Urinary stone epidemiology in Spain and worldwide. / Epidemiología de la litiasis urinaria en el mundo y en España.

Urinary stones is a pathology whose incidence and prevalence are increasing in developed and underdeveloped countries. Overall, in the United States the prevalence has been increased from 3.2% in 1980 to 10.1% in 2014. In Spain, this increase has also been significant, from 5% in 2005 to 14.6% in 2016. In the rest of the world happens in a similar way, where an average increase is observed in the last 15-20 years of approximately 5-7%. The decade of life between 40-60 years is usually the highest incidence of stones. Regarding sex, in recent years there has been a growing in women, associated with a change in diet and obesity, and currently there are no differences between sex. It is a more frequent disease in the Western world,although there are countries in the Middle East such as Saudi Arabia where the prevalence is very high, around 20%. Respect the lithiasis composition, calcium oxalate continues to be the most frequent around 70-80%, with an increase in uric acid lithiasis in recent years and a decrease in infective lithiasis. In relation to the appearance of this pathology in children, it is rare in the first years of life, being more prevalent from 12-13 years of age and increasing in adolescence. It is usually more common in girls than in boys and in the Caucasian racecompared to African Americans. There are no differences in lithiasic composition with respect to adults, calcium oxalate being the most frequent composition, but with a prevalence of 50-60%. However, the causes and etiopathogenic factors in children are less studied and well known than in adults.

La litiasis urinaria es una patología cuya incidencia y prevalencia van en aumento tanto en países desarrollados como países subdesarrollados. De forma global, en Estados Unidos se ha visto incrementada su prevalencia del 3,2% en 1980 hasta el 10,1% en 2014. En España, este aumento también ha sido significativo, desde el 5% en 2005 hasta el 14,6% en 2016. En el resto del mundo sucede de forma similar, donde se observa un incremento medio en los últimos 15-20 añosdel 5-7% aproximadamente. La década de la vida entre los 40-60 años suele ser la de mayor incidencia de litiasis. En cuanto a sexo, en los últimos años ha existid una tendencia cada vez mayor en la mujer, asociada al cambio de dieta y la obesidad, fundamentalmente y actualmente no existen prácticamente diferencias entre sexos. Es una enfermedad más frecuente en el mundo occidental, aunque existen países del Oriente Medio como Arabia Saudí en donde la prevalencia es muy elevada, en torno al 20%. En cuanto a la composición litiásica, la de oxalato cálcico sigue siendo la más frecuente en torno al 70-80% con un incremento en los últimos años de la litiasis de ácido úrico y un descenso en la litiasis infectiva. En relación a la aparición de esta patología en los niños, es poco frecuente en los primeros años de vida, siendo más prevalente a partir de los 12-13 años e incrementándose en la adolescencia. Suele ser más frecuente en niñas que en niños y en la raza caucásica respecto a los afroamericanos. No existen diferencias en cuanto a la composición litiásica con respecto a los adultos, siendo el oxalato cálcico elcompuesto más frecuente, pero con una prevalencia del 50-60%. Sin embargo, las causas y factores etiopatogénicos en los niños están peor estudiados y son menos conocidos que en los adultos.

Reduction of ureteral stent encrustation by modulating the urine pH and inhibiting the crystal film with a new oral composition: a multicenter, placebo controlled, double blind, randomized clinical trial.

