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Biomedical subjects

S B Streem

Publications and source records attributed to S B Streem.

At least 37 records · Page 2Linked to original sources
PubMed1999

13-year experience with percutaneous management of upper tract transitional cell carcinoma.

PURPOSE: We determined the immediate and long-term results of percutaneous management of upper trace transitional cell carcinoma in regard to rates of tumor recurrence and preservation of renal function. MATERIALS AND METHODS: Since July 1985, 12 men and 5 women 50 to 86 years old (mean age 72.2) years old underwent percutaneous management of upper tract transitional cell carcinoma. Of the patients 12 (71%) had a solitary kidney and 1 was treated bilaterally. In 16 of the 18 treated renal units (89%) definitive percutaneous resection of the tumor was followed by 6 weekly percutaneous installations of bacillus Calmette-Guerin. RESULTS: Complete resection was accomplished in 17 of the 18 renal units. Of the 18 renal units 15 (83.3%) had documented stage pTa lesions and 14 (77.8%) had grade 1/3 or 2/3 disease. Followup for all patients ranged from 1.7 to 75.5 months (mean 20.5). At the latest followup 11 patients (64.7%) are alive with no evidence of disease, and 6 (35.3%) died, 3 of whom (17.6%) had metastatic transitional cell carcinoma. Of the 13 patients undergoing treatment to solitary kidneys or bilaterally followup ranged from 1.7 to 75.5 months (mean 23.6). Serum creatinine ranged from 1.1 to 3.5 mg./dl. (mean 1.6) before percutaneous tumor resection and from 1.1 to 2.2 mg./dl. (mean 1.6) at the latest followup. Only 1 of these 13 patients (7.7%) with a solitary kidney has required dialysis. Ipsilateral local recurrence developed in 6 of the 18 renal units (33%), and in 4 of these 6 patients (67%) the tumor was grade 2/3 or 3/3 at initial resection. These recurrences were treated endoscopically in 4 patients, 3 of whom are currently without evidence of disease, and with nephroureterectomy in 2. Of the 17 patients only 1 (5.9%) with high grade (3/3), invasive (pT2) primary tumor at initial resection died of locally persistent or recurrent disease. CONCLUSIONS: Percutaneous management of upper tract transitional cell carcinoma is technically feasible and applicable in a significant number of patients in whom nephron sparing management is otherwise warranted. In carefully selected patients the results are at least comparable to other forms of "conservative" management in terms of tumor control and preservation of renal function.

Aged↗
PubMed1999

Impact of diagnostic ureteroscopy on long-term survival in patients with upper tract transitional cell carcinoma.

PURPOSE: We determine whether diagnostic retrograde ureteroscopy for evaluation of upper tract transitional cell carcinoma adversely affects survival outcomes in terms of urothelial and metastatic tumor recurrence, and tumor-free and overall survival. MATERIALS AND METHODS: A total of 96 patients underwent total nephroureterectomy or resection of the distal ureter with a bladder cuff for upper tract transitional cell carcinoma. Of the patients 48 (study group) had undergone preoperative diagnostic ureteroscopy while 48 (control group) had not. Grade and stage of disease were compared, and time to recurrence, and disease-free and overall survival were analyzed. RESULTS: Grade and stage of disease were equivalent in both groups. There were no significant differences in recurrence rates, time to recurrence or mortality between the groups. Metastases developed in 9 patients (18.8%) in the control group and 6 (12.5%) in the study group (p = 0.58), while 5 (10.4%) in each group died of metastases of upper tract carcinoma (p = 1.00). Kaplan-Meier estimates were 0.67 and 0.71 for metastasis-free survival at 5 years (p = 0.25, not significant) and 0.87 and 0.76 for overall 5-year survival (p = 0.75, not significant) for the study and control groups, respectively. CONCLUSIONS: Diagnostic ureteroscopy has no clinically apparent adverse effect on long-term or disease specific survival of patients with upper tract transitional cell carcinoma who subsequently undergo standard definitive surgical management.

