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Newsletter 04-16

http://www.goldjournal.net/article/S0090-4295(16)30011-5/abstract?rss=yes

Factors Associated with Preventive Pharmacological Therapy Adherence among Patients with Kidney Stones

Casey A. Dauw, MD, Yooni Yi, MD, Maggie J. Bierlein, MS, Phyllis Yan, MS, Abdulrahman F. Alruwaily, MD, Khurshid R. Ghani, MD, J. Stuart Wolf, MD, Brent K. Hollenbeck, MD, MS, John M. Hollingsworth, MD, MS

Department of Urology, From the Divisions of Endourology and Health Services Research, University of Michigan Medical School

DOI: http://dx.doi.org/10.1016/j.urology.2016.03.030

Abstract

Objective

To determine adherence patterns for thiazide diuretics, alkali citrate therapy, and allopurinol, collectively referred to as preventive pharmacological therapy (PPT), amongst patients with kidney stones.

Materials and Methods

Using medical claims data, we identified adults diagnosed with kidney stones between 2002 and 2006. Through National Drug Codes, we determined those with one or more prescription fills for a PPT agent. We measured adherence to PPT [as determined by the proportion-of-days-covered (PDC) formula] within the first 6 months of starting therapy and performed multivariate analysis to evaluate patient factors associated with PPT adherence.

Results

Among 7,980 adults with kidney stones who were prescribed PPT, less than one third (30.2%) were adherent to their regimen (indicated by PDC=80%). Among those on monotherapy, rates of adherence differed by the type of PPT agent prescribed: 42.5% for thiazides, 40.0% for allopurinol, and 13.4% for citrate therapy. Factors that were independently associated with lower odds of PPT adherence included combination therapy receipt, female gender, less generous health insurance, and residence in the South or Northeast. In contrast, older patients and those with salaried employment had a higher probability of PPT adherence.

Conclusions

Adherence to PPT is low. These findings help providers identify patients where PPT adherence will be problematic. Moreover, they suggest possible targets for quality improvement efforts in the secondary prevention of kidney stones.

***

http://www.ncbi.nlm.nih.gov/pubmed/26968488

Irreversible Renal Function Impairment due to Silent Ureteral Stones

Giovanni S. Marchini, Fábio Carvalho Vicentini, Manoj Monga, Fábio César Miranda Torricelli, Alexandre Danilovic, Artur Henrique Brito, Cesar Câmara, Miguel Srougi, Eduardo Mazzucchi

1 Section of Endourology, Division of Urology, Hospital das Clínicas, University of Sao Paulo Medical School, Sao Paulo, Brazil

2 Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio

Abstract

Objective

to evaluate if renal function loss and hydronephrosis due to a silent ureteral stone might be reversed.

Methods

We prospectively selected patients with silent ureteral stones between Jan/06-Jan/14. A silent case was considered if there were no specific or subjective symptoms related to the ureteral stone. Patient, stone and kidney characteristics were evaluated preoperatively, three and twelve months postoperatively. Renal function was accessed in the same intervals with serum creatinine (sCr), glomerular filtration rate (GFR) and 99mTc-DMSA. Patients without complete pre and postoperative evaluation were excluded. Primary end-point was mid-term progress of global and ipsilateral renal function. Secondary end-points included the evaluation of renal and collecting system anatomy from diagnosis to 12 months after treatment. ANOVA with repeated measures and marginal homogeneity test were used to evaluate renal function and hydronephrosis progression.

Results

Twenty-six patients met our inclusion criteria. Mean preoperative SCr and GFR was 1.24mg/dL and 72.5ml/min, respectively. At initial scintigraphy, mean renal function was 33.4%. Laser ureterolithotripsy was performed in 84.6% of cases and all patients were rendered stone free. Two patients (8%) developed ureteral stenosis. There was no difference regarding SCr (p=0.89), GFR (p=0.48) and renal function at scintigraphy (p=0.19) during follow-up. Hydronephrosis significantly improved from pre to three months postoperatively (p<0.0001), but not from three to twelve months (p=0.065).

Conclusions

Patients with silent ureteral stones present with significant impairment of ipsilateral renal function and hydronephrosis at diagnosis. On mid-term follow-up evaluation, renal function of the affected unit remains stable while hydronephrosis improves after treatment.

http://link.springer.com/article/10.1007/s00240-016-0879-4

Urolithiasis. 2016 Apr 4. [Epub ahead of print]

Effect of anxiety and pain on success of shockwave lithotripsy (SWL) for treatment of proximal ureteral and renal pelvic stones.

Ucer O1, Ceylan Y2, Ekren F3, Ozan E4, Muezzinoglu T5.

Abstract

The aim of this study is to evaluate the impact of anxiety and pain on success of shockwave lithotripsy (SWL) for treatment of proximal ureteral and renal pelvic stones smaller than 15 mm. One hundred thirty-two patients with proximal ureteral or renal pelvic stones <15 mm who were treated by a SWL and forty controls were enrolled in the study. State-trait anxiety inventory (STAI) was used to assess anxiety of the controls and patients (before every SWL session). Pains of the patients were measured by a visual analog scale (VAS) at three times (T) of the sessions (T11 at 11 kV, T15 at 15 kV and T end of treatment). The mean STAI scores of the patients at the first SWL session and controls were 40.61 ± 8.71 and 36.11 ± 8.18, respectively (p < 0.05). There was statistically positive moderate relationship between STAI and VAS scores at the first SWL session. The mean size of stone in men and women were 11.16 ± 2.88 and 11.00 ± 3.41, respectively (p = 0.88). In the first session, the mean STAI and VAS scores of the men were significantly lower than the women. The stone-free rate (SFR) of SWL was 72.7 % in this study. The SFR of SWL in the men and women were 78 and 64 %, respectively (p < 0.05). Our data showed that the severity of anxiety and pain in the women were higher than the men. SFR of SWL in the men was higher than the women. The severity of anxiety and pain in the patients may affect SFR of SWL.

http://www.ncbi.nlm.nih.gov/pubmed/27038481

Urolithiasis. 2016 Apr 1. [Epub ahead of print]

The influence of maternal and paternal history on stone composition and clinical course of calcium nephrolithiasis in subjects aged between 15 and 25.

Guerra A1,2, Ticinesi A3,4, Allegri F1,2, Nouvenne A1,2, Pinelli S2, Folesani G5, Lauretani F1, Maggio M1,2, Borghi L1,2, Meschi T1,2.

1Geriatric Rehabilitation Department, University-Hospital of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy.

2Department of Clinical and Experimental Medicine, University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy.

3Geriatric Rehabilitation Department, University-Hospital of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy. andrea.ticinesi@unipr.it.

4Department of Clinical and Experimental Medicine, University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy. andrea.ticinesi@unipr.it.

5INAIL-CERT Research Center at University of Parma, Via Antonio Gramsci 14, 43126, Parma, Italy.

Abstract

Our aim was to compare the influence of maternal history of stones (MHS) and paternal history of stones (PHS) on composition of calculi and disease course in a group of patients with calcium nephrolithiasis (CN) aged between 15 and 25, the age range with the maximal influence of family history on disease expression. One-hundred thirty-five patients (68 F) with CN and one stone-forming parent were retrospectively selected from the database of our outpatient stone clinic, and categorized according to MHS or PHS. Data about stone disease course and composition of passed calculi, determined by chemical analysis or Fourier-transformed infrared spectrophotometry, were collected together with information on blood chemistry and 24-h urinary profile of lithogenic risk. The characteristics of disease course and stone composition were compared using logistic regression tests adjusted for age, sex, and BMI or analysis of covariance where appropriate. Patients with MHS (n = 46) had significantly higher urinary calcium/creatinine ratio and ammonium, a higher prevalence of urological treatments (57 vs 27 %, p < 0.001) and mixed calcium oxalate/calcium phosphate stone composition (69 vs 35 %, p = 0.002) than those with PHS. At multivariate logistic regression models, MHS was independently associated with urological treatments (OR 4.5, 95 %CI 1.9-10.7, p < 0.001) and the formation of calculi with mixed calcium oxalate/calcium phosphate composition (OR 5.8, 95 %CI 1.9-17.9, p = 0.002). The method of stone analysis did not affect this result. In conclusion, in subjects aged 15-25, MHS is associated with mixed calcium stones and with a higher risk for urological procedures, and should be, therefore, considered in the management of urolithiasis.

http://atm.amegroups.com/article/view/9412/10102

Management of lower pole renal stones: the devil is in the details

Berkan Resorlu, Yasar Issi, Kadir Onem, Cankon Germiyanoglu

Department of Urology, Ondokuz Mayis University, Faculty of Medicine, Samsun 55270, Turkey

Abstract:

Shock wave lithotripsy (SWL), retrograde intrarenal surgery (RIRS) and minimally invasive percutaneous nephrolithotomy (MIP) are highly effective treatment options for lower pole stones up to 2 cm. Selecting the best treatment modality represents a controversial area in urology, because each treatment methods have their own advantages and disadvantages. Donaldson and co-workers have recently published a very comprehensive review and meta-analysis to compare the benefits and harms of SWL, RIRS and PNL techniques.

http://www.ncbi.nlm.nih.gov/pubmed/27042952

J Endourol. 2016 Apr 4. [Epub ahead of print]

Computed Tomography-based Novel Prediction Model for The Outcome of Shockwave Lithotripsy in Proximal Ureteral Stones

Park HS1, Gong MK2, Yoon CY3, Moon DG4, Cheon J5, Choi YD6.

Abstract

INTRODUCTION AND OBJECTIVES:

Computed Tomography (CT) is one of the most commonly used diagnostic modalities for urinary stone disease. In the current study we developed a CT and clinical parameter-based prediction model for shockwave lithotripsy (SWL) outcome in proximal ureteral stones.

MATERIALS AND METHODS:

Data from 223 patients with single proximal ureteral stones treated with SWL between January 2009 and January 2015 were reviewed retrospectively. Clinical parameters including age, sex, body weight, and BMI (body mass index) were analyzed in combination with stone-related CT parameters (stone diameter, height, volume, location, Hounsfield units (HU), stone-to-skin distance (SSD)) and secondary signs (hydronephrosis, perinephric edema, and rim sign). Based on the cutoff values determined by c-statistics, a scoring system for the prediction of SWL outcome was developed.

RESULTS:

The success rate was 65.9% (147 / 223), and in univariate analysis body weight, BMI, SSD (vertical, horizontal), HU, stone diameter, height, volume, and all secondary signs were significantly associated with the success of SWL. However, on multivariate analysis only BMI (OR = 1.322, CI 1.156-1.512, p = 0.00), stone diameter (OR = 1.397, CI 1.259-1.551, p = 0.00), and perinephric edema (grade 0-1 vs. 3-4, OR = 2.831, CI 1.032-7.764, p = 0.043) were independent predictors of SWL success. The prediction model based on the logistic regression analysis was as follows: SWL success = 1 / (1 + exp (-10.165 + 0.279  (BMI) + 0.334  (diameter) + 1.040 (perinephric edema)), having an AUC of 0.881. In the prediction model based on these parameters, scores of 0, 1, 2, and 3 correlated with SWL success rates of 98.5%, 65.7%, 31.4%, and 0%, respectively.

CONCLUSIONS:

BMI, stone diameter, and perinephric edema were independent predictors of SWL outcome and a prediction model based on these parameters will facilitate decision-making for SWL in proximal ureteral stones.

http://www.ncbi.nlm.nih.gov/pubmed/26966587

Arab J Urol. 2016 Mar;14(1):12-7. doi: 10.1016/j.aju.2015.11.004. Epub 2015 Dec 31.

Silodosin vs tamsulosin in the management of distal ureteric stones: A prospective randomised study.

Elgalaly H1, Sakr A1, Fawzi A1, Salem EA1, Desoky E1, Shahin A1, Kamel M1.

Abstract

OBJECTIVES:

To compare the efficacy of silodosin (8 mg) vs tamsulosin (0.4 mg), as a medical expulsive therapy, in the management of distal ureteric stones (DUS) in terms of stone clearance rate and stone expulsion time.

PATIENTS AND METHODS:

A prospective randomised study was conducted on 115 patients, aged 21-55 years, who had unilateral DUS of ⩽10 mm. Patients were divided into two groups. Group 1 received silodosin (8 mg) and Group 2 received tamsulosin (0.4 mg) daily for 1 month. The patients were followed-up by ultrasonography, plain abdominal radiograph of the kidneys, ureters and bladder, and computed tomography (in some cases).

RESULTS:

There was a significantly higher stone clearance rate of 83% in Group 1 vs 57% in Group 2 (P = 0.007). Group 1 also showed a significant advantage for stone expulsion time and analgesic use. Four patients, two in each group, discontinued the treatment in first few days due to side-effects (orthostatic hypotension). No severe complications were recorded during the treatment period. Retrograde ejaculation was recorded in nine and three patients in Groups 1 and 2, respectively.

CONCLUSION:

Our data show that silodosin is more effective than tamsulosin in the management of DUS for stone clearance rates and stone expulsion times. A multicentre study on larger scale is needed to confirm the efficacy and safety of silodosin.

http://www.ncbi.nlm.nih.gov/pubmed/27007650

Braz J Med Biol Res. 2016;49(4):e4878. doi: 10.1590/1414-431X20154878. Epub 2016 Mar 18.

Comparison of totally tubeless percutaneous nephrolithotomy and standard percutaneous nephrolithotomy for kidney stones: a randomized, clinical trial

Moosanejad N1, Firouzian A2, Hashemi SA3, Bahari M4, Fazli M4.

Abstract

This study aimed to compare the totally tubeless percutaneous nephrolithotomy and standard percutaneous nephrolithotomy techniques regarding their rates of success and complications in patients with kidney stones. Patients were randomly assigned to two groups. Forty-four patients (24 men; mean age: 50.40±2.02 years) received totally tubeless percutaneous nephrolithotomy (PCNL; no nephrostomy catheter or ureteral catheter after PCNL) and 40 patients (18 men; mean age: 49.95±13.38 years) underwent standard PCNL (a nephrostomy catheter and ureteral catheter were used after PCNL). All surgeries were performed by one surgeon. Postoperative changes in hemoglobin, the blood transfusion rate, changes in creatinine levels, operation time, analgesic need, hospitalization time, and complication rate were compared between the groups. No significant differences were observed in age, gender, stone size, and surgery side between the groups (P<0.05). The operation time was significantly lower in the totally tubeless PCNL group than in the standard PCNL group (P=0.005). Pethidine requirements were significantly higher in the standard PCNL group than the totally tubeless PCNL group (P=0.007). Hospitalization time was significantly higher in the standard PCNL group than in the totally tubeless PCNL group (P<0.0001). The complication rate was 15% in the standard PCNL group and 9.1% in the totally tubeless PCNL group (P=0.73). The totally tubeless PCNL technique is safe and effective, even for patients with staghorn stones. This technique is associated with decreased pain, analgesic needs, and operative and hospitalization time. We believe that a normal peristaltic ureter is the best drainage tube.

http://www.ncbi.nlm.nih.gov/pubmed/27035621

Sci Rep. 2016 Apr 1;6:23988. doi: 10.1038/srep23988.

Stone heterogeneity index as the standard deviation of Hounsfield units: A novel predictor for shock-wave lithotripsy outcomes in ureter calculi.

Lee JY1, Kim JH2, Kang DH1, Chung DY1, Lee DH1, Do Jung H3, Kwon JK4, Cho KS5.

Abstract

We investigated whether stone heterogeneity index (SHI), which a proxy of such variations, was defined as the standard deviation of a Hounsfield unit (HU) on non-contrast computed tomography (NCCT), can be a novel predictor for shock-wave lithotripsy (SWL) outcomes in patients with ureteral stones. Medical records were obtained from the consecutive database of 1,519 patients who underwent the first session of SWL for urinary stones between 2005 and 2013. Ultimately, 604 patients with radiopaque ureteral stones were eligible for this study. Stone related variables including stone size, mean stone density (MSD), skin-to-stone distance, and SHI were obtained on NCCT. Patients were classified into the low and high SHI groups using mean SHI and compared. One-session success rate in the high SHI group was better than in the low SHI group (74.3% vs. 63.9%, P = 0.008). Multivariate logistic regression analyses revealed that smaller stone size (OR 0.889, 95% CI: 0.841-0.937, P < 0.001), lower MSD (OR 0.995, 95% CI: 0.994-0.996, P < 0.001), and higher SHI (OR 1.011, 95% CI: 1.008-1.014, P < 0.001) were independent predictors of one-session success. The radiologic heterogeneity of urinary stones or SHI was an independent predictor for SWL success in patients with ureteral calculi and a useful clinical parameter for stone fragility.

http://www.ncbi.nlm.nih.gov/pubmed/27056703

Lasers Med Sci. 2016 Apr 7. [Epub ahead of print]

Comparison of the clinical efficacy and safety of retroperitoneal laparoscopic ureterolithotomy and ureteroscopic holmium laser lithotripsy in the treatment of obstructive upper ureteral calculi with concurrent urinary tract infections

Jiang JT1, Li WG1, Zhu YP1, Sun WL2, Zhao W1, Ruan Y1, Zhong C1, Wood K3, Wei HB4, Xia SJ1, Sun XW5.

Abstract

The aim of this study is to compare the clinical efficacy and safety of retroperitoneal laparoscopic ureterolithotomy (RPLU) and ureteroscopic holmium laser lithotripsy (UHLL) as two minimally invasive procedures in managing obstructive upper ureteral calculi with concurrent urinary tract infections (UTI). The retrospective study included 189 patients who underwent unilateral obstructive upper ureteral stones with concurrent UTI from January 2007 to November 2014 at our institution. Patients received RPLU (81 cases) or UHLL (108 cases). All patients received preoperative anti-infection treatment (indwelling ureteral stent and/or preoperative antibiotics). Collected data, including sex, age, stone size, success rate, operation duration, post-operation hospitalization time, and post-operation complications, were compared. All patients were followed up for more than 6 months after surgeries, and no ureterostenosis occurred. The study included 189 patients, 41 (21.7 %) females and 148 (78.3 %) males with a medium age of 52 years (range 22-81 years). All surgeries were successfully performed without conversion to open surgery. Stone size in the RPLU group was larger than that of the UHLL group (16.1 ± 1.4 vs. 10.4 ± 1.6 mm, P = 0.012). Operative duration (P = 0.009) and hospitalization time (P < 0.001) in the UHLL group were significantly shorter than those in the RPLU group, whereas stone clearance rate was significantly higher in the RPLU group (100 vs. 88.9 %, P = 0.002). Of note, postoperative fever was more common in patients treated with UHLL (15 cases) versus RPLU (4 cases) (13.9 vs. 4.9 %, P = 0.043). Moreover, in the UHLL group, three patients without a preoperative indwelling ureteral stent were complicated with sepsis, which was not seen in RPLU group. In our study, the safety and stone clearance rate of RPLU are better than those of UHLL in the treatment of unilateral upper ureteric calculi with concurrent UTI. Preoperative antibiotics and indwelling ureteral stent may reduce the risk of postoperative infections.

