Endoscopic Fulguration Research Articles

Arterial pseudoaneurysm complicating endoscopic fulguration of upper urinary tract urothelial carcinoma

We report a case of intrarenal arterial pseudoaneurysm after ureteroscopic fulguration of recurrent urothelial carcinoma. An asymptomatic 90-year-old woman underwent uneventful cauterization of two small papillary urothelial carcinomas. One month postoperatively, the patient presented with gross hematuria. Angiographic evaluation revealed a small pseudoaneurysm in the distal upper pole branch of the left renal artery, corresponding to the site of recent tumor fulguration. Angioembolization of this lesion was successfully performed. Acute or subacute gross hematuria after endoscopic tumor ablation may be due to an arterial pseudoaneurysm. Angiographic evaluation is critical for the successful diagnosis and treatment of this complication.

Gastroesophageal junction adenocarcinoma.

The incidence rate of adenocarcinoma of the esophagogastric junction (AEG) is increasing in association with the epidemiologic rise in distal esophageal adenocarcinoma and gastric cardial (AEG type III) tumors. The overall survival rate is poor in most patients with AEG because lymph node or visceral metastases are frequently present at the time patients become symptomatic. A few patients are identified early in the disease because of screening for gastroesophageal reflux and Barrett's esophagus. Early stage AEG (T1N0 or T2NO, carcinoma in situ, or severe dysplasia ) can in many instances be cured with surgery alone. Ablative treatments for early stage AEG, including endoscopic fulguration by cautery and laser or photodynamic therapy, are investigational at this time. Locoregionally advanced AEG (T3, T4, N1, or M1a ) without distant systemic metastases (M1b) has a poor overall survival rate with surgery alone or definitive chemotherapy and radiation therapy without surgery. Analysis of the use of multimodality treatment strategies for locoregionally advanced AEG types I and II have demonstrated improved survival rates in two small phase III trials with preoperative concurrent chemoradiotherapy followed by surgical resection. In contrast, three small phase III trials with preoperative concurrent or sequential chemoradiotherapy in patients with predominantly squamous cell carcinoma did not demonstrate any clear survival advantage. Additionally, a randomized phase III study evaluating preoperative chemotherapy without radiation therapy in esophageal cancer (predominantly adenocarcinoma) has demonstrated no survival benefit. In light of these results, additional large randomized phase III studies are needed to confirm the potential benefit of preoperative concurrent chemoradiotherapy. At the present time, preoperative chemoradiotherapy remains investigational. For locoregionally advanced gastric adenocarcinoma, including AEG type III, postoperative concurrent 5-fluorouracil (5-FU)-based chemoradiotherapy is associated with improved survival as demonstrated in a recently completed random assignment trial (INT 0116). As a result, surgery with postoperative chemoradiotherapy has recently become the standard of care for patients with AJCC stage II and III gastric adenocarcinoma (including patients with AEG type III). Metastatic AEG (M1b) should be treated with palliative chemotherapy (in good performance patients) or supportive care (poor performance) in asymptomatic patients. Radiation therapy and endoscopic stent placement (expandable wire mesh) can be used to palliate dysphagia in patients with M1b disease. The development of expandable stents and improved radiotherapy has obviated surgical bypass to palliate patients with symptomatic, metastatic AEG.

Hormonal therapy for bleeding gastrointestinal mucosal vascular abnormalities: a promising alternative

Recurrent bleeding from an obscure gastrointestinal source is a common but often frustrating clinical challenge. Frequently these bleeds can be attributed to vascular anomalies in the upper or lower gastrointestinal tract. Traditional management has included surgical resection and endoscopic fulguration. However, these methods are often ineffective when vascular lesions are diffuse, difficult to identify, or endoscopically inaccessible. Hormone therapy with a combination of oestrogen and progesterone represents a promising alternative. Since initial reports of success in patients with epistaxis from hereditary haemorrhagic telangiectasia, growing evidence supports its role in reducing bleeding from gastrointestinal vascular anomalies. Existing literature is critically reviewed and management strategies incorporating hormone therapy are suggested.

