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Newsletter 1-12

Urology. 2012 Jan;79(1):67-71. Epub 2011 Aug 5.

Anatomical variation between the prone, supine, and supine oblique positions on computed tomography: implications for percutaneous nephrolithotomy access

Duty B, Waingankar N, Okhunov Z, Ben Levi E, Smith A, Okeke Z.
Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New Hyde Park, NY.

Abstract

OBJECTIVE:
To determine anatomical variations between the prone, supine, and supine oblique positions that are likely to affect percutaneous renal access.

MATERIAL AND METHODS:
Twenty patients underwent computed tomography urograms in the supine and prone positions. Twenty patients underwent supine oblique and prone scans. Mean nephrostomy tract length, maximum access angle, and anterior-posterior renal position were calculated.

RESULTS:
Mean nephrostomy tract length was shorter in the prone position (82.6 mm right kidney, 85.4 mm left kidney) compared with the supine position (108.3 mm right kidney, P <.001; 103.7 mm left kidney, P <.001). Prone tract length was also shorter than supine oblique tract length (86.1 mm vs 96.5 mm; P = .048). Mean maximum access angle was significantly greater (P = .018 right kidney; P = .007 left kidney) in the prone position (right kidney 99.7°, left kidney 104.0°) compared with the supine position (right kidney 87.7°, left kidney 89.4°). The same was true for the prone compared with the supine oblique position (75.8° vs 58.7°; P = .004). No difference was noted in anterior-posterior renal position between the supine and prone positions (20.3 mm vs 26.7 mm; P = .094) or supine oblique and prone positions (22.8 mm vs 15.6 mm; P = .45).

CONCLUSIONS:
The prone position is associated with a significantly shorter nephrostomy tract length and more potential access sites, which may improve ease and safety of percutaneous renal access.

Copyright © 2012 Elsevier Inc. All rights reserved.


Urology. 2012 Jan;79(1):61-6.

The impact of pelvicaliceal anatomy on the success of retrograde intrarenal surgery in patients with lower pole renal stones.

Resorlu B, Oguz U, Resorlu EB, Oztuna D, Unsal A.
Kecioren Training and Research Hospital, Department of Urology, Ankara, Turkey.

Abstract

OBJECTIVES:
To evaluate the impact of pelvicaliceal anatomy on the success of retrograde intrarenal surgery (RIRS) for lower pole renal stones and determine which of these factors can be used to select patients who will benefit from RIRS.

METHODS:
We evaluated 67 patients who underwent RIRS between 2009 and 2010 for isolated lower pole renal stones. The infundibular length (IL), infundibular width (IW), pelvicaliceal height (PCH), and infundibulopelvic angle (IPA) were measured by preoperative intravenous urogram. Success was defined as either complete clearance or clearance with insignificant residual fragments ≤3 mm in size at 2-months follow-up.

RESULTS:
Mean IL was 26.7 ± 7.9 and 28.2 ± 5.3 mm, mean PCH was 20.7 ± 6.6 and 23.2 ± 4.9 mm in stone-free and non-stone-free patients, respectively. These were slightly larger in the non-stone-free group but not statistically significant (P = .140 and P = .072, respectively). Mean IW was 5.8 ± 3.5 and 5.6 ± 2.2 mm in stone-free and non-stone-free patients, respectively, which had no significant impact on the stone-free rate (P = .719). There were significant differences between the groups in terms of stone length (P = .001) and IPA (P = .003). The mean IPA was 49.37 ± 11.83 and 37.61 ± 13.22 mm in stone-free and non-stone-free patients, respectively.

CONCLUSIONS:
In addition to the influence of stone size, lower pole anatomy, especially IPA, has a significant impact on stone clearance for lower pole stones after RIRS.

Copyright © 2012 Elsevier Inc. All rights reserved.


Urology. 2012 Jan;79(1):48-54. Epub 2011 Sep 9.

Biochemical determinants of severe lithogenic activity in patients with idiopathic calcium nephrolithiasis.

Arrabal-Polo MA, Arrabal-Martin M, de Haro-Muñoz T, Poyatos-Andujar A, Palæo-Yago F, Zuluaga-Gomez A.
Department of Urology, San Cecilio University Hospital, Granada, Spain.

