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http://dx.doi.org/10.1155/2013/632790 - http://www.hindawi.com/journals/au/2013/632790/
Advances in Urology Volume 2013 (2013), Article ID 632790, 6 pages
Damage of Stone Baskets by Endourologic Lithotripters: A Laboratory Study of 5 Lithotripters and 4 Basket Types
Jens Cordes,1 Felix Nguyen,1 Birgit Lange,2 Ralf Brinkmann,2 and Dieter Jocham1
1Clinic of Urology, Luebeck Campus, University Medical Center Schleswig-Holstein, Ratzeburger Allee 160, 23538 Luebeck, Germany
2Medical Laser Center Luebeck GmbH, Ratzeburger Allee 160, 23538 Luebeck, Germany
Received 5 March 2013; Revised 6 September 2013; Accepted 12 September 2013
Academic Editor: Walid A. Farhat
Background. In some cases, the ureteral stone is simultaneously stabilized by a stone basket when endourologic lithotripsy is performed. This stabilization can be either on purpose or by accident. By accident means that an impaction in the ureter occurs by an extraction of a stone with a basket. A stabilization on purpose means to avoid a retropulsion of the stone into the kidney during lithotripsy. At this part of the operation, stone baskets have been frequently damaged. This severing of wires can lead to ureteral trauma because of hook formation. Material and Methods. In a laboratory setting, the time and the pulse numbers were measured until breaking the wires from four different nitinol stone baskets by using five different lithotripsy devices. The endpoint was gross visibledamage to the wire and loss of electric conduction. Results. The Ho:YAG laser and the ultrasonic device were able to destroy almost all the wires. The ballistic devices and the electrohydraulic device were able to destroy thin wires. Conclusion. The operating surgeon should know the risk of damage for every lithotripter. The Ho:YAG-laser and the ultrasonic device should be classified as dangerous for the basket wire with all adverse effects to the patient.
Endourology and Stones
Outcomes of Flexible Ureterorenoscopy and Laser Fragmentation for Renal Stones: Comparison Between Digital and Conventional Ureteroscope
Bhaskar K. Somania, Saeed M. Al-Qahtanib, Sixtina Diez Gil de Medinab, Olivier Traxerb
a University Hospitals Southampton National Health Services Trust, Southampton, United Kingdom
b Tenon University Hospital, Pierre and Marie Curie University, Paris, France
To compare the outcomes of flexible ureterorenoscopy and lasertripsy (FURS) using digital and conventional FURS for kidney stones.
From September 2007 to April 2011, 118 patients underwent FURS (by the same surgeon). The outcomes were compared between equal numbers of procedures (59 each) using a conventional flexible ureterorenoscope (C-FURS; Olympus URF-P5) and a digital flexible ureterorenoscope (D-FURS; Olympus URF-V). Although the deflection, working channel, and field view are similar in both, the initial and terminal diameter is 8.4F and 9.9F and 6.9F and 8.4F for the D-FURS and C-FURS, respectively. The mean stone fragmentation time was calculated by the size per operative time. The preoperative, operative, and postoperative data were retrospectively analyzed and compared.
The patient demographics were comparable. The mean stone size was 12.8 and 12 mm in the C-FURS and D-FURS groups, respectively. The initial assessment of the entire pyelocaliceal system was possible in 58 of 59 cases (98%) in the C-FURS group and 56 of 59 cases (94%) in the D-FURS group. The mean operative time was significantly longer in the C-FURS group (53.8 ± 15.2 minutes vs 44.5 ± 14.9 minutes). The overall stone-free rate 1 month after the procedure was 86% in the C-FURS group and 88% in the D-FURS group.
Although on comparison, the D-FURS had slightly limited maneuverability, comparable success rates can be achieved with both conventional and digital ureteroscopes. D-FURSs significantly reduced the operative time compared with C-FURSs.
