Validez actual de la litotricia extracorpórea como tratamiento de primera línea de la litiasis / Is extracorporeal lithotripsy a first-line treatment for urinary stones today?

Objetivo Evaluar la eficacia y complicaciones de la litotricia extracorpórea por ondas de choque (LEOCh) como tratamiento de primera línea de la litiasis renal y ureteral. Métodos Estudio observacional retrospectivo de todos los pacientes tratados con litotricia en un centro de tercer nivel entre enero de 2014 y enero de 2021. Se recogieron las características de los pacientes, de la litiasis, y las complicaciones y resultados de la LEOCh. Se realizó una regresión logística multivariante de los factores asociados a la reducción del tamaño litiásico. También se llevó a cabo un análisis estadístico de los factores asociados a la necesidad de tratamiento adicional tras la LEOCh y de los factores asociados a las complicaciones. Resultados Se incluyeron 1.727 pacientes. El tamaño litiásico medio fue de 9,5 mm. En 1.540 (89,4%) pacientes se observó la reducción del tamaño litiásico. En el análisis multivariante, el tamaño (OR=1,13; p=0,00), la localización de la litiasis en el uréter (OR=1,15; p=0,052) y el número de ondas (p=0,002; OR=1,00) utilizadas en la LEOCh son los factores asociados a la reducción del tamaño litiásico. Un total de 665 pacientes (38,5%) precisaron tratamiento adicional tras la litotricia. Los factores asociados a la necesidad de retratamiento fueron el tamaño litiásico (OR=1.131; p=0,000), el número de ondas (OR=1.000; p=0,000) y la energía administrada (OR=1.005; p=0,000). En 153 pacientes (8,8%) se produjeron complicaciones tras la LEOCh. Se encontró una asociación estadísticamente significativa entre el tamaño de la litiasis (p=0,024; OR=1.054) y la derivación urinaria previa (p=0,004; OR=0,571). Conclusión La litotricia sigue siendo eficaz como tratamiento de primera línea para la litiasis reno-ureteral, con un bajo porcentaje de complicaciones. (AU)

Objective To evaluate the efficacy and complications of extracorporeal lithotripsy (SWL) as a first-line treatment for renal and ureteral stones. Methods Retrospective and observational study of all the patients treated with lithotripsy in a third level center between January 2014 and January 2021; characteristics of the patients, the stones, complications and results of SWL is recollected. Multivariate logistic regression of the factors associated with stone size reduction was performed. A statistical analysis of the factors associated with additional treatment after SWL and factors associated with complications is also executed. Results 1727 patients are included. Stone mean size was 9,5 mm. 1540 (89.4%) patients presented reduction in stone size. In multivariate analysis, stone size (OR=1.13; P=0.00), ureteral location of the lithiasis (OR=1.15; P=0.052) and number of waves (P=0.002; OR=1.00) used in SWL are the factors associated with reduction of stone size. Additional treatment after lithotripsy was needed in 665 patients (38.5%). The factors associated with the need for retreatment were stone size (OR=1.131; P=0.000), number of waves (OR=1.000; P=0.000), energy (OR=1.005; P=0.000). 153 patients (8.8%) suffered complications after SWL. A statistically significant association was found between the size of the lithiasis (P=0.024, OR=1.054) and the previous urinary diversion (P=0.004, OR=0.571). Conclusion Lithotripsy remains an effective treatment as the first line of therapy for reno-ureteral lithiasis with a low percentage of complications. (AU)

The use of intelligent analysis (IA) in determining the tactics of treating patients with nephrolithiasis.