Abstract

OBJECTIVE:
To analyze the biochemical alterations in plasma and the urine determinants of severe lithogenic activity in patients with idiopathic calcium nephrolithiasis.

METHODS:
We performed a cross-sectional study of 120 patients divided into 2 groups: group 1, 60 patients without nephrolithiasis; and group 2, 60 patients with severe and/or recurrent calcium nephrolithiasis. In all patients, a study of renal function, calcium metabolism, and bone remodeling markers, and a study of the lithogenic factors were performed in urine after fasting and in 24-hour urine samples.

RESULTS:
We observed greater values for phosphorus in group 1 than in group 2 (P = .03). Also, we found greater values for intact parathyroid hormone (P = .01), osteocalcin (P = .000), and β-crosslaps (P = .000) in group 2 than in group 1. In the 24-hour urine samples, significant differences were found between groups 1 and 2 in calciuria (11.7 vs 17.4 mg/dL; P = .000), citraturia (50.6 vs 33.5 mg/dL; P = .002), calcium/creatinine quotient (0.14 vs 0.20; P = .001), calcium/citrate quotient (0.05 vs 0.13; P = .04), and calcium/creatinine quotient after fasting (0.09 vs 0.16; P = .000).

CONCLUSION:
We consider the determinants of severe and/or recurrent calcium lithiasis to be hypercalciuria and hypocitraturia and a calcium/citrate quotient >0.06. As risk markers we can consider phosphatemia <2.9 mg/dL, phosphate/chlorine quotient >35, alkaline phosphatase >80 U/L, intact parathyroid hormone >60 pg/mL, osteocalcin >16 ng/mL, β-crosslaps >0.400 ng/mL, and β-crosslaps/osteocalcin quotient >0.028.

Copyright © 2012 Elsevier Inc. All rights reserved.


Adv Urol. 2012;2012:543537. Epub 2011 Jun 9. [FULL TEXT ARTICLE]

Predictors of clinical outcomes of flexible ureterorenoscopy with holmium laser for renal stone greater than 2 cm.

Al-Qahtani SM, Gil-Deiz-de-Medina S, Traxer O.
Department of Urology, Tenon University Hospital, Pierre and Marie Curie University, 4 rue de la Chine, 75020 Paris, France.

Abstract

OBJECTIVE:
To evaluate the clinical outcome of flexible ureterorenoscopy (F-URS) with holmium laser in managing renal stone greater than 2 cm.

PATIENTS AND METHODS
Records of 120 patients (123 renal units) with renal stone greater than 2 cm who underwent F-URS with holmium laser iwere evaluated. The mean stone size was 26.3 mm. Patient and stone characteristics, perioperative outcomes and complications were evaluated. The outcome was determined at 4 weeks on plain radiograph (KUB) and Non-contrast CT scan (NCCT). Follow-up visit was up to 6 months to evaluate the clinical outcome and patients symptoms.

RESULTS
Stone burden was an independent predictor of FURS results. After first session of treatment, success rate was obtained in 72 renal units (58.5%). On the other hand, significant residual fragment was encountered in 51 renal units (41.5%). This was improved with “staged-therapy” to 87% and 96.7% after second and third session of treatment, respectively. Complications were recorded. They were managed in proper manner accordingly.

CONCLUSION:
This is an attractive, safe and effective technique. It is an ideal option for low volume complex stone with average burdens of 2 to 3 cm. Patient should be informed and consented about staged-therapy.

Adv Urol. 2012;2012:543537. Epub 2011 Jun 9.

Predictors of clinical outcomes of flexible ureterorenoscopy with holmium laser for renal stone greater than 2 cm.

Source

Department of Urology, Tenon University Hospital, Pierre and Marie Curie University, 4 rue de la Chine, 75020 Paris, France.

Abstract

Objective. To evaluate the clinical outcome of flexible ureterorenoscopy (F-URS) with holmium laser in managing renal stone greater than 2 cm. Patients and Methods. Records of 120 patients (123 renal units) with renal stone greater than 2 cm who underwent F-URS with holmium laser iwere evaluated. The mean stone size was 26.3 mm. Patient and stone characteristics, perioperative outcomes and complications were evaluated. The outcome was determined at 4 weeks on plain radiograph (KUB) and Non-contrast CT scan (NCCT). Follow-up visit was up to 6 months to evaluate the clinical outcome and patients symptoms. Results. Stone burden was an independent predictor of FURS results. After first session of treatment, success rate was obtained in 72 renal units (58.5%). On the other hand, significant residual fragment was encountered in 51 renal units (41.5%). This was improved with “staged-therapy” to 87% and 96.7% after second and third session of treatment, respectively. Complications were recorded. They were managed in proper manner accordingly. Conclusion. This is an attractive, safe and effective technique. It is an ideal option for low volume complex stone with average burdens of 2 to 3 cm. Patient should be informed and consented about staged-therapy.


