Prog Urol. 2011 Feb;21(2):109-13. Epub 2010 Dec 22.

Horseshoe kidney stones: benefit of flexible ureterorenoscopy with holmium laser

Chouaib A, Al-Qahtani S, Thoma A, Cordier G, Merlet B, Gil-Diez S, Traxer O.

Département d’Urologie, Hôpital Universitaire Tenon, Université Pierre-et-Marie-Curie, 4, rue de la Chine, 75010 Paris, France.

Abstract

[Article in French]

OBJECTIVES:
We aim to assess the outcome of the flexible ureterorenoscopy (F-URS) with holmium laser in treating horseshoe kidney (HSK) stones.

PATIENTS AND METHODS:
We reviewed retrospectively the records of 18 patients with HSK stone (18 renal units) who underwent F-URS using holmium laser from December 2004 to October 2009. The mean age was 37.7±6.9 years. The F-URS used after the extracorporeal shock wave lithotripsy (ESWL) failure in eight patients (44.4%) and four patients (22.2%) had PCNL failure. The follow up visit range were between 4 and 6 weeks with plain radiograph (KUB) and renal ultrasound or non contrast computed tomography scan (NCCT). Success rate was defined as stone free or residual fragment less than 3 mm. Use of auxiliary procedures like ESWL were considered as treatment failure.

RESULTS:
Eighteen patients, three females and 15 males with mean age was 37.7±6.9 years with HSK calculi underwent ureteroscopic management. The presenting symptoms were renal colic, urinary tract infection or hematuria. We found different HSK stone location (11 mixed calyceal, three mixed pelvic and calyceal and four pelvic). The average stone burden was 15.5±7.3 mm and the mean operative time was 112±9.4 minutes. All over procedures were 27, with mean average of 1.5 procedures per patient. The success rate was 89%.

CONCLUSION:
The F-URS with holmium laser is an efficient minimal invasive procedure in treating HSK stones.

Copyright © 2010. Published by Elsevier Masson SAS.


Urology. 2010 Dec;76(6):1288-92.

Ambulatory percutaneous nephrolithotomy: initial series

Shahrour W, Andonian S.

Division of Urology, Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada.

Abstract

OBJECTIVES:
To assess the safety and feasibility of ambulatory percutaneous nephrolithotomy (PCNL). PCNL is the gold standard for the management of large renal stones. Although tubeless PCNL has been previously described, no case series have been published of ambulatory PCNL.

METHODS:
The criteria for ambulatory PCNL were: single tract, stone-free status documented by flexible nephroscopy, adequate pain control, and satisfactory postoperative hematocrit level and chest radiographic findings. Patient information, including operating room and fluoroscopy times, stone size and Hounsfield units, and number of needle punctures, were collected prospectively. The time spent in the recovery room, in addition to the amount of narcotics used in the recovery room and at home, was documented.

RESULTS:
Of 10 patients, 8 had nephrostomy tracts established intraoperatively by the urologist and 2 had preoperative nephrostomy tubes placed. The median operating and fluoroscopy time was 83.5 and 4.45 minutes, respectively. The median stone diameter was 20 mm (800 Hounsfield units) in addition to a patient with a staghorn calculus. The patients spent a median of 240 minutes in the recovery room and had received a median of 19.25 mg of morphine equivalents. Only 3 patients (30%) used narcotics at home. No intraoperative complications occurred, and none of the patients required transfusions. Two postoperative complications developed: a deep vein thrombosis requiring outpatient anticoagulation and multiresistant Escherichia coli infection requiring intravenous antibiotics.

CONCLUSIONS:
In highly selected patients, ambulatory PCNL is safe and feasible. More patients are needed to verify the criteria for patients undergoing the ambulatory approach.


Urology. 2011 Feb 16

Time to Stone Clearance for Ureteral Stones Treated with Extracorporeal Shock Wave Lithotripsy.

Resit-Goren M, Dirim A, Ilteris-Tekin M, Ozkardes H.

Department of Urology, Baskent University Adana Medical and Research Center, Adana.

Abstract

OBJECTIVE:
To evaluate the time to stone-free status after shock wave lithotripsy (SWL) for ureteral stones.

METHODS:
Medical records of 387 patients with ureteral stones who have been treated were retrospectively reviewed. Exclusion criteria for this analysis included nonopaque stones, prior ureteric surgery, multiple ureteral stones, anomalous kidneys or ureters, hydroureteronephrosis, infravesical obstruction, nonfunctioning kidney, inadequate follow-up, and treatment with calcium-channel blockers and alpha blockers. Ninety or 120 shocks per minute at suggested maximum energy for safety were applied. Patients were revisited periodically and stone-free status was accepted as success. The data were analyzed according to stone localizations; size (5-10 mm [group 1], 11-15 mm [group 2], and ≥16 mm [group 3]); and number of SWL sessions.

RESULTS:
The initial stone locations were: upper ureter in 23%, middle ureter in 17.9%, and distal ureter in 59% of the patients. The average stone diameter was 10.1 mm (range, 5-23). The SWL sessions varied between 1 and 4 (mean, 1.3). Of the 117 patients 109 (93.1%) were stone free 20 days after the first session of SWL. The mean time to achieve stone-free status was 4.6 days. Group 1 had the quickest stone clearance time as expected (mean, 2.2 days [range, 1-3]). Groups 2 and 3 had longer times at 7.7 days (range, 3-18) and 12.2 days (range, 11-37), respectively.

