Urinary tract infection's etiopathogenic role in nephrolithiasis formation.

Urolithiasis has a high prevalence and recurrence rate, especially in developed countries, and is a major public health issue with a high socioeconomic cost. There are multiple causes of urolithiasis, including urinary tract infection (UTI). Infection stones (mainly composed of struvite) are associated with renal infections by urease-producing bacteria. However, there is limited knowledge about the role of UTIs in the formation of stones that are apparently not related with infection. We hypothesize that UTIs promote the formation of certain urolithiasis that appear to be non-infection stones. Some recent studies have reported the presence of bacterial growth in cultures of stones removed by endourological procedures. These findings have led to the hypothesis that UTIs have a role in the formation of stones that are apparently non-infection stones. It is unknown whether these UTIs promoted stone formation, or if the stones became infected after formation. Several in vitro studies and ultrastructural microscopic analyses of urolithiasis are consistent with our hypothesis. If our hypothesis is correct, it could have a great impact on the treatment of urolithiasis. Especially, early identification and treatment of renal infections could help to prevent septic events, which are frequently life-threatening. It could also help to reduce the recurrence of urolithiasis, and thereby reduce health care costs. In conclusion, some evidence suggests that UTIs have a role in the formation of some apparently non-infection urolithiasis. If this is so, it could have a great impact on the treatment and prevention of this disease.

Análisis comparativo entre nefrolitotomía percutánea y ureteroscopia flexible en litiasis renal de 2-3cm / Comparative analysis between percutaneous nephrolithotomy and flexible ureteroscopy in kidney stones of 2-3cm

Introducción: Comparar la nefrolitotomía percutánea y la ureterorrenoscopia flexible para el tratamiento de la litiasis renal entre 2 y 3 cm. Material y métodos: Estudio prospectivo, comparativo, no aleatorizado en 108 pacientes con litiasis renal entre 2 y 3 cm; a 54 se les realizó nefrolitotomía percutánea y a 54 una ureteroscopia flexible. Las variables comparadas son: tasa libre de litiasis (%), tiempo quirúrgico, requerimiento de proceso auxiliar, complicaciones postoperatorias, estancia hospitalaria, tasas de reingreso y tiempo de recuperación. Resultados: No existieron diferencias en la tasa libre de litiasis entre ambas técnicas quirúrgicas (76% ureteroscopia, 87% nefrolitotomía) (p = 0,1), ni en las complicaciones (nefrolitotomía: 29%; ureteroscopia: 27%; p = 0,4). Se ha requerido mayor número de procesos auxiliares en el grupo de ureteroscopia (20%) frente al de nefrolitotomía (7%) (p = 0,04). El tiempo quirúrgico fue más largo en el grupo de nefrolitotomía (121 ± 52 min) que en el grupo de ureteroscopia (93 ± 42 min) (p = 0,004). El grupo de ureteroscopia tuvo menor estancia hospitalaria (2,1 ± 1,6 vs. 3,9 ± 1,9 días, p = 0,002), menor convalecencia (8,1 ± 4,9 vs. 13,3 ± 4,2 días, p = 0,005) y mayores tasas de reingreso (7,4% vs. 0%, p = 0,05) que el grupo de nefrolitotomía. Conclusiones: La nefrolitotomía y la ureteroscopia tienen una eficacia similar para el tratamiento de la litiasis renal entre 2-3 cm, sin diferencias en las complicaciones. La ureteroscopia tiene menor estancia hospitalaria, una recuperación más rápida pero mayor reingreso y necesidad de procedimiento auxiliar

