[Solitary stones of the lower renal calyx: how to treat?]

INTRODUCTION: The choice of treatment for the stones of the lower renal calyx is one of the challenging issues of modern urology. The aim of this retrospective and prospective study was to investigate the clinical effectiveness and safety of 3 modern minimally invasive techniques for treating renal stones: percutaneous (PNL) and transurethral (TNL) nephrolithotripsy and extracorporeal shock wave lithotripsy (ESWL) in patients with solitary lower calyx stones sized from 10 to 15 mm. MATERIALS AND METHODS: The study included 136 patients with symptomatic stones of the lower calyces, who underwent ESWL, PNL and TNL from November 2010 to the present day. The criteria for inclusion in the study were: the presence of a solitary stone of the lower calyx, the stone size of 10 mm to 15 mm, the performance of the classical (standard) PNL in the prone position (puncture access 28-30 Fr) and the follow-up examination at 3 months after the operation. Forty-six patients underwent ESWL, 49 - PNL, and 41 - TNL. Postoperative follow-up was done at 3 months and included a plain radiography, ultrasound and non-contrast-enhanced computed tomography. The stone free rate (SFR) was used as a criterion for the effectiveness of the intervention, where the stone size of 3 mm was taken as the upper limit for the possible presence of fragments. Besides, the rate of repeat interventions, complications and subjective assessment of patients treatment satisfaction (0 to 10) by using visual analogue scale (VAS) were investigated. RESULTS: The effectiveness analysis of the three methods for treating the lower calyx stones sized 10-15 mm showed that PNL was no more effective than TNL (SFR 95.9% and 85.4%, respectively), but both methods were significantly more effective than ESWL (SFR 69.5%). 29.3% of patients who underwent TNL required repeat interventions (TNL or ESWL), while among those treated with ESWL, 45.6% required repeat ESWL sessions. PNL resulted in stone clearance in one stage. Postoperative inflammatory complications were most prevalent among patients who underwent TNL (26.8%). Bleeding requiring hemotransfusion was observed only after PNL (14.3%). Obstructive complications were observed in all study groups. For them, internal stenting was most often performed after ESWL (10.9%), puncture nephrostomy - after TNL (7.3%). Statistically significantly higher VAS measured quality of life was found after ESWL (7.9) and PNL (7.0) compared with THL (4.8). CONCLUSION: All three methods (PNL, TNL and ESWL) for treating lower calyceal stones sized from 10 to 15 mm are quite effective. Using them separately or in combination allows most patients to safely achieve a stone-free state.

[Extracorporeal shockwave lithotripsy of stones in lower calices of kidney].

The article presents the results of the study aimed to evaluation of possible relationship between anatomical structure of the renal pelvis of the kidney, the size of the stone and the effectiveness of extracorporeal shockwave lithotripsy (ESWL) of stones in lower calices of kidney, defined as "stone-free state". ESWL was performed in 285 patients. Sizes of stones varied from 5 to 25 mm. With interval distribution of stone sizes, the greatest number of cases was detected with size of 5 to 12 mm. The destruction of stone required one ESWL session in 196 cases, and three sessions only in 12 cases. The total number of pulses per one stone did not exceed 9500, and more than 70% of the stones have been effectively destroyed with less than 3000 pulses. The result of treatment was assessed 3-4 months after the last ESWL session on the basis of ultrasound and X-ray examination using nominal (dichotomous) scale. In addition, for verification of significant (expected and unexpected) correlations, exploratory analysis of the correlation matrices of factors possibly affecting the discharge of stone fragments was performed. Positive treatment outcome was recorded in 212 (74.4%) patients. Residual stone fragments (> or = 5 mm) were identified in 73 (25.6%) patients; in 69 patients fragments corresponded to the initial localization and 4 fragments were located in the pelvis and calices of middle and lower segments of the kidney. Statistical processing found no association between the size of the stone and the number of ESWL sessions required for its destruction (P = 0,4056). The analysis of relationship between the nature of the complications and size of stone revealed differences, but there were no significant differences in median test (p = 0.1067). Based on exploratory analysis and correlations identified, in-depth evaluation was carried out on three factors: the size of the stone, length of lower calices neck, and pyelocaliceal corner. Width of lower calices neck as a statistically nonsignificant criterion was excluded from further analysis. A full-scale statistical analysis resulted in a number of conclusions that reflect the dependence of the efficiency of ESWL of stones in lower calices of kidney on size of the stone and a number of anatomical features of the renal pelvis system.