CONCLUSIONS:
SWL appears as a quick and effective treatment modality for ureteral stones. However, high-burden ureteral stones (>16 mm) have considerably long periods of clearance and therefore appear to be unsuitable for SWL treatment.

Copyright © 2011 Elsevier Inc. All rights reserved.


Ann R Coll Surg Engl. 2011 Jan;93(1):27-30. Epub 2010 Oct 25.

‘An interventional urology list’ – a novel concept for UK urological services.

Masood J, Ismail M, El-Husseiny T, Moraitis K, Albanis S, Papatsoris A, Buchholz N.

Endourology and Stone Services, Bart’s and the London NHS Trust, UK. junaid.masood@bartsandthelondon.nhs.uk

Abstract

INTRODUCTION:
Almost all patients in the UK with obstructed and/or infected kidneys are referred to interventional radiology for percutaneous nephrostomy and/or placement of an anterograde JJ stent. Although this ‘tradition’ is going strong in the UK, urologists throughout the world have evolved their practice to encompass such interventional procedures in their remit. We have set up a local anaesthetic list ‘interventional urology list’ in our ESWL suite. We present our 4-year experience and discuss the benefits that this interventional list brings to our patients, our trainees, our interventional radiology colleagues and to the hospital trust.

PATIENTS AND METHODS:
From May 2005 to May 2009, we have been running this list, twice-weekly, performing procedures such as nephrostomies, anterograde stents, nephrostograms and stent exchanges all under local anaesthetic.

RESULTS:
A total of 580 procedures have been carried out on this list over this period. Our success rate for nephrostomy insertion is 96% with three failures, as a result of patient discomfort. No major complications and three minor complications were reported. We had four failed anterograde stenting procedures (out of 80). All other procedures including nephrostograms, stent exchanges/removals/insertions, as well as renal cyst aspiration and sclerotisation were successfully carried out.

CONCLUSIONS:
Our results of percutaneous nephrostomy and antegrade stenting are favourable when compared with published data on nephrostomies. This novel set up has resulted in several improvements to the service we offer patients and also provided significant improvement in training for our residents. We encourage other departments to try and develop this type of ‘interventional urology list’.


Prog Urol. 2011 Jan;21(1):40-7. Epub 2010 Jul 6.

In vitro study of the litholytic effects of herbal extracts on cystine urinary calculi

Meiouet F, El Kabbaj S, Daudon M.

Laboratoire de recherche et d’analyses médicales de la gendarmerie royale, Rabat, Maroc.

Abstract

[Article in French]

INTRODUCTION:
cystine stones represent 1% of urinary calculi in adults and 10% in children and are especially recurrent and resistant to ESWL. Medical therapy is often efficient but often poorly tolerated. In Morocco, various plants, Herniaria hirsuta, Opuntia ficus-indica, Zea mays and Ammi visnaga are proposed against nephrolithiasis. We assessed the effect of plant extracts on the disolution of cystine stones in vitro.

MATERIAL AND METHODS:
an extract of each plant was prepared by infusion of two grams of powdered plants during 30 minutes in 100ml of a boiled NaCl 9 g/L aqueous solution. Each extract was then filtered and thereafter set in a flask containing a cystine stone. The medium was maintained under stirring during 8 weeks. NaCl 9 g/L solution and sodium citrate 3 mmol/L solution were used as controls. At the end of each two weeks period, the stone was removed from the experimental medium and weighted after a 16h drying period at 40°C.

RESULTS:
after 8 weeks of experiment, stone dissolution was complete for all herbal extracts, and was earlier in the presence of Zea mays (4 weeks) or of Ammi visnaga (6 weeks) by comparison to only 18 ± 8 and 20 ± 1.5 % for citrate and NaCl solutions, respectively.

CONCLUSION:
the studied herbal extracts were efficient for dissolving cystine stones, probably resulting from the formation of complexes between cystine and polyhydroxylated molecules present in the extracts. These results, to be confirmed in vivo, underline the potential interest of the plant extracts to treat cystine stones.


Eur Urol. 2011 Apr;59(4):637-44. Epub 2011 Jan 25.

A prospective randomised trial comparing the modified HM3 with the MODULITH® SLX-F2 lithotripter

Zehnder P, Roth B, Birkhäuser F, Schneider S, Schmutz R, Thalmann GN, Studer UE.

Department of Urology, University of Bern, Bern, Switzerland.

Abstract

BACKGROUND:
The relative efficacy of first- versus last-generation lithotripters is unknown.

OBJECTIVES:
To compare the clinical effectiveness and complications of the modified Dornier HM3 lithotripter (Dornier MedTech, Wessling, Germany) to the MODULITH(®) SLX-F2 lithotripter (Storz Medical AG, Tägerwilen, Switzerland) for extracorporeal shock wave lithotripsy (ESWL).

DESIGN, SETTING AND PARTICIPANTS:
We conducted a prospective, randomised, single-institution trial that included elective and emergency patients.

INTERVENTIONS:
Shock wave treatments were performed under anaesthesia.

MEASUREMENTS:
Stone disintegration, residual fragments, collecting system dilatation, colic pain, and possible kidney haematoma were evaluated 1 d and 3 mo after ESWL. Complications, ESWL retreatments, and adjuvant procedures were documented.

