Stone-Forming Bacteria, Laser Lithotripsy, and Telesurgery Featured at World Congress

16th World Congress on Endourology & Shock Wave Lithotripsy

MEETING REVIEW Stone-Forming Bacteria, Laser Lithotripsy, and Telesurgery Featured at World Congress Highlights from 16th World Congress on Endourology & Shock Wave Lithotripsy (SWL) September 3-6, 1998, New York, NY [Rev Urol 1(2):76-81, 1999] Noninvasively clearing urinary calculi, treating ureteropelvic junction obstruction, excising intrarenal malignancies, and harvesting live donor kidneys are among the challenges urologists are striving to meet with endoscopic innovations. At the 16th World Congress on Endourology & Shock Wave Lithotripsy (SWL), several researchers offered new perspectives on the causes and noninvasive treatment of urinary stones; reaffirmed antegrade and explored retrograde techniques for clearing ureteropelvic junction; and evaluated percutaneous versus open surgical procedures to remove intrarenal malignancies. Nanobacteria Dr. N. Ciftcioglu’s group from the University of Kuopio, Finland, presented their work investigating small, purple, gram-negative organisms termed “nanobacteria” as a potential etiology for the production of kidney stones.1 These atypical bacteria are difficult to filter with standard techniques and have been detected in both animal and human blood. Using antinanobacteria monoclonal antibody, Ciftcioglu was able to detect encrusted nanobacteria within human kidney stones. It has been hypotheReviewed by Michael Grasso III, MD, New York University Medical Center, New York, NY. 76 REVIEWS IN UROLOGY SPRING 1999 Key words Calculus, renal • Lithotripsy • Laparoscopy • Nephrectomy • Ureteroscopy • Endoscopy Main Points √ The novel concept that tiny, atypical, gram-negative bacteria, called nanobacteria, might promote stone growth raises the possibility that a potential treatment for some patients who are recurrent stone-formers might be a tetracycline-based antibiotic. √ Holmium laser lithotripsy is the premier endoscopic lithotrite because of its ability to reduce stones down to very small particulate debris that can be irrigated or passed easily from the collecting system. √ Shock wave lithotripsy is not always effective in treating lower-pole intrarenal calculi because the stone fragments may not spontaneously clear. Small-diameter flexible endoscopic lithotripsy can offer the clinician an additional treatment option in treating lower-pole calculi. √ The small-diameter (8F at the tip and 3.6F working channel), actively deflectable, flexible ureteroscope can facilitate the most complex upper urinary tract endoscopy with minimal morbidity. √ For low-grade papillary upper tract transitional cell carcinoma, percutaneous nephroscopic tumor resection and ureteroscopic therapy seems to be as successful as standard open nephroureterectomy. For high-grade tumors, however, an open approach is preferred. √ The left kidney should be the organ of choice for laparoscopic donor nephrectomy, given the technical challenges posed by the right renal vein both in harvesting the kidney from the donor and subsequently in making the anastomosis in the recipient. sized that the production of carbonate apatite in the nanobacteria cell wall acts as a nidus for metabolic stone growth. Ciftcioglu’s group believes that the nanobacteria pass directly from blood into urine and that, once they are within urine, their calcified cell walls act as a promoter of stone growth. In addition, Dr. E.O. Kajander, also from the University of Kuopio, presented his work, which involved in- jecting radioactively labeled nanobacteria in the bloodstream of animals and monitoring the survival of these bacteria. The nanobacteria were found to accumulate in high levels in the kidneys of these animals.2 The same radioactively tagged, calciumwalled bacteria survived and multiplied in the urine. This concept is novel and quite new to the study of “metabolic” stone production. Infectious calculi sec- Stone-Forming Bacteria ondary to urea-splitting bacteria are associated with struvite production. Now there may be a mechanism for metabolic stone growth that is secondary to these newly defined, very small, and difficult-to-culture bacteria. A theorized potential treatment for this bacteremia would be using tetracycline-based antibiotics in patients who are recurrent stone-formers who may have high concentrations of nanobacteria within their stones.1 Holmium Laser Lithotripsy Dr. J. Denstedt and Dr. T.A. Wollin, representing the group from London, Ontario, Canada, and Dr. M. Grasso and Dr. Y. Chalik, representing the group from New York University, presented the results of extensive experiences with ureteroscopic laser treatment of ureteral and intrarenal calculi.3,4 The endoscopic lithotrite in all cases was the holmium laser. The enthusiasm for this technology has also spread to other, more specific, areas of stone management: Dr. M.T. Istarabadi from Albany, NY, reported on holmium laser lithotripsy in the treatment of caliceal diverticular stones, and Dr. G.J. Faerber from Ann