The urological application of electrosurgery.
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Animals↗
Biomedical subjects
E V Kramolowsky
Publications and source records attributed to E V Kramolowsky.
Endourological treatment of ureteroenteric anastomotic strictures: long-term followup.
In 1987 we reported our initial experience with an endosurgical incisional approach to ureteroenteric anastomotic strictures (that is endoureterotomy). We have extended that initial report to encompass 15 patients with 19 ureteroenteric strictures followed for an average of 2.5 years. In all cases an endosurgical approach was well tolerated, blood loss was less than 50 cc and hospital stay averaged 3.5 days. A 16 to 22F external stent was left in place for 4 to 6 weeks postoperatively in 14 strictures. A permanent external 12F catheter was left in 5 strictures due to the presence of metastatic disease (4) and a complete dense stricture (1). The only major complication was a ureteroenteric fistula that healed over a ureteral stent without any open surgical intervention. Among 14 ureteroenteric strictures in which the stent was removed, the ureteroenteric area has remained patent in 8 (57%) with an average followup of 28.6 months (range 9 to 57 months). Failures were associated with metastatic disease in 2 cases, generalized debility in 2 and unexplained in 2. In this series an endosurgical approach to ureteroenteric strictures provided long-term satisfactory management of the problem in the majority of patients with benign and malignant disease. By current standards, only 1 patient (7%) would have been considered a candidate for open surgical repair.
Adolescent↗
In vivo effect of 5 French bipolar and monopolar electrosurgical probes on the porcine bladder.
Previous in vitro studies have indicated bipolar electrosurgical probes would electrodesiccate tissue in a normal saline solution. This study applies similar sized monopolar and bipolar electrosurgical probes to porcine bladder in order to compare each probe's effect in vivo. The power delivered by each probe was calculated; the width and depth of the porcine bladder damage was measured and the volume of the damage calculated. The animals were sacrificed at 24, 48 and 96 h post-procedure so that the amount of tissue destruction could be quantitated relative to the bladder's natural tissue reaction. The data shows the power (watts) delivered by the monopolar probe to be approximately six times that of the bipolar probe. Likewise, the area of bladder wall damage was larger with monopolar at all time periods sampled and showed significant differences at 24 and 48 h. These studies indicate that in viable bladder, tissue bipolar probes will electrodessicate at a lower power and with less shortterm tissue damage.
Animals↗
Use of 5F bipolar electrosurgical probe in endoscopic urological procedures.
Experimental data have shown bipolar electrodes to function in saline solution with less volume and depth of tissue destruction compared to similar sized monopolar electrodes. We applied the same bipolar generator and electrodes used in laboratory testing in 41 procedures on 36 patients to determine if the bipolar electrode will provide clinically adequate hemostasis. The bipolar electrode was used for bladder fulguration in 37 procedures and ureteral fulguration in 4. The procedures were performed by 7 urological surgeons and in normal saline solution. The bipolar electrode was believed to perform as well as the standard monopolar probe in 39 procedures. The 2 failures included 1 bladder tumor fulguration and 1 electroincision of a ureterointestinal anastomotic stricture. There were no episodes of recurrent bleeding after any procedure. The bipolar system has the added advantage of not requiring a return electrode (ground pad), thereby eliminating the possibility of skin burns.
Ambulatory Surgical Procedures↗
Invasive adenocarcinoma of bladder response to cisplatinum, methotrexate, and vinblastine chemotherapy.
Primary invasive adenocarcinoma of the bladder was diagnosed in a fifty-two-year-old male with a two-month history of irritative voiding symptoms. He was treated with three courses of cisplatinum, methotrexate, and vinblastine with marked regression of tumor shown radiographically and cystoscopically. Subsequent prostatocystectomy and ileal loop diversion revealed invasive tumor through the bladder wall to regional lymph nodes. The patient had two postoperative courses of the same chemotherapeutic regimen and is without evidence of disease recurrence at one year.
Adenocarcinoma↗
Management of benign ureteral structures: open surgical repair or endoscopic dilation?