INTRODUCTION: The use of modern information technologies allows to increase confidence in the choice of a surgical treatment method of kidney stones, as well as to improve the quality of treatment due to an adequate combination of therapeutic techniques. MATERIALS AND METHODS: In our study we analyzed the treatment results of 625 patients with kidney stones. We created a register with the information on more than 50 parameters for each patient. Each example had an output parameter representing a predefined treatment strategy (extracorporeal shock-wave lithotripsy [ESWL]-1, percutaneous nephrolithotomy [PCNL]-2, pyelolithotomy or nephrolithotomy-3). The initial database served as the basis for training the neural network estimation technique. The aim of our study was to assess the possibility of using neural network algorithms in choosing a method for surgical treatment of urolithiasis. RESULTS: A prospective study was conducted to assess the clinical effectiveness of implementing the recommendations of the system. The average number of sessions in the group using the neural network assessment technique was 1.4. Residual fragments remained at the time of discharge in seven (15.6%) patients: four in the kidney, three in the lower third of the ureter "stone path." Inversion of therapeutic tactics-PCNL-was performed in four cases. The efficiency of the ESWL was 91.1%. The indicators of the ESWL in the comparison groups differed statistically significantly: in the second group, the efficiency was higher due to more stone fragmentation, with lower energy costs (the average number of sessions was 0.4 less). CONCLUSION: The presented technique can be of help for a practicing urologist to choose the optimal treatment method for each patient, thereby minimizing the risk of early postoperative complications.

Paediatric stone management: innovations and standards.

PURPOSE OF REVIEW: The aim of this study was to discuss current trends and recent developments in the surgical management of paediatric urolithiasis. RECENT FINDINGS: Medical expulsive therapy (MET) is considered as an option for the treatment of children with ureter stones. Extracorporeal shockwave lithotripsy (SWL) remains as a first option for majority of kidney stones and upper ureter stones. Advances in endourology have led to increased adoption of retrograde intrarenal surgeries (RIRS) and percutaneous nephrolithotomy (PCNL/mini-PCNL/ultra-mini-PCNL/micro-PCNL). SUMMARY: Management of paediatric stone disease has developed significantly in the past decade. However, the evidence in the literature remains disproportional to these advances. Well designed multicentric studies are still needed to compare effectiveness and safety of these procedures.

Tratamiento médico expulsivo de la litiasis ureteral / Medical expulsive treatment for ureteral stones

INTRODUCCIÓN: El Tratamiento Médico Expulsivo (TME) para litiasis ureterales ha sido puesto en cuestión durante los últimos años. OBJETIVOS: El objetivo principal de nuestro trabajo es definir las indicaciones del TME, los fármacos empleados y su efectividad y proponer un esquema de seguimiento. Los objetivos secundarios son analizar la efectividad del TME en algunos subgrupos especiales de la población como son las embarazadas y los niños y valorar aspectos de coste-efectividad del TME en comparación con otras opciones de tratamiento de litiasis ureterales (ureterorrenoscopia o litotricia extracorpórea por ondas de choque). MATERIAL Y MÉTODOS: Hemos realizado una revisión de los ensayos clínicos y metaanálisis de mayor relevancia que valoran la efectividad de los diferentes fármacos disponibles para el TME. Para la búsqueda bibliográfica hemos utilizado algunos términos como medical expulsive treatment/therapy", "ureteral lithiasis", "urolithiasis", "effectiveness", "alpha-blockers" y "calcium-antagonists", siendo la principal base de datos consultada MEDLINE (a través del portal web PubMed). RESULTADOS: Aún los estudios de mayor calidad presentan importantes limitaciones metodológicas, lo que condiciona que la evidencia obtenida sea heterogénea y restringida a pacientes y litiasis que cumplan determinadas condiciones. En líneas generales, el TME puede tener cierto papel en la expulsión de litiasis de tamaño ≥ 5 mm y ≤ 10 mm localizadas en uréter distal, aunque no se ha logrado demostrar que alguno de los fármacos utilizados pueda tener especial superioridad en términos de efectividad. En gestantes y niños las indicaciones del TME tampoco estan estandarizadas. Por último, el TME en comparación con opciones de tratamiento, parece ser una alternativa más coste-efectiva y la preferida por los pacientes según estudios sobre QoL. CONCLUSIONES: Es necesario realizar ensayos clínicos de mayor calidad para poder indicar el TME con un mayor nivel de evidencia. Con la evidencia actual, parece que el TME puede favorecer la expulsión de litiasis localizadas en uréter distal y con un tamaño ≥ 5 mm y ≤ 10 mm. A pesar de ello no se han podido encontrar diferencias entre las distintas opciones farmacológicas disponibles