The influence of the Rashba spin-orbit coupling on the two-dimensional magnetoexcitons.

The influence of the Rashba spin-orbit coupling (RSOC) on the two-dimensional (2D) electrons and holes in a strong perpendicular magnetic field leads to different results for the Landau quantization in different spin projections. In the Landau gauge the unidimensional wave vector describing the free motion in one in-plane direction is the same for both spin projections, whereas the numbers of Landau quantization levels are different. For an electron in an s-type conduction band they differ by one, as was established earlier by Rashba (1960 Fiz. Tverd. Tela 2 1224), whereas for heavy holes in a p-type valence band influenced by the 2D symmetry of the layer they differ by three. The shifts and the rearrangements of the 2D hole Landau quantization levels on the energy scale are much larger in comparison with the case of conduction electron Landau levels. This is due to the strong influence of the magnetic field on the RSOC parameter. At sufficiently large values of this parameter the shifts and rearrangements are comparable with the hole cyclotron energy. There are two lowest spin-split Landau levels for electrons as well as four lowest ones for holes in the case of small RSOC parameters. They give rise to eight lowest energy bands of the 2D magnetoexcitons, as well as of the band-to-band quantum transitions. It is shown that three of them are dipole-active, three are quadrupole-active and two are forbidden. The optical orientation under the influence of circularly polarized light leads to optical alignment of the magnetoexcitons with different orbital momentum projections in the direction of the external magnetic field.

[First experience with outpatient shock-wave lithotripsy].

Clinical experience with administration of extracorporeal shock wave lithotripsy (ESWL) in an outpatient clinic demonstrates feasibility of urolith fragmentation in some patients using certain lithotriptors. Concrements can be removed from about 97.0% patients without their hospitalization.

[Tamsulosin in combind treatment of patients with urolithiasis].

In administration of tamsulosine (focusin, Zentiva, Czech Republic) in combined treatment of urolithiasis concrement evacuation after extracorporeal lithotripsy occurred in 83% cases in patients with the concrement stay in the ureter for less than one month. The size of the concrement after successful lithotripsy had no significant effect on subsequent stone-eliminating therapy but long-term stay of the concrement in one place promoted inflammatory and urodynamic disturbances in the ureter treated surgically. The comparative analysis of the contractile function of the distal ureteral comparment in patients given tamsulosin showed a less active (amplitude of the contractions) and passive (tonicity) resistance to urine flow than in patients given a standard therapy. These changes were accompanied with lower pressure in the renal pelvis and suppression of enzymuria. Thus, tamsulosin addition to combined treatment of urolithiasis has a positive effect on ureteral urodynamics, concrement evacuation and functional structures of the kidney by indirectly lowering intrapelvic pressure.

[Transurethral pyelocalycolithotripsy and lithoextraction--a new method of nephrolithiasis treatment].