Aged↗
PubMed1999

Simultaneous versus staged bilateral extracorporeal shock wave lithotripsy: long-term effect on renal function.

PURPOSE: We determine whether there is a clinically significant difference in the long-term effect on renal function following simultaneous versus staged bilateral extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: Between July 1986 and October 1995, 360 patients underwent treatment for bilateral renal calculi with ESWL using a Dornier HM-3 lithotriptor. Of the patients 319 had both kidneys treated simultaneously (simultaneous group) and the remaining 41 were treated in a planned, staged fashion (staged group) with the procedures separated by 3 to 20 weeks (mean 6.0). Followup data of at least 1 year were available for 49 men and 30 women (mean age 52.4) in the simultaneous group, and 8 and 12 (mean age 45.1), respectively, in the staged group. Mean stone burden was 0.70 cm.2 on the right and 0.87 on the left side in the simultaneous group, and 1.6 and 1.5, respectively, in the staged group. RESULTS: Patients with at least 1 calculus greater than 0.5 cm.2 treated simultaneously received a mean of 1,386 shock waves to the right and 1,637 to the left side, and the staged group received a mean of 1,802 and 2,094, respectively. Mean serum creatinine was 1.03 mg./dl. before and 1.04 after treatment (normal 0.7 to 1.4 mg./dl.) in the simultaneous group, representing a mean increase of 0.01 at followup of 1.0 to 10.5 years (mean 3.7), and 0.88 and 0.88, respectively, in the staged group, representing a decrease of 0.005 at followup of 1.0 to 7.2 years (mean 3.2). The effects of simultaneous versus staged ESWL on renal function as measured by serum creatinine were not statistically significant using a multiple regression model which controlled for the effects of stone burden, number of shock waves, patient age, pretreatment serum creatinine and length of followup (p = 0.19). CONCLUSIONS: There is no clinically apparent difference in the long-term effect on renal function for patients with bilateral renal calculi treated with ESWL in a simultaneous versus staged fashion.

Adult↗
PubMed1998

Contemporary urological intervention for cystinuric patients: immediate and long-term impact and implications.

PURPOSE: We determined the immediate efficacy of contemporary urological intervention for cystine stones and the impact of such intervention on the subsequent rate of recurrent stone formation. MATERIALS AND METHODS: A total of 31 cystinuric patients underwent selected intervention for 61 stone events. Patients were subsequently followed at 6 to 12-month intervals while being treated with standard medical therapy. Logistic regression models were used to correlate potential risk factors with the efficacy of the intervention in achieving a stone-free status. Kaplan-Meier estimates of the probability of recurrence-free survivals at 1 and 5 years were generated, and risk factors for stone recurrence were analyzed using the log rank test. RESULTS: Overall stone-free rate was 86.9%, which was not significantly influenced by the initial stone burden or type of intervention selected. The probability of recurrence-free survival at 1 and 5 years was 0.73 and 0.27, respectively, and again this probability was independent of initial stone burden or type of intervention selected. Urinary cystine levels before intervention and post-procedure residual stone status also failed to impact significantly on the risk of recurrence. However, a stone-free result, in contrast to residual stones, prolonged the mean time to stone recurrence from 346 to 1,208 days. CONCLUSIONS: While cystine stones are not amenable to all currently available minimally invasive therapeutic modalities, high stone-free rates can be achieved without the need for open surgery and as such cystinuric patients clearly benefit from contemporary intervention. When such intervention is used selectively, with consideration given primarily to stone burden and location, rates of recurrence will relate primarily to the natural history of the medically treated cystinuric patient, and not the type of intervention applied.

Adolescent↗
PubMed1998

Nephron sparing management of Fraley's syndrome with a pyelopyelostomy.

