Can infundibular height predict the clearance of lower pole calyceal stone after extracorporeal shockwave lithotripsy?

PURPOSE: To evaluate the efficacy of extracorporeal shock wave lithotripsy (SWL) on lower calyceal calculi in relation to the renal anatomical factors and determine which of these factors can be used to select patients who will benefit from SWL. MATERIALS AND METHODS: We analyzed retrospectively 78 patients with single radiopaque lower calyceal stones treated with SWL. The patients were evaluated 3 months after lithotripsy with a simple abdominal X-ray and a kidney ultrasound scan. The success of the treatment, removal of all fragments, was correlated with renal anatomical factors measured in the pre-treatment intravenous urography: infundibulopelvic angle, lower infundibulum width, lower infundibulum length, ratio length/width, infundibulum height, and number of minor calyces in the lower calyceal group. RESULTS: Three months after SWL treatment, 39 patients were stone-free (NR group) and 39 had residual fragments (R group). Both groups presented no differences in relation to infundibulopelvic angle, width and length of the lower calyceal infundibulum, length/width ratio of the lower infundibulum or number of lower calyces. Height of the infundibulum, described as the distance between the line passing through the lowest part of the calyx containing the calculus and the highest point of the lower lip of renal pelvis, was the only parameter in which significant differences (p = 0.002) were found between the NR and R groups. CONCLUSIONS: Lower Infundibular height could be a good measurement tool for deciding which patients with lower calyceal lithiasis would benefit from SWL treatment. Height of less than 22 mm suggests a good outcome from lithotripsy.

Can infundibular height predict the clearance of lower pole calyceal stone after extracorporeal shockwave lithotripsy?

PURPOSE: To evaluate the efficacy of extracorporeal shock wave lithotripsy (SWL) on lower calyceal calculi in relation to the renal anatomical factors and determine which of these factors can be used to select patients who will benefit from SWL. MATERIAL AND METHODS: We analyzed retrospectively 78 patients with single radiopaque lower calyceal stones treated with SWL. The patients were evaluated 3 months after lithotripsy with a simple abdominal X-ray and a kidney ultrasound scan. The success of the treatment, removal of all fragments, was correlated with renal anatomical factors measured in the pre-treatment intravenous urography: infundibulopelvic angle, lower infundibulum width, lower infundibulum length, ratio length/width, infundibulum height, and number of minor calyces in the lower calyceal group. RESULTS: Three months after SWL treatment, 39 patients were stone-free (NR group) and 39 had residual fragments (R group). Both groups presented no differences in relation to infundibulopelvic angle, width and length of the lower calyceal infundibulum, length/width ratio of the lower infundibulum or number of lower calyces. Height of the infundibulum, described as the distance between the line passing through the lowest part of the calyx containing the calculus and the highest point of the lower lip of renal pelvis, was the only parameter in which significant differences (p = 0.002) were found between the NR and R groups. CONCLUSIONS: Lower Infundibular height could be a good measurement tool for deciding which patients with lower calyceal lithiasis would benefit from SWL treatment. Height of less than 22 mm suggests a good outcome from lithotripsy.

Experimental assessment of ureteral free autograft.

OBJECTIVE: To establish the sequence of ureteral events under ischemic and desvascularized conditions but without immunologic interference. MATERIALS AND METHODS: Sixty-two rats were divided into four groups. NU group (n 20) control group, normal ureter; SC group (n 15) only surgical control ureterolysis; NIAFG group (n 13) ureter used as non integrated autologous free graft; IAFG group (n 14): ureter used as integrated autologous free graft. Urographic, histologic and histomorphometric studies were performed. RESULTS: We established ureteral changes in the NIAFG and IAFG groups, compared to the control groups (NU, SC). Surgical findings and urographic assessment revealed normal peristalsis with no ectasia in some cases, and no ureteral fistulas or extravasations were found in the IAFG group. Histologic findings showed preservation of the architecture of the three normal layers. Histomorphometric studies showed that ureterolysis caused edema in the lamina propria, while changes in ureter free graft depended on whether the ureter was integrated or not. In the NIAFG group only the urothelial layers showed differences and in the IAFG group the ureteral wall appeared thicker. Histomorphometric studies showed preservation of the normal histologic structures in all cases. CONCLUSIONS: The rat ureter can be used as a free autologous graft and represents an experimental model for immunologic events. We may assume that the necrosis and fibrosis observed in transplanted ureters are secondary to rejection in some cases.