Introduction: To compare percutaneous nephrolithotomy and flexible ureterorenoscopy for treating kidney stones between 2 and 3 cm. Material and methods: A prospective, comparative, nonrandomised study was conducted with 108 patients with kidney stones between 2 and 3 cm. Fifty-four patients underwent percutaneous nephrolithotomy and 54 underwent flexible ureteroscopy. We compared the following variables: lithiasis-free rate (%), surgical time, the need for an auxiliary process, postoperative complications, hospital stay, readmission rates and recovery time. Results: There were no differences in the lithiasis-free rate between the 2 surgical techniques (76% for ureteroscopy vs. 87% for nephrolithotomy; P = .1) or in the complications (29% for nephrolithotomy vs. 27% for ureteroscopy; P = .4). A larger number of auxiliary process were needed for the ureteroscopy group (20%) than for the nephrolithotomy group (7%) (P = .04). The surgical time was longer for the nephrolithotomy group (121 ± 52 min) than for the ureteroscopy group (93 ± 42 min) (P = .004). The ureteroscopy group had shorter hospital stays (2.1 ± 1.6 vs. 3.9 ± 1.9 days; P = .002), shorter convalescence (8.1 ± 4.9 vs. 13.3 ± 4.2 days; P = .005) and higher readmission rates (7.4% vs. 0%, P = .05) than the nephrolithotomy group. Conclusions: Nephrolithotomy and ureteroscopy have similar efficacy for treating kidney stones measuring 2-3 cm, with no differences in complications. Ureteroscopy results in shorter hospital stays, quicker recoveries but more readmissions and a greater need for auxiliary procedures

Comparative analysis between percutaneous nephrolithotomy and flexible ureteroscopy in kidney stones of 2-3cm. / Análisis comparativo entre nefrolitotomía percutánea y ureteroscopia flexible en litiasis renal de 2-3cm.

INTRODUCTION: To compare percutaneous nephrolithotomy and flexible ureterorenoscopy for treating kidney stones between 2 and 3cm. MATERIAL AND METHODS: A prospective, comparative, nonrandomised study was conducted with 108 patients with kidney stones between 2 and 3cm. Fifty-four patients underwent percutaneous nephrolithotomy and 54 underwent flexible ureteroscopy. We compared the following variables: lithiasis-free rate (%), surgical time, the need for an auxiliary process, postoperative complications, hospital stay, readmission rates and recovery time. RESULTS: There were no differences in the lithiasis-free rate between the 2 surgical techniques (76% for ureteroscopy vs. 87% for nephrolithotomy; P=.1) or in the complications (29% for nephrolithotomy vs. 27% for ureteroscopy; P=.4). A larger number of auxiliary process were needed for the ureteroscopy group (20%) than for the nephrolithotomy group (7%) (P=.04). The surgical time was longer for the nephrolithotomy group (121±52min) than for the ureteroscopy group (93±42min) (P=.004). The ureteroscopy group had shorter hospital stays (2.1±1.6 vs. 3.9±1.9 days; P=.002), shorter convalescence (8.1±4.9 vs. 13.3±4.2 days; P=.005) and higher readmission rates (7.4% vs. 0%, P=.05) than the nephrolithotomy group. CONCLUSIONS: Nephrolithotomy and ureteroscopy have similar efficacy for treating kidney stones measuring 2-3cm, with no differences in complications. Ureteroscopy results in shorter hospital stays, quicker recoveries but more readmissions and a greater need for auxiliary procedures.

Factores predictivos de recuperación espermática en las azoospermias / Predictive Factors of Successful Sperm Retrieval in Azoospermia

Introducción: El tratamiento estándar de las azoospermias es la recuperación espermática del testículo para inyección intracitoplásmica. El objetivo de este estudio es identificar factores predictivos de recuperación espermática. Material y métodos: Intentamos recuperar espermatozoides mediante extracción espermática del testículo (TESE) en 74 pacientes azoospérmicos. Se estudiaron los niveles séricos de FSH einhibina B (INHB), la histología testicular, la genética, la criptozoospermia y el tamaño testicular. Resultados: La recuperación espermática fue del 47,2% para el total de pacientes, del 36% para las azoospermias no obstructivas y del 100% para las obstructivas. La INHB baja y la FSH alta se correlacionaron con el fracaso en la recuperación espermática. Los puntos de corte obtenidos mediante curvas ROC fueron de 67 pg/ml para la INHB y de 12,2 mUI/ml para la FSH. En ningún paciente con microdeleción Y en AZF a, b se recuperaron espermatozoides. En el 100% de los pacientes con mutaciones CFTR se obtuvieron espermatozoides. La mayor tasa de recuperación espermática fue para las hipoespermatogénesis, seguidas de los bloqueos madurativos y de los solo Sertoli. En todos los pacientes con criptozoospermia se recuperaron espermatozoides. Se encontró una relación entre el tamaño testicular y la recuperación espermática, pero no resultó estadísticamente significativa. Conclusiones: Salvo las microdeleciones en AZF a, b ningún factor predictor descarta a un paciente para TESE. La INHB baja se relaciona mejor que la FSH alta con el fracaso en la recuperación espermática. La recuperación es posible en todos los casos de mutaciones CFTR. La ausencia de células germinales se correlaciona con una alta probabilidad de fracaso en la recuperación espermática. La presencia de criptozoospermia se vincula a una alta probabilidad de éxito en la recuperación espermática (AU)