We reviewed 20 cases of ureteral strictures, 15 of which were secondary to ureteral trauma. Of the patients 6 were managed initially by open repair and 14 underwent endoscopic manipulation. All 6 open repairs were successful, compared to 9 of the 14 patients who underwent endoscopic dilation of the ureteral stricture. Of the 5 failures 3 were due to the inability to cannulate the strictured ureter with a guide wire and 2 failed to respond to balloon dilation. Of these 5 patients 4 were treated successfully by an open operation. There were no serious intraoperative or postoperative complications. The average hospitalization was less for the endoscopic group (2.1 days) compared to the open surgical group (8.3 days). Followup ranged from 6 to 48 months.
Adult↗
Magnetic resonance imaging in the diagnosis and followup of idiopathic retroperitoneal fibrosis.
Four cases of idiopathic retroperitoneal fibrosis are reported. Magnetic resonance and computerized tomographic images were obtained for diagnosis in each case, and followup scans were obtained at various intervals after therapy. In all 4 cases magnetic resonance imaging was equal or superior to computerized tomography in the diagnosis of retroperitoneal fibrosis, outlining the extent of involvement, preoperative planning and assessing response to medical or surgical therapy.
Aged↗
A comparison of urologic application of bipolar versus monopolar five French electrosurgical probes.
Urologic endoscopic procedures often involve electrosurgery. Recently bipolar probes have become commercially available. This study compares monopolar and bipolar electrosurgical probes in relation to power losses in urologic endoscopic instruments with the infusion of sterile water and saline, and the power transmitted by probes to tissue correlated to tissue destruction in each fluid. The power losses through each instrument in both solutions were minimal. The bipolar electrode functioned at a much lower power output than did the monopolar electrode. The bipolar probe was also more effective in saline than sterile water. The depth, width and volume of tissue damage for both electrodes were found to vary with generator power output. The data shows the burns had similar diameters for both probes but the bipolar probe caused significantly less burn depth than the monopolar probe. These initial studies indicate that bipolar electrodes can function in normal saline with less depth damage compared to the monopolar probe.
Animals↗
Complications of ureteroscopy.
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Dilatation↗
Urinary calculus: high-tech changes a urology practice.
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Adult↗
Flexible cystoscopy and retrograde catheterization in renal transplant patients.
Catheterizing the ureteral orifice of a renal transplant patient can be difficult using traditional rigid instruments. This report describes our experience with 4 patients who underwent cystoscopy and attempted retrograde catheterization of a transplanted ureter. In all cases attempted catheterization using rigid instruments was unsuccessful, while in 3 of the 4 patients, successful cannulation was accomplished using the flexible cystoscope. These results are attributed to the expanded range of motion achieved with the tip of the flexible cystoscope. The increased mobility afforded by this instrument facilitates access to the ureteral orifice, which is often positioned on the distensible portion of the bladder.
Adult↗
Giant prostate carcinoma: computed tomography findings and review of previous reports.
Two patients with massive prostate adenocarcinoma were evaluated by several imaging modalities. Computed tomography provided excellent anatomic delineation of the tumors. In one patient, computed tomography demonstrated significant tumor regression following orchiectomy. Giant prostate carcinoma should be considered in the differential diagnosis of a large, inhomogeneous pelvic mass.
Adenocarcinoma↗
Extracorporeal shock wave lithotripsy for the treatment of bulbous urethral stones.
Extracorporeal shock wave lithotripsy was used to treat multiple, large, bulbous urethral calculi in a paraplegic man. Prior attempt at endoscopic extraction was unsuccessful owing to the size and location of the calculi. Two treatments of 3,000 shocks each resulted in fragmentation of the calculi
Adult↗
Management of ureterointestinal anastomotic strictures: comparison of open surgical and endourological repair.
The established treatment for ureterointestinal anastomotic strictures is open surgical revision. In an effort to evaluate the efficacy of endourological surgery for this problem, we compared 7 patients (9 strictures) who underwent open revision to 6 patients (7 strictures) who underwent endoscopic incision and balloon dilation of the stricture. The success rate (that is patent ureter and no stent) was 89 per cent for the open revision group and 71 per cent (5 of 7) for the endoscopic group. All open revisions required use of general anesthesia, while 3 of the endoscopic procedures were performed with the patient under assisted local anesthesia. The endoscopic group had markedly shorter hospitalization, decreased blood loss, diminished patient discomfort and no postoperative complications. While the endoscopic procedure for ureteroileal anastomotic strictures is less successful than open revision, the lower morbidity, decreased cost and shorter hospital stay associated with the endourological approach favor its use over open revision. For elderly patients who fail initial endoscopic revision and for patients with metastatic transitional cell cancer, placement of an indwelling stent is a reasonable alternative. Given these guidelines, less than 30 per cent of the patients who suffer a ureteroileal anastomotic stricture will require open surgical revision.