Newsletter 11-14

I migliori abstracts sulla calcolosi, scelti per voi dal vostro

Marco Puglisi



http://online.liebertpub.com/doi/abs/10.1089/end.2014.0264

Hemostatic Plug: Novel Technique for Closure of Percutaneous Nephrostomy Tract

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014.0264.

Joel E. Abbott, DO,1 Arman Cicic, DO,1 Roger W. Jump III, DO,1 and Julio G. Davalos, MD2

1Department of Urology, Michigan State University, St. John Providence Health, Warren, Michigan.
2Department of Urology, University of Maryland, Chesapeake Urology Associates, Glen Burnie, Maryland.

Abstract

Percutaneous nephrolithotomy (PCNL) is a standard treatment for patients with large or complex kidney stones. The procedure has traditionally included postoperative placement of a nephrostomy tube to allow for drainage and possible reentry. This practice was first implemented after complications incurred after tubeless PCNL in a small patient population. Recently, tubeless PCNL has reemerged as a viable option for selected patients, resulting in decreased pain and analgesic use, shorter hospitalization, quicker return to normal activity, and decreased urine extravasation. Gelatin matrix sealants are occasionally used in nephrostomy tract closure. Techniques for delivery of these agents have been ill described, and placement may be performed with varying results. We present a literature review comparing tubeless PCNL to its traditional variant with indications for use of each, as well as a comparison of agents used in closure.
Finally, we outline a novel, reproducible technique for closure of the dilated percutaneous renal access tract.


http://online.liebertpub.com/doi/abs/10.1089/end.2014.0231

A Novel Device to Prevent Stone Fragment Migration During Percutaneous Lithotripsy

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014.0231.

Justin I. Friedlander, MD,1 Jodi A. Antonelli, MD,1 Heather Beardsley, PhD,2 Stephen Faddegon, MD,1 Monica S.C. Morgan, MD,1 Jeffrey C. Gahan, MD,1 Margaret S. Pearle MD, PhD,1 and Jeffrey A. Cadeddu, MD1

1Department of Urology, University of Texas Southwestern Medical Center, Dallas, Texas.
2Department of Engineering, University of Texas Arlington, Arlington, Texas.

Abstract

Purpose: We developed a novel device to capture stones in vivo in an enclosed bag (PercSac) to prevent dispersion of stone fragments during percutaneous nephrolithotomy (PCNL) or cystolitholapaxy. We report on our initial feasibility trials of the PercSac device.

Materials and Methods: PercSac consists of a specially designed polyethylene bag that is fitted over the shaft of a rigid nephroscope.
The bag is used to first entrap the target stone, then tighten around it to allow fragmentation within the bag. Matched pairs of 10 canine bladder stones (2.5 cm maximum diameter) were fragmented in a human bladder model using the CyberWand™ (Olympus America, Inc.), and the procedure was assessed for markers of efficiency and effectiveness.

Results: Median time to entrap the stone within the PercSac was 67 seconds (range 51–185 sec). Median time for stone fragmentation was significantly shorter with the PercSac than without (182.0 sec [range 108–221] vs 296.5 sec [range 226–398], P=0.004). Overall, however, there was no significant difference in the total time to entrap and fragment the stones between the two groups. A stone-free state was not achieved for any trial without the PercSac, while 9 of 10 trials with the PercSac resulted in a stone-free state.

Conclusions: Use of the PercSac in conjunction with stone fragmentation has the potential to reduce the occurrence of residual fragments after PCNL or cystolitholapaxy. Further in vitro testing in a kidney model is planned.


http://online.liebertpub.com/doi/abs/10.1089/end.2014.0421

Totally Tubeless Versus Standard Percutaneous Nephrolithotomy for Renal Stones: Analysis of Clinical Outcomes and Cost

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014.0421.

Sae Woong Choi, MD, Kang Sup Kim, MD, Jeong Ho Kim, MD, Yong Hyun Park, MD, PhD, Woong Jin Bae, MD, PhD, Sung-Hoo Hong, MD, PhD, Ji Youl Lee, MD, PhD, Sae Woong Kim, MD, PhD, Tae-Kon Hwang, MD, PhD, and Hyuk Jin Cho, MD, PhD
Department of Urology, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea.

Abstract

Purpose: To evaluate the safety and cost-effectiveness of a totally tubeless percutaneous nephrolithotomy (PCNL) by comparing the clinical outcomes and cost analysis between standard PCNL and totally tubeless PCNL for renal stones.

Patients and Methods: From June 2012 to September 2013, a total of 121 patients with renal stones who underwent totally tubeless or standard PCNL by two experienced surgeons were retrospectively evaluated by group. According to the surgeon’s preference for the nephrostomy tube and/or ureteral stent, the present study was designed to be divided into Group 1 and Group 2. Group 1 was performed by one surgeon (H.J. Cho) who preferred a totally tubeless PCNL and Group 2 was performed by the other surgeon (S.H. Hong) who preferred a standard PCNL. We excluded bilateral renal stones, multiple approach, whole staghorn calculi, and previous renal surgery. Patient and stone characteristics, intraoperative and postoperative parameters, and cost analysis were compared between the two groups.

Results: There were no significant differences in the patient demographics between groups. Mean stone burden was 501.5±361.1 mm2 in Group 1 versus 535.2±353.1 mm2 in Group 2 (P=0.651). Length of hospital stay (1.72±0.58 v 4.10±1.88 days, P<0.001), postoperative pain scores using a visual analog scale (day 0: P<0.001, day 1: P=0.002), and analgesia requirements (33.2±21.3 v 45.2±19.5 mg, P=0.005) for Group 1 versus Group 2 showed significant differences. The stone-free rate was 86.4% versus 89.8% in Group 1 and Group 2, respectively (P=0.609). There were no significant differences in overall complications between groups (P=0.213). Mean total medical treatment costs in Groups 1 and 2 were 2398.22±549.1 USD and 2845.70±824.2 USD, respectively (P=0.002).

Conclusions: Many clinical outcomes in the totally tubeless PCNL showed comparable or better results than standard PCNL. We believe that totally tubeless PCNL is an acceptable, safe, and cost-effective alternative to standard PCNL for the treatment of renal stones.


http://online.liebertpub.com/doi/abs/10.1089/end.2014.0239

Percutaneous Nephrolithotomy in Patients with Urinary Tract Abnormalities

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014.0239.

Philippe D. Violette, MD, CM, Marie Dion, MD, Thomas Tailly, MD, John D. Denstedt, MD, and Hassan Razvi, MD Department of Surgery, Division of Urology, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada.

Abstract

Background and Purpose: Patients with urinary tract abnormalities are at an increased risk of stone formation. Percutaneous nephrolithotomy (PCNL) plays an important role in the treatment of this patient population; however, outcomes are less well defined compared with patients with normal urinary tract anatomy. Our objective was to evaluate the influence of urinary tract abnormalities on intraoperative and postoperative outcomes with PCNL.

Patients and Methods: We report on a single-center prospective database of 2284 consecutive PCNLs in 1935 patients from 1990 to 2012.
For the purposes of this analysis, patients were categorized by the presence or absence of a urinary tract abnormality. Multivariable analyses were used to identify independent predictors of the length of hospital stay, operative time, complications, and residual stones at discharge and 3 months.

Results: A urinary tract abnormality was present in 14.4% (n=330) of the cohort. On univariable analysis, patients with urinary tract abnormalities were more likely to present with urinary tract infection (28% vs 19%, P<0.001) and less likely to present with hematuria (13% vs 19%, P<0.02). On multivariable regression, a urinary tract abnormality was predictive of residual stone at discharge, need for a secondary procedure, but did not increase the risk of residual stone at 3 months or the development of complications. Operative time and hospital stay were only moderately prolonged.

Conclusion: Patients with urinary tract abnormalities who undergo PCNL have a higher risk of residual stones at discharge and need for secondary procedures, but comparable complication rates, operative time, and hospital stay.


http://online.liebertpub.com/doi/abs/10.1089/end.2014-0190.ECC

Do We Really Need Kidneys-Ureters-Bladder Radiography to Predict Stone Radiopacity Before Treatment with Shockwave Lithotripsy? Development and Internal Validation of a Novel Predictive Model Based on Computed Tomography Parameters

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014-0190.ECC.

Stavros Sfoungaristos, MD, Guy Hidas, MD, Ofer N. Gofrit, MD, PhD, Vladimir Yutkin, MD, Arie Latke, Ezekiel H. Landau, MD, Dov Pode, MD, and Mordechai Duvdevani, MD
Urology Department, Hadassah University Hospital, The Hebrew University, Jerusalem, Israel.

Abstract

Purpose: To produce and validate a predictive model based on CT parameters for calculating the probability of a stone to be visible on fluoroscopy of shockwave lithotripsy (SWL) and to compare its accuracy to that of kidneys-ureters-bladder (KUB) radiography.

Methods: We retrospectively analyzed 306 patients (sample group) who underwent an SWL between March 2011 and August 2012. A multivariate analysis of several parameters extracted from the preoperative CT scan was conducted to identify independent predictors for radiopacity on SWL fluoroscopy. The results were used for the creation of a predictive model. Internal validation was made on a group of 75 patients (validation group) treated from September 2012 until December 2012. Predictive accuracy of the model was evaluated by receiver operating characteristic (ROC) curve and calibration plot. The ROCcurve was also used for comparing the predictive accuracy of the model to that of KUB radiography.

Results: From 306 evaluated stones, 238 (77.8%) were visible on fluoroscopy. Results of the multivariate analysis revealed that stone size (P<0.001), stone attenuation (P<0.001), location in the midureter (P<0.001), the distance between the stone and the anterior abdominal wall (P<0.001), and fat thickness of the anterior abdominal wall (P=0.001) were all independent predictors for stone radiopacity on fluoroscopy. A predictive model was produced based on the above parameters. The model demonstrated high calibration and areas under the curve of 0.923 and 0.965 in the sample and validation group, respectively, while its predictive performance was significantly higher (P<0.001) of that of KUB radiography (area under the curve=0.727). Conclusions: This novel model can estimate with high accuracy stone radiopacity on SWL fluoroscopy using parameters of CT scan and thus it can be used as an alternative to KUB radiography for treatment planning.


http://online.liebertpub.com/doi/abs/10.1089/end.2014-0343

Clinical Outcomes After Ureteroscopic Lithotripsy in Patients Who Initially Presented with Urosepsis: Matched Pair Comparison with Elective Ureteroscopy

Journal of Endourology. -Not available-, ahead of print.

doi:10.1089/end.2014-0343.

Ramy F. Youssef, MD, Andreas Neisius, MD, Zachariah G. Goldsmith, MD, Momin Ghaffar, BS, Matvey Tsivian, MD, Richard H. Shin, MD, Fernando Cabrera, MD, Michael N. Ferrandino, MD, Charles D. Scales, MD, Glenn M. Preminger, MD, and Michael E. Lipkin, MD

Division of Urology, Comprehensive Kidney Stone Center, Duke University Medical Center, Durham, North Carolina.

Abstract

Background and Purpose: The outcomes of ureteroscopy (URS) after urgent decompression and antibiotics for patients who initially present with urosepsis because of obstructive urolithiasis have not been previously evaluated. The aim of this study was to compare the outcomes and complications of URS in patients with a recent history of sepsis with those without sepsis.

Methods: The study included 138 patients who underwent URS for stone removal from January 2004 to September 2011 at a university medical center. A matched-pair analysis was performed using three parameters (age, sex, and race) to compare outcomes and complications between 69 patients who had sepsis vs a matched cohort who did not have sepsis before URS.

Results: The study included 138 patients, 88 (64%) females and 50 (36%) males with a median age of 57.5 years (range 18–88 years). Patients with previous sepsis had similar patient characteristics and stone-free rates (81% vs 77%) compared with patients without previous sepsis (P>0.05). Patients with previous sepsis, however, had a significantly higher complications rate (20% vs 7%), longer hospital length of stay (LOS), and longer courses of postoperative antibiotics after URS (P<0.05). Sepsis developed postoperatively in two patients with diabetes (one with and one without previous sepsis), and postoperative fever developed in five patients with previous sepsis.

Conclusions: URS after decompression for urolithiasis-related sepsis has similar success but higher complication rates, greater LOS, and longer course of postoperative antibiotics. This is important in counseling patients who present for definitive URS after urgent decompression for urolithiasis-related sepsis.


http://online.liebertpub.com/doi/abs/10.1089/end.2014.0294

The Impact of Ureteral Stent Type on Patient Symptoms as Determined by the Ureteral Stent Symptom Questionnaire: A Prospective, Randomized, Controlled Study

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014.0294.

Hyoung Keun Park, MD, PhD,1 Sung Hyun Paick, MD, PhD,1 Hyeong Gon Kim, MD, PhD,1 Yong Soo Lho, MD, PhD,1 and Sangrak Bae, MD2

1Department of Urology, Konkuk University School of Medicine, Seoul, Republic of Korea.
2Department of Urology, The Catholic University of Korea, Uijeongbu St. Mary’s Hospital, Uijeongbu, Republic of Korea.

Abstract

Purpose: To minimize stent-related symptoms, the proximal part of the Polaris™ stent is composed of a firm material and its distal part is composed of a soft material. The aim of this study was to compare stent-related symptoms of Polaris and Percuflex® stents and to assess the impacts of these stents on quality of life.

Patients and Methods: A total of 144 patients were randomized to a “test” group (Polaris; n=64) or a “conventional” group (Percuflex; n=80) at the time of ureteral stent insertion after ureteroscopic stone removal surgery. Stents were allocated using a randomization program. At 1 week postoperatively, patient symptoms were evaluated using the Ureteral Stent Symptom Questionnaire (USSQ), and patients were asked complete a 10 cm visual analogue scale (VAS). Mean scores for USSQ domains and mean VAS scores were compared.

Results: Mean patient age was 50.3 years, and the male-to-female ratio was 1:0.85. No significant intergroup differences were found in the domain scores of urinary symptoms (P=0.58), pain (P=0.87), general health (P=0.20), work (P=0.24), sexual activity (P=0.64), or additional problems (P=0.24). In addition, VAS scores were nonsignificantly different (P=0.11). Analysis of USSQ item scores, however, revealed the test group had better results for “presence of pain,” “frequency of pain killer use,” “difficulties with respect to hard physical activity,” “fatigue,” “frequency of rest,” “stent-related impact on work,” “antibiotics use” than the conventional group except for “outpatient department visits”.

Conclusion: Compared with the conventional Percuflex ureteral stent, the new Polaris ureteral stent with a soft tail was not found to offer significant advantages in terms of voiding symptoms, pain, general health, sexual matters, or additional problems as determined by the USSQ or in VAS determined pain. Sub-analysis, however, showed that the Polaris has some advantages with respect to pain, physical activities, impact on work, and additional problems. Accordingly, the soft-tipped Polaris stent was found to have some clinical advantages over the conventional Percuflex stent.


http://online.liebertpub.com/doi/abs/10.1089/end.2014.0478

Cystine Stones: A Single Tertiary Center Experience

Journal of Endourology. -Not available-, ahead of print.
doi:10.1089/end.2014.0478.

Rony Hakim, MD,2,* Ran Katz, MD,1 Ofer N. Gofrit, MD, PhD,1 Ezekiel H. Landau, MD,1 Vladimir Yutkin, MD,1 Dov Pode, MD,1 and Mordechai Duvdevani, MD1

1Urology Department, Hadassah University Hospital, the Hebrew University, Jerusalem, Israel.
2Hadassah School of Medicine, the Hebrew University, Jerusalem, Israel.

Abstract

Objective: To analyze the epidemiological and clinical characteristics and therapeutic outcomes of patients with cystine stones and to compare them with the characteristics of patients with calcium oxalate stones.

Patients and Methods: We identified 30 patients with cystine stones who were consulted in our department from January 1972 until December 2013. These patients were matched and paired, based on age and gender, to 30 calcium oxalate stone formers who were diagnosed and treated in our department from January 2011 until December 2013.

Results: Cystine stones were significantly large in size (p<0.001) and most of them were found in the kidney (p=0.002). Patients with cystinuria had their first stone episode at an early age (p<0.001) compared with patients with calcium oxalate stones. No significant differences were observed regarding the frequency and the severity of symptoms. Both groups had similar visits per year in outpatient clinics, emergency room admissions, and episodes of febrile urinary tract infections. Cystine stone formers had undergone significantly higher number of procedures for stone removal (p<0.001). No statistical differences were found in the compliance rates between the groups. Patients with cystine stones had significantly higher serum creatinine levels (p=0.005).

Conclusions: Cystine stones present in an earlier age and have the likelihood to be large in size. Patients with cystine stones undergo a greater number of procedures, and they have a greater risk to develop chronic renal impairment.


http://www.hindawi.com/journals/bmri/2014/691946/

A Comparison of Antegrade Percutaneous and Laparoscopic Approaches in
the Treatment of Proximal Ureteral Stones

BioMed Research International
Volume 2014 (2014), Article ID 691946, 5 pages

http://dx.doi.org/10.1155/2014/691946

Hikmet Topaloglu,1 Nihat Karakoyunlu,1 Sercan Sari,1 Hakki Ugur Ozok,1 Levent Sagnak,1 and Hamit Ersoy21Urology Clinic, Diskapi Yildirim Beyazit Training and Research Hospital, 06310 Ankara, Turkey
2Department of Urology, Hitit University Faculty of Medicine, 19030 Corum, Turkey

Abstract

Purpose. To compare the effectiveness and safety of retroperitoneal laparoscopic ureterolithotomy (RLU) and percutaneous antegrade ureteroscopy (PAU) in which we use semirigid ureteroscopy in the treatment of proximal ureteral stones.

Methods. Fifty-eight patients with large, impacted stones who had a history of failed shock wave lithotripsy (SWL) and, retrograde ureterorenoscopy (URS) were included in the study between April 2007 and April 2014. Thirty-seven PAU and twenty-one RLU procedures were applied. Stone-free rates, operation times, duration of hospital stay, and follow-up duration were analyzed.

Results. Overall stone-free rate was 100% for both groups.There was no significant difference between both groups with respect to postoperative duration of hospital stay and urinary leakage of more than 2 days. PAU group had a greater amount of blood loss (mean hemoglobin drops for PAU group and RLU group were 1.6 ± 1.1 g/dL versus 0.5 ± 0.3 g/dL, resp.; P = 0.022). RLU group had longer operation time (for PAU group and RLU group 80.1 ± 44.6 min versus 102.1 ± 45.5 min, resp.; P = 0.039).