Introduction: Testicular sperm extraction with intracytoplasmic sperm injection is the standard treatment for azoospermia. The objective of this study is to identify predictive factors of successful sperm retrieval. Materials and methods: Between June 2003 and May 2011, we tried testicular sperm extraction(TESE) in 74 azoospermic patients in the Reproductive Medicine Unit of Son Espases Hospital (Palma de Mallorca). Serum follicle stimulating hormone (FSH) and inhibin B levels, testicular histology, genetic study, presence or not of cryptozoospermia and testicular volume were examined. Results: Spermatozoa were successfully recovered in 47.2% of the total patients, in 36% of nonobstructiveazoospermic patients and in 100% of obstructive azoospermic patients. Low inhibin B and high FSH were correlated to sperm retrieval failure. The cutoff points were determined using ROC curves that were 67 pg/mL for inhibin B and 12.2 mUI/mL for FSH. Spermatozoa were not successfully retrieved in any patient with Y microdeletions in AZF a, b regions. Spermatozoa were successfully retrieved in 100% of the patients with CFTR mutations. The highest spermretrieval rate was for hypospermatogenesis, followed by maturation arrest and Sertoli-cellonly. Spermatozoa were successfully retrieved in all cryptozoospermic patients. Although usinga non-significant test, there seems to be a correlation between higher testicular volume and a higher probability of successful sperm retrieval. Conclusions: Except for Y microdeletions in AZF a, b regions, there is no predictive factor of testicular sperm retrieval to rule out a patient for TESE. Lower inhibin B is more related to spermretrieval failure than higher FSH. Sperm retrieval is possible for all cases of CFTR mutations but in any case of microdeletion Y in AZF a ,b. The lack of germ cells is correlated with a high probability of sperm retrieval failure. The presence of cryptozoospermia is correlated with a high probability of sperm retrieval success. We do not find a statistically significant relation between testicular volume and successful sperm retrieval (AU)

Predictive factors of successful sperm retrieval in azoospermia.

INTRODUCTION: Testicular sperm extraction with intracytoplasmic sperm injection is the standard treatment for azoospermia. The objective of this study is to identify predictive factors of successful sperm retrieval. MATERIALS AND METHODS: Between June 2003 and May 2011, we tried testicular sperm extraction (TESE) in 74 azoospermic patients in the Reproductive Medicine Unit of Son Espases Hospital (Palma de Mallorca). Serum follicle stimulating hormone (FSH) and inhibin B levels, testicular histology, genetic study, presence or not of cryptozoospermia and testicular volume were examined. RESULTS: Spermatozoa were successfully recovered in 47.2% of the total patients, in 36% of non-obstructive azoospermic patients and in 100% of obstructive azoospermic patients. Low inhibin B and high FSH were correlated to sperm retrieval failure. The cutoff points were determined using ROC curves that were 67 pg/mL for inhibin B and 12.2 mUI/mL for FSH. Spermatozoa were not successfully retrieved in any patient with Y microdeletions in AZFa,b regions. Spermatozoa were successfully retrieved in 100% of the patients with CFTR mutations. The highest sperm retrieval rate was for hypospermatogenesis, followed by maturation arrest and Sertoli-cell-only. Spermatozoa were successfully retrieved in all cryptozoospermic patients. Although using a non-significant test, there seems to be a correlation between higher testicular volume and a higher probability of successful sperm retrieval. CONCLUSIONS: Except for Y microdeletions in AZFa,b regions, there is no predictive factor of testicular sperm retrieval to rule out a patient for TESE. Lower inhibin B is more related to sperm retrieval failure than higher FSH. Sperm retrieval is possible for all cases of CFTR mutations but in any case of microdeletion Y in AZFa,b. The lack of germ cells is correlated with a high probability of sperm retrieval failure. The presence of cryptozoospermia is correlated with a high probability of sperm retrieval success. We do not find a statistically significant relation between testicular volume and successful sperm retrieval.