Transurethral pyelocalycolithotripsy (TUPCL) was made in 87 patients (36 males and 51 females, age 7-82 years) with solitary uroliths from April 2007 to April 2008. Of 51 pelvic and ureteropelvic nephroliths, 24 (47%) had the size of 0.5-1 cm, 22 (43%)--1.1-2 cm, 5 (10%)--over 2 cm. Nineteen stones of the upper segment calyx were of less than 1 cm in size, 6 (32%)--1.1-2 cm, 4 (21%)--more than 2 cm. Nine stones of the middle segment calyx were less than 1 cm in size (44%), 4--1 to 2 cm (44%). One patient had the stone of more than 2 cm in size. Transurethral contact pyelolithotripsy was performed in all 87 patients. The rigid ureteropyeloscope was employed in 64 (74%) cases, fibropyelocalycolithotripsy was made in 23 (26%) cases. Indications for TUPCL were failure or aftereffects of extracorporeal pyelolithotro[sy (50 cases, 65%), suspected stricture under the stone (10 cases, 12%), ligature stones (7 cases, 6%). Pelvic stones were detected at diapevtic ureteropyeloscopy in 11 (17%) patients suspected of calycopelvic papillary tumor. In 8(9%) patients nephroliths were destructed with the electromechanic probe (Medline, Russia), pneumatic contact lithotripsy was made in 22 (25%) cases (Lithoclast Master, EMS, Switzerland), Ho laser lithotripsy was made in 41 patients (WaveLight Laser Technologie AG, Germany) with a 365 mcm waveguide in 14 (17%) cases and a 600 mcm waveguide in 27 (31%) cases. Pyelocalycolithoextraction was conducted in 16 (18%) patients. Elimination of the nephroliths was achieved in 71 (81.6%) patients. This shows that TUPCL is effective and comparable by efficacy with such methods as extracorporeal lithotripsy, percutaneous nephrolitholapaxy. Rigid ureteropyeloscopy eliminated nephroliths in 53 (83%) patients, fibropyeloscopy--in 18 (77%) patients. The experience of the authors and literature data allowed them to formulate indications for TUPCL: cacycopelvic nephroliths up to 2 cm in size in their location in the pelvis and upper segment calyx and up to 1 cm in size in their location in the calyces of the middle and lower segments irrespective of renal dysfunction degree and dilation of the calycopelvic system in failure or contraindications for extracorporeal lithotripsy and percutaneous nephrolitholapaxy. In nephroliths more than 2 cm in size TUPCL can be used as a method of choice in patients with morbid obesity, anomaly of the kidneys, upper urinary tract and the spine, hemostatic disorders. In large calycopelvic stones the patients should be informed about possible staged treatment or extracorporeal lithotripsy in the postoperative period.

Intra-Landau-level excitations of the two-dimensional electron-hole liquid.

The intra-Landau-level excitations of the two-dimensional electron-hole liquid are characterized by two branches of the energy spectrum. The acoustical plasmon branch with in-phase oscillations of electrons and holes has a linear dispersion law in the range of small wavevectors, with a velocity which does not depend on the magnetic field strength, and monotonically increases with saturation at higher values of the wavevectors. The optical plasmon branch with oscillations of electrons and holes in opposite phases has a quadratic dependence in the range of long wavelength, a weak roton-type behaviour at the intermediary values of the wavevectors and monotonically increases with saturation similar to the case of the acoustical branch. The influence of the supplementary in-plane electric field leads to the drift of the charged particles in the crossed electric and magnetic fields and to the energy spectrum as in the reference frame, where the e-h system is moving with the drift velocity. A perturbation theory using the Green function method is developed on the basis of a small parameter v(2)(1-v(2)), where v(2) is the filling factor and (1-v(2)) displays the phase space filling effect.

[The role of phytotherapy in pre- and postoperative period in patients with urolithiasis].

Effects of a biologically active food additive Prolit (PT Industry Djamu Borobudur, Indonesia) on the urinary system and metabolic status of patients with urolithiasis were studied. Total urinalysis, biochemical blood and urine tests by 12 indices, ultrasonic investigation of the kidneys, excretory and plain urography were made in 30 patients aged 23 to 70 years (7 females, 23 males). Prolit was given in a dose 1125 mg three times a day for 1-6 months. Prolit decreased hypercalciuria and urinary pH. A trend was observed to lowering of the degree of leukocyturia, hyperuricemia, hyperuria and hyperoxaluria. Urolithiasis recurrences were absent in 10 cases of 12 (83%), in 18 of 20 patients (90%) concrements did not increase in size. Prolit had no side effects.

[New approach to improving efficacy and objective assessment of the extracorporeal lithotripsy]. / Novyi podkhod k povysheniiu éffektivnosti i ob''ektivizatsii distantsionnoi litotripsii.