Arbor, Mich, reported on its use to eliminate parenchymal stones trapped within papillary tips and medullary sponge kidneys.5,6 The techniques described were based on use of a combination of rigid and flexible endoscopes to access the stone burden. Various laser fibers were employed with the understanding that use of larger laser fibers led to more expeditious clearance of the stone burden, while use of smaller diameter fibers allowed for greater endoscope flexibility. Lasers were employed to (1) fragment and destabilize the stone, producing fine dust; (2) unroof hidden calculi; and (3) incise obstructed portions of the intrarenal collecting system, including caliceal diverticular necks and obstructed infundibulae.3-6 All groups concluded that, at this time, the holmium laser is the premier endoscopic lithotrite because of its ability to reduce stones down to very small particulate debris that can be irrigated or passed easily from the collecting system. A word of caution, however, was raised with regard to holmium laser lithotripsy for uric acid calculi. The group from San Antonio, Tex—specifically, Dr. J.M. Teichman—presented a retrospective analysis of patients with uric acid calculi treated with the holmium laser.7 Dr. Teichman has previously pub- delphia, and Oregon Health Sciences Center in Portland, Ore.8 These 3 sites began treating staghorn and large intrarenal calculi by using a retrograde endoscopic technique instead of the standard percutaneous techniques. The researchers found that a retrograde endoscopic technique was particularly useful in treating large metabolic stones in patients who have comorbid medical conditions that would complicate a percutaneous procedure. Specifically, the flexible ureteropyeloscope and holmium laser could be employed to debulk large stone An acute infundibular angle, in and of itself, did not preclude a successful retrograde endoscopic treatment of lower-pole calculi. lished his work on the production of cyanide as a by-product of holmium laser lithotripsy of uric acid calculi. In this retrospective study, Dr. Teichman could not define a group of patients with clinical sequelae from holmium laser lithotripsy of uric acid calculi. It was Dr. Teichman’s belief that there is still a theoretical risk of cyanide toxicity when treating this specific stone type with the holmium laser. However, the risk may be analogous to other clinical treatments, including the administration of nitrates in cardiac patients, among whom a small but not clinically significant level of cyanide has been noted in the serum during therapy.7 Endoscopic Management of Large Renal Calculi Endoscopic management of upper urinary tract intrarenal calculi has advanced based on improvements in endoscopes and with such developments as the aforementioned holmium laser. Dr. J. Gitlin presented a unique multicenter trial representing experiences at New York University, Thomas Jefferson University in Phila- burdens, and staged treatments could be performed to clear very large, complex, and branching calculi. The researchers were able to follow 27 patients for 6 months; they found that the new stone growth rate was 15%, which is similar to the experience reported with percutaneous nephrostolithotomies. The investigators concluded that retrograde endoscopic management is a viable treatment option for noninfectious, large intrarenal stone burdens. However, they also noted that these techniques are time-consuming and laborious for the operator; hence, these techniques should only be employed at this time in the select patient population that was studied.8 Managing Lower-Pole Intrarenal Calculi Lower-pole intrarenal calculi are frequently in a very dependent intrarenal location that impedes their spontaneous clearance even with proper fragmentation using SWL. That observation has led such groups as the Lower Pole Stone Study Group and James Lingeman, MD, from the SPRING 1999 REVIEWS IN UROLOGY 77 Stone-Forming Bacteria continued Methodist Hospital in Indiana, to suggest that calculi in excess of 1 cm in the lower pole may not respond well to SWL. Dr. Lingeman advises that, to treat lower-pole intrarenal calculi, making a primary percutaneous puncture into the lower pole to extract the stone is more effective than SWL, albeit much more invasive. Various investigators, including Demetrius Bagley, MD, in Philadelphia, and Ralph Clayman, MD, at Washington University in St. Louis, have studied the intrarenal angles created between the lower-pole infundibulum and renal pelvis. It is the considerations, we concluded that small-diameter flexible endoscopic lithotripsy should offer the clinician an additional treatment option in treating lower-pole calculi.9 Treating Ureteral Pelvic Junction Obstruction Dr. Arthur Smith and the group from Long Island Jewish Medical Center in New Hyde Park, NY, reaffirmed the usefulness of antegrade endopyelotomy in treating congenital ureteropelvic junction obstruction. This group also presented a series of patients who had complex upper uri- The group concluded that ureteropyeloscopy was the most