Análisis multivariante de factores predictivos de evolución en litiasis renal / Multivariate Analysis of Predictive Factors in the Evolution of Renal Lithiasis

Objetivo: Realizar un análisis estadístico multivariante de factores epidemiológicos, clínicos y bioquímicos que permitan identificar las variables que independientemente puedan predecir la evolución de la litiasis renal, definiendo así un grupo de riesgo con peor evolución. Material y métodos: Estudio analítico, descriptivo, retrospectivo sobre 248 pacientes visitados en nuestro centro en el periodo 2003-2007. Se ha realizado análisis univariante (Chi-cuadrado) y multivariante (regresión logística) de posibles factores predictivos epidemiológicos (sexo, edad), clínicos (antecedentes personales de litiasis, número, localización caliciar y tamaño de cálculos, bilateralidad) y bioquímicos (bioquímica urinaria y composición del cálculo) en relación con la evolución de la litiasis renal (limpio o persistencia renal). Resultados: Con un seguimiento medio de 60 meses (IC 95%=52,5-67,4) observamos una persistencia global de litiasis renal en 121 pacientes (48,8%), estando limpios de litiasis 127 pacientes (51,2%). El análisis univariante describe como variables asociadas a mayor persistencia de litiasis la edad, el número de litiasis, la localización calicilar, la bilateralidad, la composición bioquímica urinaria y la composición bioquímica del cálculo; de todas estas variables, en el análisis multivariante solo mantienen significación estadística la edad inferior a 47 años, la bilateralidad, la localización calicilar y la composición química de la litiasis (oxalato cálcico dihidrado). Conclusiones: Existe una elevada persistencia de litiasis renal. La edad inferior a 47 años, la bilateralidad, la localización calicilar y la composición química de la litiasis (oxalato cálcico dihidrato) son factores asociados a mayor persistencia de litiasis renal de forma independiente. Estos factores señalan un grupo con peor evolución clínica, en los que deberíamos replantear estrategias diagnósticas y terapéuticas más individualizadas (AU)

Objective: To perform a multivariate statistical analysis of epidemiological, clinical and biochemical factors that make it possible to identify the variables that can independently predict the course of renal lithiasis, thus defining a group at risk of worse evolution. Material and methods: A retrospective, descriptive and analytic study was in a cohort of 248 patients with kidney stones treated in our center from 2003 to 2007. A univariate (chi-square) and multivariate analysis (regression model) of possible epidemiological predictive factors (age, gender), clinical data of stones (number, localization, size and bilaterality) and biochemical factors (urinary composition, stone composition) were analyzed. Results: Based on a mean follow-up of 60 months (95% CI: 52.5-67.4) we observed a global persistence of kidney stones in 121 patients (48.8%), 127 patients being stone-free (51.2%). The univariate analysis describes the following variables as being associated to greater persistence of lithiasis: age, number of stones, calyceal localization and bilaterality, urinary biochemical composition, and stone biochemical composition. In regards to all of the above variables, only age less than 47 years, bilaterality, stone localization and chemical composition of the lithiasis (oxalate calcium dehydrated) were significantly associated to a major risk of persistence of kidney stones. Conclusion: There is a high persistence rate of kidney stones. Patient age inferior to 47 year, calyceal localization, bilaterality, and biochemical composition of stones (oxalate calcium dihydrate) are independent factors associated to higher persistence rate of kidney stones. These factors indicate a risk group with a worse clinical prognosis in which we should reconsider more individualized diagnostic and therapeutic strategies (AU)

[Multivariate analysis of predictive factors in the evolution of renal lithiasis]. / Análisis multivariante de factores predictivos de evolución en litiasis renal.