RESULTS AND LIMITATIONS:
Patients treated with the HM3 lithotripter (n=405) required fewer shock waves and shorter fluoroscopy times than patients treated with the MODULITH(®) SLX-F2 lithotripter (n=415). For solitary kidney stones, the HM3 lithotripter produced a slightly higher stone-free rate (p=0.06) on day 1; stone-free rates were not significantly different at 3 mo (HM3: 74% vs MODULITH(®) SLX-F2: 67%; p=0.36). For solitary ureteral stones, the stone-free rate was higher at 3 mo with the HM3 lithotripter (HM3: 90% vs MODULITH(®) SLX-F2: 81%; p=0.05). For solitary lower calyx stones, stone-free rates were equal at 3 mo (63%). In patients with multiple stones, the HM3 lithotripter’s stone-free rate was higher at 3 mo (HM3: 64% vs MODULITH(®) SLX-F2: 44%; p=0.003). Overall, HM3 lithotripter led to fewer secondary treatments (HM3: 11% vs MODULITH(®) SLX-F2: 19%; p=0.001) and fewer kidney haematomas (HM3: 1% vs. MODULITH(®) SLX-F2: 3%; p=0.02).

CONCLUSIONS:
The modified HM3 lithotripter required fewer shock waves and shorter fluoroscopy times, showed higher stone-free rates for solitary ureteral stones and multiple stones, and led to fewer kidney haematomas and fewer secondary treatments than the MODULITH(®) SLX-F2 lithotripter. In patients with a solitary kidney and solitary lower calyx stones, results were comparable for both lithotripters.


Urol Res. 2011 Feb;39(1):69-72. Epub 2010 Jan 28.

Antibiotics therapy was effective in preventing bilateral staghorn renal matrix stones

Miwa S, Yamamoto H, Sugata T.

Department of Urology, Kanazawa University Hospital, 13-1 Takara-machi, Kanazawa, Ishikawa, 920-8641, Japan. sotaro@oregano.ocn.ne.jp

Abstract

Herein we report a case for which antibiotic therapy was effective in preventing bilateral staghorn renal matrix stones. A 34-year-old man was referred to our hospital for right lower abdominal pain and fever. Blood data and urinary analysis indicated a urinary tract infection and renal failure. The diagnosis was bilateral pyelonephritis for staghorn renal matrix stones. He had undergone percutaneous neprolithotripsy (PNL) for bilateral staghorn renal matrix stones. Almost all fragments were removed by the grasper. However, 3 months after the operation, bilateral staghorn renal matrix stones rapidly developed, so he underwent PNL again. After the operation, low-dose antibiotic therapy was continued to prevent pyelonephritis. As a result renal matrix stones did not reoccur. Until now, 1 year after the start of antibiotic therapy, no further sign of relapse has been noted.


J Clin Pharmacol. 2011 Jan 5.

Clinical Pharmacology Profile of Raltegravir, an HIV-1 Integrase Strand Transfer Inhibitor

Brainard DM, Wenning LA, Stone JA, Wagner JA, Iwamoto M.

Merck Sharp & Dohme Corp.

Abstract

Raltegravir is an HIV-1 integrase inhibitor approved to treat HIV infection in adults in combination with other antiretrovirals. Data from healthy volunteers demonstrate that raltegravir is rapidly absorbed with a mean half-life of approximately 7 to 12 hours, with steady state achieved in approximately 2 days. Raltegravir is characterized by both high intra- and interindividual variabilities, although neither gender, race, age, body mass index, food intake, nor renal or hepatic insufficiency has a clinically meaningful effect on raltegravir pharmacokinetics. Raltegravir lacks activity as a perpetrator of drug-drug interactions and demonstrates a low propensity to be subject to drug-drug interactions. Raltegravir is metabolized primarily by UGT1A1 and is not affected by P450 inhibitors or inducers. Inhibitors of UGT1A1 (eg, atazanavir) can increase plasma concentrations of raltegravir, although this increase has not been found to be clinically meaningful. Likewise, inducers of UGT1A1 (eg, rifampin) can reduce plasma concentrations of raltegravir, and the clinical significance of this reduction is being investigated in ongoing clinical studies. Raltegravir demonstrates favorable clinical pharmacology and a drug interaction profile that permits administration to a wide, demographically diverse patient population and coadministration with many other therapeutic agents, including antiretroviral agents and supportive medications, without restrictions or dose adjustment.


J Endourol. 2011 Mar;25(3):431-5.

Effectiveness of single flexible ureteroscopy for multiple renal calculi

Herrera-Gonzalez G, Netsch C, Oberhagemann K, Bach T, Gross AJ.

Department of Urology, Asklepios Hospital Barmbek, Hamburg, Germany. gehego@hotmail.com

Abstract

PURPOSE:
To assess effectiveness of flexible ureteroscopy (fURS) in patients not with simple but with multiple unilateral renal stones.

PATIENTS AND METHODS:
A database analysis was performed to identify patients with multiple unilateral intrarenal stones. Patients were treated using an 8.8F flexible ureteroscope. Patients were considered stone free if no residual stones were seen
endoscopically and radiographically after the procedure. The efficiency and the safety of the procedures were analyzed.