Adv Urol. 2011;2011:123606. Epub 2011 Oct 13. [FULL TEXT ARTICLE]

Percutaneous nephrolithotomy in children

Demarco RT.
Departments of Surgery and Pediatrics, Division of Pediatric Urology, Sanford Children’s Hospital, 1600 W. 22nd Street, Sioux Falls, SD 57104, USA.

Abstract

The surgical management of pediatric stone disease has evolved significantly over the last three decades. Prior to the introduction of shockwave lithotripsy (SWL) in the 1980s, open lithotomy was the lone therapy for children with upper tract calculi. Since then, SWL has been the procedure of choice in most pediatric centers for children with large renal calculi. While other therapies such as percutaneous nephrolithotomy (PNL) were also being advanced around the same time, PNL was generally seen as a suitable therapy in adults because of the concerns for damage in the developing kidney. However, recent advances in endoscopic instrumentation and renal access techniques have led to an increase in its use in the pediatric population, particularly in those children with large upper tract stones. This paper is a review of the literature focusing on the indications, techniques, results, and complications of PNL in children with renal calculi.


AJR Am J Roentgenol. 2010 Oct;195(4):953-8.

Stone-targeted dual-energy CT: a new diagnostic approach to urinary calculosis.

Ascenti G, Siragusa C, Racchiusa S, Ielo I, Privitera G, Midili F, Mazziotti S.
Department of Radiological Sciences, University of Messina, Policlinico G. Martino, 98100 Messina, Italy.

Abstract

OBJECTIVE:
The objective of our study was to assess a stone-targeted low-dose protocol for the detection and characterization of urinary tract stones using a dual-energy CT scanner.

SUBJECTS AND METHODS:
Thirty-nine patients (20 men, 19 women; age range, 22-87 years; average age, 47 years) with suspected renal colic in which ureteral stones were shown at low-dose unenhanced CT were enrolled in the study. Stone composition could be established in 24 patients, and these patients represent our study population regarding the CT characterization of stones. All examinations were performed with a preliminary low-dose unenhanced CT acquisition of the whole urinary system that was immediately followed by a limited (scanning length, 5 cm) dual-energy acquisition of the region containing the ureteral stone. Stone characterization was assessed using a dual-energy software tool available on the system. Two experienced radiologists who were blinded to the chemical composition of the stones retrospectively reviewed images and analyzed data to determine the composition of the stones. Their results were compared with the biochemical analysis results obtained by stereomicroscopy and infrared spectrometry.

RESULTS:
Based on in vitro-measured data, our combined protocol reduced dose by up to 50% compared with a full dual-energy acquisition; in addition, the calculated radiation doses of our protocol in patients are comparable to those of low-dose single- and dual-energy protocols. In 24 patients, 24 ureteral stones considered to be responsible for symptoms and detected at low-dose unenhanced CT were also shown at dual-energy CT. Correct chemical composition was obtained by dual-energy analysis in all 24 ureteral calculi regarding the characterization of uric acid (n = 3), calcium salt (n = 18), and combined uric acid-calcium salt (n = 3) stones.

CONCLUSION:
The use of dual-energy CT attenuation values made it possible to characterize all ureteral calculi, discriminating uric acid stones from calcium salt stones. The increment in radiation exposure due to contemporary scanning with two tubes at different energy levels can be substantially reduced using a limited stone-targeted dual-energy protocol.


AJR Am J Roentgenol. 2011 Jun;196(6):1274-8. [FULL TEXT ARTICLE]

Nephrolithiasis: what surgeons need to know.

Eisner BH, McQuaid JW, Hyams E, Matlaga BR.
Department of Urology, Kidney Stone Center, Massachusetts General Hospital, Harvard Medical School, GRB 1102, 55 Fruit St, Boston, MA 02114, USA. beisner@partners.org

Abstract

OBJECTIVE:
In this article, we review the standard of care for imaging of nephrolithiasis as well as new technology and radiation concerns from the perspective of the urologic surgeon.