definitive diagnostic means of localizing upper-tract lesions and defining transitional cell malignancy of the upper urinary tract. consensus that the more acute the angle between the lower-pole infundibulum and ureter, the more difficult the clearance of stone fragments produced by SWL. As an alternative treatment to percutaneous nephrostolithotomy, Dr. M. Ficazzola and I presented a series of patients with lower-pole calculi that were treated with retrograde endoscopic techniques.9 The combination of flexible endoscopes and the smallest holmium laser fibers were used in the study. Fragments that were created in the lower pole were moved with endoscopic graspers to other locations within the collecting system so that they would be more easily passed. We concluded that an acute infundibular angle, in and of itself, did not preclude a successful retrograde endoscopic treatment. Other variables—including the overall dilation of the collecting system and the length of the lower-pole infundibulum, as well as any component of infundibular stenosis—were also negative parameters but frequently could be overcome with contemporary endoscopic techniques. Given these 78 REVIEWS IN UROLOGY SPRING 1999 nary tract anatomy, including horseshoe kidneys and malrotated kidneys, and they concluded that endopyelotomy can be useful in these patients as well.10 Several presentations examined retrograde incisional techniques in treating ureteropelvic junction obstruction. Dr. F. Koleski presented the experiences of Dr. Alaba’s group from Chicago, and Dr. B. Willard described the experiences of Dr. C.C. Carson’s group from Chapel Hill, NC, in using the Acucise (Applied Medical Resources, Laguna Hills, Calif) cutting balloon catheter to incise and clear an obstructed ureteropelvic junction.11,12 Dr. Carson reported that complication rates were low but could be significant. Specifically, he noted that up to 15% of patients required a transfusion.12 To explain the occurrence of intraoperative and postoperative hemorrhage after endopyelotomy, Dr. F.X. Keeley and Dr. D.A. Tolley from Edinburgh, Scotland, as well as Dr. E. El-Gabry and Dr. D.H. Bagley from Philadelphia presented a model that associated crossing posterior lateral vessels with intraoperative hemorrhage.13,14 Both groups suggested that real-time intraoperative, intraluminal sonography is superior to other imaging modalities, such as spiral CT and magnetic resonance angiography, in defining blood vessels and subdividing patients with ureteropelvic junction obstruction into 2 groups: patients with annular strictures versus those whose strictures were caused by high insertion of the ureter into the renal pelvis, which requires more extensive incisions. Dr. El-Gabry hypothesized that a lateral-crossing vessel could significantly preclude a successful endoscopic incision even if intraoperative hemorrhage was not encountered. Both groups therefore strongly suggested imaging prior to endopyelotomy to identify those patients with crossing posterior lateral vessels.13,14 Managing Upper UT Urothelial Malignancies Endoscopically Endoscopic management of upper urinary tract urothelial malignancies has been based on either percutaneous endoscopic technique or retrograde ureteroscopic therapy. At the 16th World Congress on Endourology, Dr. B.R. Lee reported on a large database accumulated by Arthur Smith’s group at Long Island Jewish Medical Center and Thomas Jarrett’s group from Johns Hopkins in Baltimore.15 In the database were patients who were treated percutaneously with standard nephroscopic tumor debulking and intrarenal instillation of Bacille Calmette Guérin (BCG), as well as those treated with standard open nephroureterectomy. The researchers concluded that the success rate with percutaneous endoscopic treatment was equivalent to the success with open surgical outcomes for low-grade disease. However, with high-grade tumors, the risk of metastasis was significant with endoscopic therapy. The rate of local recurrence of urothelial malignancies is obviously a theoreti- Stone-Forming Bacteria cal concern with percutaneous manipulation, but these investigators did not find this to be a significant problem in their series.15 Dr. S. Nesa and Dr. P.J. Van Cangh from Brussels, Belgium, also presented their series of percutaneous endoscopic therapy of urothelial malignancies. This group was very much concerned about local recurrence and tract seeding with the percutaneous technique; in an attempt to prevent tract seeding, patients received 400 cGy to the area of potential tract placement prior to access. Even with this, however, the researchers had 1 case of local recurrence secondary to a high-grade tumor, but, as with the Johns Hopkins and Long Island Jewish Medical Center data, lowgrade disease was not associated with tract seeding.16 Two groups from New York reviewed ureteropyeloscopic treatment of upper urinary tract urothelial malignancies.17-20 Dr. R.E. Sosa reaffirmed the findings of others in regard to diagnostic ureteroscopy. In Dr. Sosa’s series, 59 patients who underwent diagnostic