INTRODUCTION: Medical Expulsive Treatment (MET) for ureteral stones has been questioned for the last few years. OBJECTIVES: The main goal of our study is to define the indications of MET, the different drugs that are used and their effectiveness and to propose a follow-up strategy. Secondary objectives include the effectiveness of MET in some special subgroups such as pregnant women and children and to assess aspects of MET cost-effectiveness compared with other options for ureteral lithiasis treatment (ureterorenoscopy or extracorporeal shock wave lithotripsy). MATERIAL AND METHODS: We have reviewed the most relevant clinical trials and meta-analysis evaluating the impact of the different drugs available for MET. For the research we used some keywords like "medical expulsive treatment/therapy", "ureteral lithiasis", "urolithiasis", "effectiveness", "alpha-blockers" and "calcium-antagonists". MEDLINE database was used for the research (using the portal web Pubmed). RESULTS: Highest quality studies currently available show significant methodological limitations leading to heterogeneous and restricted evidence, which is only applicable to patients and lithiasis with specific conditions. Nevertheless, in general terms, it seems that MET can play a certain role in the expulsion of lithiasis ≥ 5 mm y ≤ 10 mm located in the distal ureter, although it has not been possible to demonstrate that any of the drugs used may have special superiority in terms of effectiveness. In pregnancy and children, the recommendations of MET are also irregular. Finally, MET seems to be an alternative cost-effective compared to active options of treatment. CONCLUSIONS: Higher quality clinical trials are needed to reliably advice MET. With the current evidence, it appears that MET can improve the expulsion of distal ureteral lithiasis ≥ 5 mm and ≤ 10 mm, even though we have not found differences between the drugs that are available for MET

Sex differences in the therapy of kidney and ureteral stones.

PURPOSE OF REVIEW: Better understanding of sex differences affecting urolithiasis may help us offer tailored treatment strategies to our patients. RECENT FINDINGS: The incidence of urolithiasis is increasing and the male-to-female ratio has decreased from 3 : 1 to 1.3 : 1 between 1970 and 2000. In women, obesity has a larger effect on the risk of developing urolithiasis [odds ratio (OR) 1.35; 95% confidence interval (CI): 1.33-1.37] compared with men (OR 1.04; 95% CI: 1.02-1.06). Urolithiasis is a risk factor for coronary artery disease in men (risk ratio = 1.23; 95% CI: 1.02-1.49) and for stroke in women (risk ratio = 1.12; 95% CI: 1.03-1.21). Women tolerate cystoscopic stent removal and shock wave lithotripsy better than men. For shock wave lithotripsy menopaused women have reported lower visual analog scale scores than menstruating women (P < 0.001). Female sex was an independent predictor of stone impaction (OR 1.15; 95% CI: 1.03-1.27) and postoperative sepsis after ureteroscopy (OR 2.31; 95% CI: 1.14-4.37). SUMMARY: The sex gap in urolithiasis is closing. The changing role of women in society and dietary habits can be responsible for this epidemiologic shift. Women show a higher threshold for pain during urologic procedures, but they suffer from infectious complications more than men. Urolithiasis is a risk factor for cardiovascular events in both sexes.

Limited sensitivity and size over measurements of ultrasound affect medical decisions for ureteral stone compared to non-contrasted computed tomography.