Clinical trials of the generator EMSE 220F XXP were conducted on the lithotriptor Dornie C" in the Research Institute of Urology from September 2203 to January 2004. Extracorporeal lithotripsy (ECL) was made in 158 patients (66 women and 92 men, age 11-89 years) with different clinical forms of nephrolithiasis. The analysis of nephrolith fragmentation showed high disintegration power of the generator in all nephrolithiasis forms (97.4%). Maximal energy intensity in ECL of nephrolithis was under 7 units, of ureterolithis--10 units. The number of additional sessions averaged 11.4%, mean Edose was 49.2 J. Complications of early postoperative period was detected in 4 (2.5%) patients. In two of them (1.3%) subcapsular hematomas 180 cm3 in size were detected. The other two patients developed exacerbation of pyelonephritis early after operation. It was managed conservatively. Thus, EMSE 220F-XXP is a novel, highly effective source of generation of shock-wave impulses providing finely divided fragmentation of uroliths in 97.4% cases. A mean Edose 49.2 J effectively destructs urinary concrements of any location with a minimal risk of postoperative complications. Maximal intensity regimes should be used carefully with consideration of a high risk of traumatic complications.

[Residual kidney stones and their treatment]. / Rezidual'nye kamni pochek i ikh lechenie.

416 case histories of patients with different forms of urolithiasis aged 6 to 70 years who had undergone sectional nephrolithotomy (83, 19.9%), pyelonephrolithotomy (24, 5.8%), pyelolithotomy (146, 35.1%), percutaneous nephrolithotomy (163, 39.9%) were analysed. Residual nephroliths occurred in 108 (25.9%) patients. 98 of them were subjected to extracorporeal lithotripsy (ELT). To determine minimal possible interval between the operation and ELT, changes in the levels of lipid peroxidation products and concentration of alpha-glutathione-S-aminotransferase were studied. The results allowed the authors to optimize ELT after operative interventions for uroliths. In the course of 206 ELT sessions the residual uroliths were destroyed in 96 (97.9%) patients. After one session a complete fragmentation was achieved in 19 (19.4%) patients, after two sessions--in 64 (65.3%) patients, after three sessions and more--in 15 (15.3%). Pyoinflammatory complications developed in 8 (8.2%) patients while retrospectively such complications were encountered in 16 of 50 patients (32%). One month after ELT, the control examination found neither nephroliths nor their fragments in 85 (86.7%) patients, in patients with large and multiple stones elimination rate 1.5 months after the treatment was 69.5%. It is inferred that ELT is an effective method of residual uroliths elimination and is a method of choice in the treatment of such patients.

[Results of clinical use of the polyfunctional lithotripsy device "Dornier-U 50"]. / Rezul'taty klinicheskogo primeneniia polifunktsional'nogo litotriptora "Dornier-U 50".

The review of the results of clinical application of a polyfunctional lithotriptor Dornier-U50 in urolithiasis patients is presented. The treatment of 324 patients produced good results of lithotripsy in uroliths of any location in generating high-energy shock waves. Complete fragmentation was achieved in 86.4%, partial one--in 11.7%. Complications occurred in 9% of which 5.3% were cases of upper urinary obstruction. The Dornier-U50 lithotriptor can be used for both extracorporeal lithotripsy (under x-ray and ultrasound targeting) and various endoscopic operations under x-ray telecontrol. This allows maximal utilization efficiency of this equipment in diagnosis and treatment in urological hospitals.

[Complications of open surgical procedures in urolithiasis and their prevention]. / Oslozheneniia otkrytykh operatsii pri lechenii mochekammenoi bolezhni i puti ikh profilaktiki.

236 operative interventions for urolithiasis have been performed in 234 patients. Of them, 187 (79.9%) patients developed complications. Intraoperatively complications resulted from opening of the pleural and abdominal cavities (20 patients, 8.5%) and intraoperative blood loss < 500 ml (19 patients, 8.1%). In one case a nephrectomy was made because of repeated hemorrhage early after the operation. Among the postoperative complications most frequent were acute pyelonephritis (34, 14.5%) and aggravation of renal failure (11, 4.7%). The former demanded extracorporeal detoxication in 9 cases, in the latter hemodialysis was not required. Residual comcrements occurred in 28 (12%) patients. 17 of them had to undergo extracorporeal lithotripsy. Thus, open urological interventions in urolithiasis are now conducted in advanced disease, provoking complications. This raises responsibility of the surgeons who must take maximal preventive measures and use novel technologies in management of the complications.