ureteroscopy at New York Hospital–Cornell Medical Center were reviewed. The group concluded that ureteropyeloscopy was the most definitive diagnostic means of localizing upper-tract lesions and defining transitional cell malignancy of the upper urinary tract.17 In selective cases, the group from Presbyterian Hospital also treated upper-tract tumors in patients who were not candidates for open surgery due to comorbid medical conditions and also had low-grade and lowstage lesions or a solitary kidney. Upper-tract malignancies were treated successfully in an analogous manner to treating similar bladder lesions. This enthusiasm for retrograde ureteroscopic management of uppertract tumors was echoed by our group from New York University Hospital. These researchers reported their experiences with an almost Endoscopic Telesurgery Urologists at the World Congress on Endourology in New York City successfully performed varicocelectomy via telesurgery on a patient nearly 200 miles away at the Johns Hopkins Bayview Medical Center in Baltimore, using AT&T’s Global ISDN (GISDN) network. The AT&T link enabled conference attendees to view the procedure, as physicians in New York maneuvered surgical instruments inside the patient hundreds of miles away. During surgery, doctors used the video and audio relayed over the GISDN network to directly control a robotic laparoscope, a miniature surgical device with a fiberoptic camera. The real-time internal images from the patient’s body allowed the doctors in New York to command the robot in Baltimore to assist in performing surgery based on real-time medical expertise provided as the surgery took place. “The technology used to enable telesurgery is defining modern health care as we know it. [With the technology] reducing both cost and risk, remotely located patients can have the benefit of working with a medical specialist miles away,” said Dr. Gopal Badlani, World Endourology Congress Chairman and Associate Chairman, Department of Urology, at Long Island Jewish Medical Center. Until recently, telesurgery had been limited to experiments in which a remote surgeon passively viewed laparoscopic images chosen by the local surgeon. With the clear images relayed by GISDN/PRI lines, the surgeons in New York were able to manipulate both the camera and surgical equipment as if they were in Baltimore. “Our connection was outstanding and the surgery was a success,” said Dr. Louis R. Kavoussi, a Johns Hopkins surgeon and pioneer in telesurgery who participated from New York. “The growing sophistication of telemedicine brings us very close to the day when the locations of patients and their doctors will be less of an issue.” Source: AT&T press release, September 4, 1998. identical group of patients who had complex comorbid medical conditions and were treated using a retrograde endoscopic approach.20 Contemporary techniques in treating urothelial lesions of the upper tract have employed semirigid and flexible ureteroscopes and various laser energies including holmium and neodymium:YAG (Nd:YAG). Typically, the holmium laser is used to resect lesions down to a smooth surface. The Nd:YAG laser has also been used to coagulate highly vascular tumors and, occasionally, to treat large bulky lesions in a staged fashion. For patients with upper-tract transitional cell carcinoma, serial endoscopic surveillance after each stage of tumor treatment is essential. As with bladder tumors, however, recurrence rates can be quite high.17-20 New Endoscopic Techniques and Instrumentation Small-diameter, actively deflectable, flexible ureteroscopes. The refinement of the small-diameter, actively deflectable, flexible ureteroscope is an area of research at New York University Hospital and at Thomas Jefferson University Medical Center.21 These 2 groups presented their extensive experiences performing more than 700 consecutive procedures using a variety of actively deflectable, flexible ureteropyeloscopes. All scopes were approximately 8F in diameter at the tip, with a standard 3.6F working channel. The specifications that were maintained during the series were 2-way active-tip deflection and secondary deflection to access the lower-pole calyx. The investigators found that these endoscopes were easier to place into the upper urinary tract and easier to direct onto the lesion to be treated. The most common indications for upper-tract endoscopy were endoscopic lithotripsy, followed by treatment of upper-tract urothelial malignancies. In addition, endoscopic management of strictures and retroSPRING 1999 REVIEWS IN UROLOGY 79 Stone-Forming Bacteria continued grade endopyelotomies were performed frequently at both centers. The researchers concluded that the small-diameter endoscopes are somewhat more fragile than their predecessors but allow much easier access to the upper tract. They are also easier to steer and direct through the collecting system; in fact, the entire collecting system was inspected in 94% of procedures performed. Access to the upper urinary tract with a flexible instrument frequently did not require active intramural