Conclusions. Both PAU and RLU appear to be comparable in the treatment of proximal ureteral stones when the history is notable for a failed retrograde approach or SWL.The decision should be based on surgical expertise and availability of surgical equipment.


http://www.hindawi.com/journals/criu/2014/161640/

A Giant Case of Pyonephrosis Resulting from Nephrolithiasis

Case Reports in Urology
Volume 2014 (2014), Article ID 161640, 3 pages

http://dx.doi.org/10.1155/2014/161640

Ali Erol,1 Soner Çoban,2 and Ali Tekin31Department of Urology, Medical Park Hospital, Istanbul, Turkey
2Department of Urology, Sevket Yilmaz Education and Research Hospital, Yildirim, Bursa, Turkey
3Department of Urology, Duzce University School of Medicine, Duzce, Turkey

Abstract

Pyonephrosis is an uncommon disease that is associated with suppurative destruction of the renal parenchyma in adults. Upper urinary tract infection and obstruction play a role in its etiology. Immunosuppression from medications (steroids), diseases (diabetes mellitus, AIDS), and anatomic variations (pelvic kidney, horseshoe kidney) may also be risk factors for pyonephrosis. Fever, shivering, and flank pain are frequent clinical symptoms. On physical examination, a palpable abdominal mass may be associated with the hydronephrotic kidney. Septic shock and death can occur if the disorder is not treated with urgent surgery. After the acute phase, most patients are treated with nephrectomy. In this paper, we share the etiology, clinical features, diagnosis and treatment of pyonephrosis using the background of a case with giant pyonephrosis developing due to a kidney stone, the most common cause of upper urinary tract obstruction.


http://www.renalandurologynews.com/aua-kidney-stone-guidelines-unveiled/article/348309/

AUA Kidney Stone Guidelines Unveiled

Renal and Urology News June 2014

Jody A. Charnow, Editor

Article

ORLANDO—The American Urological Association (AUA) announced at its annual meeting the development of its first guidelines for the medical management of kidney stones.

Margaret S. Pearle, MD, PhD, who chaired the panel that reviewed the available evidence that formed the basis of the guidelines, summarized the recommendations in a presentation at the AUA’s 2014 annual meeting.

In discussing the rationale for the new guidelines, Dr. Pearle noted that kidney stones are a common problem with a high rate of recurrence, and despite effective and established treatment regimens for medical management, evidence suggests that medical management is underused. Additionally, she said, management of patients with recurrent stones lacks uniformity.

The guidelines contain 27 statements that fall broadly into the categories of evaluation, diet therapies, pharmacologic therapies, and follow-up. All patients diagnosed with a stone should have a screening evaluation that consists of dietary intake, medical therapies, serum chemistries, urinalysis, and urine culture, said Dr. Pearle, professor of urology and internal medicine at the University of Texas Southwestern Medical Center in Dallas. The evaluation is aimed at identifying medical conditions associated with stone formation, such as primary hyperparathyroidism or type 2 diabetes, dietary aberrations, such as low or high calcium intake or excessive intake of animal protein, or medications such as topiramate, she told listeners.

Serum chemistries should be obtained to define underlying conditions that may be associated with recurrent stones, such as primary hyperparathyroidism or distal renal tubule acidosis. Measuring serum parathyroid hormone is considered an optional study that should be obtained only if primary hyperparathyroidism is suspected, Dr. Pearle said.

In addition, Dr. Pearle stated that “a stone analysis should be obtained at least once if a stone is available because knowledge of stone composition can implicate certain underlying etiologies, such as a low urine pH in patients with uric acid stones.”

Metabolic testing should be performed in high-risk or interested first-time stone formers as well as in recurrent stone formers, she said. Metabolic testing should consist of one or preferably two 24-hour urine collections obtained under random diet. These urine collections should be analyzed for total volume, pH, calcium, oxalate, uric acid, citrate, sodium, potassium, and creatinine. “The 24-hour urine is then used to guide recommendations regarding dietary measures and medication.”

The guidelines also recommend that:

All stone formers should be advised to drink enough fluids to achieve a urine volume of at least 2.5 liters daily.
Patients with calcium stones and high urinary calcium should be advised to limit their sodium intake and to consume the recommended daily allowance of calcium of 1,000 to 1,200 mg daily.
Patients with uric acid stones and calcium stones and high urinary uric acid should be advised to limit their intake of non-dairy animal protein. About 30% of urinary uric acid is derived from dietary purine intake, and animal protein accounts for most purine intake, Dr. Pearle noted.
Patients with high urinary calcium and recurrent calcium stones should be offered thiazide diuretics because these medications act directly on the distal renal tubule and indirectly at the proximal renal tubule to promote renal calcium reabsorption.
Patients with recurrent calcium stones and low urinary citrate should be offered potassium citrate because this medication provides an alkali load that promotes a citraturic response and increases urinary inhibitory activity.
Patients with recurrent calcium stones and who have hyperuricosuria should be offered allopurinol.
Thiazide diuretics and/or potassium citrate should be offered to patients with recurrent calcium stones in whom no metabolic abnormality is identified or in whom appropriate metabolic abnormalities have been addressed but stone formation persists. Allopurinol should not routinely be offered as first-line therapy to patients with uric acid stones. Uric acid nephrolithiasis is primarily a disease of urinary acidification, and at a pH greater than 6 to 6.5, most uric acid will be found in its soluble or dissociated form, and even high amounts of uric acid at these higher urinary pHs will be fully solublized, Dr. Pearle explained.

Dr. Pearle concluded her talk by mentioning the importance of follow-up. “Success in gauged by improvement in urinary stone risk factors and ultimately by reduction in stone formation,” she said. Serial urine collections must be obtained to address changes in urinary risk factors.


http://www.renalandurologynews.com/ultrasonic-propulsion-of-kidney-stones-interview-with-jonathan-harper-md/article/346605/

Ultrasonic Propulsion of Kidney Stones: Interview with Jonathan Harper, MD

Delicia Honen Yard

Renal and Urology News August 2014

Interview

Imagine a noninvasive treatment for renal calculi that does not shatter the stones but instead employs low-intensity, ultrasound-generated pulses to move them to and through the ureter.

Principal investigator Jonathan Harper, MD, assistant professor in the Department of Urology at the University of Washington (UW) School of Medicine in Seattle, explains to Renal & Urology News how he and his collaborators are turning their “Rolling Stones” concept into a feasible office procedure.

What do you call the low-power ultrasound device you are using in your studies?

Dr. Harper: We call the procedure ultrasonic propulsion. In the FDA application we called the device Propulse 1. Casually around UW, we refer to our work and our group as Rolling Stones. If this becomes a startup company, we like the name Sonomotion.

How does the device/intervention work?

Dr. Harper: Generally, sound waves are focused on the stone and they transfer momentum to the stone, which makes it move. Specifically, it looks like a diagnostic ultrasound machine with an ultrasound image. The user puts the probe against the skin and visualizes the stone and kidney, touches the image of the stone on the screen, and watches the stone move. Touching the screen sends the focused wave to the stone without interrupting imaging.

What inspired you to develop this process and device?

Dr. Harper: [Senior principal engineer and adjunct assistant professor of urology] Michael Bailey and others in the UW Applied Physics Laboratory have worked on shock wave lithotripsy (SWL) for a long time. Stones are fragmented with SWL, but often these pieces remain in areas of the kidney and do not pass. Many have wanted to find a way to help those pieces pass.

We knew ultrasound could be used to create a pushing force, and so applied that to this problem. Ultrasound engineers use the force to calibrate instruments. In our case we tried to use focused ultrasound to break stones like lithotripsy, but ended up moving the stones and had to chase them around a water tank.

Why do you think ultrasonic propulsion could be successful?

Dr. Harper: It is a practical solution to a real problem. The design and operation are pretty simple and elegant. We know the forces we can generate and have a good feel for the forces that are required. The outputs to achieve these forces have been shown to be safe and not cause pain. We have had success in multiple preliminary studies and are now performing the first clinical trial.

There also has been enthusiasm from many expert endourologists throughout the country, which is encouraging. In addition, we have had many patients contact us with questions and [express] interest in volunteering as subjects.

Approximately 300 urologists visited the hands-on demonstration [conducted at the 2013 annual meeting of the American Urological Association (AUA)], and all survey respondents marked [that they would be] “likely” or “very likely” to use the technology. They had the chance to use the system to reposition stones in a mannequin or to drive the stone through a maze. [The group will be demonstrating the procedure again at the May 2014 AUA annual meeting in Orlando, Florida.—Eds.]

What advantages does low-power ultrasound have over extracorporeal SWL and such other treatments for kidney stones as flexible ureteroscopy and percutaneous nephrolithotomy?

Dr. Harper: Ultrasonic propulsion serves a different purpose. Most stones are small enough to pass naturally; however, many of them ultimately require surgery. Any of the above-mentioned surgeries breaks the stone into fragments that either pass naturally or remain in the kidney. These fragments may slowly grow and ultimately require another surgery.

The goal of our technology is to help the small stones or residual fragments pass by moving them out of the calyx and closer to the UPJ [ureteropelvic junction] or ureter. In turn, we would expect to avoid some surgeries and improve the outcomes of others.

There are other possible scenarios of moving a stone that would be of benefit, such as dislodging a large stone obstructing the UPJ. This could not only relieve a patient’s pain and obstruction, but also could avoid an urgent procedure and allow for scheduling an elective surgery.

Moving a stone before or during surgery could facilitate access to a hard-to-reach stone. Other uses are [related to] diagnostic feedback—for example, by inducing movement, one might be able to tell that two stones next to each other are in fact two stones and not one.


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Newsletter 2-13

I migliori abstracts sulla calcolosi, scelti per voi dal vostro

Marco Puglisi


http://dx.doi.org/10.1155/2013/632790http://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

Abstract

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.


http://www.sciencedirect.com/science/article/pii/S0090429513008583

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

Objective

To compare the outcomes of flexible ureterorenoscopy and lasertripsy (FURS) using digital and conventional FURS for kidney stones.

Methods

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.

Results

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.

Conclusion

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.


http://www.sciencedirect.com/science/article/pii/S0090429513008455

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

Objective

To determine the feasibility and safety of percutaneous nephrolithotomy (PCNL) in treating upper urinary calculi under local infiltration anesthesia.

Methods

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.

Results

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%.

Conclusion

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.


http://www.sciencedirect.com/science/article/pii/S0090429513010078

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

Objective

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).

Methods

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.

Results

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.

Conclusion

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0477

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0185

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0183

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0127

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0186

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0401

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0177

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.


http://online.liebertpub.com/doi/abs/10.1089/end.2013.0257

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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Newsletter 1-13



I migliori abstracts sulla calcolosi, scelti per voi dal vostro


Marco Puglisi


Advances in Urology Volume 2012 (2012), Article ID 606754, 7 pages doi:10.1155/2012/606754

Recent Developments in Computed Tomography for Urolithiasis: Diagnosis and Characterization

P. D. Mc Laughlin, L. Crush, M. M. Maher, and O. J. O’Connor

Department of Radiology, Cork University Hospital and University College Cork, Cork, Ireland

ABSTRACT

Objective:
To critically evaluate the current literature in an effort to establish the current role of radiologic imaging, advances in computed tomography (CT) and standard film radiography in the diagnosis, and characterization of urinary tract calculi. Conclusion. CT has a valuable role when utilized prudently during surveillance of patients following endourological therapy. In this paper, we outline the basic principles relating to the effects of exposure to ionizing radiation as a result of CT scanning. We discuss the current developments in low-dose CT technology, which have resulted in significant reductions in CT radiation doses (to approximately one-third of what they were a decade ago) while preserving image quality. Finally, we will discuss an important recent development now commercially available on the latest generation of CT scanners, namely, dual energy imaging, which is showing promise in urinary tract imaging as a means of characterizing the composition of urinary tract calculi.


Advances in Urology Volume 2012 (2012), Article ID 813523, 5 pages doi:10.1155/2012/813523

Impact of Residual Fragments following Endourological Treatments in Renal Stones

Cenk Acar1 and Cag Cal2

1 Department of Urology, Faculty of Medicine, Pamukkale University, 20070 Denizli, Turkey
2 Department of Urology, Faculty of Medicine, Ege University, 35100 Izmir, Turkey

Abstract:

Today, shock wave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), and flexible ureterorenoscopy (URS) are the most widely used modalities for the management of renal stones. In earlier series, treatment success of renal calculi assessed with KUB radiography, ultrasound, or intravenous pyelography which are less sensitive than CT that leads to be diversity of study results in reporting outcome. Residual fragments (RFs) after interventional therapies may cause pain, infection, or obstruction. The size and location of RFs following SWL and PCNL are the major predictors for clinical significant symptoms and stone events requiring intervention. There is no consensus regarding schedule for followup of SWL, PCNL, and flexible URS. Active monitoring can be recommended when the stones become symptomatic, increase in size, or need intervention. RFs <4?mm after SWL and <2?mm after PCNL and flexible URS could be actively monitored on an annual basis with CT. Early repeat SWL and second-look endoscopy are recommended after primary SWL and PCNL, respectively. There is insufficient data for flexible URS, but RFs can be easily treated with repeat URS. Finally, medical therapy should be tailored based on the stone analysis and metabolic workup that may be helpful to prevent regrowth of the RFs.


Advances in Urology Volume 2012 (2012), Article ID 320104, 5 pages doi:10.1155/2012/320104

Management of Clinically Insignificant Residual Fragments following Shock Wave Lithotripsy

Elisa Cicerello, Franco Merlo, and Luigi MaccatrozzoUnità Complessa di Urologia, Ospedale Regionale Ca’Foncello, Treviso, Italy

Abstract:
Management of Clinically insignificant residual fragments (CIRFs) are small fragments (less than 5?mm) that are present in upper urinary tract at the time of regular post-SWL followup. The term is controversial because they may remain silent and asymptomatic or become a risk factor for stone growth and recurrence, leading to symptomatic events, and need further urologic treatment. Although a stone-free state is the desired outcome of surgical treatment of urolithiasis, the authors believe that the presence of noninfected, nonobstructive, asymptomatic residual fragments can be managed metabolically in order to prevent stone growth and recurrence. Further urologic intervention is warranted if clinical indications for stone removal are present.


Advances in Urology Volume 2012 (2012), Article ID 175843, 6 pages doi:10.1155/2012/175843

New Pathophysiological Aspects of Growth and Prevention of Kidney Stones

J. M. Baumann and B. AffolterLaboratories Viollier, Departement of Stone Research, Gartenstrasse 9, 2502 Biel, Switzerland

Abstract:
Kidney stones probably grow during crystalluria by crystal sedimentation and aggregation (AGN) on stone surfaces. This process has to occur within urinary transit time (UT) through the kidney before crystals are washed out by diuresis. To get more information, we studied by spectrophotometry the formation and AGN of Ca oxalate (Ca Ox) crystals which were directly produced in urine of 30 stone patients and 30 controls by an oxalate (Ox) titration. Some tests were also performed after removing urinary macromolecules (UMs) by ultrafiltration. To induce rapid crystallization, high Ox additions (0.5–0.8?mM) were necessary. The most important finding was retardation of crystal AGN by UM. In urine of 63% of controls but only 33% of patients, no AGN was observed during an observation of 60 minutes (P < 0.05). Also growth and sedimentation rate of crystals were significantly reduced by UM. For stone metaphylaxis, especially for posttreatment residuals, avoiding dietary Ox excesses to prevent crystal formation in the kidney and increasing diuresis to wash out crystals before they aggregate are recommended.


Advances in Urology Volume 2012 (2012), Article ID 589038, 4 pages doi:10.1155/2012/589038

Treatment of Kidney Stones Using Extracorporeal Shock Wave Lithotripsy (ESWL) and Double-J Stent in Infants

1 Department of Urology, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari 4813894393, Iran

2 Student Research Committee, Cancer Research Center, Thalassemia Research Center, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari 4813894393, Iran

Abstract:

Background.

Extracorporeal shock wave lithotripsy (ESWL) has progressively acquired popularity as being the gold standard treatment for upper urinary tract lithiasis in infants since 1980. Our aim was to evaluate the outcome of ESWL for kidney stones and the use of double-J stent in infants.

Material and Methods.

A prospective clinical trial study performed on 50 infants with renal calculi at pelvic admitted in the Urology ward of Shafa Hospital, Sari, Iran, between 2001 and 2010. Main outcome measure of our study was clearing stones after one or more consecutive sessions of ESWL.

Results.

The study included 50 patients with renal calculi at pelvic. Among them, there were 35 (70%) boys and 15 (30%) girls with the age ranging from 1 to 13 months (mean of 7 month ± 3 days). All of them were treated by standard ESWL using Simons Lithostor plus machine. The stone sizes ranged from 6?mm to 22?mm. Double-J stents were placed in 11 infants (22%) with stones larger than 13?mm. Most of the patients required only one ESWL session.

Conclusion.

Since there were no complications following ESWL treatment, we can conclude that, in short term, ESWL is an effective and safe treatment modality for renal lithiasis in infants. In addition, we recommend double-J stent in infants with stones larger than 13mm.


doi: 10.2214/AJR.11.7276 AJR March 2012 vol. 198 no. 3 603-608

CT-Based Determination of Maximum Ureteral Stone Area: A Predictor of Spontaneous Passage

Shadpour Demehri1, Michael L. Steigner1, Aaron D. Sodickson1, E. Andres Houseman2, Frank J. Rybicki1 and Stuart G. Silverman1

ABSTRACT OBJECTIVE:

The purpose of this study was to test the hypothesis that the maximum axial area of ureteral stones is a more accurate predictor of spontaneous passage than the maximum axial diameter.

MATERIALS AND METHODS:

This study retrospectively reviewed 211 consecutive emergency department patients (mean age, 48.8 years; age range, 18–88 years) with acute flank pain due to ureteral stones diagnosed using unenhanced CT. Measurements of maximum atrial area were obtained using fixed (FTM) and variable (VTM) threshold methods. For the FTM, stones were segmented using an attenuation threshold of 130 HU. For the VTM, stones were segmented using an attenuation threshold determined by one half of individual stone attenuation. Measurements of maximum atrial diameter were obtained using soft-tissue and bone window settings. Receiver operating characteristic (ROC) analysis was used to compare the accuracy of maximum atrial area with maximum atrial diameter measurements for predicting spontaneous passage.

RESULTS:

Fifty-seven patients (27%) required urologic intervention. The areas under the ROC curve (AUC) of maximum atrial area using FTM (0.83, p = 0.013) and VTM (0.84, p = 0.004) were larger than the AUC (0.8, p = 0.4) for maximum atrial diameter using bone window settings or AUC (0.79) for maximum atrial iameter using soft-tissue window settings. For stones with maximum atrial diameter (in soft-tissue window settings) > 5 mm and = 10 mm, the accuracy of maximum atrial area using VTM (AUC = 0.75) and FTM (AUC = 0.74) was superior to the accuracy of maximum atrial diameter in soft-tissue (AUC = 0.67) and bone (AUC = 0.69) window settings (p < 0.05) in predicting spontaneous passage.

CONCLUSION:
Determination of the maximum axial area may improve the accuracy in predicting spontaneous passage of ureteral stones, particularly those between 5 and 10 mm.


European Urology Volume 62, issue 6, pages e95-e106, December 2012

Impact of Case Volumes on the Outcomes of Percutaneous Nephrolithotomy

Dedan Opondo, Ahmet Tefekli, Tarik Esen, Gaston Labate, Kandasami Sangam, Antonello De Lisa, Hemendra Shah, Jean de la Rosette, on behalf of the CROES PCNL study group.

ABSTRACT

Background
Previous studies have demonstrated relationships between case volumes and outcomes in surgery. Little is known about the impact of case volumes on the outcomes of percutaneous nephrolithotomy (PCNL).

