Calcium-binding proteins and renal lithiasis.

The present study consists of measuring calcium-binding activity in urine obtained from 17 metabolically active noninfectious calcium oxalate stone formers, six inactive calcium oxalate stone formers, two active uric acid stone formers, one active cystine stone former, and seven nonstone-forming controls. Twenty-four hour specimens were obtained from each patient and were ultrafiltered, utilizing a series of membranes to concentrate all macromolecules of molecular weight less than 50,000 daltons. The concentrated specimen was separated by gel filtration chromatography, and each fraction was analyzed for calcium-binding activity utilizing the chelex resin binding assay. Total urinary calcium binding protein activity was significantly greater in the active calcium oxalate stone formers when compared with either inactive calcium oxalate stone formers (P less than 0.025) or nonstone-forming controls (P less than 0.05). The number of uric acid and cystine stone formers was too small to make meaningful comparisons. Urinary excretion of calcium binding appears to be related to stone activity and may be specific for calcium stone formers. Their influence on stone formation deserves further study.

Magnesium excretion and calcium oxalate urolithiasis.

One hundred fifty-five recurrent noninfectious calcium oxalate stone formers were evaluated in an effort to assess the importance of magnesium excretion on calcium oxalate stone formation. All patients evaluated had normal urinary magnesium excretion, and any elevation of the calcium/magnesium ratio was related to the presence of hypercalciuria. The findings indicate that magnesium deficiency does not appear to be a significant cause of calcium oxalate urolithiasis. If magnesium supplement is of value in some patients, it is likely related to its inhibitory effect on calcium oxalate crystallization.

Urethrovasocutaneous fistula.

We report a case of urethrovasocutaneous fistula in an elderly man. There were several possible etiologic factors in this case including: prior vasectomy and transurethral prostatectomy, urinary tract infection, and neurogenic bladder.

Surgery of urinary calculi in perspective.

Technical developments have stimulated an international interest in the dissolution of kidney stones without conventional surgery. Such techniques and instruments include real-time or manipulative imaging; the transmission and focusing of energy through body tissue by conduits or pulsation; and the instrumentation for percutaneous visual and manipulative entry into the renal pelvis. Proper assessment of these new approaches to the removal of calculi will require extensive data collected over several decades. This review sets some bench marks for the current state of the art of intrarenal surgery for the removal of calculi.

The Boyce-Vest operation for exstrophy of the bladder. 35 years later.

Twenty-four patients with exstrophy of the urinary bladder (23 patients) or epispadias (1 patient) who were treated by the Boyce-Vest operation have been followed for a total of 482 patient-years (range 3 to 34 years, mean 22 years). In all patients upper urinary morphology and renal function have remained normal, and those with preoperative compromise have stabilized or improved. Postoperatively, no patient has developed an electrolyte imbalance or metabolic acidosis requiring treatment, urinary calculi, or malignant change in the vesicorectal reservoir. Although the procedure and the exstrophy-epispadias complex present many unresolved of management. The infant with exstrophy of the urinary bladder appears best served by early neonatal closure of the exstrophic bladder as described by Jeffs, 6,8 with attempts at establishing urinary continence later in childhood. 6,8,11 When other methods to establish urinary continence are unsuccessful and satisfactory anal continence has been demonstrated, the Boyce-Vest procedure offers an acceptable long-term alternative to establish sphincteric urinary continence. Properly managed, the newborn with uncomplicated exstrophy should have a life expectancy equal to that of any other neonate. More importantly, it is within our ability to provide such patients with adult social acceptability and relative freedom from urinary disease.

Results of urinary diversion in patients with myelomeningocele.