CONCLUSION: Nephrolithiasis is a common cause of morbidity with a lifetime prevalence of 5-10% worldwide. Increasingly, diagnostic evaluation and planning for medical or surgical intervention have become reliant on imaging.


J Endourol. 2011 Oct 17.

Antibiotic Prophylaxis After Uncomplicated Ureteroscopic Stone Treatment: Is There a Difference?

Ramaswamy K, Shah O.
Department of Urology, New York University School of Medicine , New York, New York.

Abstract

Abstract Purpose:
We evaluated the risk of development of a symptomatic urinary tract infection (UTI) based on the antibiotic prophylaxis given to a patient during and after uncomplicated ureteroscopy (URS) for urolithiasis.

Patients and Methods:
We retrospectively reviewed the charts of patients who underwent URS, laser lithotripsy, and stent placement for the management of stones from 2004/2005 (group 1) and 2009/2010 (group 2). We excluded all patients with preoperative positive cultures, preoperative antibiotics, urinary diversion, who underwent concomitant percutaneous nephrolithotomy, or had strings attached to the stents. All patients received a first-generation intravenous cephalosporin or fluoroquinolone at the time of initial intervention and had ureteral stents placed intraoperatively. Group 1 received an oral fluoroquinolone for 1 week postoperatively. Group 2 received an oral first-generation cephalosporin antibiotic peri-stent removal only. Antibiotics were appropriately changed according to the local resistance patterns. All stents were removed within 5 to 7 days. Our primary end point was symptomatic UTI.

Results:
After the exclusion criteria, group 1 had 48 patients, group 2 had 49. There was no statistical difference in the incidence of symptomatic UTI between the two groups; each group had one UTI (2% risk) (P=0.988). There were no cases of readmission, pyelonephritis, UTI, surgical reintervention, or Clostridium difficile. The UTI in group 1 was secondary to Escherichia coli and in group 2, Staphylococcus species; both were managed with oral antibiotics.

Conclusions:
The use of oral peri-stent removal antibiotic prophylaxis is sufficient to prevent symptomatic UTIs in patients who have undergone uncomplicated URS for urolithiasis. The judicious use of antibiotics in uncomplicated cases may help lower the incidence of resistant organisms and other complications related to the widespread use of antibiotics.


J Endourol. 2012 Jan 4.

The Utility of Noncontrast Computed Tomography in the Prompt Diagnosis of Postoperative Complications After Percutaneous Nephrolithotomy.

Gnessin E, Mandeville JA, Handa SE, Lingeman JE.
Department of Urology, Indiana University Health , Methodist Hospital, Indianapolis, Indiana.

Abstract

Abstract Introduction:
Noncontrast computed tomography (CT) is commonly utilized after percutaneous nephrolithotomy (PNL) to assess stone-free (SF) status. In addition to assessing SF status, CT is useful in the recognition of complications after PNL. We characterized complications demonstrated by postoperative CT scan and compared hospital re-admission rates based on whether or not CT was performed.

Methods:
We retrospectively reviewed records of 1032 consecutive patients from April 1999 to June 2010. Patients were divided into two cohorts based on whether they had a CT within 24 hours of PNL. Demographic data, CT findings, and need for re-admission for complication management were assessed.

Results:
Nine hundred fifty-seven patients (92.7%) underwent post-PNL CT. CT-diagnosed complications were perinephric hematoma in 41 (4.3%; 2 requiring embolization and 9 necessitating transfusion), pleural effusion in 25 (2.6%; 10 requiring intervention), colon perforation in 2 (0.2%), and splenic injury in 2 (0.2%). Of patients with postoperative complications, 33% required intervention. Among patients with a CT, 6 (0.6%) were readmitted despite negative postoperative CT (four perinephric hematomas, one calyceal-pleural fistula, and one pseudoaneurysm). The sensitivity of CT for diagnosing complications was 92.7%. Seventy-five patients (7.3%) did not undergo CT post-PNL. Of these, four (5.33%) were readmitted: three for perinephric hematomas and one for ureteral clot obstruction. Patients undergoing post-PNL CT were less likely to be readmitted because of missed complications (p=0.02).