OBJECTIVE: To perform a multivariate statistical analysis of epidemiological, clinical and biochemical factors that make it possible to identify the variables that can independently predict the course of renal lithiasis, thus defining a group at risk of worse evolution. MATERIAL AND METHODS: A retrospective, descriptive and analytic study was in a cohort of 248 patients with kidney stones treated in our center from 2003 to 2007. A univariate (chi-square) and multivariate analysis (regression model) of possible epidemiological predictive factors (age, gender), clinical data of stones (number, localization, size and bilaterality) and biochemical factors (urinary composition, stone composition) were analyzed. RESULTS: Based on a mean follow-up of 60 months (95% CI: 52.5-67.4) we observed a global persistence of kidney stones in 121 patients (48.8%), 127 patients being stone-free (51.2%). The univariate analysis describes the following variables as being associated to greater persistence of lithiasis: age, number of stones, calyceal localization and bilaterality, urinary biochemical composition, and stone biochemical composition. In regards to all of the above variables, only age less than 47 years, bilaterality, stone localization and chemical composition of the lithiasis (oxalate calcium dehydrated) were significantly associated to a major risk of persistence of kidney stones. CONCLUSION: There is a high persistence rate of kidney stones. Patient age inferior to 47 year, calyceal localization, bilaterality, and biochemical composition of stones (oxalate calcium dihydrate) are independent factors associated to higher persistence rate of kidney stones. These factors indicate a risk group with a worse clinical prognosis in which we should reconsider more individualized diagnostic and therapeutic strategies.

Closed ankle fractures in the diabetic patient.

Systemic and local manifestations of diabetes mellitus may complicate the treatment of ankle fractures in the diabetic population. We studied 98 patients (73 non-diabetics and 25 diabetics) who were treated for closed ankle fractures by either surgical or non-surgical methods. We found that overall, the risk of infection in the diabetic population (32%) was 4 times higher than in the non-diabetic population (8%). The infection rate in the diabetic group treated surgically more than doubled that in the non-diabetic group. Four out of six diabetic patients treated with cast became infected compared to no infections in the five non-diabetics treated with a cast. Even though the diabetic foot and ankle are well studied, the medical literature is not conclusive regarding the management of ankle fractures in the diabetic patient. Diabetic patients treated conservatively had a tendency to become infected over those treated surgically. Peripherovascular disease, peripheral neuropathy and swelling and/or ecchymosis increased the risk of infection in the diabetic population. Diabetic patients with poor compliance had a tendency to become infected more than those who were compliant. We concluded that the diabetic patient who is poorly compliant with evidence of neuropathic disease, peripherovascular disease and severe swelling and ecchymosis presents the most difficult group to manage. Although these patients are poor surgical candidates, they are also the most difficult to manage and also most prone to infection and complications if treated conservatively. When faced with this difficult scenario a multidisciplinary team approach would probably yield the best possible results by early identification and intervention in these patients.

Effects of 8-Gy radiation on the microcirculation of muscle flaps in the rat.

Combination of radical excision and radiation has been used as a treatment modality for cancer patients. As a result, in reconstructive surgery there is often a need to harvest flaps in the vicinity of previously irradiated tissues. Radiation has been shown to cause progressive injury to the macrocirculation and microcirculation, often jeopardizing flap survival. The purpose of this study was to examine whether radiation significantly affects the sequence of leukocyte-endothelial interactions or the hemodynamics of the muscle flap in both acute and chronic situations. Male Sprague-Dawley rats (n = 42) were divided into seven groups of six rats each. Rats in group I were not irradiated. Groups II through VII received 8-Gy radiation to the right groin and scrotum. Groups II, III, and IV were examined at 4, 24 and 72 hours, respectively, and groups V, VI, and VII were examined at 1, 2 and 12 weeks. For intravital microscopy, the cremaster muscle was dissected on its neurovascular pedicle. Vessel diameters and red blood cell velocities were measured in the central cremasteric branches and branch arterioles. Capillary perfusion was evaluated in 27 visual fields of each flap. Leukocyte-endothelial interactions were evaluated by numbers of rolling, adhering, and transmigrating leukocytes in post-capillary venules. In the same postcapillary venule, we measured the endothelial edema index (constriction index). The hemodynamics of irradiated flaps did not differ significantly from those of controls. Diameter and red blood cell velocity were increased in the first- and second-order arterioles and were highest at 72 hours and 1 week. After irradiation, third-order arterioles were constricted. Radiation reduced capillary perfusion by 4.3, percent. None of the differences were statistically significant. Neither leukocyte behavior nor the constriction indices differed among the groups. In conclusion, low-dose radiation of 8 Gy does not affect hemodynamics or leukocyte-endothelial interactions of muscle flaps in the rat. Muscle tissue with intact microvasculature can be harvested for reconstructive procedures after low-dose radiation.