[Effects of impaired urodynamics and contractile function of the upper urinary tract on elimination of stone fragments after extracorporeal lithotripsy]. / Vliianie narushenii urodinamiki i sokratitel'noi funktsii verkhnikh mochevyvodiashchikh putei na otkhozhdenie fragmentov kamnei posle distantsionnoi litotripsii.

The authors analyze effects of amplitude, tone and frequency of ureteral contractions on elimination of stones fragmented after extracorporeal shock-wave lithotripsy (ECSWL) in 30 patients with concrements in the kidneys and ureters. Before ECSWL the patients had indications for renal pelvis cathetarization. The measurements were made with multichannel impedance ureterography. According to initial dilatation of the upper urinary tracts (UUT), the patients were divided into 3 groups. It is shown that urodynamic UUT disorders determine effectiveness of ECSWL in urolithiasis patients: the greater is the dilatation the more probable are unsatisfactory results of ECSWL. Ureteral contractile activity is essential for rehabilitation in early postoperative period after ECSWL in patients with unrevealed UUT dilation: high amplitude of ureteral contractions in low tone is good for the fragments elimination, while high tone may result to the fragments ejection into the kidney. Low contractility may contribute to development of stone path. In patients with pronounced UUT dilation ureteral contractility is less important for ECSWL effectiveness than the wall tone and retrograde ureteral peristaltic movements. ECSWL results are better in patients with low tone of UUT wall. High UUT tone, especially in combination with retrograde peristaltic ureteral contractions registered prior to ECSWL indicates high probability of residual stones and additional fragmentation procedures irrespective of initial UUT dilation.

Ral GTPases contribute to regulation of cyclin D1 through activation of NF-kappaB.

Ral GTPases have been implicated as mediators of Ras-induced signal transduction from observations that Ral-specific guanine nucleotide exchange factors associate with Ras and are activated by Ras. The cellular role of Ral family proteins is unclear, as is the contribution that Ral may make to Ras-dependent signaling. Here we show that expression of activated Ral in quiescent rodent fibroblasts is sufficient to induce activation of NF-kappaB-dependent gene expression and cyclin D1 transcription, two key convergence points for mitogenic and survival signaling. The regulation of cyclin D1 transcription by Ral is dependent on NF-kappaB activation and is mediated through an NF-kappaB binding site in the cyclin D1 promoter. Ral activation of these responses is likely through an as yet uncharacterized effector pathway, as we find activation of NF-kappaB and the cyclin D1 promoter by Ral is independent of association of Ral with active phospholipase D1 or Ral-binding protein 1, two proteins proposed to mediate Ral function in cells.

[Functional state of upper urinary tract in urgent extracorporeal lithotripsy]. / Funktsional'noe sostoianie verkhnikh mochevyvodiashchikh putei pri neotlozhnoi distantsionnoi litotripsii.

Seven patients have undergone urgent extracorporeal lithotripsy (UEL) for renal colics. 3 patients were cured. Before UEL they had insignificant defects of urodynamics and ureteral contraction. 3 patients with initial dilation of the upper urinary tracts > 2 cm and reflux ureteral motility, residual concrements eliminated spontaneously or after additional UEL procedures or combined treatment. One female with initial pelvic and uretral dilation and disturbed motility of the upper urinary tracts was treated for 6 months. 1-2.5-year follow-up detected neither concrements nor marked dilation of the calyceropelvic system. Patients with renal colics have more pronounced local defects of contraction rhythm and activity, peristaltic direction. Peristaltic disorders in the upper urinary tracts in patients with renal colics are local and may be related to acute occlusion and neuroreflex effects. This explains why UEL produces good results in renal colics, especially in patients with minimal defects of urodynamics. Complicated course after UEL early after the operation occurred in patients with dilated upper urinary tracts, high contraction amplitude registered by high tonicity of the ureteral wall and the presence of retrograde peristaltic waves.

[Percutaneous paracentric nephrostomy in infants]. / Chrezkozhnaia punktsionnaia nefrostomiia u detei grudnogo i iasel'nogo vozrasta.