RESULTS:
Between 2006 and 2008, 1054 ureteroscopic procedures were performed in our department; 125 patients met the inclusion criteria. Holmium:yttrium-aluminum-garnet laser lithotripsy was necessary in 41 (32.8%) patients. The mean stone size was 11.93 ± 8.2 mm, with a mean stone burden of 83.7 ± 67.66 mm(2). The mean number of stones was 3.59 ± 3.57. Twenty-six (20.8%) patients had a stone burden ≥ 100 mm(2), and 99 (79.2%) a stone burden <100 mm(2). The overall stone-free rate after a single procedure of fURS was 74.4%. In the remaining 32 patients with residual stones, the mean stone burden dropped from 123.24 ± 84.36 mm(2) to 56.28 ± 52.53 mm(2). The stone-free rate in patients with a stone burden ≥ 100 mm(2) was 65.4% and 79.5% in patients with a stone burden < 100 mm(2), respectively. Complications have been recorded in seven (5.6%) patients, including urinary tract infection in four, ureteral perforation in one, and hematuria in two patients. No major complications occurred. All patients were treated conservatively.

CONCLUSIONS:
fURS is an effective treatment option in patients with multiple unilateral renal stones. Single procedure stone-free rates are high with a low rate of only minor complications.
PMID: 21401396 [PubMed - in process]


Spinal Cord. 2011 May 31.

Evidence-based management of upper tract urolithiasis in the spinal cord-injured patient

Ramsey S, McIlhenny C.

Department of Urology, Stirling Royal Infirmary, Stirling, UK.

Abstract

OBJECTIVE:
The objective is to review the published literature on the aetiology and evidence-based management of stone disease in the spinal cord-injured patient.

METHODS:
A PubMed and Medline search was performed using the terms ‘spinal cord injury’, ‘paraplegia’, ‘stone’, ‘nephrolithiasis’, ‘urolithiasis’, ‘calculus’, ‘spinal cord injury’ or ‘paraplegia’ with ‘SWL’, ‘ureteroscopy’, ‘chemolysis’ and ‘PCNL.’ The Cochrane database, the National Institute for Clinical Excellence guidelines and the Scottish Intercollegiate guidelines were searched using the terms ‘spinal cord injury’ and ‘urolithiasis’ and ‘nephrolithiasis’.

RESULTS:
A total of 32 papers were identified, mainly case series or case-cohort studies with few contemporary papers. The risk of developing a renal stone after spinal cord injury (SCI) is between 7 and 20% over a period of 8-10 years. Stone formation may be related to early demineralisation of bone or chronic infection. Biochemical abnormalities are not significantly different between stone-forming and non-stone forming patients, though these patients differ from healthy controls. Presentation may be atypical, but is most commonly recurrent urinary tract infection. Treatment may be complicated by lower limb contractures limiting retrograde access. Several case series report success with shock wave lithotripsy varying from 50 to 70%, though comparisons are limited by heterogeneous indications and reporting. Percutaneous nephrolithotomy remains the gold standard for stones measuring 2 cm and above. Stone-free rates of 90% have been reported, though surgery was often complex with higher complication rates.

CONCLUSION:
Management of upper urinary tract stones in patients with SCI is complex regarding surgical technique, post-operative care and recurrence rates. Further contemporary case series must use standardised reporting tools to allow valid comparisons.

Spinal Cord advance online publication, 31 May 2011; doi:10.1038/sc.2011.50.


Kidney Blood Press Res. 2011 May 26;34(5):328-333.

Fetuin-A Pretransplant Serum Levels, Kidney Allograft Function and Rejection Episodes: A 3-Year Posttransplantation Follow-Up

Roos M, Heinemann FM, Lindemann M, Horn PA, Lutz J, Stock K, Thürmel K, Baumann M, Witzke O, Heemann U.

Department of Nephrology, Technische Universität München, Munich, Germany.

Abstract

BACKGROUND:
Fetuin-A is a negative acute-phase protein, which acts as a potent calcification inhibitor and an antagonist of transforming growth factor-β. Thus, fetuin-A levels are influenced by chronic inflammation and actively affect fibrosis and calcification processes, respectively. Graft rejection, interstitial fibrosis and tubular atrophy, chronic inflammation and calcification are common causes for kidney allograft loss. This study evaluated whether pretransplant fetuin-A levels predict long-term graft survival and rejection episodes in patients after kidney transplantation.

METHODS:
In 206 renal transplant recipients pretransplant fetuin-A levels were measured in serum by ELISA. During the 36 months’ active follow-up (median 1,249 days) 13 patients died (94% patient survival) and renal allograft failure was reported in 18 patients (91% graft survival).

RESULTS:
Pretransplant fetuin-A levels did not differ among patients with incident graft failures as compared to patients with functional graft after long-term follow-up or rejection episodes (fetuin-A: 393.6 ± 46 vs. 384.4 ± 69 vs. 405 ± 27.4 μg/ml). In logistic regression analysis, pretransplant fetuin-A levels did not correlate with graft failure after 3 years’ follow-up (p = 0.895). In COX regression analysis, fetuin-A levels were not associated with the time to graft loss. Moreover, fetuin-A levels correlated neither with renal and metabolic parameters nor with cellular or humoral rejection episodes.

CONCLUSION:
Pretransplant levels of fetuin-A are not a predictor for renal allograft loss or rejection episodes after 36 months’ follow-up in transplant recipients.

Copyright © 2011 S. Karger AG, Basel.


IEEE Trans Ultrason Ferroelectr Freq Control. 2011 May;58(5):971-80.