Urinary lithogen risk test: usefulness in the evaluation of renal lithiasis treatment using crystallization inhibitors (citrate and phytate).

OBJECTIVES: This paper presents the results of a test to globally determine the urinary risk factor of calcium stone formation in the evaluation of treatments using crystallization inhibitors, such as citrate and phytate. METHODS: Three groups of active calcium oxalate stone-formers have been selected. The lithogen urinary risk was determined using a specially designed disposable test before any medical treatment. After evaluation group I did not receive any treatment, group II was treated with potassium citrate and group III with a phytate-rich dietary complement. When 15 days had elapsed, the test to evaluate the risk of urinary calcium stone formation was applied again to the three groups. The main lithogenic biochemical parameters of each tested urine were also determined before and after treatment. RESULTS: An important number of calcium oxalate stone-formers with high urinary risk factor (positive test) became negative after medical treatment (52% of the citrate-treated patients and 50% of the phytate-treated patients), but only 7% of the untreated patients (1 patient) showed a decrease in their urinary risk factor for calcium stones (negative test) after 15 days had elapsed. When the treatment was not effective, in an important number of cases, the urine contained high levels of calcium or showed pH values greater than 6.5. CONCLUSION: From the obtained results it can be concluded that the test is useful to evaluate the efficacy of a given renal lithiasis medical treatment, and also the efficacy of the treatment of calcium oxalate renal lithiasis using crystallization inhibitors, such as citrate and phytate, in an important number of cases.

Urinary lithogen risk test: usefulness in the evaluation of renal lithiasis treatment using crystallization inhibitors (citrate and phytate).

OBJECTIVES: This paper presents the results of a test to globally determine the urinary risk factor of calcium stone formation in the evaluation of treatments using crystallization inhibitors, such as citrate and phytate. METHODS: Three groups of active calcium oxalate stone-formers have been selected. The lithogen urinary risk was determined using a specially designed disposable test before any medical treatment. After evaluation group I did not receive any treatment, group II was treated with potassium citrate and group III with a phytate-rich dietary complement. When 15 days had elapsed, the test to evaluate the risk of urinary calcium stone formation was applied again to the three groups. The main lithogenic biochemical parameters of each tested urine were also determined before and after treatment. RESULTS: An important number of calcium oxalate stone-formers with high urinary risk factor (positive test) became negative after medical treatment (52% of the citrate-treated patients and 50% of the phytate-treated patients), but only 7% of the untreated patients (1 patient) showed a decrease in their urinary risk factor for calcium stones (negative test) after 15 days had elapsed. When the treatment was not effective, in an important number of cases, the urine contained high levels of calcium or showed pH values greater than 6.5. CONCLUSION: From the obtained results it can be concluded that the test is useful to evaluate the efficacy of a given renal lithiasis medical treatment, and also the efficacy of the treatment of calcium oxalate renal lithiasis using crystallization inhibitors, such as citrate and phytate, in an important number of cases.

Thrombogenic stimulus causes long-term decrease of muscle flap perfusion.

This study was designed to evaluate the effect of a continuous thrombogenic insult at the feeding artery on skeletal muscle flap perfusion over 24 hours. Twelve male Sprague-Dawley rats were divided into two experimental groups. In the control group (N = 6) and in the treatment group (N = 6) the right cremaster muscle was isolated on its neurovascular pedicle and the tubular muscle flap was preserved in the medial part of the hind limb over a 24-hour period for subsequent microcirculatory observation. In the treatment group, an inverting suture was applied over half of the circumference of the ipsilateral common iliac artery to create a continuous thrombogenic stimulus. Intravital microcirculatory measurements obtained were red blood cell velocities, vessel diameters, capillary perfusion, endothelial edema index, and leukocytic-endothelial interactions. There were no statistically significant differences seen in red blood cell velocities, vessel diameters, and leukocytic-endothelial interactions between the groups. However, the inverting suture caused a significant drop in capillary perfusion from 6.23 to 1.50 capillaries per visual field (median; p = 0.002). An arterial thrombogenic insult may result in a significant decrease in capillary perfusion in muscle flaps over 24 hours although the blood flow through the thrombogenic main feeding vessel is maintained.