PURPOSE: We describe a new technique for nephron sparing management of functionally significant vascular compression of the upper pole infundibulocaliceal system (Fraley's syndrome). MATERIALS AND METHODS: Two patients evaluated for debilitating, narcotic dependent flank pain had significant upper pole infundibulocaliceal obstruction resulting from aberrant major arterial branches entering the hilum dorsally. Reconstructive surgery consisted of dismembered pyelopyelostomy with transposition of the crossing vessels in both patients. RESULTS: Pain relief was immediate and complete in both patients. Followup radiographic evaluation at 1 and 12 months, respectively, has also documented resolution of the obstruction. CONCLUSIONS: Vascular compression causing obstruction of the superior infundibulum can cause debilitating pain. Pathophysiologically operative intervention can be nephron sparing and gratifying for the surgeon and the patient.

Adult↗
PubMed1998

Ureteropelvic junction obstruction. Open operative intervention.

The indications to intervene for ureteropelvic junction (UPJ) obstruction have not changed despite the introduction of newer, less invasive techniques for definitive management. In contemporary practice, open operative intervention is still appropriate for those patients in whom alternative management has failed or is contraindicated, or for those in whom an unobstructed UPJ needs to be assured with the highest certainty--both immediately and with long-term follow-up. Although several techniques have been described for open operative reconstruction of an obstructed UPJ, a dismembered pyeloplasty has proven to be the most versatile, and should be a part of every urologist's treatment armamentarium. Alternative primary and salvage techniques for open operative reconstruction of the UPJ are also described in this article.

Humans↗
PubMed1998

The absence of crossing vessels in association with ureteropelvic junction obstruction detected by prenatal ultrasonography.

PURPOSE: The widespread use of prenatal ultrasonography has led to a marked increase in the incidence of ureteropelvic junction obstruction presenting in infancy. Which of these prenatally detected lesions requires repair has yet to be fully determined. Attempts to characterize prenatally detected ureteropelvic junction obstruction in regard to symptomatic obstruction detected later in life may provide useful insights into the management of these incidentally discovered lesions. We evaluated the presence of crossing vessels in ureteropelvic junction obstruction identified by prenatal ultrasonography. MATERIALS AND METHODS: We reviewed the records of patients who underwent dismembered pyeloplasty for primary ureteropelvic junction obstruction with specific attention to the mode of presentation and presence of crossing vessels associated with obstruction. RESULTS: In 30 patients with a mean age of 6 months ureteropelvic junction obstruction detected prenatally was not associated with a crossing vessel. Ureteropelvic junction obstruction was identified postnatally in 125 patients who underwent open pyeloplasty. It was detected incidentally in 8, of whom crossing vessels were present in 1 (12%). There were signs or symptoms related to ureteropelvic junction obstruction in 117 patients. In contrast to the group with prenatally detected ureteropelvic junction obstruction in which crossing vessels were never noted, crossing vessels were associated with 36 (30%) of the 120 kidneys operated on in this postnatally discovered group. CONCLUSIONS: No crossing vessels were present in patients with prenatally detected ureteropelvic junction obstruction compared with 30% in symptomatic patients. This finding may reflect the natural history of the disorder, or it may suggest that prenatally identified ureteropelvic junction obstruction is an entity largely different from obstruction presenting later in life.

Adolescent↗
PubMed1998

Contemporary management of cystinuric patients.

Cystinuria is an inherited genetic disorder that results in excessive cystine excretion through defects in renal dibasic amino acid transport. Due to the relative insolubility of cystine in urine, patients with this condition are prone to progressive and recurrent episodes of stone formation. Medical treatment is aimed at decreasing the concentration of cystine in the urine as well as increasing its solubility. A standard regimen includes dietary manipulation with hydration and moderate salt restriction, alkalinization, and thiol derivatives. Despite aggressive medical management, cystinuric patients are likely to suffer stone recurrences, and urologic intervention often is required. Contemporary technology permits the use of minimally invasive techniques for the majority of these patients, and advances in shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopic lithotripsy obviate the need for open surgery in essentially all instances.