Urinary Bladder Injuries in Obstetric and Gynecologic Procedures

ABSTRACT Twenty urinary bladder injuries in 18 patients as a result of obstetric and gynecologic operations are presented. Recognition of all the injuries was delayed, and they occurred as vesicovaginal or vesicouterine fistulas. Eighteen (90%) of these injuries resulted in vesicovaginal fistulas, and 2 (10%) caused vesicouterine fistulas. The repair procedures included 4 Latzko partial colpocleises, 5 vaginal repairs, 2 vaginal flap techniques, 3 transperitoneal transvesical approaches, 1 indwelling Foley catheterization, 1 endoscopic fulguration for vesicovaginal fistula, and 2 transperitoneal extravesicle approaches for vesicouterine fistulas. All but 2 were successful (90%). The 2 exceptions required a vaginal repair with a Martius graft and a transvesical repair with omental interposition. This study reconfirmed that a good outcome can be achieved in most cases by a careful preoperative examination and prudent selection of fresh, well-vascularized tissue for interposition during the operation. (J GYN...

Urethroscopy in small neonates with posterior urethral valves and ureteroscopy in children with ureteral calculi

Objectives To describe our recent experience using a 6.9F cytoscope in the fulguration of posterior urethral valves (PUVs) in premature neonates and distal ureteroscopy with stone extraction in children. Methods Fulguration of PUVs was performed in S premature neonates born at 34 to 36 weeks' gestation with weights of 2480 to 2900 g. The PUVs were fulgurated during a single endoscopic procedure using a 6.9F cystoscope and a 3F bugbie electrode. In addition, 11 children (8 girls, 3 boys; mean age, 11.1 years; range 5 to 16) with symptomatic calculi underwent 15 distal ureteroscopic procedures using the 6.9F cystoscope. Results In the neonates with fulguration of PUVs, vesicostomy, the only reasonable alternative, was avoided, and each infant now voids with an excellent stream 3 to 16 months later, without evidence of stricture or residual valves. In the children with distal ureteroscopy, the ureteral calculi were retrieved using a 3F fourwire stone basket. With one exception, distal ureteroscopy was performed without dilation of the ureteral orifice. Extracorporeal shock-wave lithotripsy (ESWL) was not recommended because of stone position and difficult radiographic visualization. Nine children were rendered stone free with one procedure. Two procedures were required in 1 child and three in another. In both cases, ureteral edema was present, and the stone was embedded in the ureteral wall. One child underwent separate procedures for bilateral calculi. In all cases general anesthesia was used, with a mean duration of 63 minutes (range 28 to 96). Temporary ureteral stenting was performed in 10 (93%) patients, and 9 (81 %) were discharged home on the same day or the next morning. A mean follow-up period of 8.5 months (range, 0.5 to 22) has failed to show any problems related to ureteral stricture or injury. Conclusions Endoscopic fulguration of PUVs is now possible in small neonates and is minimally invasive compared with vesicostomy. Distal ureteroscopy with stone retrieval should be considered in children, especially those with calculi that are not suitable for ESWL.

Management of Carcinoid Tumors of the Stomach, Duodenum, and Pancreas

Carcinoids of the stomach, duodenum, and pancreas are represented by a variety of tumors with variable histologic and clinical features. Multicentric gastric carcinoids and concomitant nonantral argyrophilic hyperplasia are common in chronic atrophic gastritis, more rarely due to a multiple endocrine neoplasia (MEN)-related Zollinger-Ellison syndrome (ZES). These tumors are infrequently associated with metastases and may generally be dealt with by repeated endoscopic fulguration. Sporadic carcinoids tend to be larger, invasive, and more often metastatic, especially in the presence of atypical histology. Small tumors may be removed by endoscopy, but larger lesions need to be surgically excised. In association with metastases a histamine-related atypical carcinoid syndrome may evolve and require treatment with a somatostatin analog. Poorly differentiated neuroendocrine carcinomas of the stomach constitute markedly aggressive tumors that rarely are suitable for radical surgery. Gastrinomas are the most prevalent duodenal carcinoids and a common cause of ZES especially in MEN-I. Despite a marked tendency for regional lymph node dissemination, liver metastases occur late and duodenal gastrinomas are often excisable, thereby offering favorable odds for cure in ZES. Unusual somatostatin-rich carcinoids in the ampulla of Vater relate to von Recklinghausen's disease and may be the cause of obstructive jaundice; depending on their size, these tumors may be removed by local excision or pancreaticoduodenectomy. Gangliocytic paragangliomas are unusual, generally benign lesions of the duodenum. Rare pancreatic tumors with serotonin immunoreactivity may be classified as carcinoids and constitute an unusual cause of the carcinoid syndrome.

