

PATIENTS AND METHODS

A retrospective study of the last 25 years identified 35 patients who had supravesical urinary diversion without concomitant cystectomy (33 ileal loop diversions and two cutaneous ureterostomies). Urinary diversion was performed for a variety of lower urinary tract pathologies. Patients with urinary tract neoplasia were excluded. There were 15 males (mean age 41 years, range 13-72) and 20 females (mean age 49 years, range 15-81) with a mean follow-up of 5.2 years (range 1-25).

RESULTS

There were bladder complications in 10 patients (28%) including pyocystis (one mild and two severe), haemorrhage (two mild and one severe) and pain/spasm (four mild and three severe). Patients with interstitial cystitis, bladder outflow obstruction and/or a vesical fistula appeared to have a higher risk of complications. Four patients required cystectomy to treat severe symptoms while the remaining six achieved control of symptoms with no surgery. No patient developed carcinoma during the follow-up.

CONCLUSION

We recommend that cystectomy is considered at the time of supravesical urinary diversion, particularly in patients with interstitial cystitis, bladder outflow obstruction or a chronically infected bladder and especially in those with a vesical fistula.

Is there a role for in vivo methylene blue staining in the prediction of bladder tumour recurrence?

OBJECTIVE

To assess the role of in vivo staining with intravesical methylene blue in predicting tumour recurrence.

PATIENTS AND METHODS

Thirty-nine patients (27 men and 12 women, age range 43-75 years) newly diagnosed with bladder tumours were prospectively studied and followed for a minimum of 2 years. Potential biopsy sites were identified by staining intravesically with a 1% methylene blue solution and compared with random biopsy sites.

RESULTS

Biopsy directed by methylene blue staining detected carcinoma in situ more often than random biopsy. Rates of recurrence were similar in both stained and unstained groups.

CONCLUSION

Methylene blue staining does not add significantly to the management of patients presenting with bladder tumours.

'Firm' versus 'soft' double pigtail ureteric stents: a randomised blind comparative trial

It is generally considered that 'firm' double pigtail ureteric catheters, while easier to insert and less prone to migration, may cause more patient discomfort than the 'softer' variety of stent. Objective support for these perceptions is however lacking. The aim of this study was to compare firm and soft stents regarding their ease of insertion, positional stability, biocompatibility and patient tolerance. 155 patients were randomised to receive 'firm' (polyurethane, n = 78) or 'soft' (Sof-Flex, n = 77) stents. Ease and mode of insertion was recorded at time of initial placement. Positional stability, degree of bladder inflammation, stent encrustation and patient tolerance were recorded at the time of removal. Patient tolerance was assessed by symptom score in double-blind fashion. Results showed no significant difference in ease of insertion, positional stability, degree of bladder inflammation or stent encrustation between the two groups. There was a significantly higher incidence of dysuria, renal and suprapubic pain in the firm stent group. There was no significant difference in the incidence of urgency, frequency, nocturia or haematuria. Normal activity and return to work were reported in 67 and 45% of patients with soft and firm stents, respectively. The data indicates that patient tolerance appears to be related to the softness of the stent material.

Comparison of reagent strip (dipstick) and microscopic haematuria in urological out-patients

Dipstick (reagent strip) and microscopic urine analysis for haematuria was performed prospectively on 1000 consecutive urine samples taken from urological out-patients. Haematuria was present in 185 samples (18.5%) and absent in 687 (68.7%) using both tests; 98 samples (9.8%) had dipstick haematuria that was not confirmed by microscopy and 30 samples (3%) had microscopic haematuria that was missed on dipstick urine analysis. Dipstick urine analysis had a sensitivity of 86.1% and a specificity of 85%. This study confirms that reagent strip testing for haematuria has both false positive and false negative results and indicates that cytoscopy should be considered in all patients with suspected haematuria.

Is retrograde ureterography indicated in pelviureteric junction obstruction?