BACKGROUND: Encrustation of ureteral double J stents is a common complication that may affect its removal. The aim of the proposed study is to evaluate the efficacy and safety of a new oral composition to prevent double J stent encrustation in indwelling times up to 8 weeks. METHODS: A double-blinded, multicenter, placebo-controlled trial was conducted with 105 patients with indwelling double J stents enrolled across 9 public hospitals in Spain. The patients were randomly assigned (1:1) into intervention (53 patients) or placebo (52 patients) groups for 3 to 8 weeks and both groups self-monitored daily their morning urine pH levels. The primary outcome of analysis was the degree of stent ends encrustation, defined by a 4-point score (0 - none; 3 - global encrustation) using macroscopic and electron microscopy analysis of crystals, after 3 to 8-w indwelling period. Score was exponentially transformed according to calcium levels. Secondary endpoints included urine pH decrease, stent removal, and incidence of adverse events. RESULTS: The intervention group benefits from a lower global encrustation rate of stent ends than placebo group (1% vs 8.2%; p < 0.018). Mean encrustation score was 85.12 (274.5) in the placebo group and 18.91 (102.27) in the intervention group (p < 0.025). Considering the secondary end points, treated patients reported greater urine pH decreases (p = 0.002). No differences in the incidence of adverse events were identified between the groups. CONCLUSIONS: Our data suggest that the use of this new oral composition is beneficial in the context of ureteral double J indwelling by decreasing mean, as well as global encrustation. TRIAL REGISTRATION: This trial was registered at www.clinicaltrials.gov under the name "Combined Use of a Medical Device and a Dietary Complement in Patient Urinary pH Control in Patients With an Implanted Double J Stent" with date 2nd November 2017, code NCT03343275, and URL.

Lithogenic factors in postmenopausal women with osteoporotic fracture.

BACKGROUND: The aim of this study was to show the presence of phosphorus and calcium metabolism disorders and the presence of urine lithogenic factors in women with osteoporotic fracture without previous urinary lithiasis. METHODS: We conducted a cross-sectional study including 55 women with osteoporotic fracture surgically treated in the Trauma Department. We included women with osteoporotic fracture demonstrated by the fracture area, fracture mechanism and the presence of osteoporosis by bone densitometry. We analyzed phospho-calcium metabolism as well as the calciuria, oxaluria, citraturia and uricosuria levels with fasting and 24-hour urine study. The presence of abnormal calcium and phosphorus metabolism was compared between women with hypercalciuria and normocalciuria. RESULTS: The 55 women had a mean age of 70.1±13.8 years and a mean body mass index of 27.9±3.8 kg/m2. Forty-percent of the patients showed hypercalciuria, 36.4% hyperoxaluria, 36.4% hypocitraturia, and 5.3% hyperuricosuria. When comparing patients with hypercalciuria and normocalciuria, the only statistically significant difference was fasting urinary calcium/creatinine levels (0.16 versus 0.08, respectively; P<0.0001). CONCLUSIONS: Women with osteoporotic fracture showed several lithogenic factors in the urine studies, mainly fasting hypercalciuria. Although in this study hypercalciuria did not involve the presence of lithiasis, it can favor the appearance of lithiasis with other predisposing conditions. Therefore, an accurate assessment of urine calcium levels with other lithogenic factors, such as citrate and oxalate levels, may facilitate individualized management and treatment of osteoporosis without increasing the risk of nephrolithiasis.

Ex vivo construction of a novel model of bioengineered bladder mucosa: A preliminary study.

OBJECTIVE: To generate and to evaluate ex vivo a novel model of bioengineered human bladder mucosa based on fibrin-agarose biomaterials. METHODS: We first established primary cultures of stromal and epithelial cells from small biopsies of the human bladder using enzymatic digestion and selective cell culture media. Then, a bioengineered substitute of the bladder lamina propria was generated using cultured stromal cells and fibrin-agarose scaffolds, and the epithelial cells were then subcultured on top to generate a complete bladder mucosa substitute. Evaluation of this substitute was carried out by cell viability and histological analyses, immunohistochemistry for key epithelial markers and transmission electron microscopy. RESULTS: The results show a well-configured stroma substitute with a single-layer epithelium on top. This substitute was equivalent to the control bladder mucosa. After 7 days of ex vivo development, the epithelial layer expressed pancytokeratin, and cytokeratins CK7, CK8 and CK13, as well as filaggrin and ZO-2, with negative expression of CK4 and uroplakin III. A reduction of the expression of CK8, filaggrin and ZO-2 was found at day 14 of development. An immature basement membrane was detected at the transition between the epithelium and the lamina propria, with the presence of epithelial hemidesmosomes, interdigitations and immature desmosomes. CONCLUSIONS: The present results suggest that this model of bioengineered human bladder mucosa shared structural and functional similarities with the native bladder mucosa, although the epithelial cells were not fully differentiated ex vivo. We hypothesize that this bladder mucosa substitute could have potential clinical usefulness after in vivo implantation.