PURPOSE: To evaluate the limited sensitivity and size over measurements of ultrasound (US) for ureteral stone, and demonstrate how this influenced medical decisions. PATIENTS AND METHODS: Retrospectively, we analyzed the data of patients with ureterolithiasis estimated by US and non-contrasted computed tomography (NCCT) within 48 h at our institution from January 1st 2014 to June 1st 2017. Stone size was grouped by the longest axis diameter on NCCT: < 5, 5-10, and > 10 mm. Then, US and NCCT results were compared for the sensitivity and measurements. RESULTS: A total of 614 cases of ureterolithiasis were visible on NCCT. The sensitivity of US for ureterolithiasis < 5, 5-10, and > 10 mm were 63.49, 79.06, and 84.67%, respectively (P = 0.001). US overestimated the size in 63.49 and 50.54% of patients with ureterolithiasis < 5 and 5-10 mm compared to NCCT, respectively (P < 0.001). Under the assumptions that patients with ureteral stone < 5, 5-10, and > 10 mm would be simply observed, received medical expulsive therapy (MET), and surgical interventions, 20.94 and 15.33% of patients with stone sized 5-10 and > 10 mm might be improperly observed due to negative US reports. Besides, 63.49 and 50.54% of cases with stone < 5 and 5-10 mm might receive more aggressive interventions ascribed to over measurements of US. CONCLUSIONS: Limited sensitivity and size over measurements of US might significantly influence medical decisions for ureteral stone. Inaccurate evaluation of US should be taken in consideration for appropriate counseling options.

CONTACT ULTRASOUND LITHOTRIPSY DURING URETEROLITHIASIS THERAPY. AN ANALYSIS OF LATE POSTOPERATIVE COMPLICATIONS.

Nowadays, ureteroscopy is highly effective and minimally invasive therapeutic and diagnostic method which is not connected with the risk of complications and with correlation of intracorporal lithotripsy and it is optimal at ureterolithiasis. The aim of the research is to analyze the causes and the character of late postoperative complications which occur in patients with ureterolithiasis after ureterorenoscopy and contact lithotripsy using ultrasound lithitriptor. After ureterorenoscopy with contact lithotripsy or lithoextraction from 1372 patients in 96 (6,9%) cases further postoperative complications were detected: in 81 (84,4%) vesicoureteral reflux was detected, and in 15 (15,6%) - ureteric stricture. It was proved by us that when localization of the stones in the upper and the middle thirds, the probability of the development of late postoperative complications does not depend on the size of the stones, with the localization of the stones in the lower sections of the ureter, complications are found much more often with stones sizes of 1,0 cm and more. Analyzing the density characteristics of stones, it should be noted that, regardless of the location of the stone, the possibility of the development of late postoperative complications increases with a stones density of 1000 HU and more.

Medical and surgical interventions for the treatment of urinary stones in children.