Combined Modality Therapy↗
PubMed1998

Metabolic abnormalities in patients with caliceal diverticular calculi.

PURPOSE: We determined the incidence and spectrum of metabolic abnormalities in patients with caliceal diverticular calculi. MATERIALS AND METHODS: Five men and 9 women with caliceal diverticular calculi underwent metabolic evaluation, including determination of serum electrolytes, calcium, phosphate and uric acid, and 24-hour urinary volume, creatinine, calcium, oxalate, uric acid and citrate. RESULTS: Of the 14 patients 7 (50%) had urinary excretion abnormalities promoting stone formation, including hypercalciuria in 3, hyperoxaluria in 1, hypercalciuria combined with hyperuricosuria in 1 and hyperoxaluria combined with hyperuricosuria in 2. Two patients had a history of gout while another had radiographic evidence of medullary sponge kidney. Of the patients 9 (64.3%) had a history of synchronous or metachronous calculi distant from the involved caliceal diverticular stone and 5 (55.6%) of these 9 had definable metabolic disorders. However, there was no statistically significant difference in urinary excretion values between patients with or without a history of additional extra diverticular stones. CONCLUSIONS: Urinary stasis alone does not explain stone formation in a significant number of patients with caliceal diverticular calculi. Rather, the local physiological environment of the urine likely has a predisposing role and evaluation for metabolic abnormalities should be considered. In some patients cure may be effected by treating the stone and any associated metabolic disorders rather than the diverticulum.

Adult↗
PubMed1997

The psychosocial impact of donating a kidney: long-term follow-up from a urology based center.

PURPOSE: We conducted a psychosocial followup of living kidney donors from 1983 to 1995. MATERIALS AND METHODS: A new questionnaire about donor satisfaction and the Medical Outcomes Study Short-Form Health Survey, a standardized measure of health related quality of life, were completed by 167 donors (67% response rate). RESULTS: Of respondents 90% would make the same choice again and 83% would strongly encourage others to donate. However, 15% of respondents believed that donating had impacted negatively on their health and 23% reported negative financial consequences. Respondent health related quality of life was not impaired. The strongest correlates of donor dissatisfaction included a conflicted initial relationship with the recipient, believing that information given preoperatively had been inadequate and perceived damage to health or finances. CONCLUSIONS: Only a minority of living kidney donors suffer psychosocial morbidity. Better psychological preparation for surgery and more consistent followup could decrease negative outcomes further.

Adult↗
PubMed1997

Ureteroscopic diagnosis of intraluminal metastatic rectal carcinoma.

Ureteral obstruction resulting from metastatic adenocarcinoma is almost always extrinsic in nature. In contrast, true intraluminal metastases are extremely rare. With this report, we document the videoendoscopic appearance of true intraluminal ureteral metastases from metastatic rectal cancer confirmed with histopathologic examination. The value of transureteroscopic biopsy for accurate diagnosis is also demonstrated.

Adenocarcinoma↗
PubMed1997

Sandwich therapy.

When applying new technology to the management of patients with complex stone disease (especially those with infection-related stones), multiple factors should be considered. The primary goals of intervention in this setting, however, should be to minimize the rates of residual and recurrent stones and infection and to preserve renal function. A sequential, combined approach using percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy has proved valuable in minimizing the complication rates and maximizing the stone-free rates compared with using either modality alone.

Combined Modality Therapy↗
PubMed1997

Spiral noncontrast CT versus combined plain radiography and renal US after extracorporeal shock wave lithotripsy: cost-identification analysis.