In vitro comminution of model renal calculi using histotripsy

Duryea A, Maxwell A, Roberts W, Xu Z, Hall T, Cain C.

Abstract

Shock wave lithotripsy (SWL) suffers from the fact that it can produce residual stone fragments of significant size (>2 mm). Mechanistically, cavitation has been shown to play an important role in the reduction of such fragments to smaller debris. In this study, we assessed the feasibility of using cavitationally-based pulsed ultrasound therapy (histotripsy) to erode kidney stones. Previous work has shown that histotripsy is capable of mechanically fractionating soft tissue into fine, acellular debris. Here, we investigated the potential for translating this technology to renal calculi through the use of a commonly accepted stone model. Stone models were sonicated using a 1-MHz focused transducer, with 5-cycle pulses delivered at a rate of 1 kHz. Pulses having peak negative pressures ranging from 3 to 21 MPa were tested. Results indicate that histotripsy is capable of effectively eroding the stone model, achieving an average stone erosion rate of 26 mg/min at maximum treatment pressure; substantial stone erosion was only observed in the presence of a dense cavitational bubble cloud. Sequential sieving of residual stone fragments indicated that debris produced by histotripsy was smaller than 100 μm in size, and treatment monitoring showed that both the cavitational bubble cloud and model stone appear as hyperechoic regions on B-mode imaging. These preliminary results indicate that histotripsy shows promise in its use for stone comminution, and an optimized erosion process may provide a potential adjunct to conventional SWL procedures.


J Urol. 2011 Jan;185(1):264-8. Epub 2010 Nov 13.

Modified Clavien classification in percutaneous nephrolithotomy: assessment of complications in children

Ozden E, Mercimek MN, Yakupoǧlu YK, Ozkaya O, Sarikaya S.

Department of Urology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey. eozden@omu.edu.tr

Abstract

PURPOSE:
Although percutaneous nephrolithotomy has been accepted as an effective minimally invasive procedure in children, there is still no consensus on how to define and stratify complications by severity.

MATERIALS AND METHODS:
We retrospectively reviewed data of children who underwent percutaneous nephrolithotomy at our center between January 2002 and March 2010. A total of 100 procedures were performed in 94 patients with a mean age of 9.5 years. Complications were recorded according to modified Clavien classification.

RESULTS:
Average stone burden ranged from 100 to 2,850 mm(2) (mean ± SD 507.5 ± 475). Stones were located in the renal pelvis in 32 kidneys, calices in 20, renal pelvis and calices in 31, and upper ureter in 3. Stone-free rate after a single session of percutaneous nephrolithotomy was 85%. After auxiliary procedures in 7 cases stone-free rate increased to 89%. Grade I complications were seen in 7 patients postoperatively, grade II in 19 (hematuria requiring blood transfusion in 13 and nonseptic infection requiring antibiotics in 6) and grade III in 4 (hydrohemothorax in 2 and urine leakage requiring Double-J® stent in 2). No grade IV or V complications were observed. Regression analysis showed that stone burden (OR 1.006, 95% CI 1.001-1.011; p = 0.03) and operative time (OR 1.044, 95% CI 1.011-1.077; p = 0.009) were independent risk factors for complications.

CONCLUSIONS:
Percutaneous nephrolithotomy in children is safe, feasible and effective. Stone burden and operative time are independent risk factors for complications. The modified Clavien system provides a straightforward and validated method to classify postoperative complications.

Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.


Eur Urol. 2011 Apr 29.

Modified Supine Percutaneous Nephrolithotomy for Large Kidney and Ureteral Stones: Technique and Results

Hoznek A, Rode J, Ouzaid I, Faraj B, Kimuli M, de la Taille A, Salomon L, Abbou CC.

Service d’Urologie CHU Henri Mondor, Créteil, France.

Abstract

BACKGROUND:
Percutaneous nephrolithotomy (PCNL) is the standard treatment for kidney stones >2cm. Recently, a novel approach in the modified supine lithotomy position has been developed.

OBJECTIVE:
To demonstrate with a video our technique of supine PCNL (sPCNL) and present our experience.

DESIGN, SETTING, AND PARTICIPANTS:
From September 2009 to August 2010, 47 consecutive patients were prospectively evaluated. There were 31 single, 9 multiple, and 7 staghorn stones. The mean body mass index was 26.1±5 (range: 17.3-45.7), the mean stone size was 29.6±15.3mm (range: 10-75), and patients’ American Society of Anesthesiologists scores were 1, 2, and 3 in 31, 11, and 5 cases, respectively.

SURGICAL PROCEDURE:
Patients were positioned in Galdakao-modified supine Valdivia position. The details of the technique are shown in the film.

MEASUREMENTS:
Success was defined as patients free of stones or with residual stone fragments <4mm.

RESULTS AND LIMITATIONS:
Average operative room occupation time was 123.5±51.2min (range: 50-245). In the single, multiple, and staghorn stone groups, the immediate success rate after sPCNL was 90%, 78%, and 43%, respectively. Complications included one fever, two incidents of pyelonephritis, one renal colic, two urinary fistulae, one postoperative hemorrhage, and one incident of acute urinary retention. Mean hospital stay was 3.4±1.9 d (range: 2-12). Nine patients (19%) had a secondary procedure (extracorporeal shock wave lithotripsy or flexible ureterorenoscopy). At 3 mo, the success rate was 97%, 100%, and 100% in the single, multiple, and staghorn stone groups, respectively. However, the limitation of this study is its design, which is descriptive rather than comparative.