Experimental study of ureteral free grafts. IV. Histomorphometric study.

OBJECTIVES: The ureteral changes that occur when rat ureter is used as an autologous free graft were evaluated using histomorphometrical methods. METHODS: The normal values were determined in ureters from normal rats (NU group) and compared with those of a control group undergoing ureterolysis, as well as with two groups in which the ureter was used as an autologous free graft (in one of these groups the ureter was integrated into the urinary tract by anastomosis, whereas in the other group the ureter was not integrated). The main histomorphometrical parameters were thickness or length and surface or area. Thickness measurements were made using a micrometer. For area determinations, paper prints of light micrographs from each segment were measured using a Koizumi KP-90 digital planimeter. A non-parametric variance analysis (Kruskal-Wallis test) was used to compare the results. These results were compared with those of the Wilcoxon test. The results are expressed as different levels of alpha, (0.05, 0.01 and 0.001). RESULTS: When p < 0.01, there were practically no statistically different variables between NU and AU. Comparison of NU to SC and SC to AU showed only seven statistically different variables. Muscle layer thickness was different only when the comparison was made with the RUb group. When p < 0.001, RUa and RUb were not different, nor were NU and AU or SC and NU. Differences were observed between RUb and all the other groups. RUa was different from NU, SC, or AU in 3, 4 or 5 of the 18 variables analyzed. Most of the surface variables were significantly different in RUb in comparison to the other groups. There were also differences between RUa and NU, as well as between NU and SC, in the area of the lamina propria. CONCLUSIONS: Initial ischemia and denervation are not the cause of the observed changes, as these changes are different in both types of free graft. Histomorphometrical studies constitute a useful method in the assessment of differences between ureteral free graft groups. None of the histomorphometric findings is inconsistent with the use of the rat ureter as a free graft.

Experimental study of ureteral free grafts. III. Histological findings.

OBJECTIVES: To analyze histological findings in rat ureter used as free autologous graft and compare them with two controls. METHODS: They were randomly distributed into four groups: NU group (n = 20), ureter from healthy rats; SC group (n = 15), ureter from rats undergoing ureterolysis, the surgical control group; AU group (n = 13), rats with ureter used as ANIFG (autologous non-integrated free graft); RU group (n = 14), rats with ureter used as AIFG (autologous integrated free graft). For the histological study, ureteral cross sections were obtained (A proximal, B middle, and C distal) and kidney (K) was studied. In addition, in the RU group, we obtained one cross section above the proximal suture (D), one below the distal suture (E), and two longitudinal sections of the surgical anastomoses (F and G). RESULTS: The results showed a histological similarity between the NU, SC and AU groups and an apparent viability of all RU group ureters in which necrosis has not been found. SC group: Mild edema could be noted in the lamina propria in some of the sections. None of the three ureteral layers showed any fibrosis or other lesions. AU group: All layers were preserved. The urothelium showed changes from mild hyperplasia to a wider area of denudation. Some of the sections showed mild fibrosis in the lamina propria. Nearly all sections showed an increased number of blood vessels in comparison to the NU group. Necrosis, fibrosis or loss of ureteral lumen were not usually observed. RU group with correct functional result (RUa): This group consisted of seven cases. The three layer structure was preserved, although some sections showed some ureteral disorganization. Three cases showed foci of fibrosis in the lamina propria. Some ureteral segments had abundant subepithelial blood vessels. The muscle layer was also preserved, with increased vasculature and in some cases partial fibrosis. The RU group with poor functional results comprised six animals. All the ureteral layers could be identified, although they had more abnormalities and "disorderly" appearance than the RUa. CONCLUSIONS: Rat ureter can be used as a free autologous graft. Both AIFG and ANIFG can be utilized as homologous grafts in order to study ureteral immunological changes. When the ureter was used as ANIFG, no significant necrosis or fibrosis were observed and only a slight reduction in diameter was noted. The AIFG graft can result in ureteral integration that allows normal function.

Experimental study of ureteral free grafts. II. Urographic findings of integrated graft.