PURPOSE: To investigate the costs of spiral computed tomography (CT) versus those of combined plain radiography and renal ultrasound (US) in screening for postprocedural complications after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: Twenty-five adult patients who had undergone ESWL were prospectively examined with spiral CT, renal US, and plain abdominal radiography. Each examination was timed, and direct technical costs were calculated by using a procedural-based cost-accounting system. The combined cost of US and plain radiography was compared with the cost of spiral CT. RESULTS: The average time for spiral CT was 15.3 minutes compared with 37.2 minutes for combined US and plain radiography. The direct technical cost of spiral CT was $36.86 compared with $57.60 for combined US and plain radiography. Average examination times were varied to assess the effect on overall costs. Within reasonable time ranges, combined US and plain radiography cannot be cost equivalent to spiral CT. CONCLUSION: Spiral CT is faster and is associated with less direct technical cost than combined US and plain radiography when used to examine patients after ESWL, given the dependence of this model on time of examination. Further studies are needed to assess the relative accuracy of these alternative approaches.

Adult↗
PubMed1997

The use of kidneys from living donors with renal vascular disease: expanding the donor pool.

PURPOSE: The disparity between the number of patients awaiting organ transplantation and the number of available donor organs continues to increase. We report the outcomes of transplantation using kidneys from living donors who had unilateral renovascular disease. MATERIALS AND METHODS: We identified 5 living donors who had unilateral renovascular disease, including saccular renal artery aneurysms, an arteriovenous malformation, localized atherosclerosis and fibromuscular renal artery stenosis. Each donor was normotensive and asymptomatic, and had otherwise normal renal function. RESULTS: In each case the abnormal kidney was removed, the lesion was repaired ex vivo and the kidney was successfully transplanted without complication in the donor or recipient. Each recipient had a serum creatinine of less than 2 mg./dl. and each donor remained normotensive with stable renal function at up to 3 years of followup. CONCLUSIONS: Kidneys from living donors with renovascular disease can be transplanted safely provided that careful selection, informed consent and a normal remaining kidney are ensured.

Adult↗
PubMed1997

Contemporary clinical practice of shock wave lithotripsy: a reevaluation of contraindications.

PURPOSE: The current clinical practice of shock wave lithotripsy is reviewed, specifically regarding patients in whom the presence of presumed absolute or relative contraindications may preclude treatment. MATERIALS AND METHODS: Peer reviewed basic scientific and clinical studies on shock wave lithotripsy in patients with urinary stones and concomitant conditions that might contraindicate treatment reported between 1982 and 1996 were critically reviewed. RESULTS: The exclusion of patients with conditions previously believed to contraindicate shock wave lithotripsy has almost always been empiric rather than based on experimental or clinical studies showing adverse effects in those settings. The contemporary literature suggests that shock wave lithotripsy in patients with proximate calcified aneurysms, implanted cardiac pacemakers and defibrillators, and bleeding diatheses can be accomplished safely and effectively with careful treatment and monitoring before, during and after shock wave lithotripsy. Likewise, patients with morbid obesity, children, and those with mid and distal ureteral calculi can also be treated successfully, even with first generation lithotriptors, with minor modifications that allow for appropriate positioning of the patient and stone. CONCLUSIONS: The designation of most conditions as absolute or relative contraindications to shock wave lithotripsy has been empiric. A review of experimental and clinical studies pertinent to these issues clearly shows that most concomitant conditions previously precluding shock wave treatment can be circumvented to allow safe and effective use of this minimally invasive technology. Currently, pregnancy is the only condition that should remain an absolute contraindication to this treatment.

Aneurysm↗
PubMed1997

Combination "sandwich" therapy for extensive renal calculi in 100 consecutive patients: immediate, long-term and stratified results from a 10-year experience.

