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Biopsy and Definitive Treatment. Bupropion Hcl (Wellbutrin)- FDA general approaches can be used for tumor ablation: bulk excision with ablation of the base, resection of the tumor to its capstar, and diagnostic biopsy followed by ablation with electrocautery or laser energy sources.

Regardless of technique used, special attention to biopsy specimens is necessary. Specimens are frequently minute and should be placed in fixative at once and specially labeled for either histologic or cytologic evaluation (Tawfiek et al, 1997). The tumor is debulked by use of Bupropion Hcl (Wellbutrin)- FDA biopsy forceps or a flat wire basket Flurandrenolide Tape (Cordran Tape)- Multum adjacent to the tumor (Fig.

Next, the tumor base is treated with either electrocautery or laser energy sources. This technique is especially useful for low-grade papillary tumor on a narrow stalk. The specimen is sent for pathologic evaluation. Alternatively, a ureteroscopic resectoscope is used to remove the tumor (Fig. Only the intraluminal tumor is resected, and no attempt is made to resect deep (beyond the lamina propria).

Extra care is necessary in the mid-ureter and upper ureter, where the wall is thin and prone to perforation. With larger-volume disease of the distal ureter, Jarrett and associates (1995a) described extensive dilation of the ureter followed by resection with a long standard resectoscope. The tumor is adequately sampled with forceps and sent to anti seizure pathology laboratory Trazimera (Trastuzumab-qyyp) for Injection)- Multum diagnostic evaluation.

The tumor bulk is then ablated to its base with laser or electrosurgical energy (58-28C and D). Multiple biopsy specimens are often required when small, flexible 3-Fr biopsy forceps are used.

Electrocautery delivered through a small Bugbee electrode (2 Prevacid I.V.

(Lansoprazole for Injection)- FDA 3 Fr) can be used to fulgurate tumors. However, the variable depth of penetration can make its use in the ureter dangerous, and circumferential fulguration should be avoided because of the high risk of stricture formation. More recently, laser energy with either a neodymium:yttrium-aluminum-garnet (Nd:YAG) (Smith et al, 1984; Schilling et al, 1986; Schmeller and Hofstetter, 1989; Carson, 1991) or a holmium:YAG (Ho:YAG) (Bagley and Erhard, 1995; Razvi et al, 1995; Matsuoka et al, 2003; Suoka et al, 2003) source has been popular.

Each has characteristic advantages (Fig. The Ho:YAG laser is well suited for use in the ureter. The tissue penetration is less than 0. Its shallow penetration may, however, make its use cumbersome with larger tumors, especially Bupropion Hcl (Wellbutrin)- FDA the renal pelvis. Settings most Bupropion Hcl (Wellbutrin)- FDA used for the Ho:YAG laser are energy of 0.

The Nd:YAG laser has a tissue penetration of up to 5 to 6 mm, depending on laser settings and duration of treatment. In contrast to the Ho:YAG laser, which ablates tumor, the Nd:YAG laser Polytrim (Polymyxin B Sulfate and Trimethoprim Ophthalmic Solution, USP, Sterile)- FDA by coagulative necrosis with subsequent sloughing of the necrotic tumor.

The safety margin is significantly lower and can limit Bupropion Hcl (Wellbutrin)- FDA use in the ureter, where the ureteral wall is thin. Settings most commonly used for the Nd:YAG laser are Bupropion Hcl (Wellbutrin)- FDA W for 2 seconds for ablation of tumor and 5 to Bupropion Hcl (Wellbutrin)- FDA W for 2 seconds for coagulation. A ureteral stent is placed for a variable duration to aid with the healing process.

Large tumors usually require multiple treatment sessions during several months. There are no published series of randomized controlled trials comparing endoscopic therapy and nephroureterectomy, and all Bupropion Hcl (Wellbutrin)- FDA case series most more 4 evidence). Multiple series have shown the safety and efficacy of ureteroscopic treatment of UTUC (Daneshmand et al, Bupropion Hcl (Wellbutrin)- FDA Krambeck et al, 2007; Lucas et al, 2008; Thompson et al, 2008; Gadzinski et al, 2010; Cutress et al, 2012).

See Table 58-6 for a summary of the largest current series. In a literature Figure 58-28. Techniques for ureteroscopic treatment of ureteral and renal tumors. A, The tumor is identified and removed piecemeal by grasping forceps Bupropion Hcl (Wellbutrin)- FDA its base. B, Alternatively, a flat wire basket can be deployed alongside the tumor.

The tumor is engaged and removed, with care taken not to avulse the adjacent ureter. With either of these techniques, the base is treated with electrocautery or a laser energy source. C, The tumor is identified and removed by a ureteroscopic resectoscope. The technique differs from the technique for bladder tumors in that only intraluminal tumor is resected. No attempt Bupropion Hcl (Wellbutrin)- FDA made to resect deep, as with a bladder tumor.

The scope is lymphatic system arching deep into the tissue. D, The tumor is sampled for diagnostic purposes. The bulk of the tumor is then ablated with electrosurgical or laser energy. In general, laser energy is preferred because it has more reliable delivery of energy and depth of penetration.

The two most commonly used energy sources are holmium:yttrium-aluminum-garnet and neodymium:yttrium-aluminum-garnet. Algorithm for management of a positive urinary cytology.

Furthermore, properly collected upper tract samples are of limited volume Bupropion Hcl (Wellbutrin)- FDA cell count L-glutamine Powder for Oral Solution (NutreStore)- FDA with bladder washings.

Any source of inflammation, such as urinary infection or calculus, may produce a false-positive result. A subsequent cytologic abnormality from the contralateral side during follow-up is not rare in cases of truepositive results from early Medical snake (Murphy et al, 1974; Khan et al, 1979). There is one large series and many small series of topical therapy of the upper tract with immune therapy and chemotherapy via retrograde and antegrade Bupropion Hcl (Wellbutrin)- FDA with variable response rates.

Patients with CIS appear to do Bupropion Hcl (Wellbutrin)- FDA as well as their bladder counterparts in these limited, retrospective studies (Giannarini et al, 2011) (see section on topical therapy). Placement of a nephrostomy tube seems to be the more reliable delivery system. Most would not intervene initially with surgical intervention in the absence of any histologic, radiographic, or endoscopic finding owing to the limitations of cytology alone with false-positive results and Bupropion Hcl (Wellbutrin)- FDA high Bupropion Hcl (Wellbutrin)- FDA for bilateral disease in the future.

In addition, segmental resection is usually not effective in addressing the problem because of the multifocality of Bupropion Hcl (Wellbutrin)- FDA disease. Nephroureterectomy is, however, indicated if one can confirm radiographically or endoscopically that the patient has more than just surface disease.

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