The role of retrograde ureterography in the management of pelviureteric junction (PUJ) obstruction remains controversial and it has recently been reiterated that visualisation of the entire ureter on the affected side is mandatory owing to the high incidence of other ureteric abnormalities. In a review of 119 consecutive adult pyeloplasties carried out over a 9-year period, only 2 ureteric abnormalities were found in association with PUJ obstruction (duplex ureter/3-cm proximal stricture). Other anatomical abnormalities included aberrant vessels, fascial bands and renal anomalies. Most secondary abnormalities were undiagnosed prior to surgery and all were easily dealt with per-operatively.

Treatment strategy for piezoelectric shock wave lithotripsy of upper ureteral calculi

In situ piezoelectric lithotripsy monotherapy for upper ureteral stones is an attractive option because it can be conducted on an outpatient basis. Difficulty in calculus localization with ultrasound is the limiting factor. We reviewed our experience with 99 patients treated for upper ureteral calculi with the EDAP LT.01 lithotriptor. For stones above the lower renal border we achieved a 53% stone-free rate compared to 25% for calculi below the lower renal border. In situ piezoelectric lithotripsy of upper ureteral calculi may be considered for stones above the lower renal border.

Effect of high-energy shock wave frequency on viability of malignant cell lines in vitro

In this study, the effects of high-energy shock wave (HESW) frequency on the viability of three different malignant cell lines were evaluated using a piezo-electric generator. The cell lines studied were AR42-J, VX-2 and HeLa. These cells were targeted both in free suspension and immobilised in gelatine beads. All cell lines in free suspension were acutely sensitive to HESW over a range of frequencies. When cells were immobilised in gelatine, however, the effect on cell viability was not as pronounced. However, at frequencies of 80- and 160-Hz kill rates approaching 80 and 90%, respectively, were observed. Cell proliferation following HESW treatment was not adversely affected. This study demonstrates that single cell suspensions are not appropriate for assessing the in vitro cellular effects of HESW. However, even when cells were immobilised in gelatine, high-frequency HESW produced substantial kill rates. The effects of high-frequency HESW merit further evaluation particularly using in vivo tumour.

Acute and chronic bioeffects of single and multiple doses of piezoelectric shockwaves (EDAP LT.01)

Piezoelectric second generation lithotriptors are an established means of administering extracorporeal shockwave lithotripsy (ESWL) enabling treatment to be performed without anaesthesia or analgesia, but higher shockwave doses and multiple or staged treatment are frequently required. The bioeffects of this modality of ESWL, therefore, require further assessment. Seven experimental groups of adult male rabbits were treated using the EDAP LT.01 in order to determine the acute and chronic bioeffects of clinical dose, excess dose, divided excess dose, high frequency and multiple treatment (X10) piezoelectric shockwaves (PSW). Renal function was measured before and after treatment using mercaptoacetyltriglycine (MAG 3) scans. Gross and histological morphological changes were assessed at one and 30 days following application of PSW. Application of single clinical dose PSW was not associated with any significant functional or morphological renal injury. Excess dose PSW caused transient gross renal contusion, which resolved in the majority of animals with no persistent microscopic abnormality. Divided excess dose PSW resulted in no gross or microscopic damage. High frequency PSW was associated with mild histological abnormality. Multiple PSW treatments caused small discrete fibrotic lesions in all cases, without any change in renal function.

Use of the double pigtail stent in stone retrieval following unsuccessful ureteroscopy

Insertion of a double pigtail stent is known to cause ureteric dilatation. We analysed the effect of an indwelling double pigtail stent on the success rate of calculus extraction by second ureteroscopy when the initial ureteroscopy fails. Over a 12-month period, a first ureteroscopy failed in 42 patients; 30 were then treated by ureteroscopy combined with a ureteric stent and 12 were treated without a ureteric stent. The group with an indwelling stent had a successful second ureteroscopy or spontaneously passed the calculus in 24 cases (84%) compared with 5 unstented cases (45%). Ureterolithotomy was necessary in 2 patients with a stent and 3 with no stent. It was concluded that following failed ureteroscopic manipulation of calculi, insertion of a double pigtail stent was associated with a higher subsequent success rate for removal of stone by ureteroscopy and a consequent lower rate of ureterolithotomy.

