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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…