Objective
To investigate the influence of case volumes on the efficacy and safety outcomes of PCNL.

Design, setting, and participants
From November 2007 to December 2009, prospective data were collected by the Clinical Research Office of the Endourological Society from consecutive patients over a 1-yr period in 96 centers globally. Data of 3933 patients in the Global PCNL study database were included in this study.

Outcome measurements and statistical analysis
Patients were divided into low- and high-volume groups based on the median annual case volume of their respective treatment center. Preoperative characteristics and outcomes were compared between the two groups. Case volume was treated as a continuous variable. The relationship between case volume and stone-free (SF) rate, complication rate, and duration of hospital stay was explored using multivariate regression analysis.

Results and limitations
SF rates were higher in high-volume centers (82.5% vs 75.1%; p value <0.001). Complication rates were lower in high-volume centers (15.9% vs 21.7%; p value 0.002), whereas the mean (standard deviation [SD]) duration of stay was shorter in high-volume centers (3.4 [2.6] vs 4.9 [3.7] d; p value <0.001). SF rate increased with case volume, whereas complication rate and duration of stay diminished with increasing case volumes after adjusting for stone burden, urine culture status, American Society of Anesthesiologists score, and the presence of staghorn stones. The highest SF rates were observed in centers with >120 cases per year.

Conclusions
Centers that perform high numbers of PCNLs per year achieve better results. Both the efficacy and safety outcomes of PCNL improve with the number of surgeries performed in a given center per year.

Take Home Message
Centers that perform large numbers of percutaneous nephrolithotomies (PCNLs) per year achieve higher stone-free rates and lower complication rates with a shorter duration of hospital stay, suggesting that both efficacy and safety outcomes of PCNL improve with the number of surgeries.


Journal of Endourology. February 2013, 27(2): 162-167. doi:10.1089/end.2012.0470.

Absolute Hounsfield Unit Measurement on Noncontrast Computed Tomography Cannot Accurately Predict Struvite Stone Composition

Giovanni Scala Marchini, Surafel Gebreselassie, Xiaobo Liu, Cindy Pynadath, Grace Snyder, and Manoj Monga.

ABSTRACT:

Background:
The purpose of our study was to determine, in vivo, whether single-energy noncontrast computed tomography (NCCT) can accurately predict the presence/percentage of struvite stone composition.

Methods:
We retrospectively searched for all patients with struvite components on stone composition analysis between January 2008 and March 2012. Inclusion criteria were NCCT prior to stone analysis and stone size =4?mm. A single urologist, blinded to stone composition, reviewed all NCCT to acquire stone location, dimensions, and Hounsfield unit (HU). HU density (HUD) was calculated by dividing mean HU by the stone’s largest transverse diameter. Stone analysis was performed via Fourier transform infrared spectrometry. Independent sample Student’s t-test and analysis of variance (ANOVA) were used to compare HU/HUD among groups. Spearman’s correlation test was used to determine the correlation between HU and stone size and also HU/HUD to % of each component within the stone. Significance was considered if p<0.05.

Results:
Fourty-four patients met the inclusion criteria. Struvite was the most prevalent component with mean percentage of 50.1%±17.7%. Mean HU and HUD were 820.2±357.9 and 67.5±54.9, respectively. Struvite component analysis revealed a nonsignificant positive correlation with HU (R=0.017; p=0.912) and negative with HUD (R=-0.20; p=0.898). Overall, 3 (6.8%) had <20% of struvite component; 11 (25%), 25 (56.8%), and 5 (11.4%) had 21% to 40%, 41% to 60%, and 61% to 80% of struvite, respectively. ANOVA revealed no difference among groups regarding HU (p=0.68) and HUD (p=0.37), with important overlaps. When comparing pure struvite stones (n=5) with other miscellaneous stones (n=39), no difference was found for HU (p=0.09) but HUD was significantly lower for pure stones (27.9±23.6 v 72.5±55.9, respectively; p=0.006). Again, significant overlaps were seen.

Conclusions:
Pure struvite stones have significantly lower HUD than mixed struvite stones, but overlap exists. A low HUD may increase the suspicion for a pure struvite calculus.


Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2012.0324.

Holmium: YAG Laser Lithotripsy Versus Pneumatic Lithotripsy for Treatment of Distal Ureteral Calculi: A Meta-Analysis

ABSTRACT:
The objective of this study was to estimate the treatment effect of Pneumatic Lithotripsy (PL) versus holmium: YAG laser lithotripsy (LL) in the treatment of distal ureteric calculi. A bibliographic search covering the period from 1990 to April 2012 was conducted using search engines such as MEDLINE, EMBASE, and Cochrane library. Data were extracted and analyzed with RevMan5.1 software. A total of 47 studies were scant, and 4 independent studies were finally recruited. Holmium: YAG LL conveyed significant benefits compared with PL in terms of early stone-free rate [odds ratio (OR)=4.42, 95% confidence interval (CI) (1.14, 17.16), p=0.03], delayed stone-free rate [OR=4.42, 95%CI (1.58, 12.37), p=0.005], mean operative time [WMD=-16.86, 95%CI (-21.33, -12.39), p<0.00001], retaining double-J catheter rate [OR=0.44, 95%CI (0.25, 0.78), p=0.004], and stone migration incidence [OR=0.26, 95%CI (0.11, 0.62), p=0.003], but not yet in the postoperative hematuria rate and the ureteral perforation rate according to this meta-analysis. Precise estimates on larger sample size and trials of high quality may provide more uncovered outcomes in the future.


Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2012.0218.

Supracostal Tubeless Percutaneous Nephrolithotomy: A Retrospective Cohort Study

Brian Duty, M.D.,1 Michael Conlin, M.D.,2 Matthew Wagner, M.D.,2 Aaron Bayne, M.D.,2 Gregory Adams, M.D.,2 and Eugene Fuchs, M.D.2

1Department of Urology, Smith Institute for Urology, Hofstra University, North Shore–Long Island Jewish Health System, New Hyde Park, New York.
2Division of Urology, Oregon Health Science University, Portland, Oregon.

Purpose:
To evaluate the safety of tubeless percutaneous nephrolithotomy in patients undergoing supracostal percutaneous renal access.

Patients and Methods:
Between October 1999 and October 2010, 302 patients underwent percutaneous nephrolithotomy via a supracostal access tract. Two hundred forty-eight (82.1%) patients had a nephrostomy tube placed at the end of the case and 54 (17.9%) did not. The medical records of both cohorts were compared regarding patient demographics (age, sex, body mass index, preoperative creatinine level), operative characteristics (estimated blood loss, length of stay, treatment efficacy), and complication rates (overall, thoracic, hemorrhage necessitating transfusion).

Results:
Patient demographics did not differ between the tubeless and nephrostomy tube groups. Estimated blood loss was significantly less in the tubeless patients (67?mL vs 123 mL; P=0.019). The tubeless group had a shorter mean length of stay than the nephrostomy tube group (2.5 vs 3.4 days, P<0.01). Treatment success was comparable between the two groups (tubeless 81.5% vs nephrostomy tube 77.8%; P=0.553). Overall complication (P=0.765) and blood transfusion (P=0.064) rates were equivalent. Chest complications were higher in the tubeless group (22.2%) compared with the nephrostomy tube patients (10.9%) (P=0.024). Nevertheless, chest complications necessitating intervention were not different (P=0.152).

Conclusions:
Tubeless supracostal percutaneous nephrolithotomy was associated with less intraoperative blood loss and a shorter hospital stay. Although the tubeless group experienced more chest complications overall, the need for intervention was no different among the two cohorts. Tubeless supracostal percutaneous nephrolithotomy appears safe.


Urology Volume 80, Issue 6 , Pages 1192-1197, December 2012

Comparative Study of Outcome in Treating Upper Ureteral Impacted Stones Using Minimally Invasive Percutaneous Nephrolithotomy With Aid of Patented System or Transurethral Ureteroscopy

Zhongsheng Yang, Leming Song, Donghua Xie, Min Hu, Zuofeng Peng, Tairong Liu, Chuance Du, Jiuqing Zhong, Wen Qing, Shulin Guo,
Lunfeng Zhu, Lei Yao, Jianrong Huang, Difu Fan, Zhangqun Ye

ABSTRACT:

Objective
To determine an efficient method for treating upper ureteral impacted stones, we compared the outcome of minimally invasive percutaneous nephrolithotomy with the aid of our patented system and transurethral ureteroscopy.

Materials and Methods
A total of 182 patients with complicated impacted upper ureteral stones above the level of L4 were randomly divided into 2 groups. Group 1 included 91 patients who were treated with minimally invasive percutaneous nephrolithotomy with the aid of a patented system. Group 2 included 91 patients who were treated with ureteroscopy. The patients underwent postoperative shock wave lithotripsy, when necessary. The operative time, stone clearance rate, operative complication markers (amount of intraoperative bleeding and postoperative fever rate), and cost of treatment were compared.

Results
A significantly shorter operative time, greater rate of stone clearance, lower need for postoperative shock wave lithotripsy, and lower rate of postoperative fever was found in group 1 than in group 2 (P <.05). However, the cost of treatment and amount of intraoperative bleeding were significantly greater.

Conclusion
We believe minimally invasive percutaneous nephrolithotomy with the aid of the patented system could be the first choice in treating complicated impacted upper ureteral stones above the level of L4.


Urology Volume 80, Issue 6 , Pages 1198-1202, December 2012

Standardized Flexible Ureteroscopic Technique to Improve Stone-free Rates

Arkadiusz Miernik, Konrad Wilhelm, Peter Uwe Ardelt, Fabian Adams, Franklin Emmanuel Kuehhas, Martin Schoenthaler

ABSTRACT:

Objective
To present a unique completely standardized sequence of steps performed before, during, and after flexible ureteroscopy (FURS) that achieves superior results for FURS treatment of renal calculi.

Materials and Methods
The “Freiburg FURS technique” includes the following steps: (a) preoperative ureteral stenting; (b) placement of 2 hydrophilic wires; (c) semirigid ureteroscopy before FURS; (d) the use of a large access sheath (14F-16F) if multiple ureteral passages are expected; (e) the use of a 2-working channel flexible endoscope; (f) a modified active flushing system; and (g) an advanced holmium laser technique with complete stone extraction. We performed a prospective analysis of 153 consecutive FURS procedures for nephrolithiasis from August 2009 to July 2011.

Results
Data analysis revealed an “immediate” stone-free rate of 96.7% (as confirmed by endoscopy, fluoroscopy, and ultrasonography), a medium of 2.3 stones, and a cumulative stone size of 10.5 mm (range 3-43). The operative time was 67 minutes (range 20-160). The use of an access sheath was required in 71% of the patients and the postoperative use of a double-J stent in 57% of patients. Complications (Clavien grade II and III) developed in 9.1% of patients (including 7 with minimal perforation that required ureteral stenting for 1 month, 3 with secondary flank pain/hydronephrosis requiring double-J stenting and hospitalization, and 4 with fever or urinary tract infections requiring antibiotic therapy. Follow-up examinations after 3 months showed no late complications.

Conclusion
The modified FURS technique provided clinically superior results with a low complication rate. However, the approach requires the use of considerable resources, both technical and surgical and financial.


Urology Volume 80, Issue 6 , Pages 1203-1208, December 2012

Gas-containing Renal Stones: Findings From Five Consecutive Patients

Ted B. Manny,Patrick W. Mufarrij, Jessica N. Lange, Majid Mirzazadeh, Ashok K. Hemal, Dean G. Assimos

ABSTRACT

Objective
To describe the clinical course, microbiology, and metabolic findings of 5 patients presenting to our institution with gas-containing renal stones.

Materials and Methods
During a 20-month period beginning in 2009, 5 patients were identified by computed tomography scanning to harbor gas-containing renal calculi. Despite similar imaging and referral practice patterns, no such cases had been seen at our institution in the preceding 20 years. The records of these patients were reviewed to better characterize this unique condition.

Results
All 5 subjects were premenopausal women. One patient presented with urosepsis and 4 presented with flank pain. All had urinary tract infections, and Escherichia coli was isolated from a voided urine specimen in 3. Stone culture was positive in 2 and was concordant with the voided specimen in 1. The stones were solitary in 4 and multiple in 1 patient. All the stones were composed of calcium phosphate. Of the 5 patients, 3 had pure calcium phosphate stones and 2 had stones with calcium oxalate monohydrate components. Also, 3 subjects had diabetes mellitus, 3 had hypertension, and 1 had a history of gout. Two subjects underwent 24-hour urine metabolic testing, and abnormalities were identified in both. All patients were rendered stone free: 4 with percutaneous nephrostolithotomy and 1 using robotic pyelolithotomy.

Conclusion
Gas-containing renal stones are rare but might be increasing in prevalence. The pathophysiology is unknown but is most likely influenced by a combination of metabolic and infectious factors.

Newsletter 2-12

European Urology Volume 61, issue 6, pages e53-e66, June 2012

Percutaneous Nephrolithotomy in the United Kingdom: Results of a Prospective Data Registry

James N. Armitage, Stuart O. Irving, Neil A. Burgess, for the British Association of Urological Surgeons Section of Endourology.

Abstract

Background
Percutaneous nephrolithotomy (PCNL) is commonly used in the management of large upper renal tract stones. It is highly effective but carries a greater risk of significant morbidity than less invasive treatment options such as ureteroscopy or extracorporeal shock wave lithotripsy.

Objective
Evaluate the current practice and outcomes of PCNL using a national prospective data registry.

Design, setting, and participants
All surgeons undertaking PCNL in the United Kingdom were invited to submit data to an online registry.

Measurements
Effectiveness was assessed by stone-free rates and safety according to complications including blood transfusion, fever, and sepsis rates.

Results and limitations
Since January 2010, data on 987 patients who had 1028 PCNL procedures were collected. A total of 299 of 1012 procedures (30%) were for staghorn calculi, 299 (30%) for stones >2 cm, 329 (33%) for stones 1–2 cm, and 89 (9%) for stones <1 cm. There were no significant differences in rates of failed access or complications according to whether a urologist or radiologist obtained renal access. There was a nonsignificant trend to a higher transfusion rate with balloon dilatation (7 of 222 [3.2%]) compared with serial dilatation (2 of 245 [0.8%]) of the renal tract (p = 0.093). Totally tubeless procedures were not associated with higher complication rates but did lead to a significant reduction in median length of stay (3 d vs 1.5 d; p <0.0001). Intraoperatively, 78% of patients were believed to be stone free, which was confirmed in 68% with postoperative imaging. Blood transfusion was required in 24 of 968 patients (2.5%). The incidence of postoperative fever was 16% and of sepsis was 2.4%.

Conclusions
The PCNL data registry is a unique resource providing vital information on current practice and critical outcome data. Using the registry, endourologists can audit their practice against national outcome data for this benchmark procedure. It will help surgeons counsel patients during consent for this complex endourologic procedure about the possible outcome in their hands.


CROES PCNL Study Group.. Journal of Endourology – doi:10.1089/end.2012.0046

Prospective Comparison of Outcomes of Percutaneous Nephrolithotomy in Elderly Patients Versus Younger Patients

Zeph Okeke, M.D.,1 Arthur D. Smith, M.D.,1 Gaston Labate, M.D.,2 Alessandro D’Addessi, M.D.,3 Ramakrishna Venkatesh, M.D.,4 Dean Assimos, M.D.,5 Willem E.M. Strijbos, M.D.,6 and Jean J.M.C.H. de la Rosette, on behalf of the CROES PCNL Study Group., M.D.7

1Arthur Smith Institute for Urology, North Shore-Long Island Jewish Health System, New York, New York.
2Department of Urology, Urosalud, Buenos Aires, Argentina.
3Department of Urology, Catholic University School of Medicine, Rome, Italy.
4Department of Urology, University of Kentucky, Lexington, Kentucky.
5Department of Urology, Wake Forest University, Winston-Salem, North Carolina.
6Department of Urology, Atrium Medisch Centrum, Heerlen, The Netherlands.
7Department of Urology, AMC University Hospital, Amsterdam, The Netherlands.

Abstract

Purpose:
The purpose of the study was to prospectively compare operative and postoperative characteristics and outcomes in elderly patients undergoing percutaneous nephrolithotomy (PCNL) compared with younger patients.

Patients and Methods:
Prospectively collected data from the Clinical Research Office of the Endourological Society (CROES) Global PCNL Study database were used. Elderly patients were defined as those aged 70 years and above, while younger patients were those between 18 and 70 years of age. Matched and unmatched group comparisons were performed based on imaging modality used for assessing stone-free status. Patient characteristics, operative data, and postoperative outcomes were compared.

Results:
The median age of the elderly group vs the young group was 74 years (range 70–93 years) vs 49 years. In the unmatched analysis, staghorn stones were seen at higher rates in the elderly group (27.8% vs 21.8%, P=0.014); however, the mean stone size was not significantly different (465.0 vs 422.8, P=0.063). The length of hospitalization was significantly longer in the elderly group compared with the young group in the unmatched analysis (5 days vs 4.1 days, P<0.001). The same difference was not apparent in the matched analysis (5.0 days vs 4.4 days, P=0.288). Overall complication rates were not significantly different in the unmatched analysis. In the matched analysis, however, a statistically significant higher rate of overall complications was seen. Stone-free rates were similar among all groups.

Conclusion:
PCNL in elderly patients over the age of 70 years produces results comparable to those seen in younger patients. With only a slightly higher—be it statistically significant—complication rate, the stone-free rate in older patients was the same as in the younger group.


Journal of Endourology. doi:10.1089/end.2011.0481.

Cost Analysis of Metallic Ureteral Stents with 12 Months of Follow-Up

Eric R. Taylor, M.D., Aaron D. Benson, M.D., and Bradley F. Schwartz, D.O. Division of Urology, Southern Illinois University, Springfield, Illinois.

Abstract

Background and Purpose:
The metallic ureteral stent was first developed for patients with ureteral obstruction related to malignant disease, but it can be used in all patients needing chronic indwelling ureteral stents, including those with benign disease. The traditional method of polymer stent management often necessitates multiple exchanges per year depending on patient and logistical factors. This has significant direct financial cost and likely a negative effect on patients’ overall health. The objective was to analyze and compare the costs associated with chronic indwelling metal and silicone-based ureteral stents.

Patients and Methods:
A prospective database of patients undergoing metal stent placement from February 2008 to June 2010 was reviewed. Mean charges for a single traditional nonmetal and metal stent insertion were calculated. Charges were based on direct hospital charges related to stent cost and surgery. Cost data were based on the fiscal year 2010 cost for polymer or metal stent insertions.

Results:
Twenty-one patients underwent metal stent placement at our institution. Of these, three traditional stent placements were omitted from analysis because of bundled charges for ureteroscopy at the same setting. Mean charges per single traditional and metal stent placement were $6072.75 and $9469.50, respectively. The estimated annual charges for traditional stents (3–6 exchanges) would be $18,218.25 to $36,436.50. Compared with metal stents, this is a potential financial savings of 48% to 74%. The mean direct cost to patients was 21.6% and 25.4% of the charges for metal and polymer stents, respectively. No patient needed early discontinuation of his or her metal stent because of lower urinary tract symptoms or gross hematuria.