Ultrasonic imaging for extracorporeal shockwave lithotripsy: analysis of factors in successful treatment

The emergence of real-time ultrasonic imaging for extracorporeal shockwave lithotripsy poses questions regarding the factors and techniques which facilitate stone imaging for clinicians with no previous practical experience in ultrasonography. The ability of these clinicians to assess when stone disintegration has been achieved also needs to be confirmed. A wide range of data was recorded from each of 2688 lithotripsy treatments performed over a 2-year period using the EDAP LT.01 ultrasound-imaged piezoelectric lithotriptor. An analysis of these data was performed using a comprehensive microcomputer-based statistics package. The mean time taken for stone imaging and positioning was reduced from 11.2 to 7.5 min over the 2-year period. Obese patients and those with renal pelvic stones were best imaged in a lateral position. Overall there was no difference in percentage stone disintegration or clearance between treatments in the supine or lateral positions, but a significant reduction in the clearance of small caliceal stones resulted when the lateral position was used. Factors associated with a significantly greater percentage of stone disintegration and clearance included pain experienced by the patient during fine adjustment of the processing head during treatment, acoustic focus attenuation and widening and acoustic shadow widening as detected by the urologist at the end of treatment. Among the factors not associated with significant alterations in the percentage of stone disintegration or clearance were the lithotriptor operator, the side or site of the calculus, obesity and shockwave frequency or power. This study confirmed the ability of urologists to develop expertise in ultrasonography for renal stone imaging and to interpret successfully the subtle signs of stone disintegration.

Study of appropriate antibiotic therapy in transurethral prostatectomy

Septicaemia is the commonest cause of morbidity and mortality following transurethral prostatectomy. Routine blind antibiotic prophylaxis is not always effective and there is a tendency to over-use potent new and expensive antimicrobials. Attempts to "sterilise" the urine preoperatively are also expensive and disruptive. However, appropriate treatment/prophylaxis can be administered economically using rapidly obtained laboratory results. We describe here a technique of routine direct antibiotic sensitivity testing (DST) of the patient's urine pre-operatively and before catheter removal. Such testing can be performed by junior medical staff in a ward side-room. An appropriate antibiotic may then be administered parenterally 1 h before surgery or catheter removal. A total of 102 consecutive patients underwent TURP and only 1 of those with infected urine became septicaemic. In this instance, an appropriate antibiotic had been incorrectly given orally before removal of the catheter. If the antibiotic sensitivities of a patient's urine are known, and an appropriate antibiotic is given parenterally 1 h pre-operatively or before catheter removal, the incidence of septicaemia following transurethral surgery may be significantly reduced.

Extracorporeal shockwave lithotripsy using ultrasonic imaging: urologists' experience

The EDAP LT.01 is a second generation shockwave lithotripter which employs ultrasound imaging and piezoelectric shockwave generation. We describe the first 12 months of its use in the treatment of urinary calculi by urologists with no previous practical experience of ultrasonography. A total of 406 calculi (359 renal and 47 ureteric) in 317 patients were treated. Analgesia or sedation was not routinely used and 59% of all treatments were performed as outpatient procedures. The clearance rate of renal calculi smaller than 1 cm was 81%, while that of calculi larger than 3 cm was 80% (mean clearance 77.5%). Lithotripsy of ureteric calculi following retrograde manipulation to a renal site resulted in 94.4% clearance compared with 39% for those treated at a ureteric site; 93% of 684 lithotripsy treatments were either painless or caused only mild pain. Our experience with imaging and treating urinary calculi with the EDAP LT.01 lithotripter has been excellent. Patients are treated effectively and inexpensively as out-patients without analgesia or sedation.

Endoscopic treatment of urinary tract calculi

Removal of urinary tract calculi by endourological techniques is now widely practised and has reduced the indications for open surgical removal to a minority of cases. A review of 270 consecutive patients who presented to the Meath Hospital Urology department with urinary tract calculi and were treated by percutaneous or transurethral endoscopy is herein reported. The rates of successful clearance of renal (95%) and ureteric (78%) calculi compare well with previous reports. The majority of complications were minor and a low overall complication rate was experienced at ureterorenoscopy. In our experience, endourological treatment of urinary tract calculi is successful, efficient and safe and is the recommended approach to urinary tract calculi that require surgical intervention.