ureteral dilation. The endoscopes were most commonly placed over a nickel titanium guide wire that was positioned into the upper tract with the aid of a 10F dual-lumen catheter. Larger graduated dilators or balloon dilating catheters were only required for endoscopic access in 12% of the procedures in this series. In summary, tigators evaluating the learning curve required to perform laparoscopic live collection of a kidney from a donor revealed that, in about 200 cases overall, the operative time, warm ischemia time, and length of hospital stay did not differ much from the first 100 patients. The operative time averaged 202 minutes and warm ischemic time averaged just less than 3 minutes. The length of hospital stay was somewhat less than 3 days (61 hours). The conversion to laparotomy was 2.5%.22 Both the group from Johns Hopkins University and that from the University of Maryland reported similarly high rates of graft survival and creatinine clearing in the recipient as well as similarly low rates of ureteral complication and graft rejection. In addition, no patients in the laparoscopy group at Johns Hopkins required conversion The left kidney should be the organ of choice for laparoscopic donor nephrectomy, given the technical challenges. this new class of small-diameter flexible ureteropyeloscopes can facilitate the most complex upper urinary tract procedures with minimal morbidity.21 Laparoscopic donor nephrectomy. The safety and efficacy of laparoscopic donor nephrectomy versus standard open surgical technique was evaluated by 3 university centers, and their data were presented at the 16th World Congress.22-24 The largest series of laparoscopic donor nephrectomies was from the University of Maryland and Dr. Stephen Jacobs’ group, reported by J.T. Bishoff, MD.22 A somewhat similar extensive experience was presented by Dr. J.J. Del Pizzo on behalf of Dr. Louis Kavoussi’s group from Johns Hopkins.23 Finally, a smaller but significant series of patients was presented by Dr. Raju Thomas, representing Tulane University in New Orleans.24 The University of Maryland inves80 REVIEWS IN UROLOGY SPRING 1999 to open nephrectomy.23 Another small but significant series of patients was also presented by the group from Tulane University. Dr. Raju Thomas echoed the enthusiasm of the other 2 groups.24 All 3 groups concluded that the left kidney should be the organ of choice for laparoscopic donor nephrectomy, given the technical challenges presented by harvest of the right renal vein and the difficulty in subsequent anastomosis.22-24 Radiowave and Holmium Laser Treatment for BPH Today there are a variety of minimally invasive surgical treatments for bladder outlet obstruction and benign prostatic hyperplasia. Two very interesting presentations were positively received at the 16th World Congress. First, Dr. Christopher Dixon described a series of patients who un- derwent transurethral radiowave treatment of the prostate.25 All patients had been scheduled for radical open surgical resection of the prostate for other reasons. Before the open resection, the patients agreed to radiowave treatment to help define the actual extent of prostate necrosis and ablation with this modality. Dr. Dixon’s technique involves passing an antenna that is basically an endoscopic needle through the working channel of the flexible cystoscope. The needle is then used to inject hypertonic saline into the prostate, which significantly expands the size of the antenna and creates more rapid ablation of prostatic tissue. Dr. Dixon discovered that this technique of transurethral endoscopic directedneedle ablation of the prostate creates rapid ablation of the prostatic tissue. Additional clinical studies were planned.25 Another area of interest has been the use of holmium laser energy to resect prostatic tissue. This technique was first described 3 years ago by Dr. Peter Gilling from New Zealand. At the 16th World Congress, Dr. Gilling, representing a multicenter trial, reported how this technique compared with standard transurethral resection of the prostate (TURP) with 1-year follow-up.26 The technique was based on using this laser energy to sculpt the prostatic lobes and basically free the lobes from the surrounding capsule. This is analogous to an open prostatectomy where the lobes are shelled out from surrounding tissue. The adenoma is then removed from the bladder using a morsalating device. In the 120 urodynamically obstructed patients studied in this series, the postoperative urodynamics were similar at 6 months, and the reoperation rates in both groups were identical and quite small. The major difference in the 2 groups was the shorter period of catheterization (20 hours vs 37.2 hours) and the shorter hospital Stone-Forming Bacteria stay (26.2 hours vs 47.5 hours). In addition, 6.8% of the patients in the TURP group required a blood transfusion, whereas none did in the holmium laser resection group. It was the researchers’ conclusion that the holmium laser resections of the prostate, while technically more challenging than a standard TURP, have similar end results with regard to uroflow and urodynamics, with the benefit of a shorter hospital stay and less morbidity than a standard TURP.26 8. 