BACKGROUND: Urolithiasis is a condition where crystalline mineral deposits (stones) form within the urinary tract. Urinary stones can be located in any part of the urinary tract. Affected children may present with abdominal pain, blood in the urine or signs of infection. Radiological evaluation is used to confirm the diagnosis, to assess the size of the stone, its location, and the degree of possible urinary obstruction. OBJECTIVES: To assess the effects of different medical and surgical interventions in the treatment of urinary tract stones of the kidney or ureter in children. SEARCH METHODS: We searched the Cochrane Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid) as well as the World Health Organization International Clinical Trials Registry Platform Search Portal and ClinicalTrials.gov. We searched reference lists of retrieved articles and conducted an electronic search for conference abstracts for the years 2012 to 2017. The date of the last search of all electronic databases was 31 December 2017 and we applied no language restrictions. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) and quasi-RCTs looking at interventions for upper urinary tract stones in children. These included shock wave lithotripsy, percutaneous nephrolithotripsy, ureterorenoscopy, open surgery and medical expulsion therapy for upper urinary tract stones in children aged 0 to 18 years. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures according to Cochrane guidance. Two review authors independently searched and assessed studies for eligibility and conducted data extraction. 'Risk of bias' assessments were completed by three review authors independently. We used Review Manager 5 for data synthesis and analysis. We used the GRADE approach to assess the quality of evidence. MAIN RESULTS: We included 14 studies with a total of 978 randomised participants in our review, informing eight comparisons. The studies contributing to most comparisons were at high or unclear risk of bias for most domains.Shock wave lithotripsy versus dissolution therapy for intrarenal stones: based on one study (87 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on stone-free rate (SFR), serious adverse events or complications of treatment and secondary procedures for residual fragments.Slow shock wave lithotripsy versus rapid shock wave lithotripsy for renal stones: based on one study (60 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures for residual fragments.Shock wave lithotripsy versus ureteroscopy with holmium laser or pneumatic lithotripsy for renal and distal ureteric stones: based on three studies (153 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Shock wave lithotripsy versus mini-percutaneous nephrolithotripsy for renal stones: based on one study (212 participants), SWL likely has a lower SFR (RR 0.88, 95% CI 0.80 to 0.97; moderate quality evidence); this corresponds to 113 fewer stone-free patients per 1000 (189 fewer to 28 fewer). SWL may reduce severe adverse events (RR 0.13, 95% CI 0.02 to 0.98; low quality evidence); this corresponds to 66 fewer serious adverse events or complications per 1000 (74 fewer to 2 fewer). Rates of secondary procedures may be higher (RR 2.50, 95% CI 1.01 to 6.20; low-quality evidence); this corresponds to 85 more secondary procedures per 1000 (1 more to 294 more).Percutaneous nephrolithotripsy versus tubeless percutaneous nephrolithotripsy for renal stones: based on one study (23 participants) and consistently very low quality evidence, we are uncertain about the effects of SWL on SFR, serious adverse events or complications of treatment and secondary procedures.Percutaneous nephrolithotripsy versus tubeless mini-percutaneous nephrolithotripsy for renal stones: based on one study (70 participants), SFR are likely similar (RR 1.03, 95% CI 0.93 to 1.14; moderate-quality evidence); this corresponds to 28 more per 1,000 (66 fewer to 132 more). We did not find any data relating to serious adverse events. Based on very low quality evidence we are uncertain about secondary procedures.Alpha-blockers versus placebo with or without analgesics for distal ureteric stones: based on six studies (335 participants), alpha-blockers may increase SFR (RR 1.34, 95% CI 1.16 to 1.54; low quality evidence); this corresponds to 199 more stone-free patients per 1000 (94 more to 317 more). Based on very low quality evidence we are uncertain about serious adverse events or complications and secondary procedures. AUTHORS' CONCLUSIONS: Based on mostly very low-quality evidence for most comparisons and outcomes, we are uncertain about the effect of nearly all medical and surgical interventions to treat stone disease in children.Common reasons why we downgraded our assessments of the quality of evidence were: study limitations (risk of bias), indirectness, and imprecision. These issues make it difficult to draw clinical inferences. It is important that affected individuals, clinicians, and policy-makers are aware of these limitations of the evidence. There is a critical need for better quality trials assessing patient-important outcomes in children with stone disease to inform future guidelines on the management of this condition.

[Biomarkers of renal injury in contact ureteral lithotripsy].

AIM: To optimize the transurethral endoscopic management of patients with ureterolithiasis by measuring biomarkers of renal parenchymal damage. MATERIALS AND METHODS: One hundred fifty-one patients with solitary ureteral stones were tested for levels of cystatin C, neutrophil gelatinase-associated lipocalin, 2-microglobulin and interleukin 18. RESULTS: An increase in the levels of markers of renal injury was observed both in the preoperative period and after CULT. Differences in the values of these indices depended on the timing of the CULT, the size and location of the stone and the type of lithotripter. CONCLUSIONS: All patients were found to have damage to the renal tubular system. The established critical values of the markers of renal injury in ureterolithiasis may be used as diagnostic criteria for renal injury.

Influence of acetylsalicylic acid and low-molecular weight heparins on the formation of renal hematoma after shock wave lithotripsy.