Conclusions:
Metal stents are well tolerated by patients with ureteral obstruction of various etiologies and provide a significant financial benefit compared with polymer ureteral stents. For patients who are not fit for surgical intervention regarding their ureteral occlusive disease, the metal Resonance stent is a financially advantageous and well-tolerated option.


Journal of Endourology. May 2012, 26(5): 489-493. doi:10.1089/end.2011.0405.

Retrograde Intrarenal Surgery in Treatment of Nephrolithiasis: Is a 100% Stone-Free Rate Achievable?

Martin Schoenthaler, M.D.,1 Konrad Wilhelm, M.D.,1 Arndt Katzenwadel, M.D.,1 Peter Ardelt, M.D.,1 Ulrich Wetterauer, Ph.D.,1 Olivier Traxer, Ph.D.,2 and Arkadiusz Miernik, M.D.1

1Department of Urology, University Medical Center Freiburg, Freiburg, Germany.
2Department of Urology, Tenon Univerity Hospital, Paris, France.

Abstract

Purpose:
To achieve an almost 100% stone-free rate by means of further developing and standardizing the procedure.

Patients and Methods:
100 consecutive patients with single or multiple renal calculi were prospectively enrolled in the study. Flexible ureterorenoscopy was performed as a completely standardized operation by the same two experienced surgeons. Primary outcome was an “endoscopic” (immediate) stone-free status as determined by endoscopic inspection at the end of surgery. In cases of residual fragments, a reevaluation by CT was performed after 3 months.

Results:
The endoscopic stone-free rate was 97%. In three patients with a cumulative stone size >20?mm, a completely stone-free status could not be achieved in the primary procedure. In these patients, a CT scan after 3 months showed complete clearance from all residual fragments in two; this translates into a primary (after one procedure) stone-free rate after 3 months of 99%. Medium cumulative stone size was 9.8?mm (4–40?mm); in 44 patients, multiple calculi were extracted. Forty-nine patients received a ureteral stent at the end of the operation; two patients had to have stent placement for new onset hydronephrosis and/or colicky pain or fever. Overall complication rate was 7%. Results are limited, because no routine CT scan was used to evaluate stone clearance.

Conclusion:
By means of a standardized surgical approach and use of technical equipment of the newest generation, it is possible to achieve very high stone-free rates without compromising safety. This approach, however, necessitates use of considerable resources, both technical/surgical and financial.


Journal of Endourology. doi:10.1089/end.2011.0639.

Prevalence of Nephrolithiasis in Human Immunodeficiency Virus Infected Patients on the Highly Active Antiretroviral Therapy

Omer A. Raheem, M.D., Hossein S. Mirheydar, M.D., Kerrin Palazzi, M.P.H., Marianne Chenoweth, R.N., Charles Lakin, M.D., and Roger L. Sur, M.D.

Division of Urology, Department of Surgery, University of California San Diego Health Care System, San Diego, California.

Abstract

Background and Purpose:
Protease inhibitors, specifically indinavir, have historically been implicated as a cause of nephrolithiasis in the human immunodeficiency virus (HIV) infected patients. There is a paucity of data, however, on stone disease with nonindinavir etiologies since the introduction of highly active antiretroviral therapy (HAART). We sought to describe the prevalence of nephrolithiasis in the HIV population since the use of HAART.

Patients and Methods:
We retrospectively reviewed HIV-positive patients currently receiving HAART treatment in whom image proven kidney and/or ureteral urolithiasis developed, between 1998 and 2010. A detailed analysis of patients’ current treatment, surgical intervention, and metabolic studies was performed.

Results:
A total of 436 HIV-positive patients were included and 46 (11%) patients had nephrolithiasis. Each patient included in this study was receiving nonindinavir-based antiretroviral therapy. There were 41 men of whom 36 were Caucasian. Eleven (24%) patients underwent 24-hour urine collections with 11 metabolic abnormalities identified. Stone analysis was available for seven patients (four calcium oxalate monohydrate, one cystine, one uric acid, and one atazanavir).

Conclusions:
We report the largest series of nephrolithiasis in an HIV population since the introduction of HAART and highlight not only the similar prevalence of nephrolithiasis to the non-HIV population but also the lack of consistent comprehensive metabolic evaluations in HIV patients with recurrent nephrolithiasis.


Journal of Endourology. doi:10.1089/end.2011.0478.

Cone Beam Computed Tomography for Percutaneous Nephrolithotomy: Initial Evaluation of a New Technology

Ornob P. Roy, M.D.,1 John F. Angle, M.D.,2 Alan D. Jenkins, M.D.,1 and Noah S. Schenkman, M.D.1

1Department of Urology, University of Virginia Health System, Charlottesville, Virginia.
2Department of Interventional Radiology, University of Virginia Health System, Charlottesville, Virginia.

Abstract

Background and Purpose:
Cone beam CT (CBCT) is a novel imaging modality that combines the versatility of conventional C-arm imaging with the functionality of cross-sectional imaging. This is a pilot study to evaluate the capabilities of this new technology to obtain percutaneous access and for the immediate postoperative evaluation of residual fragments in percutaneous nephrolithotomy (PCNL).

Materials and Methods:
A retrospective analysis of all PCNL cases performed between April 2007 and November 2007 was performed. One urologist (NSS) and one radiologist (JFA) reviewed the studies postoperatively. Preoperative films were evaluated to see if CBCT influenced or improved percutaneous access. Postoperative films were evaluated that compared CBCT with conventional noncontrast CT to determine efficacy in finding postoperative stone fragments. Parameters of stone size, location, and quantity of fragments were compared.

Results:
For preoperative access, CBCT was used in 52 cases of PCNL between April 2007 and November 2007. In eight of these cases, CBCT altered the percutaneous access. In postoperative evaluation, 26 cases had both CBCT and conventional CT for comparison. In 11 cases with residual stones, conventional CT identified a greater number of fragments, but these were less than 2?mm. The postoperative recommendation for a secondary procedure concurred in 22 of 26 studies.

Conclusions:
CBCT may provide advantages of improved preoperative imaging, which may result in better percutaneous access, and improved postoperative imaging, which allows surgeons to have “real-time” access to CT quality images. The intraoperative availability of these high quality tomographic images may obviate the need for other postoperative imaging and subsequent adjunctive procedures for residual fragments.


Journal of Endourology. doi:10.1089/end.2011.0664.

Ureteroscopic Management with Laser Lithotripsy of Renal Pelvic Stones

Gokhan Atis, M.D., Cenk Gurbuz, M.D., Ozgur Arikan, M.D., Lutfi Canat, M.D., Mert Kilic, M.D., and Turhan Caskurlu, M.D. Department of Urology, Goztepe Training and Research Hospital, Istanbul, Turkey.

Abstract

Background and Purpose:
The development of semirigid and flexible ureteroscopes has permitted easier access to calculi throughout the urinary tract. We compared the use of semirigid and flexible ureteroscopy for the management of shockwave lithotripsy-refractory, isolated renal pelvic calculi by evaluating stone-free rates, operating room times, and associated complications.

Patients and Methods:
Ureteroscopic stone treatment was attempted in
47 patients with isolated renal pelvic stones between November 2008 and December 2010. The procedures were performed under general anesthesia. Semirigid ureteroscopy was routinely performed in all patients. If the stones were accessible in the renal pelvis with the semirigid ureteroscope (S-URS), they were then treated with the holmium:yttrium-aluminum-garnet (Ho:YAG) laser through S-URS under direct vision. If the stones were not accessible, flexible ureteroscopy was then performed. Preoperative, operative, and postoperative data were retrospectively analyzed.

Results:
In 25 of 47 patients, renal pelvic stones were accessible with S-URS, and the stones were fragmented with the Ho:YAG laser using S-URS. In the remaining 22 patients, the stones were accessed with the flexible ureteroscope (F-URS), and the fragmentation of stones was performed with the Ho:YAG laser using the F-URS. There were no significant differences in age, body mass index, grade of hydronephrosis, mean stone size, and stone laterality among the two groups. The mean operative times were 71.90±17.90 minutes in the S-URS group and 93.41±18.56 minutes in the F-URS group (P=0.001). The stone-free rates at postoperative day 1 and at the 1 month follow-up were 72% and 76% in the S-URS group and 81.8% and 86.4% in the F-URS group, respectively (P=0.861 and P=0.368). We found no significant differences among groups with regard to stone-free rates, complication rates, and hospital lengths of stay.

Conclusions:
Although it is well known that flexible ureteroscopy permits a detailed caliceal examination and therapeutic interventions, semirigid ureteroscopy is also often another sufficient means of reaching the renal pelvis in selected patients.


Journal of Endourology. doi:10.1089/end.2011.0624.

Postshockwave Lithotripsy Outcome Evaluation in Ureteral Stones: Comparison Between Noncontrast Computed Tomography and Plain Abdominal Radiography

Hasan Soydan, M.D., Ilker Akyol, M.D., Temucin Senkul, M.D., Ferhat Ates, M.D., Sami Uguz, M.D., Omer Yilmaz, M.D., and Kadir Baykal, M.D.

Urology Department, GATA Haydarpasa Teaching Hospital, Istanbul, Turkey.

Abstract

Background and Purpose:
There are no definite data indicating which modality to use to assess the efficacy of shockwave lithotripsy (SWL). Usually, plain abdominal radiography (PAR) is recommended in percutaneous nephrolithotomy (PCNL) afterward and in the follow-up of asymptomatic stones, whereas noncontrast CT (NCCT) is recommended in cases of residual fragments. We compared the efficacies of PAR and NCCT in terms of assessing the outcome of SWL treatment for radiopaque ureteral stones.

Patients and Methods:
Those patients with renal colic and a radiopaque ureteral stone of 5 to 20?mm that was detected on PAR were included in the study; body mass index (BMI) values were calculated and recorded. Patients whose PAR revealed opacities suspicious for ureteral stones were evaluated with NCCT at 3-mm slices. Stone status was assessed with PAR and NCCT on post-SWL day 3. Detection of no stone, a residual fragment of =4?mm, and a residual fragment of >4?mm was defined as success, clinically insignificant residual fragments, and failure, respectively.

Results:
On post-SWL day 3, both PAR and NCCT revealed stones in 31 patients, and no stones were seen in either modality in 29 patients. NCCT revealed stones whereas PAR had negative results for stones in two patients. These patients had upper ureteral stones of 7.5?mm (6–9 mm) before SWL. Mean stone size on NCCT after SWL was 2.5?mm (1–4?mm). Mean BMI of these two patients was 27.72, and mean BMI of the patients with upper ureteral stones that were revealed by both PAR and NCCT was 27.68; these two values were statistically similar.

Conclusion:
PAR is capable of detecting clinically significant residual fragments, and patients can be followed up with PAR alone after SWL treatment for radiopaque ureteral stones. This approach both decreases the cost and prevents excessive radiation exposure.


Journal of Endourology. June 2012, 26(6): 621-624. doi:10.1089/end.2011.0547.

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

Seyed Mohamad Kazem Aghamir, M.D.,1 Alborz Salavati, M.D.,1 Mehdi Aloosh, M.D.,2,3 Hasan Farahmand, M.D.,1 Alipasha Meysamie, M.D.,4 and Gholamreza Pourmand, M.D.3

1Department of Urology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
2Research Development Center, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
3Urology Research Center, Tehran University of Medical Sciences, Tehran, Iran.
4Department of Community Medicine, Tehran University of Medical
Sciences, Tehran, Iran.

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.


Journal of Endourology. -Not available-, ahead of print. doi:10.1089/end.2011.0518.

Does the Hounsfield Unit Value Determined by Computed Tomography Predict the Outcome of Percutaneous Nephrolithotomy?

Adnan Gücük, M.D.,1 Ugur Üyetürk, M.D.,1 Ufuk Öztürk, M.D.,2 Eray Kemahli, M.D.,1 Mevlüt Yildiz, M.D.,1 and Ahmet Metin, M.D.1

1Department of Urology, Abant Izzet Baysal University Faculty of Medicine, Bolu, Turkey.
2Department of Urology, S.B Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey.

Abstract

Purpose:
We aimed to evaluate whether the Hounsfield unit (HU) value predicts outcome in percutaneous nephrolithotomy (PCNL).

Patients and Methods:
One hundred and seventy-nine patients who had undergone PCNL in our clinics in the last 4 years were included. Demographic and clinical data of the patients and complications, if any, were recorded. The mean age of the patients was 45.3±14.3 years (range 5–82?y), and 111 of them were males (62%). The mean stone size and HU values were found to be 693.1±628.0 (95–4200) mm2 and 706.3±245.0 (214–1325), respectively.

Results:
In logistic regression analysis, the size of the stone, the opacity of the stone, and the HU values were found to be independent predictors of the failure of the procedure (P<0.05). A cutoff value of 677.5 was used for the HU in the receiver operating characteristics analysis. Having a HU value under the cutoff value increased the likelihood of procedure failure by 2.65 times, whereas stones residing in the staghorn localization increased failure by 5.68. It was also observed that if the stone’s size was 485?mm2 or more, the chance of failure increased by 1.9, whereas when the stone was nonopaque, failure increased by 6.04 times (P<0.05). There was a positive correlation between hematocrit decrease and a decrease in HU values (P<0.05), but no correlation was observed between the HU values and duration of surgery or fluoroscopy (P>0.05).

Conclusion:
In addition to the size and location of the stones, the HU value determined in the unenhanced CT scan may be one of the parameters affecting PCNL outcomes. PCNL is a more efficient method in stones with higher HU values. Therefore, the HU values may be a useful tool for the selection of the treatment modality in patients with renal stones.


Journal of Endourology. April 2012, 26(4): 347-350. doi:10.1089/end.2011.0504.

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

Ehud Gnessin, M.D., Jessica A. Mandeville, M.D., Shelly E. Handa, R.N., and James E. Lingeman, M.D.

Department of Urology, Indiana University Health, Methodist Hospital, Indianapolis, Indiana.

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).


Urology Volume 79, Issue 6 , Pages 1247-1251, June 2012

Doppler Ultrasound-guided Percutaneous Nephrolithotomy With Two-step Tract Dilation for Management of Complex Renal Stones

Youming Xu, Zhonghua Wuemail address, Jianhua Yu, Shulong Wang, Fang Li, Jiushun Chen, Jin Liu, Kan Chen

Department of Urology, Hubei Provincial Corps Hospital, Chinese People’s Armed Police Forces, Wuhan, China

Objective
To report our experience and assess the safety and efficacy of Doppler ultrasound–guided percutaneous nephrolithotomy (PCNL) with 2-step tract dilation for complex renal stones.

Materials and Methods
From March 2009 to February 2011, 262 patients underwent PCNL. Eighty-three patients had a complete and 105 had partial staghorn calculus, and 74 had a renal pelvic stone of >2 cm in diameter. Thirty-five patients had renal surgical history. Doppler ultrasound–guided PCNL with 2-step tract dilation were performed. Stones were fragmented and cleared using a combination of ultrasonic and pneumatic lithotripters.

Results
All PCNL procedures were successful. Successful access to the collecting system was 100%. Although most of the cases (231/262) were managed satisfactorily by a single tract, a second tract was used in 31 cases. Mean operation time was 56 minutes (range 25–145). The primary stone-free rate of PCNL was 80.9%. There were 39 auxiliary procedures (13 second PCNL and 26 extracorporeal shock wave lithotripsy). One month after treatment, the overall stone-free rate was 92.7%. Five patients (1.9%) received blood transfusion. Eight patients (3.1%) with a postoperative fever of =38.5°C were cured by intravenous antibiotics. No other severe complications occurred. The mean postoperative stay was 3.8 days (range 2–12).

Conclusion
Doppler ultrasound–guided PCNL with 2-step tract dilation for complex renal stones is safe, effective, and worthy of wider use in clinical practice.


Urology Volume 79, Issue 6 , Pages 1242-1246, June 2012

Medical Expulsive Therapy in a Tertiary Care Emergency Department

Nancy Itano, Elisabeth Ferlic, Rafael Nunez-Nateras, Mitchell R. Humphreys

Department of Urology, Mayo Clinic Arizona, Phoenix, Arizona

Objective
To assess the extent of Medical expulsive therapy (MET) use and practice patterns in our tertiary care emergency department. MET is the first-line intervention for select symptomatic urolithiasis recommended by the American Urological Association and supported by clinical trials investigating its efficacy. Nonetheless, MET is not always prescribed in the emergency department setting for symptomatic patients with ureteral stones.

Methods
Using the “International Classification of Diseases” diagnostic codes, we retrospectively reviewed the medical records of all emergency department patients treated for urolithiasis at our institution from January to December 2008. Abstracted patient data included demographic and medically relevant information; MET use was determined by reviewing the electronic prescriptions at discharge.

Results
Of 165 patients identified with a diagnosis of renal colic owing to urolithiasis, 23 were excluded for suspected stone passage or failure to document a stone on cross-sectional imaging. Most (138 [97%] of 142) of the remaining patients met the criteria for outpatient treatment of symptomatic stone episodes and were eligible for MET. Urology consultation was requested in 19 outpatients (13%), and MET was prescribed for most (14 [73.7%] of 19). Of the 119 patients seen by an emergency department physician without urologic input and discharged, 17 (14%) received MET. Overall, tamsulosin was prescribed to 31 (22%) of 138 stone episodes treated with an outpatient trial of passage.

Conclusion
The underusage of tamsulosin in the emergency department of our
institution highlights the need for educational interventions to
improve the quality and cost of emergent patient care.


Urology Volume 79, Issue 6 , Pages 1230-1235, June 2012

Pulsed Fluoroscopy in Ureteroscopy and Percutaneous Nephrolithotomy

Mohamed A. Elkoushy, Walid Shahrour, Sero Andonian

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

Objective
To assess the impact of pulsed fluoroscopy (PF) at a rate of 4 frames per seconds (fps) on the total fluoroscopy time during ureteroscopy (URS) and percutaneous nephrolithotomy (PCNL).

Methods
A retrospective review of prospectively collected data was performed for consecutive patients undergoing URS and PCNL by a single surgeon between July 2009 and July 2011. PF was routinely used in all URS procedures since January 2011 and in all PCNL procedures since November 2010. Before these dates, standard fluoroscopy (SF) at a rate of 30 fps was used. Patient and stone characteristics together with operative data were compared using univariate and multivariate analyses.

Results
There were a total of 163 URS (117 SF and 46 PF) and 100 PCNL (50 SF and 50 PF). In the URS cohort, there were no significant differences between both SF and PF groups in terms of age, gender, body mass index, stone location, and multiplicity (P =.20). For both URS and PCNL cohorts, the duration of surgery and stone-free rates were comparable in both SF and PF groups (P =.06). Compared with SF groups, patients in the PF groups were exposed to significantly less fluoroscopy during URS (109.1 vs. 44.1 sec, P<0.001) and PCNL (341.1 vs. 121.5 sec, P<0.001). These differences in mean fluoroscopy times retained their significance in multivariate analyses (P<.001).