Among 481 children with myelomeningocele seen at the North Carolina Baptist Hospital since 1949, 46 have undergone a urinary diversion procedure, as follows: ileal loop in 43; sigmoid loop in two; and transverse colon conduit in one. The indications for diversion were incontinence in 28, urinary infection or pyelonephritis in 27, and hydronephrosis, pyelocaliectasis, and reflux in 12 patients. No deaths resulted from the diversionary procedures. One patient required early surgical revision and seven patients required late surgical revision. Two patients have since died, 44 have been followed for an average of 7.9 years, 15 for more than 10 years. Overall, of 26 patients with normal prediversionary intravenous pyelograms (IVP's), 88% now have normal or nearly normal IVP's; of 14 patients with abnormal prediversionary IVP's, 79% now have normal, improved, or unaltered IVP's. Renal function has remained normal in all 44 patients, and renal calculi have developed in 10 patients. Ileal loop diversion appears to convert a high-pressure system into a low-pressure system, thereby helping to prevent further renal damage. This procedure tends to stabilize, rather than improve, urinary-tract function. For these children already so incapacitated by their basic disease, this goal is acceptable, particularly since it also provides continence and independence from parental nursing.

Ultrasonic velocimetry in resection of renal arteriovenous fistulas and other intrarenal surgical procedures.

The Doppler velocimetry is considered to be useful frequently and indispensable occasionally for intrarenal surgery. Current equipment is relatively inexpensive, the operation is technically simple and maintenance is minimal. The instrument provides an instantaneous appraisal of the precise location of a blood vessel and some characteristics of blood flow with a facility unlikely to be achieved with any other technique. It is important that the limitations of current instruments be appreciated since the concepts of the procedure and current instrumentation are deceptively conductive to expectations beyond their capability.

The localization of intrarenal calculi during surgery.

This is a summary review of past and present technology for accurate anatomical localization of calculi within the surgically exposed kidney. The methodology is applicable to reconstructive renal surgery for pathological processes other than calculi.

Isolated vesicorectal internal urinary diversion: a 37-year review of the Boyce-Vest procedure.

The challenges that management of exstrophy of the bladder pose the pediatric urological surgeon have resulted in a multitude of ingenious operations and a voluminous literature on exstrophy. Despite this intense interest in an uncommon anomaly, no consistently satisfactory approach to achieve urinary continence in children with exstrophy has evolved. We summarize a 37-year clinical experience with a form of urinary diversion that provides sphincteric urinary continence, and unexcelled long-term preservation of renal function and upper urinary anatomy. From our review it appears that the infant with exstrophy is served best by neonatal closure of the exstrophic bladder with attempts to establish urinary continence later in childhood. When other methods to establish urinary continence are unsuccessful and satisfactory anal continence has been demonstrated, a diverting colostomy combined with anastomosis of the isolated bladder to the isolated rectal stump offers an acceptable long-term alternate form of urinary diversion to produce sphincteric urinary continence with relative freedom from upper urinary deterioration.

Spherical calcium bodies in stone-forming urine.

Twenty-four hour urine specimens from 26 active stone formers and 15 non-stone formers were passed through an ultrafilter that retained all molecules with a molecular weight greater than 50,000. Microscopic spherical bodies that laked alizarin red were observed in the urinary ultrafiltrate from 24 of 26 active stone formers. Only three of 15 non-stone-forming control urines contained these bodies. Histochemical studies showed the presence of calcium, phosphorus, and carbohydrate-protein complexes. No crystalline elements were detected.

Biochemical profiles of stone-forming patients: a guide to treatment.

A formal protocol, controlled metabolic evaluation is essential to the most effective treatment of any patient with renal calculi, regardless of the crystalline composition of the stone. The design of the protocol and of the data sheets should be compatible with ease of diagnosis and selection of corrective therapeutic measures. These data also serve as a reference to monitor response to treatment. Treatment is highly individualized with the objective to reduce all potentially crystallizable ions to basal levels. If this is difficult to accomplish certain ratios of ions are brought to as near normal values as possible.

Bilateral staghorn calculi--patient evaluation and management.

A total of 44 patients (17 men and 27 women) with simultaneous bilateral staghorn calculi underwent anatrophic nephrolithotomy with caliceal reconstruction. Excluding patients with urinary tract infection alone all but 3 had identifiable metabolic abnormalities that required treatment postoperatively. Based on numbers of kidneys operated upon the stone recurrence rate was 8.8 per cent for men and 7.4 per cent for women. No patient has required an operation for recurrent stone disease.