PURPOSE: To investigate the risk of renal hematoma (RHT) after shock wave lithotripsy (SWL) among patients on acetylsalicylic acid (ASA) or low-molecular-weight heparin (LMWH). PATIENTS AND METHODS: Retrospective analysis of 434 patients treated with SWL for nephrolithiasis and ureterolithiasis of the proximal ureter. Primary endpoint was detection of RHT by ultrasound the day after SWL. Secondary outcome variables included transfusion of erythrocyte concentrate(s), interventions, hospital readmission or death due to RHT within 30 days of SWL. Binary logistic regression analysis was used including a post hoc one-way analysis. RESULTS: Of 434 patients, 33 (7.6%) and 67 (15.4%) patients were medicated with ASA and LMWH, respectively. RHT was detected in 20 of 434 (4.6%) patients. Of those, 3 (20%) were on ASA, 6 (35%) were on LMWH, 1 (5%) was on ASA and LMWH, and 10 (50%) had no anticoagulation. Univariate analysis showed a statistically significant higher risk for RHT among patients on ASA (p = 0.04) and LWMH (p = 0.02) with an untreated urinary tract infection (UTI) (p = 0.008) and history of cardiovascular disease (p = 0.028). On multivariate analysis, ASA medication, untreated UTI (OR 4.4, 95% CI 1.31-14.75, p = 0.016 and OR 5.79, 95% CI 1.65-20.32, p = 0.03) and a therapeutic dose of LMWH (OR 10.4, 95% CI 1.74-62.27, p = 0.01) were independent predictors for RHT. CONCLUSIONS: Before SWL, a patient risk profile should be evaluated. If feasible, LMWH in therapeutic dosing should be avoided, and ASA should be discontinued. UTI should be treated before SWL in any case. TRIAL REGISTRATION: http://www.clinicaltrials.gov ; Identifier NCT02875717.

Transurethral contact ureterolithotripsy in gas (СО2) medium.

BACKGROUND: Transurethral intracorporeal lithotripsy is the modality of choice for the endoscopic disintegration of large, long-standing, radiolucent or high-density stones. Despite several advantages and proven benefits of contact ureterolithotripsy/ureterolithoextraction (CULT), the application of irrigation carries significant risks of untoward perioperative events including retrograde stone migration and postoperative pyelonephritis. METHODS: We describe a new technique - endoscopic intracorporeal lithotripsy in the gas (СО2) medium. It is a prospective randomized, single blinded pilot study that included total of (n = 60) patients with urolithiasis who were allocated to either experimental or control group. Out of the total pool of patients, 30 underwent treatment with the new approach (experimental group) and other 30 (control group) had contact ureterolithotripsy in a standard of care 0.9% NaCL medium. We included patients >18 years old, with known symptomatic renal calculi disease who were eligible and scheduled for CULT and free from significant coexisting pathologies of urinary tract. RESULTS: No retrograde migration of the stone fragments into the kidney was reported in the experimental group [complications rate 0%, confidence interval (CI): 0-11.6%]. In the control group, complications were observed in eight cases (complications rate 26.7%, CI: 14.7-42.3%); retrograde migration was in five patients (16.6%), and acute pyelonephritis/exacerbation of chronic pyelonephritis was seen in three (10%) patients. There was not any acute pyelonephritis in the experimental group. Reliability of frequency differences - p = 0.0023 (χ2). CONCLUSIONS: The novel method of contact ureterolithotripsy is a safe and promising alternative to the conventional contact ureterolithotripsy in a fluid medium in a carefully selected patient population.

Safety and Efficacy of Pneumatic Lithotripters Versus Holmium Laser on Multiple Ureteral Calculi.

BACKGROUND: Different energy sources can be used for ureteroscopic stone fragmentation, such as pneumatic, ultrasonic, laser or electrohydraulic. The aim of this study was to compare the efficacy and safety of pneumatic lithotripters versus Ho: YAG laser in the treatment of multiple stones in the distal ureter. METHODS: A retrospective evaluation was done using the data of patients to whom ureteroscopic lithotripsy (URL) was applied for ureter stones in our clinic. From these patients, those with multiple unilateral distal ureter stones were identified, then these patients were separated into 2 groups according to the type of lithotriptor used in stone fragmentation as laser lithotripsy (Group 1) and pneumatic lithotripsy (Group 2). RESULTS: Statistically, the two groups were similar in respect of the number of stones, stone burden and the number of double J stents applied intra-operatively. The mean operating time was similar in the 2 groups as 53.47 (±17.3) minutes in Group 1 and 50.59 (±15.3) minutes in Group 2. On postoperative day 1 after the URL, the stone free rate (SFR) of Group 1 (78.7%) was found to be significantly high compared to the SFR of Group 2 (63.6%), while at postoperative month 1, the SFR of both groups was found to be similar. Binary logistic regression was applied to determine the effect of related independent variables on the 1st month SFR. In this model, age and stone burden were affecting variables. CONCLUSION: Compared to the pneumatic lithotripter, the Ho: YAG laser seems to have advantages of a higher SFR in the early postoperative period, eventhough there are statistically similar success rates and complication rates.