Conclusions:
Serious post-PNL complications are uncommon, but their prompt diagnosis and treatment is imperative. In addition to identifying residual stones, CT is useful in diagnosing postoperative complications. Postoperative CT could potentially be considered for all patients undergoing PNL, particularly in complex cases such as patients with anatomical abnormalities (renal anatomic abnormality or retrorenal colon), patients requiring upper pole access (risk of thoracic, hepatic, and splenic complications), and patients requiring multisite access (higher risk of perinephric hematoma or need for transfusion).


J Endourol. 2012 Jan 4.

Ureteroscopic Lithotripsy for Distal Ureteral Calculi: Comparative Evaluation of Three Different Lithotriptors.

Salvadó JA, Mandujano R, Saez I, Saavedra A, Dell’oro A, Dominguez J, Trucco C.
Facultad de Medicina, Pontificia Universidad Católica de Chile , Santiago, Chile .

Abstract

Abstract Introduction and Objectives:

We report the results of a randomized controlled trial comparing three different lithotriptors using semirigid ureteroscopy (URS) for distal ureteral stones.

Methods:
Between September 2009 and November 2010 69 patients undergoing ureteroscopy were randomized to three groups: LithoClast classic (Group 1), Holmium Laser (Group 2), and StoneBreaker™ (Group 3). A 7.5F semirigid ureteroscope was used in all procedures. The primary outcome was differences in fragmentation time. Secondary outcomes were stone-free rates, intraoperative complications, stone-up migration, hospital stay, analgesic requirement, and need for auxiliary procedures. Patients were followed up at 15 days, 30 days, and 3 months. The stone-free status was defined with noncontrast computed tomography performed at first control. Univariate and multivariate analysis were performed to determine clinical and surgical factors that have direct impact on the success of ureteroscopy. Chi-square test and Analysis of Covariance (ANCOVA) tests were used for statistical comparisons.

Results:
There were no differences between sociodemographic variables. Average stone size was 7.17±2.04 mm in Group 1; 7.89±2.73 mm in Group 2; and 7.79±2.97 mm in Group 3 (p=0.79). Fragmentation time were similar between lithotriptors; 27.12±4.07 minutes in Lithoclast group; 21.78±2.81 minutes in Laser group, and 27.14±4.71 minutes in StoneBreaker group (p=0.74). Stone-free rates were 96%±11.18% (group 1), 96.9%±8% (group 2), and 96.9%±8.4% (group 3) (p=0.1). No difference was observed in stone-up migration, postoperative Double-J stent placement, or auxiliary procedures. Stone size and the placement of a second working wire were associated with shorter fragmentation time (p<0.01).

Conclusions:
The three lithotripsy devices evaluated behaved similarly in terms of the ability to fragment stones, and were equally effective for distal ureteral stones. Adequate fragmentation and fragment removal are mainly dependant on stone size and surgical technique (use of auxiliary wire).


J Endourol. 2012 Jan 4.

Feasibility of Totally Tubeless Percutaneous Nephrolithotomy Under the Age of 14 Years: A Randomized Clinical Trial.

Aghamir SM, Salavati A, Aloosh M, Farahmand H, Meysamie A, Pourmand G.
1 Department of Urology, Sina Hospital, Tehran University of Medical Sciences , Tehran, Iran .

Abstract

Abstract Objective:
To assess the outcome and safety of the totally tubeless percutaneous nephrolithotomy (PCNL) in comparison with standard PCNL in the children under the age of 14 years.

Patients and methods:
Twenty-three patients under the age of 14 with renal stones were enrolled in a prospective randomized clinical trial during March 2010 to June 2011. The inclusion criteria were existence of renal stone larger than 2.5 cm in diameter or extracorporeal shockwave lithotripsy-resistant kidney stone; furthermore, exclusion criteria were kidney anomalies, renal failure on admission, and serious bleeding or perforation in the collecting system during the operation. The patients were divided into two groups according to block randomization. Group A comprised of 13 children with mean age 10.31 (4-14) years, were rendered totally tubeless at the end of surgery, while 10 patients in group B with mean age 11.1 (9-14) years underwent standard PCNL. The incidence of complications, transfusion rate, analgesic use, hemoglobin drop, operation time, and hospital stay were compared between the two groups during a one-month study period.