Calcium nephrolithiasis and bone demineralization: pathophysiology, diagnosis, and medical management.

PURPOSE OF REVIEW: To establish the relationship between calcium nephrolithiasis, bone densitometry scoring, and bone mineral density (BMD) loss according to bone turnover markers (BTMs) and urinary metabolites. RECENT FINDINGS: Patients with recurrent calcium nephrolithiasis and idiopathic fasting hypercalciuria (urinary calcium/creatinine ratio >0.11) are more likely to have BMD loss that may lead to osteopenia or osteoporosis. In these patients, BTMs may be used as a surrogate for both bone health and stone recurrence. Suspect higher lithogenic states when calcium stone formers have serum beta-crosslaps (resorptive marker) greater than 0.311 ng/ml, serum osteocalcin (formative marker) greater than 13.2 ng/ml, and beta-crosslaps/osteocalcin ratio greater than 0.024. SUMMARY: Patients with recurrent calcium nephrolithiasis and fasting hypercalciuria have a higher incidence of osteopenia and osteoporosis, measured by the dual-energy X-ray absorptiometry. These patients present not only with hypercalciuria and increased BTMs (mainly resorptive), but also up to 30% have hypocitraturia and increased urinary calcium/citrate ratio (>0.25). On the basis of these results, a diagnostic algorithm was created, classifying hypercalciurics according to their fasting calcium/creatinine and calcium/citrate ratio. Medical therapy for these patients is aimed at improving the dietary habits (normocalcemic, low salt, low animal protein diet), prescribing combinations of potassium citrate, thiazides, and bisphosphonates, and correcting bone and urinary abnormalities that may lower future skeletal and kidney stone risk.

Vitamin D insufficiency is associated with higher carotid intima-media thickness in psoriatic patients.

BACKGROUND: Psoriasis has been associated with vitamin D insufficiency and cardiovascular risk factors. Reports show that serum 25-hydroxyvitamin D (25-OHD) levels are inversely associated with chronic inflammatory systemic diseases, cardiovascular risk factors and cardiovascular outcomes. OBJECTIVE: To analyze the association between 25-hydroxyvitamin D serum levels and subclinical carotid atherosclerosis (maximal intima-media thickness (MIMT)) in psoriasis patients and controls. MIMT was compared and associated factors were analyzed. PATIENTS AND METHOD: This was a case-control study with 44 psoriatic patients without arthritis from a Dermatology outpatient clinic in Granada (Spain) and 44 controls. Confounding factors related to 25-OHD serum levels and cardiovascular risk factors were also analyzed. RESULTS: 25-OHD levels were significantly lower in the psoriatic than in the control group (29.20 vs. 38.00 ng/mL p<0.0001) and a significant negative correlation was found between serum 25-OHD levels and the MIMT (rs=-0.678, p<0.0001) in psoriatic patients. No correlation was found in healthy controls. This association remained after adjusting for confounders. Serum 25-OHD levels were significantly lower (p=0.003) in psoriatic patients with carotid atheromatous plaque (22.38±10.23 ng/mL) than in those without (31.74±8.62 ng/mL). Patients with a longer history of psoriasis presented significantly higher MIMT than controls (638.70±76.21 vs 594.67±80.20 µm; p=0.026 for ≥6 yrs with psoriasis). CONCLUSIONS: In psoriasis patients, lower serum 25-OHD levels were associated with higher MIMT after adjusting for selected confounding factors. The MIMT risk increases with a longer history of psoriasis, regardless of the patient's age.

Association of 25-hydroxyvitamin D with metabolic syndrome in patients with psoriasis: a case-control study.

Vitamin D deficiency is associated with higher cardiovascular risk and metabolic syndrome (MeS) criteria. The main objective of this study was to analyse the association of 25-hydroxyvitamin D (25-OHD) serum levels with MeS (National Cholesterol Education Program-Adult Treatment Panel-III criteria) in 46 Spanish patients with psoriasis, but without arthritis and systemic treatment, and 46 control subjects, matched by sex and age. The patients with psoriasis showed significantly lower level of 25-OHD than controls (30.5 vs. 38.3 ng/ml; p = 0.0001). Patients with MeS had significantly lower serum levels of 25-OHD than those without MeS (24.1 ± 7.5 vs. 32.8 ± 8.9, p = 0.007), and a negative correlation was found between 25-OHD and waist circumference, diastolic blood pressure, fasting glucose, and triglyceridaemia. In the control group no significant correlation between 25-OHD and MeS was found. Al-though the sample was small, our results suggest a potential protective role for 25-OHD in the metabolic profile of patients with psoriasis without arthritis.