PURPOSE: We determined the immediate and long-term efficacy of combination "sandwich" therapy for management of large, extensively branched calculi in 100 consecutively treated patients. MATERIALS AND METHODS: We treated 61 women and 39 men for stones ranging from 2.2 to 66 cm2 (mean 20.8) with percutaneous debulking followed by shock wave lithotripsy and, when necessary, secondary nephroscopy via the mature tract. The primary debulking was performed via 1 to 3 tracts (total 106, mean 1.06 per patient), following which 1 to 3 shock wave treatments (total 127, mean 1.3 per patient) were administered. Subsequently, 62 patients underwent 71 secondary or tertiary percutaneous procedures (mean 1.1 per patient). RESULTS: Total hospital stay ranged from 3 to 44 nights (mean 12.2) and decreased with experience. In 34 patients 40 complications developed, the most frequent of which were bleeding requiring transfusion in 14 patients and fever or sepsis delaying a planned procedure or hospital discharge in 20 patients. For patients with struvite stones the transfusion rate and fever/sepsis rate was 20 and 33%, respectively, compared to only 10 and 12%, respectively, for those patients with noninfection related stones. Of 87 patients available for 1-month radiographic followup 55 (63%) were stone-free, while 32 (37%) had discrete residual gravel. With time and experience, the stone-free rate improved from 52 to 70%. Of 55 patients followed for a mean of 40.5 months ipsilateral stones recurred in 13 (22.8%). Of 39 patients with struvite calculi 11 (28%) had recurrent bacteriuria or infection. Renal function, defined by serum creatinine, ranged from 0.6 to 3.9 mg./dl. (mean 1.3) before treatment and from 0.5 to 6.4 mg./dl. (mean 1.4) 1 to 101 months (mean 31) after treatment. CONCLUSIONS: This combined sandwich approach offers immediate and long-term results comparable to other forms of management currently available for these challenging cases. Furthermore, this approach may be applied successfully to virtually any patient with large, extensively branched or otherwise complex stones.

Adolescent↗
PubMed1996

Long-term follow-up of kidneys transplanted from elderly cadaveric donors.

This report examines the long-term results obtained in 50 patients transplanted between 1977 and 1990 with kidneys from cadaveric donors aged 55-70 (median 59) years. The recipients comprised 27 men and 23 women aged 8-68 (median 42) years. In all, 20 patients (40%) had end-stage renal disease on the basis of glomerulonephritis, whereas 8 (16%) were diabetic. Immunosuppression was induced with antilymphocyte globulin and maintained with azathioprine and prednisone in all patients in addition to cyclosporine in the 35 patients transplanted since 1985. Immediate graft function occurred in 18 patients (36%), and 36 patients (72%) were off dialysis at 1 year posttransplant. Altogether, 25 patients (50%) had functioning grafts at 5 years posttransplant, and at up to 13 years of follow-up (mean 5.8 years), 22 patients (44%) are off dialysis and their serum creatinine levels range from 0.8 to 3.8 mg/dl (mean 2.0 mg/dl). In all, 12 patients (24%) expired from 2 months to 15.5 years posttransplant (mean 4.3 years), and 5 of these patients died with functioning grafts. These 5 deceased recipients and the 22 who remain alive with functioning grafts had a mean antigen match of 2.27 with their donors. The other 23 patients whose grafts failed had a mean antigen match of 2.13 (P = 0.77). The 15 recipients who were transplanted prior to the cyclosporine era had lower 1- and 5-year allograft survival rates of 67% and 47%, respectively, as compared with their counterparts, who took cyclosporine-based immunosuppression (74% and 51%, P = 0.58 and 0.76, respectively). Likewise, the 32 recipients with delayed graft function had lower 1- and 5-year allograft survival rates of 66% and 47%, respectively, as compared with the group with immediate graft function (83% and 56%, P = 0.18 and 0.56, respectively). We conclude that acceptable long-term patient and graft survival may be achieved by transplanting these organs and that the degree of HLA matching does not affect their outcome significantly. Patients with immediate allograft function also tended to do better over the long term. Although cyclosporine-based immunosuppression was advantageous within 1 year of transplant, its beneficial effect was less marked 5 years out.

Adolescent↗