Algorithms↗
The value of testosterone deprivation in stage D1 carcinoma of the prostate.
The question of whether hormonal manipulation is effective in the treatment of stage D1 carcinoma of the prostate has yet to be determined conclusively. To study this question a retrospective review was conducted of 68 patients with stage D1 disease. Of the patients 22 underwent immediate orchiectomy, 24 delayed orchiectomy and 11 exogenous antiandrogen treatment (8 immediate and 3 delayed treatment), and 11 had no androgen deprivation. The patients were placed into 2 groups consisting of those receiving immediate hormonal deprivation (30) and those having treatment at the time of bone metastasis or who are as yet untreated (38). The minimum followup was 60 months. The median interval to progression to bone metastasis was 43 months in the delayed treatment group compared to 100 months in the immediate hormonal deprivation group. This difference was statistically significant (p equals 0.0087). Likewise, the median period from diagnosis to death was 90 months in the delayed treatment group and 150 months in the immediate treatment group. This difference was not significant (p equals 0.1110). Thus, orchiectomy or adequate androgen deprivation from our data significantly prolongs the interval to bone metastasis in patients with metastatic prostate cancer limited to the pelvic lymph nodes. The apparent increased length of survival of the immediate treatment group lacks statistical confirmation.
Aged↗
Advances in endosurgery. Treatment of ureteral-enteric anastomotic strictures.
The described endourologic technique of incision and dilation of a ureteral-intestinal stricture is effective in most patients. Indeed, with the outlined treatment regimen, less than 30 per cent of patients with ureteral-intestinal anastomotic strictures will eventually require open surgical revision. Further advances in the use of lasers or the endourologic positioning of free tissue grafts may further improve the success rate of the endoscopic approach.
Dilatation↗
Percutaneous transperineal placement of gold 198 seeds for treatment of carcinoma of the prostate.
Thirty-one patients have been treated for carcinoma of the prostate with 198Au seeds placed transperineally using transrectal ultrasonic guidance. Twenty patients have been followed postoperatively for periods ranging from 3 to 31 months, with an average follow-up time of 12 months. Cumulative dose of radiation to the prostate calculated by dosimetry was either 9,000 rads or 15,000 rads. Serial transrectal ultrasound examinations performed on these patients showed a decrease in prostate size in all patients within 6 months of treatment, with a statistically significant decrease observed between the third and sixth months. No significant difference in amount or rate of tumor regression was noted when tumor stage and grade were correlated to volume decrease after treatment. Patients who received the larger doses of radiation (15,000 rads) showed a significantly greater rate of decline in prostatic volume than those who received 9,000 rads. Seven patients underwent prostate biopsy between 12 and 18 months after treatment; six biopsies showed residual tumor. Complications after treatment included urinary retention because of prostatic edema (three), radiation urethritis (three), and rectal ulceration (one). Transperineal placement of 198Au is well tolerated and offers an alternative to external beam radiation for treatment of carcinoma of the prostate.
Adenocarcinoma↗
Ureteral perforation during ureterorenoscopy: treatment and management.
Ureterorenoscopy has become a popular diagnostic and therapeutic tool for the modern urologist but this procedure is not without complications and risks. The technique may result in perforation of the ureter and subsequent stricture formation in some cases. In this study a ureteral perforation rate of 17 per cent was noted after 142 ureteroscopic procedures, with stricture formation occurring in 5 per cent. The type of dilation, reason for the procedure or placement of a postoperative stent did not seem to affect the formation of stricture but the location of the injury appeared to be significant. Of those injuries not requiring immediate surgical repair perforations within the pelvis (6 of 11) led to strictures more often than those beyond the pelvis (1 of 9). Treatment of the strictures with either an open repair or percutaneous antegrade dilation was successful.
Dilatation↗