Association of 25-hydroxyvitamin D serum levels and metabolic parameters in psoriatic patients with and without arthritis.

BACKGROUND: Psoriasis has been related to a higher prevalence of cardiovascular risk factors. Vitamin-D deficiency has been associated with metabolic syndrome, cardiovascular disease, and psoriasis. However, there has been no comparative study on the effects of vitamin-D status between patients with and without psoriatic arthritis. OBJECTIVE: The objective was to assess the relationship of 25-hydroxyvitamin D [25-(OH)D] levels with lipid and glucose metabolism parameters in psoriatic patients with and without arthritis. METHODS: We studied 122 patients with psoriasis (61 without arthritis and 61 with arthritis) from the psoriasis unit (dermatology department) and rheumatology department of our hospital, analyzing lipid and glucose metabolism variables and serum 25-(OH)D concentrations. Measurements were conducted within a 2-month period to minimize seasonal bias in 25-(OH)D levels. RESULTS: In the psoriatic patients without arthritis, serum 25-(OH)D levels were inversely correlated with fasting glucose (r = -0.285; P = .026), total cholesterol (r = -0.440; P = .000), low-density lipoprotein (r = -0.415; P = .001), total cholesterol/high-density lipoprotein (r = -0.303; P = .01), and triglyceride (r = -0.280; P = .029) values. This association remained statistically significant for glucose, total cholesterol, and low-density lipoprotein after controlling for confounding factors in multivariate analysis. No association was found between serum 25-(OH)D levels and any metabolic parameter in the patients with psoriatic arthritis. LIMITATIONS: This is a cross-sectional study that supports the hypothesis of an association between vitamin D and metabolic parameters but does not establish a causal relationship. CONCLUSIONS: Serum 25-(OH)D was inversely related to lipid and glucose metabolism parameters in psoriatic patients without arthritis, whereas no such association was observed in psoriatic patients with arthritis. Interventional studies are warranted to assess the effects of vitamin-D supplements on the metabolic profile of psoriatic patients without arthritis.

Iatrogenic false aneurysms. A rare complication of hip surgery.

The purpose of this study was to determine the incidence of arterial false aneurysms following hip surgery diagnosed and treated in our hospital between January 1995 and January 2010. We conducted a retrospective analysis of all patients undergoing hip surgery (osteosynthesis, hemiarthroplasty, total arthroplasty, or revision arthroplasty) under our care. To determine the incidence of arterial false aneurysm, we identified patients with abnormal bleeding through the surgical wound postoperatively. Out of the 11,839 patients undergoing hip surgery during the study period, 321 had abnormal bleeding that aroused suspicion of an associated vascular lesion. Among these, the presence of a false aneurysm requiring specific treatment was confirmed in eight patients. False aneurysms are a rare and occasionally severe complication of hip surgery that typically manifest with significant haemorrhage during the postoperative period. The management of these lesions by interventional radiology is associated with few complications and permits rapid patient stabilisation and early recovery, avoiding more aggressive and sometimes fruitless surgical exploration.

Intermittent claudication caused by a giant atypical lipoma of the thigh.

The main cause of intermittent claudication in lower limbs is peripheral vascular disease. Less commonly, the etiology can be extrinsic to vascular structures, as in the cases of tumors that, due to their rapid growth, can reduce the blood supply and produce intermittent claudication during gait. We report the case of a 49-year-old patient with intermittent claudication in the left lower limb, reporting the presence of a tumor in the inner side of the left thigh with rapid growth. Doppler and angiography magnetic resonance imaging examinations demonstrated the presence of an adipose tumor that was producing deep and superficial extrinsic compression of the femoral arteries.

Meta-analysis of studies analyzing the role of human papillomavirus in the development of bladder carcinoma.