9. 10. 11. References 1. Ciftcioglu N, Bjorklund M, Willman K, et al: Nanobacteria: A main cause for kidney stones? 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract BS4-12. 2. Kajander EO, Vali H, Akerman K, et al: Nanobacteria, unique stone-makers from our blood, are targeted to kidneys. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract BS4-13. 3. Wollin TA, Rasvi HA, Nott L, et al: Treatment of upper ureteral and renal calculi with retrograde ureteroscopy and the holmium: YAG laser. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P20-21. 4. Grasso M, Chalik Y: Laser lithotripsy: Extended experience with the holmium laser lithotrite. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P16-14. 5. Istarabadi MT, Moran ME, Mehlhaff BA, et al: Holmium: YAG laser lithotripsy in the treatment of pyelocalyceal diverticular calculi. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P16-16. 6. Faerber GJ: Ureteroscopic holmium laser lithotripsy of embedded renal calculi in patients with medullary sponge kidney. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P16-17. 7. Teichman JM, Champion PC, Wollin TA, et al: Holmium: YAG lithotripsy of uric acid calculi: 12. 13. 14. 15. 16. 17. clinical experience. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F3-1. Grasso M, Gitlin J, Bagley D, et al: Retrograde treatment of large (>2 cm) upper urinary tract and partial staghorn calculi. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F3-8. Ficazzola M, Gitlin J, Grasso M: Ureteroscopic treatment of lower pole renal calculi. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F3-7. Jabbour ME, Goldfischer ER, Stravodimos KG, et al: Endopyelotomy in congenital renal anomalies. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P3-1. Koleski F, Jahoda A, Kim F, et al: Cutting balloon endopyelotomy: Experience in 107 procedures. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P3-5. Willard B, Williams C, Krishnan R, et al: Acucise endopyelotomy: review of the UNC experience. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P3-6. Keeley FX Jr, Moussa SA, Miller J, et al: A comparison of endoluminal ultrasound versus CT angiography for the evaluation of crossing vessels at the ureteropelvic junction. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P3-17. El-Gabry E, Liu J, Bagley DH: Crossings vessels at the obstructed ureteropelvic junction: Anatomic features on endoluminal ultrasound. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P3-18. Lee BR, Jabbour ME, Marshall FF, et al: 13-year survival comparison of percutaneous and open nephroureterectomy approaches for management of upper tract transitional cell carcinoma. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F4-9. Nesa S, Van Cangh PJ, Wese FX, et al: Percutaneous treatment of transitional cell carcinoma of the pelvis: a review of 18 cases. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P17-4. Guarnizo E, Sosa RE: Primary ureteropyeloscopic treatment for elected cases with transi- 18. 19. 20. 21. 22. 23. 24. 25. 26. tional cell carcinoma of upper tract. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P13-2. Pardalidis N, Kosmaoglou E, Alevrofas J: Ureteroscopic treatment of upper urinary tract TCC. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P13-3. Guarnizo E, Schulsinger DA, Sosa RE: The diagnosis of upper tract tumors by ureteropyeloscopy for various indications. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P13-4. Levine MA, Chan S, Grasso M: Minimally invasive treatment of upper urinary tract carcinoma. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P17-3. Grasso M, Ficazzola M: Small diameter, actively deflectable, flexible ureteropyeloscopy. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F3-5. Bishoff JT, Ratner LE, Montgomery RA, et al: Laparoscopic live donor nephrectomy: evaluation of the learning curve for a new operation. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F1-4. Del Pizzo JJ, Sklar GN, Cho E, et al: Laparoscopic donor nephrectomy: the first 200 cases. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P4-13. Thomas R, Slakey D, Ruiz-Deya: Laparoscopic donor nephrectomy: an optimal and safe technique. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract P4-14. Dixon C, Hoey M, Kaula N, et al: Thermal lesion characteristics in the human prostate using a new radiofrequency treatment (RFT™) device. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract BS6-2. Gilling PJ, Kennett KM, Mackey M, et al: Holmium laser resection of the prostate (HoLRP) versus transurethral resection of the prostate (TURP): analysis at 1 year. 16th World Congress on Endourology and SWL, 14th Basic Research Symposium, New York, N.Y. J Endourol 12(S1), 1998. Abstract F2-3. Editorial Offices: Reviews in Urology has changed its address! 330 Boston Post Road PO Box 4027 Darien, CT 06820-4027 203-662-6400 Fax: 203-662-6776 SPRING 1999 REVIEWS IN UROLOGY 81