Results:
The mean stone burden was 29.23 mm (SD=4.85) in group A versus 31.4 mm (SD=5.19) in group B. Hospitalization averaged 39.54 (SD=11.39) hours versus 58.7 (SD=10.37) (p<0.001) and the average analgesics use was 0.07 (SD=0.03) mg/kg of morphine versus 0.15 (SD=0.04) (p<0.001), respectively. Operation time, transfusion rate, complications, retreatment, and hemoglobin drop were not different, significantly.

Conclusion:
Totally tubeless PCNL for pediatric population yields decreased hospital stay and analgesic use with no more complications. So, it can be considered as a standard and cost-beneficial procedure in appropriately selected group of patients.


J Endourol. 2012 Jan 17.

The Ureteroscope as a Safety Wire for Ureteronephroscopy.

Patel SR, McLaren ID, Nakada SY.
Department of Urology, University of Wisconsin School of Medicine and Public Health , Madison, Wisconsin.

Abstract

Abstract Background and Purpose:
The recent technologic advances in the newer generation of flexible ureteroscopes have significantly enhanced the therapeutic and diagnostic efficacy of ureteroscopy. The purpose of our study was to assess ureteroscopy and lithotripsy of renal calculi without a safety wire, using the ureteroscope as the safety device.

Patients and Methods:
Medical records for patients undergoing ureteroscopy by a single surgeon were retrospectively reviewed from December 2006 to December 2009. Inclusion criteria for our study included all adult patients who underwent wireless flexible ureteroscopy for the management of renal calculi and had 1 month follow-up data.

Results:
Of the 568 patients who underwent ureteroscopy during this period, 268 patients met our study inclusion criteria. The mean age of the patients undergoing wireless ureteroscopy was 33 years, and the mean body mass index was 33.1 kg/m(2). Mean stone diameter of the renal calculi treated was 12.0±5.9 mm. Fifteen percent of the patients had a ureteral stent in place before the procedure, and 84% of the patients had a stent placed after ureteroscopy. Twenty percent of the patients needed ureteral dilation, and 15% of the patients had a ureteral access sheath placed intraoperatively. The overall complication rate was 2.6% (major=0.7%, minor=1.9%). Complications included: Four urinary tract infections, two patients with urosepsis, and one patient with urinary retention. No patients had ureteral perforation or ureteral avulsion.

Conclusions:
Using the ureteroscope as the safety mechanism, ureteroscopy is safe with regard to maintaining renal access and control. Routine safety wires during ureteronephroscopy are not necessary assuring the ureteroscope is in the kidney.


J Endourol. 2012 Jan;26(1):52-7. Epub 2011 Oct 17.

A Randomized Controlled Study to Analyze the Safety and Efficacy of Percutaneous Nephrolithotripsy and Retrograde Intrarenal Surgery in the Management of Renal Stones More Than 2 cm in Diameter.

Bryniarski P, Paradysz A, Zyczkowski M, Kupilas A, Nowakowski K, Bogacki R.
Department of Urology, Medical University of Silesia , Zabrze and Katowice, Silesia, Poland .

Abstract

Abstract Objective:
The gold standard for removal of renal stones more than 2 cm in diameter is percutaneous nephrolithotripsy (PCNL). Retrograde intrarenal surgery (RIRS) has become more and more fashionable because of its high safety and repeatability, especially in smaller stones. Many retrospective studies have proved its efficacy and safety in larger calculi, however. We decided to compare prospectively both procedures in terms of safety and efficacy in renal pelvic stones more than 2 cm in diameter.

Patients and Methods:
This was a randomized single tertiary care center trial with two arms (32 patients in each arm). The first group comprised patients who underwent PCNL, while in the second group, there were patients in whom RIRS with a semirigid ureteroscope was used. The primary end points were hematocrit and hemoglobin drop after surgery as equivalents of safety and stone disintegration rate in terms of efficacy. The secondary end points comprised operating room time, visual analogue scale of pain, pain treatment, and hospital stay.

Results:
The mean hematocrit drop after the procedure was lower in the second group. Similarly, operating room time and hospital stay were significantly shorter after RIRS in comparison with PCNL. In the second group, patients had favorable features in terms of pain intensity and treatment after the procedure. PCNL showed higher efficacy (94%) in comparison with RIRS (75%). The power of 83% was calculated for the primary end point.