OBJECTIVE: An experimental study was conducted in rats to assess urographically the function of the integrated autologous free graft (IAFG) of the ureter, in which the ureter is reimplanted after being extracted from the animal's body and involves complete devascularization and ureteral ischemia. METHODS: The technique employed included direct vascular injection of contrast (iliac vein). The 40 rats were randomly distributed into three groups: NU group (n = 20), normal ureter; SC group (n = 15), surgical control, only ureterolysis; RU group (n = 14), reimplanted ureter as IAFG. RESULTS: The results show the urographic characteristics of the normal ureter (NU). The SC group IVUS were not distinct from those of the NU group. In the RU group, the segment of the ureter used as IAFG showed a normal or abnormal urographic image, depending on the result of the anastomosis. No ureteral fistula or leakage was observed in the urograms.

[Urology specialization. Part I. Current status and perspectives]. / La especialización en urología. Parte I. Estado actual y perspectivas.

At present the only official way for training and obtention of a degree of specialist in Urology is through the Resident In-house Physician (MIR) program. Although in general terms, the MIR program offers the best way to train specialists, we believe a review and self-evaluation of this system aimed both to elucidate the existing problems and to improve the programme would be useful and necessary. Three different questionnaires were prepared and sent to the Heads of Training Services, to the Residents in all the Urology Services where certified training is being given, or has been given over a five-year period, and to a random sample of Heads of Services who have no Residents appointed. The objective was to get to know the state of opinion on the specialization system, the attitude with regard to other possibilities, as well as to shape a resident's profile, make an evaluation of the professional and working environment, and obtain a general objectivization of the Spanish hospitals. Although the level of response was not consistent in all three groups, it was sufficient to be able to state that the system is considered good and the training correct. However, not all centres fulfill the requirements to have a Teaching Service. Training is not as consistent as it should be in a MIR-type system.

[Urology specialization. Part II. Survey of the heads of teaching services]. / La especialización en urología. Parte II. Encuesta a los jefes de servicios docentes.

The Heads of the Teaching Services have in their hands a large share of responsibility for the training of specialists. Therefore, they are the group with greater power to decide and give their opinion on this question. A large majority (77%) responded to the survey conducted. The questions covered 213 of the 252 residents preparing their specialty at the time in Spain. From their answers it can be deduced that a Teaching Service attends 30-35 beds (although there are exceptions) with 8-10 attached physicians, 5 residents on average. They are well equipped (although marked differences can be noted), they mainly do calls in their specialty and most of the services have been training residents for more than eight years. The Heads of the Teaching Services believe the MIR programme is the best way to prepare the degree, although an important portion postulates it should not be the only one.

[Urology specialization. Part III. Opinion of resident internal physicians]. / La especialización en urología. Parte III. La opinión de los médicos internos residentes.

At present the only official way for the training and obtention of a degree of specialist in Urology is through the Resident In-house Physician (MIR) program. With the passing of time both the rights and the wrongs of the training program under consideration come to light. From the former we try to obtain the maximum yield and with the latter we attempt to improve them or withdraw them if obsolete. The purpose of this survey was to evaluate from the Urology resident in-house physicians point of view, their training term. To that end, we have chosen the MIR examination of groups for the years between 1988 and 1992, both inclusive, a population that amounts to 252 subjects. There has been three releases of the questionnaire to all Teaching Hospitals within the national geography but only 81 (32.1%) resident physicians have answered it. The extensive questionnaire was divided in 6 sections: demographics, personal evaluation of the hospital staff and service, health care activities (admittance schedule, out-patient surgery, operating theatre and emergencies), non-health care activities (publications, attendance to congresses, etc...), evaluation of the MIR system, and professional aspirations.

[Urology specialization. Part IV. Survey of the heads of non-teaching services]. / La especialización en urología. Parte IV. Encuesta a los jefes de servicios no docentes.

Presentation of the results obtained from the answers to the survey sent to the Heads of Urology Services with no certification for teaching the specialty. Information relative to Service possibilities, training aspects and evaluation of the current specialization system is requested. Also, an evaluation is made of the suitability of the number of specialists per year and their training level. Finally, they are also asked for an evaluation of assistants in urology.

[Characteristics of bladder leiomyoma in our setting]. / Características del leiomioma vesical en nuestro medio.