Biochemical profiles of stone-forming patients: a guide to treatment.

A formal protocol, controlled metabolic evaluation is essential to the most effective treatment of any patient with renal calculi, regardless of the crystalline composition of the stone. The design of the protocol and of the data sheets should be compatible with ease of diagnosis and selection of corrective therapeutic measures. These data also serve as a reference to monitor response to treatment. Treatment is highly individualized with the objective to reduce all potentially crystallizable ions to basal levels. If this is difficult to accomplish certain ratios of ions are brought to as near normal values as possible.

Low molecular weight urinary proteins and renal lithiasis.

Twenty-four hour urine specimens were obtained from 20 active calcium oxalate stone formers, 20 inactive calcium oxalate stone formers, 8 struvite stone formers, and 9 non-stone forming controls. Proteins with molecular weights less than 50,000 daltons were concentrated by ultrafiltration and separated by sodium dodecyl sulfate polyacrylamide gel electrophoresis. Fourteen of the 17 active calcium oxalate stone formers had low molecular weight urinary proteins (less than 35,000 daltons) present in their urine whereas none of the inactive stone formers or struvite stone formers had similar patterns. Only one of the nine control patients had similar proteins present.

Hypertension and decreased renal blood flow following methylene blue injection.

Renal blood flow (RBF) and arterial blood pressure (BP) were monitored in 12 patients undergoing nephrolithotomy in the lateral flexed position. All patients were preoxygenated and were anesthetized with sodium thiopental, N2O, O2, and fentanyl. Maintenance relaxation was obtained with pancuronium bromide. Arterial pressure was monitored by percutaneous arterial catheter. Following exposure of the kidney and renal pedicle, an electromagnetic flow probe was attached to the renal artery and baseline flows recorded. Following baseline measurements, 20 ml of 1 percent methylene blue was given intravenously. All patients studied showed an immediate rise in BP, and 11/12 showed a simultaneous decrease in RBF. The average fall in RBF was 35 percent at one minute. Both parameters returned to normal values on the average in 177 seconds. The decreased RBF appeared to be part of a generalized vasoconstrition caused either by sympathetic reflexes or by the direct action of methylene blue.

Bilirubin as a cholestatic agent. III. Prevention of bilirubin-related cholestasis by sulfobromophthalein.

The administration of sulfobromophthalein sodium (BSP) to manganese-loaded animals had been found to prevent effectively the cholestasis normally created by bilirubin infusion following manganese loading. Measurement of bilirubin levels in blood, liver, and bile in manganese-bilirubin animals with and without BSP fails to provide convincing evidence for a BSP-induced shift in site or magnitude of total bilirubin concentration as an explanation for this anticholestatic action of BSP. Nevertheless, increasing the dose of bilirubin partially reinstitutes the cholestasis. The results are important in that they demonstrate (1) that under certain circumstances intrahepatic cholestasis can be immediately and directly prevented by a pharmacologic agent (by a means not as yet defined) and (2) that the cholestatic activity of bilirubin is, to some extent or under some circumstances, separable from its concentration in blood, liver, and bile.

Bilirubin as a cholestatic agent. IV. Effect of bilirubin and sulfobromophthalein (BSP) on biliary manganese excretion.

These experiments demonstrate that the adminstration of bilirubin does not significantly alter biliary manganese excretion in manganese-loaded animals. Sulfobromophthalein sodium (BSP), which has been shown to afford prophylaxis against manganese-bilirubin cholestasis, significantly increases the biliary excretion of manganese. These results are meaningful in that they indicate that the amount of manganese per se in the bile is not critical in this cholestasis, and suggest that intracanalicular reactions are probably not etiologically critical in this model. They point to the conclusion that the critical cholestatic events are occurring within the hepatocyte. The results also indicate that the biliary excretion of manganese is obligate, and to some extent independent of bile flow. The critical cholestatic events are presumably mediated through the biochemical effects of either a manganese-bilirubin complex or of manganese and bilirubin acting separately but synergistically.