PURPOSE: We aimed to ascertain the degree of association between bladder cancer and human papillomavirus (HPV) infection. MATERIALS AND METHODS: We performed a meta-analysis of observational studies with cases and controls with publication dates up to January 2011. The PubMed electronic database was searched by using the key words "bladder cancer and virus." Twenty-one articles were selected that met the required methodological criteria. We implemented an internal quality control system to verify the selected search method. We analyzed the pooled effect of all the studies and also analyzed the techniques used as follows: 1) studies with DNA-based techniques, among which we found studies with polymerase chain reaction (PCR)-based techniques and 2) studies with non-PCR-based techniques, and studies with non-DNA-based techniques. RESULTS: Taking into account the 21 studies that were included in the meta-analysis, we obtained a heterogeneity chi-squared value of Q(exp)=26.45 (p=0.383). The pooled odds ratio (OR) was 2.13 (95% confidence interval [CI], 1.54 to 2.95), which points to a significant effect between HPV and bladder cancer. Twenty studies assessed the presence of DNA. The overall effect showed a significant relationship between virus presence and bladder cancer, with a pooled OR of 2.19 (95% CI, 1.40 to 3.43). Of the other six studies, four examined the virus's capsid antigen and two detected antibodies in serum by Western blot. The estimated pooled OR in this group was 2.11 (95% CI, 1.27 to 3.51), which confirmed the relationship between the presence of virus and cancer. CONCLUSIONS: The pooled OR value showed a moderate relationship between viral infection and bladder tumors.

Deficiency of serum concentration of 25-hydroxyvitamin D in psoriatic patients: a case-control study.

BACKGROUND: Some autoimmune conditions have been associated with reduced vitamin D levels, including systemic lupus erythematosus, rheumatoid arthritis, diabetes mellitus, and multiple sclerosis. OBJECTIVE: The main objective of this study was to analyze the 25-hydroxyvitamin D (OHD) status of patients with psoriasis in comparison with control subjects without this disease. METHODS: This case-control study included 86 patients (43 with psoriasis and 43 age- and sex-matched control subjects) from the outpatient clinic of our hospital dermatology department in Granada, Spain. All patients and control subjects were studied during one 4-week period to avoid seasonal variations in vitamin D levels. RESULTS: Serum 25-OHD levels were significantly lower in psoriatic patients than in control subjects even after adjusting for confounding factors in a multivariate analysis (odds ratio 2.89, 95% confidence interval 1.02-7.64, P < .03 for vitamin D insufficiency). Low 25-OHD levels were negatively associated with C-reactive protein (inflammatory activation marker) and body mass index in multiple linear regression analysis. Psoriatic patients with body mass index greater than or equal to 27 kg/m(2) had a higher risk of 25-OHD insufficiency (sensitivity of 82.3% and specificity of 51.7%). LIMITATIONS: Further studies with larger numbers of patients are required to analyze the pathogenic mechanisms underlying the relationship between 25-OHD deficiency and psoriasis. CONCLUSIONS: The 25-OHD values are significantly lower in psoriatic patients than in control subjects. Low 25-OHD levels are negatively associated with C-reactive protein, an inflammatory activation marker, and with obesity. Psoriatic patients with a body mass index of 27 or more are likely to have vitamin D insufficiency.

The oblique supine decubitus position: technical description and comparison of results with the prone decubitus and dorsal supine decubitus positions.

Our objective was to analyze the advantages of the percutaneous nephrolithotomy in oblique supine decubitus compared to the prone and dorsal supine position. In 87 patients diagnosed with urolithiasis (495.5-530.8 mm(2)), percutaneous nephrolithotomy (PNL) was performed from 2000 to 2011. The patients were divided into three groups: Group A, 32 patients, PNL in the prone decubitus position; Group B, 24 patients, PNL in the dorsal supine position; Group C, 31 patients, PNL in the oblique supine position. We analyzed intraoperative parameters, complications, and results among the three groups. The three procedures were performed with a single access, 24-30 Ch. No statistically significant differences were found among the three groups regarding the patients' characteristics, or the morphology or size of the kidney stone treated. The operation time was shorter in the cases of PNL in dorsal supine and oblique supine compared to the prone position. The complication rate was very similar in the three groups. The main advantage of the PNL in oblique supine compared to the dorsal supine was that the puncture could in all cases be directed by ultrasonography, with greater precision, more safety, and more control of the percutaneous renal access. The oblique supine decubitus position is a safe position for the percutaneous treatment of urolithiasis and it becomes easier when the puncture is guided by ultrasound.