Conclusion:
The efficacy of RIRS is acceptable and, emphasizing its high safety, it should be considered as a valuable alternative option for management of renal pelvic stones more than 2 cm in diameter.


J Endourol. 2011 Oct 14.

The History of Kidney Stone Dissolution Therapy: 50 Years of Optimism and Frustration With Renacidin.

Gonzalez RD, Whiting BM, Canales BK.
Department of Urology, University of Florida , Gainesville, Florida.

Abstract

Abstract Background and Purpose:
Over the last 50 years, chemolysis as a primary or adjuvant treatment for urinary stones has fallen in and out of favor. We review the literature for a historical perspective on the origins and chronology of Renacidin therapy, focusing on landmark studies and impracticalities that have seemingly condemned it to history.

Materials and Methods:
A MEDLINE search was performed on the topic of chemolysis of urinary calculi. Historical literature was reviewed with regard to stone composition, treatment modalities, outcomes, and complications.

Results:
A total of 61 articles were reviewed, 40 of which were case series, representing a total of 817 patients studied. Mulvaney first introduced Renacidin in 1959 as a modification of Suby and Albright’s 1943 solution. Because of an overabundance of nonstandardized irrigation protocols, six deaths were reported in the early 1960s resulting in a Food and Drug Administration ban on the practice of upper urinary tract stone dissolution. Over time, Renacidin returned to the urologist’s arsenal, appearing first as an adjunct to dissolve catheter and bladder calculi and later (1990) as an approved agent for renal pelvis and ureter use. This feat was almost single-handedly the result of a successful hemiacidrin case series published in 1971 by Nemoy and Stamey. By using daily urine cultures, prophylactic antibiotics, and meticulous intrarenal pressure monitoring, Nemoy and Stamey virtually eliminated all major irrigation complications, paving the way for a flurry of studies. More importantly, they established the link between residual struvite stones, persistent infection, and recurrent staghorn stone formation.

Conclusions:
Dissolution of urinary calculi by chemolysis has been shown to be safe and effective if performed with sterile urine cultures, prophylactic antibiotics, and low intrapelvic pressures. The pioneers of this therapy are remembered for their attempts to develop an alternative to open surgery, and, in the process, solidified the “stone-free” concept for infection-based stones.


J Endourol. 2012 Jan 10.

Retroperitoneal Laparoendoscopic Single-Site Ureterolithotomy: A Comparison with Conventional Laparoscopic Surgery.

Wen X, Liu X, Huang H, Wu J, Huang W, Cai S, Li X, Ye C, Zhu B, Cai Y, Gao X.
Department of Urology, Third Affiliated Hospital, Sun Yat-sen University , Guangzhou, China .

Abstract

Abstract Background and Purpose:
Laparoendoscopic single-site (LESS) surgery through the retroperitoneal approach has been seldom reported. We aimed to compare the feasibility and outcomes of LESS and conventional laparoscopic surgery via the retroperitoneal approach in the management of large, impacted ureteral stones.

Patients and Methods:
From June 2010 to May 2011, LESS ureterolithotomy through the retroperitoneal approach was performed in 10 patients (the LESS group). Another 15 patients who underwent conventional retroperitoneal laparoscopic ureterolithotomy (the conventional laparoscopic group) by the same surgeon were involved and compared. The operative time, complications, and surgical outcomes were evaluated.

Results:
All the operations were completed successfully, without conversion to conventional laparoscopic or open surgeries. The operative time of the LESS group and of the conventional laparoscopic group were 132.7±16.3 and 128.1±20.1 minutes, respectively (P=0.782). The estimated blood loss were 30.7±5.9 vs 28.0±4.5 mL (P=0.620). Duration of analgesia postoperatively was 2.0±0.8 vs 3.5±0.5 days (P=0.005). All targeted stones were successfully extracted without major complications. Postoperative urine leakage was noted in one patient in each group. Cosmetic results were superior in the LESS group according to both the study nurse’s and the patients’ assessments (8.5 vs 5.3; P=0.012, and 8.3 vs 5.6; P=0.025, respectively). All patients showed no obstructions or stricture formations on postoperative follow-up.