Endourology and Stones
Percutaneous Nephrolithotomy Under Local Infiltration Anesthesia: A Single-center Experience of 2000 Chinese Cases
Hulin Li1, Kai Xu1, Bingkun Li, Binshen Chen, Abai Xu, Yuanbo Chen, Yawen Xu, Yong Wen, Shaobo Zheng, Chunxiao Liu
Department of Urology, Zhujiang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
To determine the feasibility and safety of percutaneous nephrolithotomy (PCNL) in treating upper urinary calculi under local infiltration anesthesia.
A series of 2000 patients with upper urinary calculi underwent PCNL under local infiltration anesthesia. Of the 2000 patients, 536 had upper ureteral calculi, 805 patients had pelvic calculi, and 659 patients had complex renal calculi. Pethidine premedication (75-100 mg) and Phenergan (25 mg) were used half an hour preoperatively. The mean pain scores at 0, 6, 24, and 48 hours postoperatively, the demographic characteristics, and the stones characteristics were evaluated to determine the feasibility. The complications were evaluated to determine the safety, and stone-free rate was evaluated to determine effectivity.
The mean American Society of Anesthesiologists score was 1.55 ± 0.54 (range, 1-3). The mean operative time was 48 minutes (range, 20-125). The mean Visual Analogue Scale scores at 0, 6, 24, and 48 hours postoperatively were 3.62, 3.02, 2.27, and 2.09, respectively. The mean hemoglobin drop was 1.06 g/dL (range, 0.2-6.8). Sixty-five patients (3.3%) received transfusions, 10 patients (0.5%) required selective renal angioembolism (Clavien grade II), and 1 patient (0.05%) received chest drainage therapy (Clavien grade II). The total stone-free rate was 85.8%.
Local infiltration anesthesia is a well-tolerated alternative anesthesia technique that provides effective intraoperative and postoperative analgesia for PCNL. PCNL performed under local infiltration anesthesia in a selected group of patients is feasible and provides satisfactory clinical outcomes. Comparative studies should be performed to classify efficacy, safety, tract quantity, dilation method, and the best candidates.
Endourology and Stones
Calculating the Number of Shock Waves, Expulsion Time, and Optimum Stone Parameters Based on Noncontrast Computerized Tomography Characteristics
Khaled Foda, Hussein Abdeldaeim, Mohamed Youssif, Akram Assem
Department of Urology, College of Medicine, University of Alexandria, Alexandria, Egypt
To define the parameters that accompanied a successful extracorporeal shock wave lithotripsy (ESWL), namely the number of shock waves (SWs), expulsion time (ET), mean stone density (MSD), and the skin-to-stone distance (SSD).
A total of 368 patients diagnosed with renal calculi using noncontrast computerized tomography had their MSD, diameter, and SSD recorded. All patients were treated using a Siemens lithotripter. ESWL success meant a stone-free status or presence of residual fragments <3 mm, ET was the time in days for the successful clearance of stone fragments. Correlation was performed between the stone characteristics, number of SWs, and ET. Two multiple regression analysis models defined the number of SWs and ET. Two receiver operating characteristic curves plotted the best MSD cutoff value and optimum SSD for a successful ESWL.
Three hundred one patients were ESWL successes. A significant positive correlation was elicited between number of SWs and stone diameter, density and SSD; between ET and stone diameter and density. Multiple regressions concluded 2 equations:
Number of SWs = 265.108 + 5.103 x1 + 22.39 x2 + 10.931 x3
ET (days) = −10.85 + 0.031 x1 + 2.11 x2
x1 = stone density (Hounsfield unit [HUs]), x2 = stone diameter (mm), and x3 = SSD (mm).
Receiver operating characteristic curves demonstrated a cutoff value of ≤934 HUs with 94.4% sensitivity and 66.7% specificity and P = .0211. The SSD curve showed that a distance ≤99 mm was 85.7% sensitive, 87.5% specific, P <.0001.
Stone disintegration is not recommended if MSD is >934 HUs and SSD >99 mm. The required number of SWs and the expected ET can be anticipated.
Malic Acid Supplementation Increases Urinary Citrate Excretion and Urinary pH: Implications for the Potential Treatment of Calcium Oxalate Stone Disease
To cite this article:
Allen L. Rodgers, Dawn Webber, Rachelle de Charmoy, Graham E. Jackson, and Neil Ravenscroft. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0477.