Conclusion
The use of PF during URS and PCNL was associated with significantly lower fluoroscopy time, thus reducing radiation exposure to both patients and personnel.


Journal of Endourology. June 2012, 26(6): 625-629. doi:10.1089/end.2011.0526.

Outcomes of Retrograde Intrarenal Surgery Compared with Percutaneous Nephrolithotomy in Elderly Patients with Moderate-Size Kidney Stones: A Matched-Pair Analysis

Tolga Akman, M.D., Murat Binbay, M.D., Mesut Ugurlu, M.D., Mehmet Kaba, M.D., Muzaffer Akcay, M.D., Ozgur Yazici, M.D., Faruk Ozgor, M.D., and Ahmet Yaser Muslumanoglu, M.D.

Haseki Teaching and Research Hospital, Department of Urology, Istanbul, Turkey.

Abstract

Purpose:
The aim of our study was to evaluate the outcomes of retrograde intrarenal surgery (RIRS) in elderly patients with stones of moderate size.

Patients and Methods:
Between September 2008 and June 2011, a total of 28 patients over 65 years of age with single renal stones that measured 1.5 to 3?cm were treated with RIRS. The outcomes of these patients were compared with those of the patients who underwent percutaneous nephrolithotomy (PCNL) using matched-pair analysis (1:1 scenario). The matching parameters were the size and location of the stone as well as age, sex, body mass index, degree of hydronephrosis, presence of previous shockwave lithotripsy, and open surgery. SPSS version 16 was used for statistical analysis.

Results:
Stone-free rates after a single procedure were achieved in 82.1% of patients for the RIRS and 92.8% of patients for the PCNL group. The second flexible ureterorenoscopy procedure was performed for five patients in the RIRS group. Finally, stone-free rates during the third month of the follow-up period were 92.8% in the RIRS group and 96.4% in the PCNL group. The mean operative time per patient was 64.5±20.9 minutes in the RIRS group after a total of 33 procedures, while it was 40.7±10.7 minutes in the PCNL groups (P<0.0001). The overall complication rates for the RIRS and PCNL groups were 7.1% and 10.7%, respectively. Blood transfusions were needed in two patients in the PCNL group. Hospitalization time was significantly shorter in the RIRS group (26.5±10.6?h per patient vs 60.0±28.8?h; P<0.0001). In both groups, stones were most frequently composed of calcium oxalate (68.4% in the RIRS group and 77.7% in the PCNL group).

Conclusion:
RIRS has a low complication rate and represents a safe and effective treatment alternative in selected geriatric patients with kidney stones of moderate size.


Urology Volume 79, Issue 6 , Pages 1226-1229, June 2012

The Impact of Dietary Calcium and Oxalate Ratios on Stone Risk

Jessica N. Lange, Kyle D. Wood, Patrick W. Mufarrij, Michael F. Callahan, Linda Easter, John Knight, Ross P. Holmes, Dean G. Assimose

Wake Forest University School of Medicine, Winston-Salem, NC

Objective
To determine whether the ratio of dietary calcium and oxalate consumption at mealtime affects gastrointestinal oxalate absorption and urinary oxalate excretion.

Methods
A study was conducted with 10 non–stone-forming adults placed on controlled diets with daily calcium and oxalate contents of 1000 and 750 mg, respectively. Subjects consumed a balanced calcium/oxalate ratio diet for 1 week, observed a minimum 1-week washout period, and subsequently consumed an imbalanced calcium/oxalate ratio diet for one week. Urine specimens were collected on the last 4 days of each diet. Outcome measures included urinary creatinine, calcium, and oxalate as well as the Tiselius index for assessing urinary calcium oxalate supersaturation.

Results
Total daily calcium excretion, oxalate excretion, and Tiselius index were similar between balanced and imbalanced dietary phases. There were significant differences in calcium excretion (mg/g creatinine) between balanced and imbalanced diets in the 1-6 pm (83.1 vs 110.2, P <.04), 6-11 pm (71.3 vs 107.2, P <.02), and 11 pm-8 am collections (55.0 vs 41.8, P <.02). There was significantly higher oxalate excretion on the balanced diet in the 1-6 pm time period (28.1 vs 16.7, P <.01). There were no differences in the Tiselius index in these collections.

Conclusion
These results demonstrate that the sequence of ingesting relatively large amounts of oxalate does not significantly affect calcium oxalate stone risk if the recommended daily quantity of dietary calcium is consumed.


Journal of Endourology. May 2012, 26(5): 478-483. doi:10.1089/end.2011.0465.

A Randomized Control Trial Evaluating Efficacy of Nephrostomy Tract Infiltration with Bupivacaine After Tubeless Percutaneous Nephrolithotomy

Hemendra N. Shah, M.Ch, D.N.B., MRCS (Ed),1,2 Rashmi H. Shah, M.S., D.N.B.,3 Hiren S. Sodha, M.S., D.N.B.,3 Amit A. Khandkar, M.S., D.N.B.,2 and Aniruddha Gokhale, M.Ch.2

1Department of Urology, S. L. Raheja (Fortis) Hospital, Mahim (West), Mumbai, India.
2Department of Urology, R. G. Stone Urological Research Institute, Mumbai, India.
3Minimal Access Surgery, R. G. Stone Urological Research Institute, Mumbai, India.

Abstract

Purpose:
We conducted a randomized controlled trial to assess the efficacy of nephrostomy tract infiltration with bupivacaine in tubeless percutaneous nephrolithotomy (PCNL).

Patients and Methods:
All adult patients undergoing unilateral tubeless PCNL from July 1, 2007 to October 31, 2007 were included in the study. Patients were randomized to receive infiltration of bupivacaine in the nephrostomy tract at the end of the procedure or not to receive bupivacaine. To show a 10% difference in postoperative pain, a sample size of 30 persons per group would be needed. Postoperatively, the pain score were obtained at 4 and 24 hours by a nurse who was blinded to the protocol. The perioperative outcome of these patients (study group) was compared with those undergoing tubeless PCNL without nephrostomy tract infiltration of bupivacaine (control group).

Results:
Patient demographics and intraoperative parameters in both groups were comparable. Supracostal access was needed in 65.7% and 72.7% patients in the study and control group, respectively. The nephrostomy tract were infiltrated with bupivacaine in 31 patients. The visual analogue pain score at 4 hours and 24 hours for the study group was 2.66±1.07 & 2.23±0.50 respectively, while in control group was 5.15±1.52 and 3.22±1.11, respectively (P=0.000). There was a trend toward lesser analgesia requirement in the study group (94.8 vs 124.2 mg of diclofenac sodium). There was no difference in the duration of postoperative catheterization, hospital stay, stone-free rates, and complication between both groups.

Conclusions:
Nephrostomy tract infiltration of bupivacaine in tubeless PCNL is associated with less postoperative pain and analgesia requirement.


Clinics vol.67 no.5 São Paulo  2012

Metabolic assessment of elderly men with urolithiasis.

Freitas Junior CH, Mazzucchi E, Danilovic A, Brito AH, Srougi M.

Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil.

ABSTRACT

OBJECTIVE:
To assess the presence of metabolic disorders in elderly men with urolithiasis.

METHODS:
We performed a case-control study. The inclusion criteria were as follows: (1) men older than 60 years of age and either (2) antecedent renal colic or an incidental diagnosis of urinary lithiasis after age 60 (case arm) or (3) no antecedent renal colic or incidental diagnosis of urolithiasis (control arm). Each individual underwent an interview, and those who were selected underwent all clinical protocol examinations: serum levels of total and ionized calcium, uric acid, phosphorus, glucose, urea, creatinine and parathyroid hormone, urine culture, and analysis of 24-hour urine samples (levels of calcium, citrate, creatinine, uric acid and sodium, pH and urine volume). Each case arm patient underwent two complete metabolic urinary investigations, whereas each control arm individual underwent one examination. ClinicalTrials.gov: NCT01246531.

RESULTS:
A total of 51 subjects completed the clinical investigation: 25 in the case arm and 26 in the control arm. In total, 56% of the case arm patients had hypocitraturia (vs. 15.4% in the control arm; p = 0.002). Hypernatriuria was detected in 64% of the case arm patients and in 30.8% of the controls (p = 0.017).

CONCLUSION:
Hypocitraturia and hypernatriuria are the main metabolic
disorders in elderly men with urolithiasis.

Keywords: Urolithiasis; Calculi; Citrate; Metabolism; Aging; Elderly.


Clinics vol.67 no.5 São Paulo  2012

Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital

Oliver Rojas Claros; Carlos Hirokatsu Watanabe Silva; Horacio Consolmagno; Americo Toshiaki Sakai; Rodrigo Freddy; Oscar Eduardo Hidetoshi Fugita

Hospital Universitário da Faculdade de Medicina da Universidade de São Paulo, São Paulo/SP, Brasil

ABSTRACT

OBJECTIVE:
Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital.

MATERIALS AND METHODS:
Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients.

RESULTS:
Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i.e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers.

CONCLUSION:
Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

Keywords: Ureterolithiasis; Emergency Department; University Hospital.


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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.


Vi segnaliamo i seguenti eventi:

EAU 2012 Annual meeting
Paris,
24-28 Febbraio 2012
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11° Congresso Nazionale IEA
Manfredonia (FG),
29-31 Marzo 2012
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AUA 2012 Annual meeting
Atlanta GA USA,
19-23 Maggio 2012
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XXII Congresso Nazionale SIUrO
Bologna,
13-15 Giugno 2012
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85° Congresso Nazionale SIU
Venezia,
21 – 24 Ottobre 2012

Newsletter 3-11

BJU Int. 2011 Apr 21. doi:10.1111/j.1464-410X.2011.10495.x

Trends in urological stone disease

Benjamin W. Turney, John M. Reynard, Jeremy G. Noble and Stephen R. Keoghane*

Oxford Stone Group, Department of Urology, Nuffi eld Department of Surgical Sciences, The Churchill Hospital, Oxford, and *Department of Urology, Queen Alexandra Hospital, Portsmouth, UK

Abstract

OBJECTIVE:
To summarize the changes in prevalence and treatment of upper urinary tract stone disease in the UK over the last 10 years.

METHODS:
Data from the Hospital Episode Statistics (HES) website (http://www.hesonline.nhs.uk) were extracted, summarized and presented.

RESULTS:
- The number of upper urinary tract stone hospital episodes increased by 63% to 83050 in the 10-year period.
- The use of shock wave lithotripsy (SWL) for treating all upper tract stones increased from 14491 cases in 2000 – 2001 to 22402 cases in 2010 (a 55% increase) with a 69% increase in lithotripsy for renal stones.
- There was a 127% increase in the number of ureteroscopic stone treatments from 6   283 to 14   242 cases over the 10-year period with a 49% increase from 2007/2008 to 2009/2010.
- There was a decline in open surgery for upper tract stones from 278 cases in 2000/2001 to 47 cases in 2009/2010 (an 83% reduction).
- Treatment for stone disease has increased substantially in comparison with other urological activity. In 2009/2010, SWL was performed almost as frequently as transurethral resection of the prostate or transurethral resection of bladder tumour, ureteroscopy for stones was performed more frequently than nephrectomy, radical
prostatectomy and cystectomy combined, and percutaneous nephrolithotomy was performed more frequently than
cystectomy.

CONCLUSIONS:
- The present study highlights the increase in prevalence and treatment of stone disease in the UK over the last 10 years.
- If this trend continues it has important implications for workforce planning, training, service delivery and research in the fi eld of urolithiasis.


JOURNAL OF ENDOUROLOGY JOURNAL OF ENDOUROLOGY Volume 23, Number 9, September 2009 (C) Mary Ann Liebert, Inc. Pp. 1395–1398 DOI: 10.1089=end.2009.0391olume 23, Number 9, September 2009 (C) Mary Ann Liebert, Inc. Pp. 1395–1398 DOI: 10.1089=end.2009.0391

Retrograde Ureteroscopy for Renal Stones Larger Than 2.5 cm

Julie M. Riley, M.D., Laura Stearman, M.D., and Scott Troxel, M.D.

Department of Urology, University of Missouri, Columbia, Missouri.

Abstract

Introduction and Objectives:
Because of the advances in endoscopic technology, retrograde flexible ureteroscopy (URS) is being applied to larger renal stone burdens. For stones greater than 2.5 cm, percutaneous nephrolithotomy has long been considered the standard of care. We have encountered a growing population of patients who desire a less invasive, less disruptive approach to large renal stones. We present our experience with retrograde ureteroscopic management of renal stones larger than 2.5 cm.

Methods:
Twenty-two patients between October 2004 and June 2008 underwent retrograde flexible URS with holmium laser lithotripsy. Each patient underwent retrograde URS using the Storz Flex-X and a ureteral access sheath.  Patients  were  evaluated  for  number of  procedures,  stone  clearance  rates,  and hospital admissions. Postoperative kidney, ureter, and bladder radiograph was used to determine stone-free rates.

Results:
Mean stone size was 3.0 cm. The average number of procedures was 1.82 with 5 patients requiring one,
14 requiring two, and 1 requiring three procedures. There were two failures who went on to have percutaneous
nephrolithotomy, both of whom had significant lower pole stone burden. Overall stone-free rate was 90.9%.
There were three overnight admissions for stent pain, and one 3-day admission for bacteremia in a patient who
was noncompliant with preoperative antibiotics.

Conclusions:
Planned staged URS is a viable option for the treatment of renal stones larger than 2.5 cm with
excellent stone-free results. Significant lower pole stone burden is a limiting factor.


J Urol. 2011 Oct;186(4 Suppl):1728-33. Epub 2011 Aug 19.

Use of the ureteral access sheath during ureteroscopy in children.

Wang HH, Huang L, Routh JC, Kokorowski P, Cilento BG Jr, Nelson CP.

Department of Urology, Children’s Hospital Boston, Boston, Massachusetts.

Abstract

PURPOSE:
The use of ureteral access sheaths during ureteroscopy is common but there are sparse data on the safety and outcomes of ureteral access sheath use in children. We compared the outcomes of ureteroscopy with vs without a ureteral access sheath in children.

MATERIALS AND METHODS:
We retrospectively reviewed all ureteroscopy procedures for urolithiasis in patients younger than 21 years at our hospital from 1999 to 2009. The primary outcome was intraoperative complications. Secondary outcomes were postoperative hydronephrosis, emergency room visit/hospital readmission within 90 days, stone-free status and need for re-treatment. We analyzed associations of a ureteral access sheath with outcomes.

RESULTS:
A total of 34 boys and 62 girls with a mean age of 13 years underwent ureteroscopy. A ureteral access sheath was used in 40 of the 96 patients (42%). The mean stone burden was 9.6 mm. Median followup was 11 months (range 0.2 to 110). Intraoperative complication occurred in 7 cases, including perforation/extravasation in 4, a submucosal wire in 2 and stent migration in 1. Intraoperative complications were more common when a sheath was used (15% vs 2%, adjusted OR 8.2, 95% CI 1.3-50.9, p = 0.02). Postoperative hydronephrosis was observed in 7 of 73 cases (10%) but it was not significantly more common when a sheath was used. No ureteral stricture was identified. Sheath use was not associated with postoperative telephone calls, emergency room visits or rehospitalization. Although the stone-free rate tended to be higher in cases without a sheath (78% vs 59%, p = 0.09), this association was not significant in a multivariate model (p = 0.6).

CONCLUSIONS:
Although intraoperative complications occur more commonly during ureteroscopy with a ureteral access sheath, no increase in longer term adverse effects were observed. Future prospective studies of ureteral access sheath use in children with longer followup are warranted.

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


Urol Res. 2011 Oct;39(5):357-60. Epub 2010 Dec 30.

Clinical significance of uric acid dihydrate in urinary stones.

Strohmaier WL, Seilnacht J, Schubert G.

Department of Urology and Paediatric Urology, regioMed Kliniken, Klinikum Coburg, Ketschendorfer Str. 33, 96450, Coburg, Germany, walter.strohmaier@klinikum-coburg.de.

Abstract

Uric acid crystallizes as an anhydrous compound (UAA), a dihydrate (UAD) or a mixture of both. A monohydrate form is very rare. About 20% of uric acid stones contain a significant amount (≥20%) UAD. It is believed that UAD crystallizes under highly acidic conditions (urine pH ≤ 5.0). Up to now, metabolic data on patients with UAD stones have not been reported in the literature. One hundred and fifty patients with pure uric acid calculi were studied. Stone analysis was performed using X-ray diffraction. According to the stone analysis, they were divided in two groups: 1. UAD (≥20% UAD), 2. UAA (<20% UAD). In all patients the following parameters were examined: age, sex, number of recurrences, body mass index (BMI); blood: creatinine, uric acid, calcium, sodium, and potassium; urine: pH-profiles, volume, calcium, uric acid, citrate, ammonia, and urea. Group 1 (≥20% UAD) consisted of33patientsand group 2 (<20% UAD) of 117 patients. Between these groups, there was a significant difference concerning the number of recurrences, the urine volume, and the urinary excretion of calcium. Patients with ≥20% dihydrate had a mean BMI of 31.6 ± 7.5, a mean number of recurrences of 0.24 ± 0.44, an urine volume of 2.6 ± 0.8 l/24 h, and a calcium excretion of 4.5 ± 2.2 mmol/24 h, whereas those with <20% dihydrate had BMI of 29.9 ± 5.0, 1.10 ± 1.42 recurrences, urine volume of 2.3 ± 1.2 l/24 h, and calcium excretion of 3.2 ± 2.4 mmol/24 h. All the other parameters tested were not significantly different. For the first time, our study shows metabolic data in uric acid patients with a significant amount of UAD. The comparison between this group and those patients with <20% UAD revealed that the first group is less prone to develop recurrences. This is a relevant difference concerning the necessity of metaphylactic measures. We could not confirm in patients with dihydrate if the urinary pH is more acid than in those with insignificant amounts of dihydrate. The higher 24-h urine volume, the higher excretion of calcium, and the higher BMI in the UAD group may be of pathophysiological relevance and requires further attention.


Urol Res. 2011 Sep 10.

Distension of the renal pelvis in kidney stone patients: sensory and biomechanical responses.

Pedersen KV, Liao D, Osther SS, Drewes AM, Gregersen H, Osther PJ.

Urological Research Center, Department of Urology, Fredericia Hospital, Part of Hospital Littlebelt, University of Southern Denmark, Dronningensgade 97, 7000, Fredericia, Denmark.

Abstract

The pathogenesis of symptoms in urolithiasis is poorly understood. Traditionally increased endoluminal pressure is considered the main mechanism causing pain in the upper urinary tract but clinical data are sparse. The aim of the present study was to develop a new model related to mechanosensation in order to describe the geometric and mechanical properties of the renal pelvis in patients with kidney stone disease. Pressure measurement in the renal pelvis was done during CT-pyelography in 15 patients who underwent percutaneus nephrolithotomy. The sensory intensity was recorded at the thresholds for first sensation and for pain. 3D deformation and strain were calculated in five patients. The deformation of pelvis during distension was not uniform due to the complex geometry. The pelvis deformed to 113 ± 6% and 115 ± 11% in the longitudinal and circumferential directions, respectively. Endoluminal pressure in the renal pelvis corresponded positively to the sensory ratings but the referred pain area was diffuse located and varied in size. The present study provides a method for describing the mechanosensory properties and 3D deformation of the complex renal pelvis geometry. Although there was a relation between pressure and pain score, the non-homogenous spatial strain distribution suggests that the 3D biomechanical properties of the renal pelvis are not reflected by simple estimates of tension based on pressure and volume.