Bilateral ureteric carcinoma

We report two rare cases of bilateral simultaneous ureteric carcinoma. The radiological features and problems of management are discussed.

Transcriptional activation of the glutathione S-transferase pi gene in human ureteric and bladder carcinomas

Using a cDNA clone derived from the rat Glutathione S-Transferase P (GST-P) gene, we have investigated homologous transcripts in a range of normal and malignant human tissues. A major transcript, of 0.75 Kb, representing human GST-pi mRNA, was present in total RNA purified from peripheral white blood cells, bladder, ureteric and prostate tissues. In total RNA derived from histopathologically benign/normal tissues, peripheral leucocytes and from hyperplastic and malignant prostates, levels of the mature transcript varied by less than 1.5-fold (n = 70). In contrast, levels of transcript were significantly elevated (up to 16-fold) in total RNA derived from bladder and ureteric carcinomas, with the highest levels of elevation approaching those previously found only for the GST-P gene in experimentally induced rodent hepatocellular carcinomas. A wide range of stage and grade of tumour has been investigated (pT1 to pT4; G1 to G3, respectively), suggesting that the transcriptional activation of the GST-pi gene is a characteristic common to many bladder/ureteric carcinomas in man.

Superficial bladder tumors (stage pTa, grades 1 and 2): the importance of recurrence pattern following initial resection

We treated 414 new patients with stage pTa, grades 1 and 2 bladder tumors by transurethral resection between 1970 and 1982. All of the patients with grade 3 or previous upper tract tumors, or who had been treated at some stage with intravesical chemotherapy were excluded. Followup for 5 or more years was available in 188 of the patients. There was a low increase in T stage (6 per cent). Of the patients followed for 5 or more years 46 per cent remained free of tumor. Only 16 per cent of the patients had multiple tumors at presentation and 20 per cent had tumors of 10 gm. or more. These factors were associated with a worse prognosis. Patients free of tumor at 3 months had an 80 per cent chance of having no further recurrences and this rate remained the same up to 2 years from the start of the disease. Patients with a recurrence at 3 months were much less likely to remain free of tumor, and had a higher chance of recurrence at every future visit.

Bladder neck contracture following prostatectomy

In an 11-year period, 49 patients developed bladder neck contracture after prostatectomy--an incidence of 0.86%. This complication was found to be more common after resection of small fibrous hyperplastic prostates. The best results for treatment of the contracture were obtained after bladder neck incision, which gave a 9% incidence of recurrence; after transurethral resection of the bladder neck contracture the recurrence rate was 46%, and after bladder neck dilatation it rose to 100%.

Preperitoneal ectopic testis: a case report

We report a 5 1/2-year-old boy with preperitoneal ectopic testes. This condition has been reported only once before. Both testes were attached to the umbilicus and at operation were successfully placed in the scrotum.

Testicular tumors in subfertile men: report of 4 cases with implications for management of patients presenting with infertility

We report on 4 men attending our infertility clinic in whom seminomas developed. A review of testicular biopsies performed for investigation of subfertility in 2 patients revealed in situ and early invasive carcinoma. Infertile men have a prevalence of carcinoma in situ in the range of 1 per 100 to 200, with a high risk of progression to invasive germ cell tumor (50 per cent within 5 years of diagnosis). Biopsy is the only method of detection of the in situ lesion and, therefore, is recommended in the investigation of oligospermic and azoospermic male subjects. The surgical approach to and diagnostic sensitivity of testicular biopsy are reviewed, and the management of carcinoma in situ is discussed.

Flexible cystourethroscopy: advantages and limitations

Much interest has been expressed in flexible cystourethroscopy, which has obvious potential advantages. In this study it was compared to rigid endoscopy in 25 patients. It was found to be a painless procedure, but not as accurate in diagnosing vesical lesions as the rigid endoscope.