Online Ahead of Print: November 9, 2013
Online Ahead of Editing: September 23, 2013
Background and Purpose: Raising urinary pH and citrate excretion with alkali citrate therapy has been a widely used treatment in calcium nephrolithiasis. Citrate lowers ionized Ca+2 concentrations and inhibits calcium salt precipitation. Conservative alternatives containing citrate such as fruit juices have been investigated and recommended. Any compound that induces systemic alkalosis will increase citraturia. Malate, a polycarboxylic anion like citrate, is a potential candidate for chelating Ca+2 and for inducing systemic alkalinization. We undertook to investigate these possibilities.
Materials and Methods: Theoretical modeling of malic acid’s effects on urinary Ca+2 concentration and supersaturation (SS) of calcium salts was achieved using the speciation program JESS. Malic acid (1200 mg/day) was ingested for 7 days by eight healthy subjects. Urines (24 hours) were collected at baseline and on day 7. They were analyzed for routine lithogenic components, including pH and citrate. Chemical speciation and SS were calculated in both urines.
Results: Modeling showed that complexation between calcium and malate at physiological concentrations of the latter would have no effect on SS. Administration of the supplement induced statistically significant increases in pH and citraturia. The calculated concentration of Ca+2 and concomitant SS calcium oxalate (CaOx) decreased after supplementation, but these were not statistically significant. SS for the calcium phosphate salts hydroxyapatite and tricalcium phosphate increased significantly as a consequence of the elevation in pH, but values for brushite and octacalcium phosphate did not change significantly.
Conclusions: We speculate that consumption of malic acid induced systemic alkalinization leading to reduced renal tubular reabsorption and metabolism of citrate, and an increase in excretion of the latter. The decrease in SS(CaOx) was caused by enhanced complexation of Ca+2 by citrate. We conclude that malic acid supplementation may be useful for conservative treatment of calcium renal stone disease by virtue of its capacity to induce these effects.
Dietary Hydroxyproline Induced Calcium Oxalate Lithiasis and Associated Renal Injury in the Porcine Model
Sri Sivalingam, Stephen Y. Nakada, Priyanka D. Sehgal, Thomas D. Crenshaw, and Kristina L. Penniston. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0185.
Online Ahead of Print: November 12, 2013
Background and Purpose: We previously reported hyperoxaluria and calcium oxalate calculi in adult pigs (sows) fed hydroxyproline (HP). The purpose of this study was to grossly and histopathologically characterize intrarenal effects in this model.
Methods: In the swine facility at our campus, we maintained 21 gestating sows, of which 15 received daily treatment (5% HP mixed with dry feed) and 6 received no treatment (controls). Nine were sacrificed at 21 d (three control, six HP). All kidneys were extracted and examined grossly and for radiographic evidence of stones (GE CT scanner, 80kV, 400MA, 1 sec rotation, 0.625 mm slices). Papillary and cortical samples were processed for histologic analysis.
Results: Kidneys from treated sows showed significant calculi distributed within the renal papilla on CT, appeared mottled in the renal cortex and papillary areas, and had less distinct corticomedullary borders. Tiny crystals and mucinous debris lined the papillary tips, calices, and pelvis in kidneys from four of six treated sows, and multiple stones were noted at the papillary tips. Hematoxylin and eosin stain revealed crystals in collecting tubules and papillary tips in treated kidneys and none in controls. Yasue staining confirmed crystals in proximal periglomerular tubules of treated but not control animals. Tubular dilation and inflammatory/fibrotic changes were identified in kidneys from treated animals; none of these changes were evident in control kidneys.
Conclusions: We report renal damage as a result of dietary-induced hyperoxaluria in adult sows. Specifically, we found crystalluria in proximal periglomerular tubules and collecting ducts, with tubular damage at all segments.
Does Baseline Radiography of the Kidneys, Ureters, and Bladder Help Facilitate Stone Management in Patients Presenting to the Emergency Department with Renal Colic?