CONCLUSIONS:
sPCNL is a safe and reproducible method. It offers the advantage of simultaneous retrograde and antegrade endoscopic combined intrarenal surgery, and we believe it is a further advancement in stone management. In addition, it is easier from the anesthetist point of view than the traditional prone approach. In our hands, it meant a simplification of the operative technique, resulting in a more time-efficient procedure.


Kidney Int. 2011 Feb;79(4):393-403. Epub 2010 Dec 1.

Nephrolithiasis-associated bone disease: pathogenesis and treatment options

Sakhaee K, Maalouf NM, Kumar R, Pasch A, Moe OW.

Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas 75390-8885, USA. Khashayar.sakhaee@utsouthwestern.edu

Abstract

Nephrolithiasis remains a formidable health problem in the United States and worldwide. A very important but underaddressed area in nephrolithiasis is the accompanying bone disease. Epidemiologic studies have shown that osteoporotic fractures occur more frequently in patients with nephrolithiasis than in the general population. Decreased bone mineral density and defects in bone remodeling are commonly encountered in patients with calcium nephrolithiasis. The pathophysiologic connection of bone defects to kidney stones is unknown. Hypercalciuria and hypocitraturia are two important risk factors for stone disease, and treatments with thiazide diuretics and alkali, respectively, have been shown to be useful in preventing stone recurrence in small prospective trials. However, no studies have examined the efficacy of these agents or other therapies in preventing continued bone loss in calcium stone formers. This manuscript reviews the epidemiology, pathophysiology, and potential treatments of bone disease in patients with nephrolithiasis.


J Endourol. 2011 May;25(5):751-4. Epub 2011 Mar 9.

Preoperative stenting decreases operative time and reoperative rates of ureteroscopy

Chu L, Sternberg KM, Averch TD.

Department of Urology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.

Abstract

ABSTRACT PURPOSE:
Large stone burden can be treated ureteroscopically, but the treatment often requires more than one procedure. Placement of a preoperative stent may theoretically enhance stone clearance by dilating the ureter to facilitate both access and stone removal. This study determines the impact of stent placement before ureteroscopy on operative time, radiologic stone clearance, and reoperative rates.

MATERIALS AND METHODS:
We retrospectively reviewed the records of patients who underwent ureteroscopic stone intervention at our institution from 2002 to 2008 by a single surgeon. Nonstented matched controls were used for comparison. Demographics, stone characteristics (size, number, density, and location), presence of preprocedural ureteral stent, operative time, and results of postoperative imaging were compared between the two cohorts. Statistical analysis was performed.

RESULTS:
There were 104 patients included in the study (45 prestented and 59 nonstented). Median stone size was 1 cm (range 0.3-4 cm). Overall stone clearance was 95.8%. The median number of procedures was one. Prestenting significantly reduced operative time during first ureteroscopy in patients with large stone requiring multiple ureteroscopies (p = 0.008) and total operative time to stone clearance in patients with stone >1 cm (p = 0.01), but not in patients with stone burdens <1 cm (p = 0.48). Prestenting also significantly reduced reoperative rates in patients with stone burden >1 cm (p = 0.001), especially for stones located in proximal ureter and kidney. Prestenting improves postoperative radiologic clearance, but this was not statistically significant (p = 0.56).

CONCLUSIONS:
Results show that ureteroscopic lithotripsy of large stone burden can be performed with a high success rate. Preureteroscopic stent placement was associated with a decreased operative time and reoperative rates in patients with larger stone burdens of >1 cm.


BJU Int. 2011 Apr 8. doi: 10.1111/j.1464-410X.2010.09936.x.

Prospective comparative study of Miniperc and standard PNL for treatment of 1 to 2 cm size renal stone

Mishra S, Sharma R, Garg C, Kurien A, Sabnis R, Desai M.

Department of Urology, Muljibhai Patel Urological Hospital, Nadiad, Gujarat, India.

Abstract

Study Type – Therapy (case series) Level of Evidence 4

OBJECTIVE:
To evaluate the results of miniperc vis-à-vis standard PNL in the treatment of stones of 1-2 cm in size. Miniperc may represent a reasonable procedure in patients with nonbulky urolithiasis offering a similar outcome as standard percutaneous nephrolithotomy (PNL) with advantage of reduced morbidity.

PATIENTS AND METHODS:
55 procedures including 27 miniperc and 28 standard PNL were performed for renal stones 1-2 cm in size. Pediatric patient, active urinary tract infection, renal malformation, uncorrected coagulopathy and morbid obesity patients were excluded from the study. • The parameters studied were demography, operative time, postoperative analgesic requirement, hemoglobin drop, complications and stone clearance.

RESULTS:
Mean tract size was 18.2 ± 2 F (15-20) and 26.8 ± 2 F (24-30), P value <0.0001 in the miniperc and standard PNL, respectively. Holmium LASER and pneumatic lithotripter were the main energy sources used in miniperc and standard PNL, respectively. • Miniperc operative time was longer than that of standard PNL (45.2 ± 12.6 vs 31 ± 16.6 min, P= 0.0008 respectively). • Conversely, there was an advantage of miniperc over standard PNL in terms of a significantly reduced hemoglobin drop (0.8 ± 0.9 vs 1.3 ± 0.4 gram%, P= 0.01), analgesic requirement (55.4 ± 50 vs 70.2 ± 52 mg tramadol, P= 0.29) and hospital stay (3.2 ± 0.8 vs 4.8 ± 0.6 days, P≤ 0.001), respectively. • Intra- operative conversion of the procedure into a tubeless PNL was significantly more in the miniperc group (P≤ 0.001). The miniperc and standard PNL group had clearance rates of 96% and 100%, respectively at 1 month follow up.