Conclusions:
In experienced hands, LESS for ureterolithotomy through the retroperitoneal approach is feasible and can acquire outcomes equal to those of conventional multiport laparoscopic surgery. Prospective long-term follow-up studies with a larger number of patients are needed to further evaluate its benefits.


J Endourol. 2012 Jan 12.

Ureterorenoscopy with Holmium-Yttrium-Aluminum-Garnet Fragmentation Is a Safe and Efficient Technique for Stone Treatment in Patients with a Body Mass Index Superior to 30 kg/m(2).

Delorme G, Huu YN, Lillaz J, Bernardini S, Chabannes E, Guichard G, Bittard H, Kleinclauss F.
1 Dept. of Urology and Renal Transplantation, University Hospital Saint-Jacques , Besançon, France .

Abstract

Abstract Purpose:
The aim of the study was to analyze results and morbidity after flexible ureterorenoscopy in patients with a body mass index (BMI) >30 kg/m(2) and to compare with results obtained in a large cohort of nonobese patients.

Patients and Methods:
We conducted a retrospective study including all flexible ureterorenoscopy performed for stone retrieval in our institution between January 2004 and December 2008. During the study period, 224 procedures were performed, of which 18 had to be excluded because of missing BMI data. Thus, a total of 206 procedures were included in the final analysis (34 in 29 obese patients, 172 in 149 nonobese patients). Characteristics of the patients (age, BMI, previous treatment), stones (nature, location, number), and procedures (operating time, morbidity, outcome) were analyzed. Success was defined as clear imaging (completely stone free) on renal tomography and ultrasonography at 1, 3, and 6 months follow-up.

Results:
Mean BMI was 34±0.6 kg/m(2) in obese patients (OP) and 24±0.2 kg/m(2) in nonobese patients (NOP). Mean stone size, location, and composition were not significantly different between groups. Operative time was also similar in OP and NOP (102.5±6.1 min vs 103±3.4 min, P=NS). The rate of minor complications (fever, hematuria, flank pain) was similar in OP (11.8%) and NOP (11.4%). No major complication necessitating prolonged hospital stay or new surgical procedure was observed. The overall stone-free rate was not significantly different between OP (79.4%) and NOP (70%).

Conclusion:
Flexible ureterorenoscopy is an appropriate treatment for use in obese patients and achieves excellent stone-free rates with low morbidity.


J Endourol. 2011 Nov 21.

Which Is More Important in Predicting the Outcome of Extracorporeal Shockwave Lithotripsy of Solitary Renal Stones: Stone Location or Stone Burden?

Khalil MM.
Department of Surgery (Division of Urology), Mubarak Al-Kabir Hospital , Ministry of Health, Hawally, Kuwait .

Abstract

Abstract Purpose:
To assess the effect of stone location and burden on the outcome of extracorporeal shockwave lithotripsy (SWL) as a primary treatment of solitary renal stone.

Patients and Methods:
The study included 438 patients with a solitary renal stone who underwent SWL as a primary treatment for their stones. All were evaluated by plain radiography of the kidneys, ureters, and bladder (KUB), ultrasonography, intravenous urography, or noncontrast enhanced CT before SWL and followed up for 3 months after treatment by KUB radiography and/or ultrasongraphy. Patients were classified into four groups according to stone location (renal pelvis, lower, middle, and upper calix) and three groups according to stone burden (≤1 cm(2), 1.1-2 cm(2), and >2 cm(2)). Treatment outcome was considered successful if no residual fragments (stone free) or clinically insignificant nonobstructing residuals less than 4 mm remained after 3 months of follow-up.

Results:
The mean age of the patients was 45.1±12.5 years. The mean stone burden, number of sessions, and shockwaves for the whole study were 1.3±0.49 cm(2), 2.1±0.7 sessions, and 5616.6±2017.4 shockwaves, respectively. The stone-free rate of the study was 65.1%. The stone-free rates of the stones in the renal pelvis, lower, middle, and upper calices were 72.4%, 56%, 55.6%, and 69%, respectively. The stone-free rate of the stones ≤1 cm(2), 1.1 to 2 cm(2), and >2 cm(2) was 50.2%, 39.6%, and 10.2%, respectively (P<0.05).

Conclusion:
Stone burden rather than stone location is considered as a predicting factor for the outcome of SWL in a solitary renal stone, especially in the renal pelvis and lower calix.


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