Urology. 2011 Sep 20.

Effective Radiation Exposure in Evaluation and Follow-up of Patients With Urolithiasis.

Fahmy NM, Elkoushy MA, Andonian S.

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

Abstract

OBJECTIVE:
To quantify the effective radiation dose associated with the evaluation and follow-up of patients with urolithiasis.

METHODS:
Retrospective review was performed for consecutive patients presenting to a tertiary stone clinic with acute stone episodes between November 2007 and December 2008, and had at least 2 years of follow-up. Number and modality of imaging studies were collected. Effective radiation exposure (ERE) doses were calculated from the dose length product values reported with each computed tomography (CT) scan.

RESULTS:
There were 72 males and 32 females with a mean age of 49 years (range 21-78). Patients underwent an average 1.8 (range 0-5) and 0.7 (range 0-2) plain radiographs, 0.82 (range 0-4) and 0.15 (range 0-2) CTs, 0.09 (range 0-1) and 0.03 (range 0-1) intravenous urograms, and 0.3 (range 0-1) and 0.6 (range 0-2) ultrasounds (US) during the first and second years, respectively (all P <.05). The average calculated ERE dose per CT scan was 23.16 mSv (range 4.94-72.77). The calculated mean ERE dose per patient significantly decreased from 29.29 mSv (range 1.7-77.27) in the first year to 8.04 mSv (range 1.4-24.72) in the second year (P <.01). This was because of significantly fewer CT scans and significantly more US imaging during the second year (P <.05). Although 18 (17.3%) patients exceeded 50 mSv during the first year, none exceeded this threshold during the second year. The mean ERE dose did not correlate with stone location, patient age, and sex.

CONCLUSION:
The calculated mean ERE dose significantly decreased during the second year of follow-up in patients with urolithiasis because of significantly higher use of US.

Copyright © 2011 Elsevier Inc. All rights reserved.


Eur Urol. 2011 Sep 28.

Incidence, Prevention, and Management of Complications Following Percutaneous Nephrolitholapaxy.

Seitz C, Desai M, Häcker A, Hakenberg OW, Liatsikos E, Nagele U, Tolley D.

Department of Urology, St. John of God Hospital, Teaching Hospital of the Medical University of Vienna, Austria.

Abstract

CONTEXT:
Incidence, prevention, and management of complications of percutaneous nephrolitholapaxy (PNL) still lack consensus.

OBJECTIVE:
To review the epidemiology of complications and their prevention and management.

EVIDENCE ACQUISITION:
A literature review was performed using the PubMed database between 2001 and May 1, 2011, restricted to human species, adults, and the English language. The Medline search used a strategy including medical subject headings (MeSH) and free-text protocols with the keywords percutaneous, nephrolithotomy, PCNL, PNL, urolithiasis, complications, and Clavien, and the MeSH terms nephrostomy, percutaneous/adverse effects, and intraoperative complications or postoperative complications.

EVIDENCE SYNTHESIS:
Assessing the epidemiology of complications is difficult because definitions of complications and their management still lack consensus. For a reproducible quality assessment, data should be obtained in a standardized manner, allowing for comparison. An approach is the validated Dindo-modified Clavien system, which was originally reported by seven studies. No deviation from the normal postoperative course (Clavien 0) was observed in 76.7% of PNL procedures. Including deviations from the normal postoperative course without the need for pharmacologic treatment or interventions (Clavien 1) would add up to 88.1%. Clavien 2 complications including blood transfusion and parenteral nutrition occurred in 7%; Clavien 3 complications requiring intervention in 4.1.%; Clavien 4, life-threatening complications, in 0.6%; and Clavien 5, mortality, in 0.04%. High-quality data on complication management of rare but potentially debilitating complications are scarce and consist mainly of case reports.

CONCLUSIONS:
Complications after PNL can be kept to a minimum in experienced hands with the development of new techniques and improved technology. A modified procedure-specific Clavien classification should be established that would need to be validated in prospective trials.

Copyright © 2011. Published by Elsevier B.V.


Urol Res. 2011 Sep 8.

Is shock wave lithotripsy efficient for the elderly stone formers? Results of a matched-pair analysis.

Philippou P, Lamrani D, Moraitis K, Bach C, Masood J, Buchholz N.

Endourology and Stone Services, Department of Urology, Barts and The London NHS Trust, Smithfield, London, EC1A 7BE, UK.

Abstract

The aim of the study was to evaluate the impact of age on the efficacy of extracorporeal shock wave lithotripsy (SWL), in a comparative study based on the principles of matched-pair analysis. Over a period of 4 years, 2,311 patients were treated with SWL in a tertiary referral center. Patient and stone data were recorded in a prospective electronic database. Among these patients, 115 (4.97%) were older than 70 years of age and fulfilled the criteria for inclusion in the study (Group A). For the purposes of the comparative analysis, Group A patients were matched for gender and stone parameters (side, location of stone, and diameter ±2 mm) with a control group of patients under the age of 70 (Group B). Following matching, the patients’ electronic medical records were reviewed, to identify SWL success rates at 3 months and McNemar’s test was used to compare the efficacy of SWL between the two groups. Matching was possible in all cases. The results indicate that there were no statistically significant differences in the mean number of SWL sessions or in the mean number of impulses per session between the two groups. The overall stone clearance rate achieved by SWL alone was 71.3% for Group A and 73.9% for group B. Discordant pairs were found in 37 cases (in 17 pairs only patients in Group A became stone-free, while in 20 pairs only patients in Group B became stone-free). By using McNemar’s test, the difference in stone clearance rates between the two groups was not found to be statistically significant (p = 0.742). A total of 22 patients (19.1%) in Group A and 17 patients (14.7%) in Group B underwent an adjuvant procedure to achieve stone clearance. McNemar’s test also revealed the absence of any statistically significant difference in SWL success rates between older and younger patients in the subgroups of patients presenting with either ureteric or renal stones (p = 0.727 and p = 0.571, respectively). In conclusion, SWL is still considered one of the first-line tools for geriatric patients suffering from urolithiasis, as increased age alone does not seem to adversely affect the efficacy of SWL.


Kidney Int. 2011 Sep 28. doi: 10.1038/ki.2011.336.

Nephrocalcinosis and urolithiasis in children.

Habbig S, Beck BB, Hoppe B.

Division of Pediatric Nephrology, Department of Pediatrics, University of Cologne, Cologne, Germany.

Abstract

The incidence of adult urolithiasis has increased significantly in industrialized countries over the past decades. Sound incidence rates are not available for children, nor are they known for nephrocalcinosis, which can appear as a single entity or together with urolithiasis. In contrast to the adult kidney stone patient, where environmental factors are the main cause, genetic and/or metabolic disorders are the main reason for childhood nephrocalcinosis and urolithiasis. While hypercalciuria is considered to be the most frequent risk factor, several other metabolic disorders such as hypocitraturia or hyperoxaluria, as well as a variety of renal tubular diseases, e.g., Dent’s disease or renal tubular acidosis, have to be ruled out by urine and/or blood analysis. Associated symptoms such as growth retardation, intestinal absorption, or bone demineralization should be evaluated for diagnostic and therapeutic purposes. Preterm infants are a special risk population with a high incidence of nephrocalcinosis arising from immature kidney, medication, and hypocitraturia. In children, concise evaluation will reveal an underlying pathomechanism in >75% of patients. Early treatment reducing urinary saturation of the soluble by increasing fluid intake and by providing crystallization inhibitors, as well as disease-specific medication, are mandatory to prevent recurrent kidney stones and/or progressive nephrocalcinosis, and consequently deterioration of renal function.

Kidney International advance online publication, 28 September 2011; doi:10.1038/ki.2011.336.


Pediatr Nephrol. 2011 Aug 4.

Urinary calcium and uric acid excretion in children with vesicoureteral reflux.

Madani A, Kermani N, Ataei N, Esfahani ST, Hajizadeh N, Khazaeipour Z, Rafiei S.

Department of Pediatric Nephrology, Children’s Hospital Medical Center, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.

Abstract

Urolithiasis is relatively common in children, and identifiable predisposing factors for stone formation, including metabolic and structural derangements, can be established in most cases. Vesicoureteral reflux (VUR) is a common cause of kidney stone formation. The pathophysiological mechanism of urolithiasis in reflux is related to urinary tract infection and urinary stasis, both of which promote urinary crystal formation, but metabolic causes, such as crystallurias (mostly hypercalciuria), may also be involved in this process. However, few studies on urinary calcium and uric acid excretion in children with VUR have been conducted. We have studied the frequency of hypercalciuria and hyperuricosuria in children with VUR and compared the results with those from a control group. The VUR group comprised 108 children with VUR (19 boys, 89 girls; age range 3 months to 12 years), and the control group comprised 110 healthy children without any history of reflux or urinary tract infection (30 boys, 80 girls; age range 2 months to 12 years). Fasting urine was analyzed for the calcium/creatinine (Ca/Cr) and uric acid/creatinine (UA/Cr) ratios. Hypercalciuria was more frequently diagnosed in the VUR patients than in the control group (21.3 vs. 3.6%; P = 0.0001). Significant differences between the two groups were also found for the mean Ca/Cr and UA/Cr ratios (P = 0.0001 and P = 0.0001, respectively). No differences were found in the urinary Ca/Cr or UA/Cr ratios related to VUR grading or unilateral/bilateral VUR in the patient group, with the exception of those for hypercalciuria and mild VUR (P = 0.03). The association of urinary stones and microlithiasis in the VUR group was 29.6%. Our results demonstrate that the frequency of hypercalciuria and hyperuricosuria was higher in pediatric patients with VUR than in healthy children. Knowing this relationship, preventive and therapeutic interventions for stone formation in VUR could be greatly expanded.


J Urol. 2011 Oct;186(4 Suppl):1728-33. Epub 2011 Aug 19.

Use of the ureteral access sheath during ureteroscopy in children.

Wang HH, Huang L, Routh JC, Kokorowski P, Cilento BG Jr, Nelson CP.

Department of Urology, Children’s Hospital Boston, Boston, Massachusetts.

Abstract

PURPOSE:
The use of ureteral access sheaths during ureteroscopy is common but there are sparse data on the safety and outcomes of ureteral access sheath use in children. We compared the outcomes of ureteroscopy with vs without a ureteral access sheath in children.

MATERIALS AND METHODS:
We retrospectively reviewed all ureteroscopy procedures for urolithiasis in patients younger than 21 years at our hospital from 1999 to 2009. The primary outcome was intraoperative complications. Secondary outcomes were postoperative hydronephrosis, emergency room visit/hospital readmission within 90 days, stone-free status and need for re-treatment. We analyzed associations of a ureteral access sheath with outcomes.

RESULTS:
A total of 34 boys and 62 girls with a mean age of 13 years underwent ureteroscopy. A ureteral access sheath was used in 40 of the 96 patients (42%). The mean stone burden was 9.6 mm. Median followup was 11 months (range 0.2 to 110). Intraoperative complication occurred in 7 cases, including perforation/extravasation in 4, a submucosal wire in 2 and stent migration in 1. Intraoperative complications were more common when a sheath was used (15% vs 2%, adjusted OR 8.2, 95% CI 1.3-50.9, p = 0.02). Postoperative hydronephrosis was observed in 7 of 73 cases (10%) but it was not significantly more common when a sheath was used. No ureteral stricture was identified. Sheath use was not associated with postoperative telephone calls, emergency room visits or rehospitalization. Although the stone-free rate tended to be higher in cases without a sheath (78% vs 59%, p = 0.09), this association was not significant in a multivariate model (p = 0.6).

CONCLUSIONS:
Although intraoperative complications occur more commonly during ureteroscopy with a ureteral access sheath, no increase in longer term adverse effects were observed. Future prospective studies of ureteral access sheath use in children with longer followup are warranted.

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


CORSI DI AGGIORNAMENTO E CONGRESSI:

31st congress of the societè internazionale d’urologie
16-20 ottobre 2011
Berlino

84th congress nazionale della società italiana di urologia
23-26 ottobre 2011
Roma

XXI congresso nazionale AIUG
6-8 novembre 2011
Torino

Congresso nazionale SUN
10-12 novembre 2011
Roma

Technology and training in endourology
10-12 novembre 2011
Torino

Newsletter 2-11

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

NEWSLETTER 1-11

Lunedì, 24 Gennaio, 2011

Urine Calcium: Laboratory Measurement and Clinical Utility

Kevin F. Foley, PhD, DABCC; Lorenzo Boccuzzi, DO

Laboratory Medicine. 2010;41(11):683-686. © 2010 American Society for Clinical Pathology

http://www.medscape.com/viewarticle/732914?src=rss

Abstract

Urine calcium measurement is a commonly ordered test in clinical laboratories. Unlike other urine markers, the utility of urine calcium is less clear to many laboratorians and physicians. Urine calcium can be used to assess parathyroid disease and familial hypocalciuric hypercalcemia (FHH). Although not predictive of stone formation, urine calcium is frequently elevated in patients with lithiasis. The primary clinical value of urine calcium measurement is to aid in the differential diagnoses of patients and direct optimal treatment options for patients with abnormal serum calcium.


Shockwave Lithotripsy Preferred to Ureteroscopy for Single, Distal Ureteric Stones

Laurie Barclay, MD

BJUI. 2010;106:1748-1752.

http://www.medscape.com/viewarticle/732904?src=rss

November 19, 2010 — Extracorporeal shockwave lithotripsy (ESWL) was better than ureteroscopy (URS) as first-line therapy for patients with single, distal ureteric stones, according to the results of a prospective, randomized study reported in the December issue of BJUI.

“ESWL and URS are both accepted treatments for distal ureteric stones, but there is a lot of discussion about which surgical technique should be used as a first-line strategy for this condition,” senior author Vincenzo Mirone, MD, from University Federico II of Naples, in Italy, said in a news release. “Approximately one in three adults with kidney stones will have a distal ureteric stone at some point in their lives. Most stones with a diameter of up to 0.5cm will be expelled spontaneously when the patient urinates without requiring any active intervention. For larger stones that get stuck in the ureter, spontaneous expulsion is very difficult and requires active intervention.”

The study goal was to compare ESWL and URS as first-line therapy in 273 patients with single, monolateral, radiopaque, distal ureteric stones 0.5 to 1.5 cm in size.

Patients were randomly assigned to undergo ESWL (n = 137) with an electromagnetic Modulith SLX lithotripter (Storz Medical) or URS (n = 136) with a semi-rigid ureteroscope. Most (98%) of ESWL treatments were done on outpatients, and none of the patients needed anesthesia or sedation, whereas 96% of URS treatments were done on inpatients, with 22% of patients receiving general anesthesia, 66% receiving local anesthesia, and 12% receiving sedation only.

Both groups were similar in terms of clinical factors, including average age (50 years) and male:female ratio (~1:1). Outcomes were overall stone-free rates (SFRs), rates of repeat treatment, need for additional procedures, and complication rates. Subgroups of patients with stone size of 1 cm or smaller and larger than 1 cm were also analyzed separately.

In the overall ESWL group. SFR was 92.70%, retreatment rate was 44.88%, auxiliary procedure rate was 11.02%, and complication rate was 15.32%. One ESWL session was sufficient in 55% of patients, whereas 31% needed 2 sessions and 13% needed 3 sessions. In the overall URS group, SFR was 94.85%, retreatment rate was 7.75%, auxiliary procedure rate was 18.60%, and complication rate was 19.11%.

Among patients treated with ESWL, those with stones larger than 1 cm had significantly higher need for retreatments and for additional procedures and had higher complication rates. In contrast, for patients with stones 1 cm or smaller, those treated with ESWL had significantly lower rates of retreatment, auxiliary procedures, and complications than those treated with URS.

“Statistical analysis showed no significant differences in overall [SFR], treatment duration, complications and the need for auxiliary procedures,” Dr. Mirone said. “However, there were clear differences in both groups when we divided them into patients with stones of up to 1cm and stones of over 1cm…. These results clearly indicate that ESWL should be the first choice for patients with stones of 1cm and under and URS should be the first choice for patients with stones exceeding 1cm.”

The study authors have disclosed no relevant financial relationships.


Preoperative Stone Attenuation Predicts Lithotripsy Success in Children

Sean McAdams, Nicholas Kim, Daniel Dajusta, Manoj Monga, Indupur R. Ravish, Rajendra Nerli, Linda Baker, Aseem R. Shukla

The Journal of Urology Volume 184, Issue 4, Supplement , Pages 1804-1809, October 2010

http://www.jurology.com/article/S0022-5347%2810%2903210-6/abstract

Abstract

Purpose: We determined whether stone attenuation can predict stone fragmentation after shock wave lithotripsy in the pediatric population. Previous studies show that preoperative attenuation in HU on noncontrast computerized tomography predicts shock wave lithotripsy success. To our knowledge study of this parameter in the pediatric population has been lacking to date.

Materials and Methods: We performed a multi-institutional review of the records of 53 pediatric patients 1 to 18 years old who underwent shock wave lithotripsy for 3.8 to 36.0 mm renal calculi. Stone size, average skin-to-stone distance and attenuation value were determined by bone windows on preoperative noncontrast computerized tomography. Success was defined as radiographically stone-free status at 2 to 12-week followup after a single lithotripsy session without the need for further sessions or ancillary procedures.

Results: After lithotripsy 33 patients (62%) were stone-free and 20 had incomplete fragmentation or required additional procedures. Mean ± SD stone attenuation in successfully treated patients vs those with incomplete fragmentation was 710 ± 294 vs 994 ± 379 HU (p = 0.007). Logistical regression analysis revealed that only attenuation in HU was a significant predictor of success. When patients were stratified into 2 groups (less than 1,000 and 1,000 HU or greater), the shock wave lithotripsy success rate was 77% and 33%, respectively (p <0.003).

Conclusions: Stone attenuation less than 1,000 HU is a significant predictor of shock wave lithotripsy success in the pediatric population. This finding suggests that attenuation values have a similar predictive value in the pediatric population as that previously reported in the adult population.


Editorial – The effect of restrictive bariatric surgery on urinary stone risk factors

Semins MJ, Asplin JR, Steele K, Assimos DG, Lingeman JE, Donahue S, Magnuson T, Schweitzer M, Matlaga BR

Urology. 2010 Oct;76(4):826-9 – 10.1016/j.urology.2010.01.037

http://www.urotoday.com/index.php?option=com_content&task=view_ua&id=2234087

http://www.ncbi.nlm.nih.gov/pubmed/20381135?s_cid=pubmed

Abstract

Objectives: Malabsorptive bariatric procedures such as Roux-en-Y gastric bypass (RYGB) place patients at risk for developing kidney stones. Stone risk factors after purely restrictive procedures such as gastric banding and sleeve gastrectomy are not well characterized. Therefore, we performed a study to examine urinary risk factors of patients who underwent restrictive gastric surgery for bariatric indications.