Therapeutic possibilities for urolithiasis in childhood. / Posibilidades terapéuticas de las urolitiasis en la infancia.

OBJECTIVES: We present our case studies on paediatric urolithiasis, the techniques employed in its treatment and its results. MATERIAL AND METHODS: A retrospective study of paediatric urolithiasis of the upper urinary tract (UUT) treated at our centre between 2003 and 2014. We recorded demographic, clinical, diagnostic and therapeutic data and the complications. The therapeutic plan was recorded as isolated (extracorporeal lithotripsy, ureterorenoscopy, nephrolithotomy or surgery) or combined therapy. RESULTS: We examined 41 renal/urethral units in 32 patients. The median age was 5 years (range, 11 months-14 years). The mean size was 12.9cm (±7.3mm). The locations were as follows: 23 (56%) in the renal pelvis (staghorn in 15 cases), 10 (24) in lower calyx and 8 (20%) in the urethra. We performed 80 procedures, with no differences in the age groups, which resulted in 12 complications (15%) but no septic condition secondary to lithotripsy. Stone removal from the urethra had a 100% success rate with the ureterorenoscopy. The overall cure rate was 90%. CONCLUSION: The paediatric urolithiasis approach offers multiple alternatives. It is therefore important to tailor the procedure according to the size, location and composition of the stone. In our centre, the use of paediatric extracorporeal shock wave lithotripsy is safer. Ureterorenoscopy, semirigid or flexible, provides excellent results in ureters. Percutaneous nephrolithotomy with minimal access can be performed on small children and nursing infants.

SMS text pre-notification and delivery of reminder e-mails to increase response rates to postal questionnaires in the SUSPEND trial: a factorial design, randomised controlled trial.

BACKGROUND: Patient-reported outcomes are vital in informing randomised controlled trials (RCTs) and health-care interventions and policies from the patient's perspective. However, participant non-response may introduce bias and can affect the generalisability of the trial. This study evaluates two interventions aimed at increasing response rates to postal questionnaires within a large, UK-wide RCT: pre-notification via short messenger service (SMS) text prior to sending the initial mailing of trial questionnaires versus no pre-notification; for non-responders to the initial mailing of the questionnaires, an e-mail reminder (containing a hyperlink to complete the questionnaire online) versus a postal reminder. METHODS: This study is a 2 × 2 partial factorial design RCT nested within an RCT of medical expulsive therapy for ureteric stone disease. Participants who supplied a mobile telephone number were randomly assigned to receive an SMS text pre-notification of questionnaire delivery or no pre-notification. Those who supplied an e-mail address were randomly assigned to receive a questionnaire reminder by e-mail or post. Participants could be randomly assigned to the pre-notification comparison or the reminder comparison or both. The primary outcome measure was response rate at each questionnaire time point. RESULTS: Four hundred eighteen participants were randomly assigned to the SMS pre-notification comparison (80% were male, and the mean age was 41 years with a standard deviation (SD) of 11.1). The intervention had no effect on response rate at either questionnaire time point. In subgroup analyses, SMS pre-notification increased response rates in women but only at the first questionnaire time point. One hundred nineteen participants were randomly assigned to the reminder comparison (80% were male, and the mean age was 42 years with an SD of 12.1). There was no difference in response rate in those who received an e-mail reminder compared with those who received a postal reminder. CONCLUSIONS: SMS text pre-notification of questionnaire delivery and email delivery of questionnaire reminders did not improve response rates. There was some evidence to suggest that SMS text pre-notification may be effective in women, and further studies to investigate this may be warranted. E-mail reminders for participants to return their postal questionnaire could be advantageous given that response rates were similar following either type of reminder and the low cost of delivering an e-mail compared with a postal reminder. This is a substudy of the SUSPEND trial (ISCTRN69423238) (18 Nov. 2010).