Kirsten Foell, Michael Ordon, Daniela Ghiculete, Jason Y. Lee, R. John D’A. Honey, and Kenneth T. Pace. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0183.
Online Ahead of Print: November 12, 2013
Background and Purpose: A baseline kidneys, ureters, and bladder (KUB) radiograph, at the time of computed tomography (CT) for ureteral stones, might aid interpretation of future KUBs. The CT scout radiograph might render the baseline KUB redundant, however. We sought to assess the diagnostic utility of baseline KUB for patients with ureteral stones.
Patients and Methods: Patients with ureteral stones were retrospectively identified. All had a baseline KUB in addition to CT and were reassessed after 4 to 60 days with KUB. Each patient’s imaging was randomized 1:1 into either “KUB&CT” or “CT” groups. Three urologists independently assessed the imaging: CT (with scout film) and baseline KUB in the KUB&CT group, but only the CT (not KUB) in the CT group. Definitive stone assessment on follow-up KUB was defined as all three reviewers answering either Yes or No (not Indeterminate) to the question of stone passage or migration.
Results: Of 154 stones, the mean diameter was 4.8±2.1 mm, density was 914±300 Hounsfield units (HU), with 54.4% in the distal ureter. Stone visibility was 60.4% on KUB vs 43.5% on scout film (P<0.001). Scout film visibility favored the CT group (52.7 vs 35.0%, P=0.027). After adjusting for body mass index, skin-to-stone distance, size, density, and location, definitive assessment rates were higher in the KUB&CT group (P=0.047). When reviewers reassessed the CT group using the baseline KUB, they were able to do so definitively in an additional 16 (21.6%, P<0.001). Definitive assessments were associated with higher rates of stone visibility on scout film (86.1 vs 21.1%, P<0.001), KUB (86.1 vs 50.0%, P<0.001), and larger (6.0 vs 3.7 mm, P<0.001), denser stones (1046 vs 802 HU, P<0.001).
Conclusions: The addition of a baseline KUB to the CT scout film improves the ability of urologists to determine stone outcome when following patients with KUB imaging and might reduce the subsequent need for additional imaging.
Minimally Invasive Percutaneous Management of Large Bladder Stones with a Laparoscopic Entrapment Bag
Yung K. Tan, Dilan M. Gupta, Aaron Weinberg, August J. Matteis, Sunny Kotwal, and Mantu Gupta. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0127.
Online Ahead of Print: November 12, 2013
Online Ahead of Editing: September 27, 2013
Introduction: The treatment of large volume bladder stones is a management conundrum. Transurethral methods are plagued by long operative times, trauma to the bladder mucosa, and the need for a postoperative urethral catheter. Open cystolithotomy has higher morbidity. We present the percutaneous management of bladder stones with the novel use of a laparoscopic entrapment bag.
Materials and Methods: Twenty-five patients (mean age 65.7), including 22 men and 3 women, 4 with a neurogenic bladder and 21 with a prior diagnosis of benign prostatic hyperplasia, underwent our novel technique. The mean number of stones was 6.8±8.0 (range, 1 to 30) and total stone burden 10.4±10.5 cm (range, 3.0 to 50.0 cm). Using regional or general anesthesia and flexible cystoscopic guidance, percutaneous bladder access was achieved. The tract was balloon dilated to 30F and stones captured in a laparoscopic entrapment bag. The bag’s opening was exteriorized and stone fragmentation and comminution were achieved using a nephroscope and pneumatic or ultrasonic lithotripters. The bag was extracted and a 22F suprapubic catheter was inserted into the bladder; the patient was discharged the next day after a voiding trial. The procedure was done without fluoroscopy. No foley catheter was necessary.
Results: All patients were rendered stone free. The mean estimated blood loss was 11.1±3.93 mL (range, 10 to 25 mL). The mean operative time was 102.3 minutes. There was minimal trauma to the bladder mucosa and no complications of fluid extravasation, hematuria, or urethral trauma were noted. All patients were discharged within 24 hours of the operation.