OBJECTIVES: To determine the incidence, form of presentation, symptoms, diagnostic methods and treatment most commonly used, and prognosis of leiomyoma of the bladder in our setting. METHODS: We conducted a retrospective, multicenter analysis of the last 700 cases submitted to surgery for a bladder tumor that was found to be leiomyoma of the bladder. We reviewed the Spanish literature of the last twenty years for the following variables: patient age, sex, presenting symptoms, incidental finding or not, value of the tests performed, treatment, follow-up and prognosis. RESULTS: Leiomyoma of the bladder accounted for 0.43% of the bladder tumors diagnosed at three urological centers. Apart from the three cases described, ten additional cases are reviewed. Forty-six percent were incidentally discovered. US proved to be the best diagnostic method. Treatment was frequently by open surgery. The prognosis was excellent; there has been no recurrence at 22 months' mean follow-up. CONCLUSIONS: Leiomyoma of the bladder is a benign tumor with little or no clinical symptoms or signs, often discovered incidentally during US and accounts for 0.5% of the cases that had undergone surgery for a bladder tumor.

Experimental study of ureteral free grafts. I. Surgical findings in transplanted and abandoned ureter.

OBJECTIVE: To develop two experimental models in rats to study the ureter under conditions of total devascularization and denervation. METHODS: The ureter was autotransplanted as an integrated autologous free graft (IAFG) or abandoned in the retroperitoneum as a non integrated autologous free graft (NIAFG). Both models were compared with a normal group and a surgical control group. Sixty-two rats were randomly distributed: Normal ureter (NU) group (n = 20); surgical control, only ureterolysis (SC) group (n = 15); abandoned ureter as NIAFG (AU) group (n = 13); reimplanted ureter as IAFG (RU) group (n = 14). RESULTS: SC group: in all cases a ureter with no alterations was observed although with slight periureteral fibrosis. AU group: some ureter specimens had a smaller caliber. Periureteral fibrosis was observed in all the cases. Vessel distribution was similar to that of the NU group. All the ureters conserved their lumen. 53.8% of the ureters showed spontaneous contractions and 100% contractions after mechanical stimulation. Cyst formation, necrosis, fistulas or stenosis of the lumen were not observed. RU group: microscopic findings of the ureter segment used as IAFG were compatible with those of a normal ureter. In all the cases a moderate degree of periureteral fibrosis was observed. In the majority of the cases a vascular framework of the fat immediately adjacent to the ureter was observed. In 13 of the 14 operated cases spontaneous contractions were observed. The ureteral segment used as IAFG showed no alterations in 10 cases and with alterations of various types in 4 cases. In 8 cases there was a greater or lesser degree of stenosis of the proximal suture. CONCLUSIONS: The surgical findings and the macroscopic aspects of the four groups show the viability of the ureter free graft, IAFG as well as the NIAFG, in spite of the macroscopic changes.

[Extracorporeal shock-wave lithotripsy in horseshoe kidney]. / Litotricia extracorpórea por ondas de choque en el riñón en herradura.

Presentation of our experience in the use of extracorporeal shock wave lithotripsy (ESWL) for the treatment of lithiasis that occurred in 34 renal units from 28 patients with horseshoe kidneys. All patients but one were placed in supine decubitus with the calculus positioned in F2. A total of 47 sessions were performed for 34 treatments apart from 3 ureteroscopies for ureteral voiding. The results of the follow-up is absence of lithiasis in 13 renal units, debris of less than 3 mm in six, non-removable debris in 13 cases and relapse in two.

[Critical analysis of the bibliography of Actas Urológicas Españolas]. / Análisis crítico de la bibliografía de Actas Urológicas Españolas.

In the absence of Spanish journals and publications with a high impact factor and since one of the primary reasons to obtain such an impact is the frequency with which the publication is referenced, we wanted to check the general belief by which even in the Spanish journals the proportion of national articles that get referenced is very small. We reviewed all articles published by Actas Urológicas Españolas during 1989 and 1990 (12 issues, 246 articles with 4,549 references), and found that only 14.42% of references were from publications or books edited in Spain or at congresses held within Spain. After excluding books and communications originates in congresses, the figure is 10.9%. On the other hand, we noticed that over 25% articles do not include one single Spanish reference. Finally, the publication most often consulted is the USA Journal of Urology, which approaches some 20% of all mentions.