Long-term Adverse Effects of Extracorporeal Shock-wave Lithotripsy for Nephrolithiasis and Ureterolithiasis: A Systematic Review.

This study presents a systematic review of the published literature on possible long-term adverse effects after extracorporeal shock wave lithotripsy (ESWL). Although published disagreement exists, this review finds that previous evidence supporting an association between ESWL and long-term adverse effects is weak and that the majority of studies show no evidence for any increase in post-ESWL incidence of arterial hypertension (24 of 30 studies), diabetes mellitus (4 of 6 studies), kidney dysfunction (14 of 14 studies), or infertility (2 of 2 studies). Currently, no strong evidence exists to support the hypothesis that ESWL causes long-term adverse effects.

Staphylococcus saprophyticus bacteremia after ESWL in an immunocompetent woman.

Staphylococcus saprophyticus is a well-known cause of uncomplicated urinary tract infections, especially in young and sexually active women. Presence in blood cultures is rare and often attributed to contamination. When bacteremia is significant, it occurs mostly in patients with hematologic malignancies and is predominantly catheter-related. However, we describe a case of significant bacteremia with S. saprophyticus associated with urinary tract infection after extracorporeal shock wave lithotripsy of an ureterolithiasis in an otherwise healthy patient.

Extracorporeal shock waves lithotripsy versus retrograde ureteroscopy: is radiation exposure a criterion when we choose which modern treatment to apply for ureteric stones?

The aim of this study is to compare two major urological procedures in terms of patient exposure to radiation. We evaluated 175 patients, that were subjected to retrograde ureteroscopy (URS) and extracorporeal shock waves lithotripsy (ESWL) for lumbar or pelvic ureteral lithiasis, at two urological departments. The C-arm Siemens (produced in 2010 by Siemens AG, Germany) was used for ureteroscopy. The radiological devices of the lithotripters used in this study in the two clinical centers had similar characteristics. We evaluated patient exposure to ionizing radiation by using a relevant parameter, the air kerma-area product (PKA; all values in cGy cm(2)), calculated from the radiation dose values recorded by the fluoroscopy device. PKA depends on technical parameters that change due to anatomical characteristics of each case examined, such as body mass index (BMI), waist circumference, and stone location. For the patients subjected to ESWL for lumbar ureteral lithiasis the mean of PKA (cGy cm(2)) was 509 (SD=180), while for those treated for pelvic ureteral lithiasis the mean of PKA was 342 (SD=201). In the URS group for lumbar ureteral lithiasis, the mean of PKA (cGy cm(2)) was 892 (SD=436), while for patients with pelvic ureteral lithiasis, the mean of PKA was 601 (SD=429). The patients treated by URS had higher exposure to ionizing radiation dose than patients treated by ESWL. The risk factors of higher radiation doses were obesity, exposure time, and localization of the stones.

[Ureteroscopy: is it the best?]. / Ureteroscopia: risolve molto di più?

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in '80s many technological improvements allowed to reduce endourological instruments' size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

Acute pancreatitis due to extracorporeal shock wave lithotripsy: a rare complication.

Extracorporeal shock wave lithotripsy (ESWL) is considered the treatment of choice for most renal and upper ureteral stones. Although extensive data have documented its safety, serious complications have been reported in 1% of patients, including acute pancreatitis, perirenal hematoma, urosepsis, venous thrombosis, biliary obstruction, bowel perforation, lung injury, and rupture of aortic aneurysms. Here, we report a 41-year-old woman who underwent ESWL for a calculus at the right renal pelvis and immediately developed acute pancreatitis after the procedure. Although the possibility of post-ESWL acute pancreatitisis extremely low, physicians must be aware of this complication in emergency departments.