Conclusion: Percutaneous cystolithotomy with the use of an entrapment bag is an efficient, safe technique for treating large volume bladder calculi. We recommend this technique as an alternative to open surgery for patients with too large a stone burden to remove transurethrally.
Management of Stones Associated with Intrarenal Stenosis: Infundibular Stenosis and Caliceal Diverticulum
Steven G. Koopman and Gerhard Fuchs. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0186.
Online Ahead of Print: November 19, 2013
Purpose: To review our experience with retrograde intrarenal surgery (RIRS) for management of conditions associated with intrarenal stricture and present a treatment algorithm based on the series.
Patients and Methods: RIRS was offered to all patients with symptomatic intrarenal stenosis regardless of location if stone burden was 2 cm or less. With a combined endourology and lithotripsy table, patients with stones between 2 and 3 cm were also offered RIRS using a combined approach of RIRS and shockwave lithotripsy (SWL). A total of 108 patients with symptomatic stones and caliceal diverticulum or infundibular stenosis were included in the data analysis. A standard technique was used in all cases. Failures or patients not suitable for RIRS were treated with either percutaneous nephrolithotomy (PCNL) or laparoscopic surgery.
Results: Successful identification and dilation/incision of the stenotic opening was accomplished in 94% of cases. Seventy-five percent of stones were managed with basketing and/or holmium laser ablation. In these patients, 90% were stone free (<2 mm stone fragments). For stones between 2 and 3 cm, the use of holmium laser in combination with SWL provided stone-free rates of 75%. Five percent of patients needed PCNL because of larger stone burden and posterior location.
Conclusions: With the appropriate equipment, RIRS provides a valid treatment option for patients with intrarenal strictures. While upper pole and midrenal lesions are ideal, lower pole segments may be approached as well. A treatment algorithm based on the results provides a simplified approach for the minimally invasive management of intrarenal stenosis.
Flexible Ureterorenoscopy for Lower Pole Stones: Influence of the Collecting System’s Anatomy
Jan Peter Jessen, Patrick Honeck, Thomas Knoll, and Gunnar Wendt-Nordahl. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0401.
Online Ahead of Print: November 19, 2013
Online Ahead of Editing: October 1, 2013
Background: The impact of renal anatomy on the success rate of flexible ureterorenoscopy (fURS) for lower pole stones is less clear than it is on shock wave lithotripsy, for which it is a recognized influence factor. We analyzed safety and efficiency of fURS using modern endoscopes for lower pole stones dependent on the collecting system’s configuration.
Patients and Methods: We retrospectively evaluated a consecutive sample of 111 fURS for lower pole stones at our tertiary care center between January 2010 and September 2012 from our prospectively kept database. All procedures were performed with modern flexible ureterorenoscopes, nitinol baskets, holmium laser lithotripsy, and ureteral access sheaths whenever needed. The infundibular length (IL) and width (IW) and infundibulopelvic angle (IPA) were measured and the data were stratified for stone-free status and complications classified by the Clavien–Dindo scale. Univariate and multifactorial statistical analyses were performed. Correlation of operation time (OR-time) with anatomical parameters was conducted.
Results: Ninety-eight (88.3%) of the 111 patients were stone free after a single fURS. On multifactorial analysis, the stone size and IL had significant influence on the stone-free rate (SFR) (p<0.01), whereas IW did not. An acute IPA (<30°) also had significant influence (p=0.01). The incidence of complications and OR-time were not influenced by the pelvicaliceal anatomy.
Conclusions: fURS is a safe and efficient treatment option for lower pole kidney stones. A long infundibulum and a very acute IPA (<30°) negatively affect the SFR. However, with second look procedures, a complete stone clearance is achievable even in case of unfavorable anatomic conditions. A narrow infundibulum has no negative effect while using modern endoscopes. The complication rate is not affected by the collecting system’s anatomy.