604 Surgical management of carcinoid tumors

Carcinoids are uncommon tumors which may have their origin in endocrine cells anywhere along the gastrointestinal tract. Appendiceal carcinoids are prevalent, but often insignificant clinically, since they rarely require no more than simple appendectomy. More unusual, generally benign multicentric gastric carcinoids in chronic atrophic gastritis may most often be safely dealt with by endoscopic fulguration. In contrast, midgut carcinoids, which have prevailed in many clinical series due to their common association with the carcinoid syndrome, often require more complicated management. The midgut tumors metastasize early to mesenteric lymph nodes, whereby tumor growth and concomitant fibrosis may entrap the intestine and cause obstruction or ischemia. In presence of liver metastases a carcinoid syndrome frequently develops with flush, diarrhea and ultimately disabling heart valve fibrosis. Medical therapy may alleviate these symptoms and surgery may counteract progression of the abdominal complications. Together, these treatment modalities seem to offer improved prospects of survival for the midgut carcinoid tumor patients.

Percutaneous fetal cystoscopy and endoscopic fulguration of posterior urethral valves

Percutaneous fetal cystoscopy was performed in a male fetus with ultrasonographic evidence of lower urinary tract obstruction at 19 weeks of gestation. The diagnosis of posterior urethral valves was confirmed. Percutaneous endoscopic fulguration of the valves was successfully performed at 22 weeks of gestation, and urethral patency was established. This case illustrates the feasibility of performing diagnostic and therapeutic endoscopic procedures within the human fetus for the management of a congenital anomaly. While we believe that fetal cystoscopy may improve our diagnostic, prognostic, and therapeutic capabilities in the management of fetuses with lower obstructive uropathy, studies are needed to establish the actual value, risks, and limitations of this new approach in fetal medicine.

The mild end of the clinical spectrum of posterior urethral valves

Posterior urethral valves have a broad clinical spectrum. In this series of 87 patients, 36 had mild valvular obstruction, the most common clinical variety. Boys with mild valves had a greater frequency of diurnal and nocturnal enuresis, superimposed infection, and a poor stream. The diagnosis was established by a very strict correlation of the radiological and endoscopic findings. Urodynamic studies, although performed in a limited number of patients, add validity to the diagnosis of mild valves. A classification based on the secondary anatomical changes and functional damage, which divides the valves in mild, moderate, and severe is recommended. Results of the endoscopic fulguration were excellent and without complications; 34 of 36 patients were improved or cured of their disturbing symptoms.

Angiodysplasia as a cause of iron deficiency anaemia

Angiodysplasia, a condition of unknown aetiology, is thought to represent the commonest cause of obscure gastrointestinal bleeding, particularly in the elderly population. The lesions of angiodysplasia, which are small (less than 5 mm) and usually multiple, consist of microvascular abnormalities in the mucosa and submucosa of the bowel wall. They are most commonly found in the caecum and right side of the colon, but have been observed in the stomach, ileum and elsewhere in the colon. The diagnosis is made by either selective visceral angiography and/or colonoscopy, but the lesions cannot be detected on barium studies or with the naked eye at laparotomy. Localisation of the abnormalities by the histopathologist is greatly facilitated by special injection techniques demonstrating the blood vessels of resected colonic specimens prior to fixation and section. Treatment may be conservative (iron replacement) if the anaemia is not severe, by endoscopic fulguration or by colonic resection. Other common causes of gastrointestinal blood loss should always be excluded before the final diagnosis of angiodysplasia is accepted. Although the condition is well recognised as a significant cause of gastrointestinal blood loss a number of questions remain to be answered. The true incidence of angiodysplasia in the population is not known, the aetiology of the condition remains a mystery, although many theories abound.