Cold cutting of ureteral stenosis with endoscopic scissors.

OBJECTIVES: To study the procedure and results of cold cutting of ureteral stenosis with endoscopic scissors. Intrinsic or extrinsic ureteral stenosis can be congenital or acquired. Endoscopic dilation and incision is 1 potential option for ureteral intrinsic stenosis. METHODS: During a 3-year period (2005-2007), a prospective study was performed of cold cutting of ureteral stenosis with endoscopic scissors in 17 consecutive patients (11 women and 6 men), aged 22-64 years. Of the 17 patients, 6 had been diagnosed with proximal ureteral stenosis, 3 with iliac ureteral stenosis, and 8 with pelvic ureteral stenosis. The procedure was performed with a semirigid 8.5Ch ureteroscope, catheterizing and dilation of the stenosis with a balloon catheter, cold cutting of the ureteral wall with scissors, including margins of healthy tissue at both ends of the stenosis, and a 6F double-J ureteral stent for 6 weeks. RESULTS: The results were evaluated after 3 months with urography in 15 cases and diuretic renography in 2 cases. Analysis of the postoperative complications and urography was done at 12-24 months. Immediate success was obtained after the first endoscopic ureterotomy with scissors in 16 of 17 cases (94%). At 12-24 months, success was maintained in 88.5% of cases. CONCLUSIONS: Cold cutting of ureteral stenosis with endoscopic scissors is a safe technique for the patient. This procedure could be a therapeutic option in cases of benign intrinsic ureteral stenosis of <15 mm.

Treatment of ureteric lithiasis with retrograde ureteroscopy and holmium: YAG laser lithotripsy vs extracorporeal lithotripsy.

OBJECTIVE: To analyse the efficiency of extracorporeal shockwave lithotripsy (ESWL) vs retrograde ureteroscopy and holmium:YAG laser lithotripsy, as ESWL is successful in 67-90% of cases but endoscopic lithotripsy with pneumatic lithotrites or lasers is successful in 90-96% of distal ureteric calculi, and holmium:YAG lithotripsy is effective in proximal ureteric calculi. PATIENTS AND METHODS: From April 2006 to April 2008 we assessed 164 patients undergoing ureteric lithiasis in two homogeneous groups: group A included 83 treated with retrograde ureteroscopy and holmium:YAG endoscopic lithotripsy, and group B, 81 treated by ESWL. For laser lithotripsy we used 2071 mJ pulses at 3-6 Hz, with a mean of 1105 pulses and 2.5 kJ of total energy. ESWL was carried out using 37.5-87.5 mJ shock waves, a mean of 3650 shock waves and 187.6 J, with a radioscopy time of 1-4 min. The results were assessed after 3 weeks with plain films and ultrasonography, or urography. The efficiency of each procedure was assessed by calculating the relative risk, and results compared using the chi-square or Student's t-test. The efficiency quotient (EQ) was determined for both procedures, and the focal applied energy quotient (FAEQ) used to assess ESWL. RESULTS: The overall success rate for retrograde ureteroscopy and laser lithotripsy was 96.4% (80/83 patients), with an EQ of 0.52; a JJ catheter was placed in 67 patients. The success rate for the first ESWL session was 48%, and after repeat ESWL was 64% (52/81 patients), giving an EQ of 0.39. For successful treatments the FAEQ was 9.22, vs 6.47 for the failures (P < 0.005). There was a significant difference (P < 0.001) favouring laser lithotripsy, with an absolute benefit of 46% (95% confidence interval 33.8-57.9%), and number needed to treat of 2 (2-3), but no significant differences for lumbar ureteric calculi. CONCLUSIONS: Endoscopic lithotripsy with the holmium laser is more effective than ESWL, but for lumbar ureteric calculi ESWL is therapeutically recommended as it is less invasive.