Methods: A total of 18 patients were enrolled in the study; 14 underwent gastric banding and 4 underwent sleeve gastrectomy. All subjects collected 24-hour urine specimens; at least 6 months had elapsed between surgery and urine collection. Standard stone risk parameters were assessed, and comparisons were made with a group of normal adult nonstone-formers, routine stone-formers, and RYGB bariatric surgery subjects.

Results: Urinary oxalate excretion of the restrictive cohort was significantly less than the RYGB cohort (35.4 vs. 60.7 mg/d; P <.001) and not significantly different from that of the normal subjects (32.9 mg/d; P = .798) and routine stone-formers (37.2 mg/d; P = .997). There were no other significant differences in urinary parameters.

Conclusions: Restrictive bariatric surgery does not appear to be associated with an increased risk for kidney stone disease. In particular, urinary oxalate levels were significantly less than those of RYGB subjects and not significantly different from routine stone-formers and nonstone-forming controls.

Copyright © 2010 Elsevier Inc. All rights reserved.


Nephrolithotomy Superior to Lithotripsy for Asymptomatic Kidney Stones

From Reuters Health Information

J Urol 2010;183:1424-1428.

http://www.medscape.com/viewarticle/719375

http://www.thedoctorschannel.com/video/3094.html

NEW YORK (Reuters Health) Mar 29 – When asymptomatic lower pole renal calculi require intervention, percutaneous nephrolithotomy provides a higher stone-free rate than shock wave lithotripsy, and with less scarring, Turkish researchers report.

In the April Journal of Urology, they note that asymptomatic caliceal stones require intervention within five years in more than half of cases. To compare treatments and expectant management, Dr. Ahmet Tefekli from Haseki Teaching and Research Hospital in Istanbul and colleagues randomized 94 patients to receive nephrolithotomy, lithotripsy, or observation.

They evaluated patients’ stone status with non-contrast abdominal computed tomography, and they monitored for renal scarring with dimercapto-succinic acid scintigraphy.

All 31 subjects in the nephrolithotomy group were stone free at 12 months. One patient (3.2%) had scarring at 3 months.

With lithotripsy, however, only 19 of 31 patients (61.3%) were stone free at 12 months, and five patients (16.1%) had renal scarring.

Over an average of 20 months, 7 (18.7%) of 32 patients in the observation group required intervention, and one (3.1%) spontaneously passed the stone. No patient in the observation group had renal scarring.

“Patients with asymptomatic lower caliceal stones must be informed in detail about all management options, especially focusing on percutaneous nephrolithotomy with its outstanding outcome,” the authors conclude.

They add that these results “must be further evaluated by comparison with new digital flexible ureterorenoscopy devices.”

J Urol 2010;183:1424-1428.

Reuters Health Information © 2010


Urine Crystals in a 1-year-old Male

Justin Fender, BS; Monte S. Willis, MD, PhD; Yuri Fedoriw, MD

Laboratory Medicine. 2010;41(7):388-392

http://www.medscape.com/viewarticle/723846

Abstract

Clinical History

Patient: A 1-year-old Latino male. Chief Complaint: Vomiting and fever of 39.8°C for 24 hours, pain with urination.

Chief Complaint: Vomiting and fever of 39.8°C for 24 hours, pain with urination.

History of Present Illness: The patient presented to the emergency department with his mother, who reported that he had a fever along with vomiting and trouble urinating for the past 24 hours. The mother denied that the patient had shown signs of ear pain, eye irritation, nasal discharge, congestion, or sore throat. She also did not report a cough, difficulty breathing, diarrhea, bloody stools, skin rash, or decreased urine output. The patient has had no known contact with any sick individuals. At presentation, the patient is not on any medications and has no known drug allergies.

Past Medical History: Product of term vaginal delivery. No birth complications. Immunization status is up-to-date.

Social History: The patient and his mother moved to North Carolina from Mississippi in 2008 and do not have a primary pediatrician. His mother is his primary care giver, and he attends daycare.

Family History: No known family history of kidney stones, abnormal endocrine disorders, or hypercalcemia.

Principal Laboratory Findings: Table 1

Physical Exam

Vital Signs: Heart rate, 118 bpm; respiratory rate, 22 per minute.

General: Active, alert, in no acute distress.

Height: 50th percentile.

Weight: 70th percentile.

Eyes: No lid lag, proptosis, periorbital swelling, or photophobia.

Neck: Supple, no masses.

Lungs: No respiratory distress; clear to auscultation bilaterally.

Heart: Regular rate and rhythm without murmurs.

Extremities: Unremarkable.

Skin: No rash, warm, dry.

Additional Testing: A urine organic acid profile showed increased lactic, 3-OH butyric, acetoacetic, ethylmalonic, and dicarboxylic acids. The patient was discharged prior to additional urine testing.


Stone-Targeted Dual-Energy CT: A New Diagnostic Approach to Urinary Calculosis

Giorgio Ascenti1, Carmelo Siragusa2, Sergio Racchiusa1, Isidora Ielo2, Giambattista Privitera1, Federica Midili2 and Silvio Mazziotti1

1 Department of Radiological Sciences, University of Messina, Policlinico “G. Martino,” Via Consolare Valeria 1, 98100 Messina, Italy.

2 Medical Physics and Radiation Protection Unit, University of Messina, Policlinico “G. Martino,” Messina, Italy.

AJR 2010; 195:953-958 – DOI:10.2214/AJR.09.3635

http://www.ajronline.org/cgi/content/abstract/195/4/953

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.

Keywords: dual-energy CT • dual-source CT • radiation dose • urinary calculosis • urinary tract stones • urolithiasis


The role of salt abuse on risk for hypercalciuria

Patricia CG Damasio , Carmen RPR Amaro , Natalia B Cunha , Ana C Pichutti , Jose Goldberg , Carlos R Padovani and Joao L Amaro

Nutrition Journal 2011, 10:3doi:10.1186/1475-2891-10-3

http://www.nutritionj.com/content/10/1/3

Background

Elevated sodium excretion in urine resulting from excessive sodium intake can lead to hypercalciuria and contribute to the formation of urinary stones. The aim of this study was to evaluate salt intake in patients with urinary lithiasis and idiopathic hypercalciuria (IH). Methods: Between August 2007 and June 2008, 105 lithiasic patients were distributed into 2 groups: Group 1 (n=55): patients with IH (urinary calcium excretion > 250mg in women and 300mg in men with normal serum calcium); Group 2 (n=50): normocalciuric patients (NC). Inclusion criteria were: age over 18 years, normal renal function (creatinine clearance [greater than or equal to] 60 ml/min), absent proteinuria and negative urinary culture. Pregnant women, patients with intestinal pathologies, chronic diarrhea or using corticoids were excluded. The protocol of metabolic investigation was based on non-consecutive collection of two 24-hour samples for dosages of: calcium, sodium, uric acid, citrate, oxalate, magnesium and urinary volume. Food intake was evaluated by the three-day dietary record quantitative method, and the Body Mass Index (BMI) was calculated and classified according to the World Health Organization (WHO). Sodium intake was evaluated based on 24-hour urinary sodium excretion. Results: The distribution in both groups as regards mean age (42.11 +/- 10.61 vs. 46.14 +/- 11.52), weight (77.14 +/- 16.03 vs. 75.99 +/- 15.80), height (1.64 +/- 0.10 vs. 1.64 +/- 0.08) and BMI (28.78 +/- 5.81 vs. 28.07 +/- 5.27) was homogeneous. Urinary excretion of calcium (433.33 +/- 141.92 vs. 188.93 +/- 53.09), sodium (280.08 +/- 100.94 vs. 200.44 +/- 65.81), uric acid (880.63 +/- 281.50 vs. 646.74 +/- 182.76) and magnesium (88.78 +/- 37.53 vs. 64.34 +/- 31.84) was significantly higher in the IH group (p<0.05). There was no statistical difference in calcium intake between the groups, and there was significantly higher salt intake in patients with IH than in NC. Conclusions: This study showed that salt intake was higher in patients with IH as compared to NC.


Single session cystolitholapaxy and PCNL for encrusted DJ stent with large associated stone burden

Mario Ferruti, Stefano Paparella, Gabriele Cozzi, Isabella Oliva, Elisabetta Finkelberg, Augusto Maggioni, Francesco Rocco

Urologia – 2010; 77: 267 – 270 – DOI 10.5301/RU.2011.6236

http://www.rivistaurologia.it/public/RU/Article/Articleabstract.aspx?UidArticle=2E5BC6F7-0133-487B-8415-7B1D7F2B6248&t=RU

Abstract

Introduction. Ureteral stent use is commonplace in urology to prevent or relieve ureteral obstruction. If ureteral stents are neglected, they can cause severe morbidity due to migration, occlusion, encrustation, breakage, stone formation, and even death, due to life-threatening urosepsis or complications related to operative intervention. Extracorporeal shockwave lithotripsy, ureterorenoscopy, electrohydraulic lithotripsy, laser lithotripsy, and percutaneous nephrolitholapaxy (PCNL) have been reported for forgotten ureteral stent management, but currently there are no guidelines for this challenging situation and only few algorithms have been introduced by some studies.

Methods. We present a case of a man presenting with an encrusted left double J (DJ) stent, inserted two years before, and bulky radiolucent lithiasis at both ends of the stent. The patient was studied with intravenous pyelogram and non contrast-enhanced computed tomography, and then treated with cystolithotripsy and PCNL in a single session.

Results. Complete clearance of the stones was obtained and the DJ stent was removed without breaking from the percutaneous access.?

Conclusions. Neglected stents still represent a challenge in urology: while endourology remains the best option for treatment, the management of ureteral stents should be based on follow-up and prevention, using for example a computerized warning and stent retrieval software system


Extracorporeal shock wave lithotripsy in the treatment of pediatric urolithiasis: a single institution experience

Konstantinos N. Stamatiou, Ioannis Heretis, Dimitrios Takos, Vaios Papadimitriou, Frank Sofras

International Braz J Urol  - Vol. 36 (6): 724-731, November – December, 2010 – doi: 10.1590/S1677-55382010000600011

http://www.brazjurol.com.br/november_december_2010/Stamatiou_724_731.htm

Abstract

Purpose: To compare the efficacy and safety of the electromagnetic lithotripter in the treatment of pediatric lithiasis to that of the earlier electrohydraulic model.

Materials and Methods: Two groups of children with lithiasis aged between 10 and 180 months who underwent extracorporeal shock wave lithotripsy (ESWL). In the first group (26 children), ESWL was performed by using the electrohydraulic MPL 9000X Dornier lithotripter between 1994 and 2003 while in the second group (19 children) the electromagnetic EMSE 220 F-XP Dornier lithotripter was used from April 2003 to May 2006.

Results: In the first group, 21/26 children (80.7%) were stone free at first ESWL session. Colic pain resolved by administration of an oral analgesic in 6 (23%), brief hematuria (< 24 h) resolved with increased fluid intake in 5 (19.2%), while slightly elevated body temperature (< 38°C) occurred in 4 (15.3%). Four children (15.3%) failed to respond to treatment and were treated with ureteroscopy. In the second group 18/19 children were completely stone free at first ESWL session (94.7%). Complications were infrequent and of minor importance: colic pain treated with oral analgesic occurred in 1 (5.26%), brief hematuria (< 24 h), resolved with increased fluid intake in 4 (21%) and slightly elevated body temperature (< 38°C) monitored for 48 hours occurred in 6 (31.5%). Statistical analysis showed that electromagnetic lithotripter is more efficacious and safer than the earlier electrohydraulic model.

Conclusions: Technological development not only has increased efficacy and safety of lithotripter devices in treating pediatric lithiasis, but it also provided less painful lithotripsy by eliminating the need for general anesthesia.

Key words: lithiasis; children; treatment; ESWL; efficacy; complications

Int Braz J Urol. 2010; 36: 724-31


Prognostic factors of spontaneous expulsion in ureteral lithiasis

Sáenz Medina J, Alarcón Parra RO, Redondo González E, Llanes González L, Crespo Martínez L, Fernández Montarroso L, Durán Poveda M, Páez Borda A.

Actas Urol Esp. 2010 Nov;34(10):882-7.

http://www.ncbi.nlm.nih.gov/pubmed/21159285

Abstract

Medical treatment, extracorporeal shock wave lithotripsy (ESWL) and ureteroscopy are therapeutic options for ureteral stones. EWSL and endoscopic treatment of ureteral stones have a high success rate. However it has surgical as well as anaesthetic risks. For many patients, a medicinal treatment without invasive procedures is an option. Watchful waiting does not always result in stone clearance and may be associated with recurrent renal colic. The study of the prognostic factors for expulsion and the medical therapy will help us to select candidates for medical expulsive treatment.

Objectives: To evaluate the characteristics of the stones and the medication administered (alpha blockers, NSAIDs or a combination of both) as predictors of spontaneous passage of the stone.

Material and methods: A retrospective observational study of 260 patients with 278 ureteral stones was conducted. Primary endpoint was stone expulsion. Univariate and multivariate analysis were conducted testing the effect of stone location, size and composition, and medication (alpha-blockers, NSAIDs, or combination) on stone clearance.

Results: 34,2% of the stones studied were spontaneously eliminated. Stone location (pelvic ureter, OR=1.823, p=0.013), size (>5 mm, OR=3.37, p>0.02), and medication (combination of alpha blockers and NSAIDs, OR=8.70, >0.001) were predictors of spontaneous clearance. Multivariate analysis confirmed size (p=0.006) and medication (p>0.001) as independent predictive factors.The use of the combination of NSAIDs and alpha-blockers versus observation multiplied times 8.21 (95%CI 3.37-20.01) the possibilities of spontaneous expulsion.

CONCLUSIONS: Size of stone and medication were confirmed as independent factors for spontaneous expulsion of ureteral stones.


Renal lithiasis in patients with primary hyperparathyroidism. Evolution and treatment.

Valle Díaz de la Guardia F, Arrabal Martín M, Arrabal Polo MA, Quirosa Flores S, Miján Ortiz JL, Zuluaga Gómez A.

Arch Esp Urol. 2010 Jan;63(1):41-2.

http://www.ncbi.nlm.nih.gov/pubmed/20157217

Abstract

Objectives: The relationship between hyperparathyroidism and lithiasis is quite known, so the study of parathyroid glands is especially mandatory in the face of relapses. Our objective is to analyze both primary hyperparathyroidism (PHPT) associated with renal lithiasis and the evolution of this condition after parathyroidectomy, as well as to study factors associated with the presence of lithiasis or bone pathology, and carry out a review on bibliography.

Methods: We describe a retrospective study of a series comprising 287 cases of hyperparathyroidism: 237 of them were primary and the remaining 50, secondary. We have included: sex, age, evolution time and symptoms, diagnostic tests (biochemical, radiological and histological). Factors such as number of episodes prior to diagnosis and treatments were analyzed in patients with symptomatic lithiasis to know whether patients exhibited residual lithiasis after the management of calculi or whether patients underwent episodes after parathyroidectomy, or whether or not they were treated. Statistical analysis was carried out through SPSS 15.0 for Windows.

Results: Forty five percent of the patients had suffered lithiasis episodes; 50%, osteopenia/osteoporosis; 23%, musculoskeletal pain; 23%, asthenia and/or depressive syndrome. In 13.5% of cases, diagnosis was supported by the presence of hypercalcemia; no other symptoms were detected. We have analyzed factors that favor or inhibit renal lithiasis formation and compared biochemical parameters from the group of primary hyperthyroidism that exhibited lithiasis (41 patients) with those patients who did not (49). We noted that lithiasis patients showed higher values of calcium, alkaline phosphatase, intact PTH, mean PTH, osteocalcin, and chlorine/phosphate, calciuria and phosphaturia indexes. Student’s t test on two independent samples revealed significant statistical differences in calcium levels (p<0.05), intact PTH (<.05) and osteocalcin.

Conclusions: Primary hyperparathyroidism patients with lithiasis presented higher values of parathormone, alkaline phosphatase, osteocalcin, and Cl/P and calciuria indexes than lithiasis-free PHPT patients. These patients exhibit objective improvement of symptoms after parathyroidectomy, and rarely a recurrence of lithiasis, a factor that generally coincides with persistence of residual lithiasis.


 

ALTRI CONGRESSI:

 
10° Congresso Nazionale IEA
Roma,
3-5 Marzo 2011
 
EAU 2011 Annual meeting
Vienna,
18-22 Marzo 2011
 
2nd International EAU-EULIS Comprehensive Urolithiasis Workshop
Sofia (Bulgaria),
28-29 Aprile
 
AUA 2011 Annual meeting
Washington DC,
14-19 Maggio 2011
 
XXI Congresso Nazionale SIUrO
Napoli,
22-24 Giugno 2011
 
IV Congresso Nazionale Club Della Litiasi Urinaria CLU
Catania,
22-24 Settembre 2011
 
AURO.IT – Congresso nazionale 2011
Sorrento,
15-18 ottobre 2011
 
84° Congresso Nazionale SIU
Roma,
23 – 26 Ottobre 2011
 

Newsletter 1-10

Sabato, 23 Ottobre, 2010

J Urol. 2010 Aug;184(2):579-83. Epub 2010 Jun 19

Adequacy of a single 24-hour urine collection for metabolic evaluation of recurrent nephrolithiasis.

Castle SM, Cooperberg MR, Sadetsky N, Eisner BH, Stoller ML.

Department of Urology, University of California-San Francisco, San Francisco, California, USA.

Abstract

PURPOSE: There is much debate about whether 1 or 2, 24-hour urinalyses are adequate for metabolic evaluation of stone formers. We determined whether repeat 24-hour urine collection provides information similar to that of the initial 24-hour urine collection and whether repeat collection is necessary.

MATERIALS AND METHODS: We analyzed 2, 24-hour urine collections in 777 patients obtained from 2001 to 2005. Samples were collected 3 days or less apart before pharmacological intervention and analyzed elsewhere for routine stone risk profiles of urine calcium, oxalate, citrate, uric acid, sodium, potassium, magnesium, phosphorus, ammonium, chloride, urea nitrogen and creatinine.

RESULTS: No parameters showed a statistically significant difference between 24-hour urine samples 1 and 2 when mean values were compared (pairwise t test each p >0.05, range 0.06 to 0.87). Using Pearson’s correlation all parameters showed positive correlation coefficients (r = 0.68 to 0.89, each p <0.0001). The mean of individual patient differences in samples 1 and 2 were compared to 0 and 6 of 12 showed no difference (p >0.05) while for the remaining 6 p value was <0.05. The percent difference was 0.5% to 4.19% for all urinary parameters.

CONCLUSIONS: One 24-hour urine sample is sufficient for metabolic evaluation of recurrent stone disease. There is no significant difference in 12 urinary parameters between 24-hour urine samples collected within 3 days of each other. This information is useful to providers and may decrease patient inconvenience and the overall cost of metabolic stone evaluation. prosegui la lettura…