The paper describes the technique of transcutaneous paracentetic nephrostomy in infants, emphasizes advantages of this method in infants versus the others used to correct supravesical obstruction (open nephrostomy, ureterocutaneostomy, kidney catheterization, internal stenting), describes relevant indications. The nephrostomy was performed in 16 infants. The results show effectiveness and safety of this method.

[Initial results of the clinical use of a novel Russian lithotriptor LitURAT-UR]. / Pervye rezul'taty klinicheskogo primeneniia novogo otechestvennogo litotriptora "LitURAT-UR".

By its performance characteristics LitURAT-UR lithotriptor is different from previous units made in Russia or abroad. Besides the double stone-directing system (ultrasound + x-ray), LitURAT-UR is furnished with two interchangeable generators of shock-wave impulses (electrohydraulic and electromagnetic) allowing effective destruction of any urolith. The TV system is able to control the interelectrode space and to change it in the course of lithotripsy. Efficiency of the new lithotriptor in different clinical forms of urolithiasis reached 93.1%. Thus, universal, effective and low-traumatic characteristics of the lithotriptor LitURAT-UR hold much promise for urological practice in Russia.

[Extracorporeal shock-wave lithotripsy (ESWL) in removal of stones in anomalies of kidney and upper urinary tracts]. / Distantsionnaia udarnovolnovaia litotripsiia v lechenii kamnei pri anomaliiakh pochek i verkhnikh mochevykh putei.

The authors analyze the results of ESWL (URAT-P unit) for urolithiasis performed in 106 patients (49 females and 57 males) aged 16-67 years with anomalous kidneys and upper urinary tracts. 28, 1, 11, 14, 24, 4, 22 and 2 patients had horseshoe, L-shape, solitary, lumbar distopic, double, sponge, cystic kidneys, congenital megacallicosis, respectively. The stones ranged in size from 7 to 30 mm. Bilateral urolithiasis was in 7 patients. The number of impulses averaged 1745 +/- 168.4 per the procedure. The average number of ESWL procedures per stone was 1.4 (1-4). The stones were completely eliminated after one ESWL session in 78(73.6) patients, after two sessions in 23(21.7%) patients, after three sessions in 4, after for in 1 patient. Complications developed in 18 patients: urinary tract obstruction and attack of acute pyelonephritis (15 and 3 patients, respectively). Within 2-10-year follow-up recurrences arose in 12 patients who were retreated. Thus, ESWL is a method of choice in the treatment of urolithiasis patients with malformations of the kidneys and upper urinary tracts. Good results of ESWL are achieved in strict adherence to principles of the patients' selection, preoperative preparation technique, individual approach to patients in postoperative period, follow-up to detect complications and recurrences.

[Functional state of the upper urinary tract during and after extracorporeal lithotripsy]. / Funktsional'noe sostoianie verkhnikh mochevyvodiashchikh putei vo vremia vypolneniia i posle distantsionnoi litotripsii.

Ureteral motility reaction to extracorporeal lithotripsy was studied in patients with urolithiasis. This reaction depended on the initial function of the urinary tracts. Multichannel impedance ureterography provides objective information on ureteral function. Individual approach is necessary in the treatment of urolithiasis patients.

[Extracorporeal lithotripsy of stones in the single kidney]. / Distantsionnaia litotripsiia kamnei edinstvennoi pochki.

The authors used shockwave lithotripsy (SWL) in 130 patients with solitary kidney to crush renal calculi. Valid policy in preoperative drainage may result in a significant reduction of the occurrence of postoperative obstructive complications. It was only 11.5%. A valid choice of sparing regimen of crushing kidney and prepelvic ureter calculi help prevent hematomas, a severe complication of early postoperative period. No cases of this complication were seen in the study. A significant renal function failure in early postoperative period was not recorded. A 2.5--5-year follow-up in 21 patients has found that in 61.9% of patients renal function recovered or remained stable, in 38.1% of patients renal function declined. This was due to deterioration of the underlying disease (chronic pyelonephritis, frequent recurrences of lithogenesis).