Prospective Randomized Controlled Trial Comparing Laser Lithotripsy with Pneumatic Lithotripsy in Miniperc for Renal Calculi
Raguram Ganesamoni, Ravindra B. Sabnis, Shashikant Mishra, Narendra Parekh, Arvind Ganpule, Jigish B. Vyas, Jitendra Jagtap, and Mahesh Desai. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0177.
Online Ahead of Print: November 19, 2013
Background and Purpose: The energy source used for stone fragmentation is important in miniperc. In this study, we compared the stone fragmentation characteristics and outcomes of laser lithotripsy and pneumatic lithotripsy in miniperc for renal calculi.
Patients and Methods: After Institutional Review Board approval, 60 patients undergoing miniperc for renal calculi of 15 to 30 mm were equally randomized to laser and pneumatic lithotripsy groups. Miniperc was performed using 16.5F Karl Storz miniperc sheath and a 12F nephroscope. Laser lithotripsy was performed using a 550-μm laser fiber and 30 W laser with variable settings according to the need. Pneumatic lithotripsy was performed using the EMS Swiss lithoclast. Patient demographics, stone characteristics, intraoperative parameters, and postoperative outcomes were analyzed.
Results: The baseline patient demographics and stone characteristics were similar in both groups. The total operative time (P=0.433) and fragmentation time (P=0.101) were similar between the groups. The surgeon assessed that the Likert score (1 to 5) for fragmentation was similar in both groups (2.1±0.8 vs 1.9±0.9, P=0.313). Stone migration was lower with the laser (1.3±0.5 vs 1.7±0.8, P=0.043), and fragment removal was easier with the laser (1.1±0.3 vs 1.7±1.1, P=0.011). The need for fragment retrieval using a basket was significantly more in the pneumatic lithotripsy group (10% vs 37%, P=0.002). The hemoglobin drop, complication rates, auxiliary procedures, postoperative pain, and stone clearance rates were similar between the groups (P>0.2).
Conclusion: Both laser lithotripsy and pneumatic lithotripsy are equally safe and efficient stone fragmentation modalities in miniperc. Laser lithotripsy is associated with lower stone migration and easier retrieval of the smaller fragments it produces.
Contemporary Management of Struvite Stones Using Combined Endourologic and Medical Treatment: Predictors of Unfavorable Clinical Outcome
Muhammad Waqas Iqbal, Ramy F. Youssef, Andreas Neisius, Nicholas Kuntz, Jonathan Hanna, Michael N. Ferrandino, Glenn M. Preminger, and Michael E. Lipkin. Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2013.0257.
Online Ahead of Print: November 19, 2013
Background and Purpose: Struvite stones have been associated with significant morbidity and mortality, yet there has not been a report on the medical management of struvite stones in almost 20 years. We report on the contemporary outcomes of the surgical and medical management of struvite stones in a contemporary series.
Patients and Methods: A retrospective review of patients who were treated with percutaneous nephrolithotomy (PCNL) for struvite stones at Duke University Medical Center between January 2005 and September 2012 identified a total of 75 patients. Of these, 43 patients had adequate follow-up and were included in this analysis. Stone activity, defined as either stone recurrence or stone-related events, and predictors of activity were evaluated after combined surgical and medical treatment.
Results: The study included 43 patients with either pure (35%) or mixed (65%) struvite stones with a median age of 55±15 years (range 21–89 years). The stone-free rate after PCNL was 42%. Stone recurrence occurred in 23% of patients. Postoperatively, 30% of patients had a stone-related event, while 60% of residual stones remained stable with no growth after a median follow-up of 22 months (range 6–67 mos). Kidney function remained stable during follow-up. Independent predictors of stone activity included the presence of residual stones >0.4 cm2, preoperative large stone burden (>10 cm2), and the presence of medical comorbidities (P<0.05).
Conclusions: Struvite stones can be managed safely with PCNL followed by medical therapy. The majority of patients with residual fragments demonstrated no evidence of stone growth on medical therapy. With careful follow-up and medical management, kidney function can be maintained and stone morbidity can be minimized. Initial large stone burden, residual stones after surgery, and associated medical comorbidities may have deleterious effect on stone recurrence or residual stone-related events.
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