CONCLUSIONS:
This study demonstrated significant advantages of the miniperc procedure in terms of reduced bleeding leading to a tubeless procedure and reduced hospital stay. • The stone free rates and the complications were similar in either group.

© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.


J Endourol. 2011 Mar;25(3):487-93. Epub 2011 Mar 1.

Shockwave lithotripsy in patients with horseshoe kidney: determinants of success

Ray AA, Ghiculete D, D’A Honey RJ, Pace KT.

Division of Urology, Department of Surgery, St. Michael’s Hospital, University of Toronto, Toronto, Canada.

Abstract

BACKGROUND AND PURPOSE:
Horseshoe kidney (HSK) is the most common renal fusion anomaly, with a prevalence of ∼1 in 400 and an incidence of urolithiasis between 20% and 60%. The role of shock wave lithotripsy (SWL) in patients with HSK remains poorly studied.

METHODS:
Data from all patients treated since January 1994 with a known HSK was reviewed. Analysis was restricted to all patients with a minimum follow-up of 2 weeks after SWL. Success was defined as patients who were stone-free or had asymptomatic, clinically insignificant residual fragments ≤ 4 mm.

RESULTS:
Data from 41 patients with HSK were analyzed (61 calculi). Mean stone size was 91.3 ± 71.6 mm(2); mean body mass index was 27.1 ± 5.3 kg/m(2). At 3 months, the single-treatment success and stone-free rates were 25.0% and 9.1%, respectively. The overall treatment success rate at 3 months was 63.6%, and the stone-free rate was 39.1%. Little incremental benefit was found for more than two SWL treatments per stone. The auxiliary treatment rate was 72.7%, with an efficiency quotient of 10.5%. On multivariate analysis, stone burden (p = 0.074), other calyceal location (p = 0.026), and body mass index (p = 0.013) were found to be prognostic for SWL success.

CONCLUSIONS:
Patients with HSK appear to have lower success and stone-free rates after SWL than patients with normal kidneys. This likely has to do with factors such as greater skin-to-stone distance (particularly for calyceal stones) and restricted urinary drainage. SWL may be offered to patients with a HSK once limitations in stone clearance have been considered.

J Endourol. 2011


BJU Int. 2011 Jun 2. doi: 10.1111/j.1464-410X.2011.10291.x.

Twenty-year prevalence of diabetes mellitus and hypertension in patients receiving shock-wave lithotripsy for urolithiasis

Chew BH, Zavaglia B, Sutton C, Masson RK, Chan SH, Hamidizadeh R, Lee JK, Arsovska O, Rowley VA, Zwirewich C, Afshar K, Paterson RF.

Department of Urologic Sciences, Gordon & Leslie Diamond Health Care Centre, Vancouver UBC Faculty of Medicine, Department of Radiology, University of British Columbia, Vancouver BC, Canada.

Abstract

Study Type – Prevalence (retrospective cohort) Level of Evidence 2b What’s known on the subject? and What does the study add? Shockwave lithotripsy is a common and effective treatment method for kidney stones, but has been associated with long-term complications, namely hypertension and diabetes. We compared the prevalence of these two disease in patients treated with lithotripsy to the background provincial population. Our analyses did not find an association between lithotripsy and the development of these diseases. Shockwave lithotripsy is an effective treatment modality for urolithiasis. The mechanism of stone communition during lithotripsy as well as the acute complications that occur following this treatment have been well described; however, the long-term consequences of this procedure have not been clearly defined. Diabetes and hypertension have been associated with lithotripsy at 19 years follow-up, though this relationship is controversial. This issue is further complicated by the interrelatedness of metabolic dysfunction and stone disease. Our data show that there is no association between lithotripsy and the development of either hypertension or diabetes. Patients treated for urolithiasis 20 years ago with shockwave lithotripsy were contacted, and their prevalence of diabetes and hypertension in these subjects was compared to the background population of British Columbia. The analysis also considered whether the properties of shockwaves delivered by the original Dornier HM-3 versus a modified Dornier HM-3 differentially affected the risk of our subjects developing these diseases. We did not find that lithotripsy, let alone the type of lithotriptor, was a risk factor for developing hypertension and diabetes. We postulate that the development of renal calculi in our subjects is more indicative of an overall metabolic syndrome where there is increasing evidence that patients with kidney stones get hypertension and diabetes and vice-versa. The development of these diseases is not related to shockwave lithotripsy, but rather to a systemic metabolic dysfunction.

OBJECTIVES:
To compare the prevalence of hypertension and diabetes mellitus (DM) in patients treated with an unmodified HM-3 lithotripter (USWL) and a second-generation modified HM-3 lithotripter (MSWL) 20 years ago at our Centre with that in the provincial population. • To determine whether the type of lithotripter was differentially associated with the development of these sequelae.