The anterior cricoid split procedure for the management of subglottic stenosis in infants and children

Severe acquired subglottic stenosis occurs most commonly in infants and children who require long-term ventilatory support with indwelling endotracheal tubes for underlying respiratory disease. A variety of operative and endoscopic procedures have been advocated for this problem including endoscopic fulguration, cryotherapy, direct incision or excision, and several types of extensive direct laryngotracheoplasties. The failure rate with these procedures is high. We have treated 22 patients including 12 neonates and 10 older children with acquired airway injury and obstruction with a simple cricoid split. In 15 patients the airway obstruction was completely relieved and these youngsters were extubated without difficulty. An additional 3 patients failed initial extubation which was subsequently successful, however, after repeat intubation for a short period of time. Endoscopic follow-up shows complete healing of the incised area. In 2 neonates the procedure was unsuccessful, and tracheotomy was needed. One of these had additional severe airway injury in the distal tracheobronchial tree secondary to selective bronchial intubation in the newborn period. Two older children also required tracheotomy because of severe airway scarring unrelieved by this procedure. The cricoid split is a simple and successful way of dealing with subglottic stenosis, especially in the newborn premature infant. A significant advantage is that it disturbs the anatomy very little, allowing for more extensive laryngotracheoplasty in the future should it fail.

Posterior Urethral Valves in the British Isles: a Multicenter B.A.P.S. Review

The management of 108 patients with posteriorurethral valves from 7 pediatric surgical centers has been reviewed. All the patients have been treated in the 10 year period since 1970. 53 were under 3 mo of age at presentation (Group I), 8 between 3 mo and 1 yr (Group II), 22 between 1 and 5 yr (Group III), and 25 over 5 yr of age (Group IV). Under 5 yr of age urinary infection (37) and renal failure (22) were the commonest methods of presentation. Over 5 yr of age diurnal and nocturnal enuresis were the commenest sysptoms. Endoscopic fulguration of the valves with or without preliminary catheter drainage has been the treatment of choice. Repeated fulguration of residual valve cusps was often required. The incidence of urethral stricture (2 patients) was highest after the use of the resectoscope. Refashioning and reimplantation of the ureters is associated with a high complication rate and is not recommended. Secondary operations on the bladder neck have been avoided in this series due to the risk of incontinence. 8 patients died (7.4%) and 7 of these deaths occurred in patients presenting under 3 mo of age. One patient died from renal failure 7 yr after the diagnosis of posterior urethral valves at 2 yr of age. It is suggested that the high mortality from renal failure in the group presenting early is related to renal dysplasia.

Vesicoureteric reflux with urethral valves.

A retrospective review was undertaken of 66 boys with posterior urethral valves with regard to incidence and prognostic significance of vesicoureteric reflux. The results indicate that: Regardless of the age of the patient, the existence of bilateral reflux at the time of presentation implies a worse prognosis than does unilateral or no reflux. Reflux which does not stop spontaneously after the valves have been destroyed is generally associated with a functionless and often dysplastic kidney; surgical cure of such reflux is therefore pointless. Reflux stops spontaneously after valve ablation when the involved kidney possesses useful function; surgical cure of reflux is therefore unnecessary. In some cases, however, it remains possible that reflux may continue to damage the kidney during the interval between relief of the urethral obstruction and spontaneous cure of the reflux. Nevertheless, the grossly dilated refluxing ureter is poor surgical material and it is concluded that the best chance of preserving renal function in the majority of boys with urethral valves and reflux lies in endoscopic fulguration of the valves, controlling infection and awaiting spontaneous reflux cure.

Anterior urethral valves.

Abstract Anterior urethral valves were found in 4 young male patients in less than one year. The patients complained of enuresis, blood from the penis, or urine leakage. Evaluation consisted of voiding and retrograde urethrograms and endoscopy to include the urethra distal to the veru. Successful management included valve fracture with instrumentation or endoscopic fulguration. Open surgical correction was not employed. We believe that anterior urethral valves may occur more frequently than previously thought.

Massive Secondary Post-Prostatectomy Hemorrhage, Controlled by Endoscopic Fulguration

No AccessJournal of Urology1 Sep 1932Massive Secondary Post-Prostatectomy Hemorrhage, Controlled by Endoscopic FulgurationReport of Five Cases Edwin Davis Edwin DavisEdwin Davis More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(17)72669-9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail © 1932 by The American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsCited byDavis E and Lee L (2018) Progress in Perineal Prostatectomy: Results in 2050 Consecutive PatientsJournal of Urology, VOL. 73, NO. 1, (142-154), Online publication date: 1-Jan-1955. Volume 28Issue 3September 1932Page: 365-370 Advertisement Copyright & Permissions© 1932 by The American Urological Association Education and Research, Inc.MetricsAuthor Information Edwin Davis More articles by this author Expand All Advertisement PDF downloadLoading ...