PATIENTS AND METHODS:
Retrospective review of 727 patients at Vancouver General Hospital who underwent shock-wave lithotripsy (SWL) between 1985 and 1989. • Our study group was compared with Statistics Canada data describing the provincial prevalence of these diseases. • Multivariate analysis was performed.

RESULTS:
The response rate was 37.3%. • There was a greater proportion of overweight and obese individuals in the study group compared with the provincial average. • In univariate analysis, lithotripsy with an unmodified HM-3 (USWL) was associated with a higher rate of DM than the provincial rate, whereas lithotripsy with the modified HM-3 (MSWL) was not. • Hypertension was more prevalent in all lithotripsy subjects. • On multivariate analysis the type of lithotripter was not associated with the development of either sequela.

CONCLUSIONS:
No association between lithotripsy and the development of either DM or hypertension in a multivariate analysis • Metabolic syndrome may have elevated the prevalence of DM and hypertension observed in our subjects on univariate analysis, which is in keeping with the fact that our study population had statistically higher body mass indices than the provincial rate. • Lithotripsy using the HM-3 was not associated with increased DM or hypertension.


Curr Opin Urol. 2011 Mar;21(2):134-40.

Update on technological and selection factors influencing shockwave lithotripsy of renal stones in adults and children

Cortes JA, Motamedinia P, Gupta M.

Department of Urology, Columbia University, New York, New York 10036, USA.

Abstract

PURPOSE OF REVIEW:
The aim of this review is to evaluate recently published peer reviewed literature on the subject of shockwave lithotripsy.

RECENT FINDINGS:
Based on in-vitro animal studies, escalating voltage results in better stone comminution and ultimately applies less total voltage to the surrounding tissue, theoretically causing less harm. Several studies have also shown that a slower shockwave rate improves stone fragmentation for intrarenal stones. Stones measuring greater than 1000 HU require a significantly greater number of shocks to destroy. The current literature continues to support shockwave lithotripsy as both a safe and effective means for managing stone disease in pediatric patients. Medical expulsive therapy with alpha-blockers appears to be efficacious, shortening the time to stone and fragment expulsion as well as minimizing pain. Skin-to-stone distance, Hounsfield units, stone size, and location are the best studied and most validated parameters that correlate with shockwave lithotripsy success.

SUMMARY:
Shockwave lithotripsy continues to evolve with the advent of better technology, improved imaging, and the development of several parameters that can be used to predict success, to counsel our patients, and improve stone-free rates.


J Endourol. 2011 May;25(5):751-4. Epub 2011 Mar 9.

Preoperative stenting decreases operative time and reoperative rates of ureteroscopy


Chu L, Sternberg KM, Averch TD.

Department of Urology, University of Pittsburgh School of Medicine , Pittsburgh, Pennsylvania.

Abstract

ABSTRACT PURPOSE:
Large stone burden can be treated ureteroscopically, but the treatment often requires more than one procedure. Placement of a preoperative stent may theoretically enhance stone clearance by dilating the ureter to facilitate both access and stone removal. This study determines the impact of stent placement before ureteroscopy on operative time, radiologic stone clearance, and reoperative rates.

MATERIALS AND METHODS:
We retrospectively reviewed the records of patients who underwent ureteroscopic stone intervention at our institution from 2002 to 2008 by a single surgeon. Nonstented matched controls were used for comparison. Demographics, stone characteristics (size, number, density, and location), presence of preprocedural ureteral stent, operative time, and results of postoperative imaging were compared between the two cohorts. Statistical analysis was performed.

RESULTS:
There were 104 patients included in the study (45 prestented and 59 nonstented). Median stone size was 1 cm (range 0.3-4 cm). Overall stone clearance was 95.8%. The median number of procedures was one. Prestenting significantly reduced operative time during first ureteroscopy in patients with large stone requiring multiple ureteroscopies (p = 0.008) and total operative time to stone clearance in patients with stone >1 cm (p = 0.01), but not in patients with stone burdens <1 cm (p = 0.48). Prestenting also significantly reduced reoperative rates in patients with stone burden >1 cm (p = 0.001), especially for stones located in proximal ureter and kidney. Prestenting improves postoperative radiologic clearance, but this was not statistically significant (p = 0.56).

CONCLUSIONS:
Results show that ureteroscopic lithotripsy of large stone burden can be performed with a high success rate. Preureteroscopic stent placement was associated with a decreased operative time and reoperative rates in patients with larger stone burdens of >1 cm.


CORSI DI AGGIORNAMENTO E CONGRESSI:

UTICS Giornate Nazionali di Urologia Territoriale:
30 giugno – 2 luglio 2011 – Lucca

50th Annal ESPE meeting:
25-28 settembre 2011 – Glasgow

4° Congresso Nazionale Club della Litiasi Urinaria:
22-24 Settembre 2011 – Catania

Giornate video-urologiche Sassolesi di Chirurgia in diretta:
30 Settembre – 01 ottobre 2011 – Sassuolo

7hth International Course of Flexible Uretroscopy:
15-16 Settembre 2011 – Roma

SIU World Meeting 2011:
16-20 Ottobre 2011 – Berlino

84° Congresso Nazionale SIU:
23-26 Ottobre 2011 – Roma

XXVII Congresso Nazionale SIA:
2-5 novembre 2011- Fiuggi

Video-Urologia Congresso del Trentennale:
25-26 novembre 2011 – Ravenna