Percutaneous nephrolithotomy in the pediatric population.

PURPOSE: Percutaneous nephrolithotomy is an established technique used in children with renal calculi. We review our experience with percutaneous nephrolithotomy for treating nephrolithiasis in childhood. MATERIALS AND METHODS: We retrospectively reviewed the records of children who underwent percutaneous nephrolithotomy procedures for renal calculi from 1985 to 1996. Antegrade percutaneous access was obtained in all patients and the tract was dilated to 24F. Grasper forceps, ultrasound and/or electrohydraulic lithotripsy was used to remove and disintegrate stones. In all patients a nephrostomy tube was placed intraoperatively, and a plain abdominal x-ray and nephrostogram were done postoperatively. The nephrostomy tube was removed after ensuring free drainage down the ureter and no untoward effects from clamping. Complete anatomical and metabolic evaluation was performed in all cases. Patients were followed 2 to 6 weeks, and 3 and 6 months postoperatively with a plain abdominal x-ray and excretory urography or renal ultrasound. RESULTS: In 5 boys and 3 girls (9 renal units) 4 to 11 years old (mean age 6.4) a total of 10 percutaneous nephrolithotomy procedures were performed. At presentation 6 children had flank and/or abdominal pain, 5 gross hematuria and 3 urinary tract infection. Three patients had associated metabolic abnormalities. One patient with a staghorn calculus had hydronephrosis and multiple infundibular stenoses. No underlying urological anatomical abnormalities were noted in the remaining cases. Four renal units that were obstructed at presentation required initial nephrostomy tube insertion. Average operative time was 131.8 minutes (range 58 to 240). An 87.5% stone-free rate was achieved using percutaneous nephrolithotomy monotherapy. Percutaneous nephrolithotomy was not successful for eradicating a staghorn stone in 1 patient. Hypothermia developed in 2 patients in whom operative time exceeded 150 minutes. No blood transfusions were required. CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective in children, and should be considered a viable management option. However, staghorn calculi may require alternative management, particularly in the setting of underlying anatomical abnormalities. Children with renal calculi should undergo a complete anatomical and metabolic assessment with the institution of medical therapy, as appropriate.

Percutaneous stone removal in horseshoe kidneys.

PURPOSE: We review our experience with percutaneous nephrolithotomy for stones in horseshoe kidneys when extracorporeal shock wave lithotripsy was unsuccessful or inappropriate because of stone burden. MATERIALS AND METHODS: Stone burden, nephrostomy and percutaneous surgical techniques, and clinical outcome of 12 consecutive patients undergoing percutaneous nephrolithotomy for calculi in horseshoe kidneys between 1988 and 1997 were reviewed. RESULTS: Complete stone removal was achieved by percutaneous methods alone in 9 patients (75%). More than 1 nephrostomy tract was required in 5 patients and additional intraoperative nephrostomies were necessary in 4. Flexible nephroscopy was essential in achieving complete stone removal in 9 of 11 patients (82%). Second look procedures for stone removal were required in 3 patients. No sepsis occurred and no transfusions were needed. CONCLUSIONS: Percutaneous nephrolithotomy is a safe and effective method of stone removal in patients with calculi in horseshoe kidneys. Multiple nephrostomy tracts, the use of flexible nephroscopy and second look procedures may be necessary to achieve optimum stone removal.

Is stenting following ureteroscopy for removal of distal ureteral calculi necessary?

PURPOSE: We determine the morbidity associated with no stent placement following uncomplicated ureteroscopy for removal of distal ureteral calculi. MATERIALS AND METHODS: A total of 93 patients undergoing uncomplicated, complete removal of distal ureteral calculi were contacted 1 to 3 days and 7 to 10 days postoperatively to determine analgesic requirements and time of return to normal activity. Radiological followup consisted of an excretory urogram or renal ultrasound 8 weeks postoperatively. RESULTS: Of 93 patients 40 (43%) had no discomfort postoperatively. Of the 53 patients who had discomfort 45 (85%) had mild discomfort only, controlled with oral analgesics. When discomfort occurred it resolved in 41 patients (77%) in 2 days or less. Of 12 patients who required intravenous narcotics postoperatively 5 required preoperative hospitalization for the narcotics and were still hospitalized at the time of stone removal. None of the 59 patients who had followup excretory urogram or renal ultrasound has had a newly identified ureteral stricture to date. CONCLUSIONS: In the majority of patients undergoing uncomplicated ureteroscopy for removal of distal ureteral calculi postoperative discomfort is modest, lasts less than 2 days and is easily controlled with oral analgesics. Stricture formation has not been identified. We do not believe that routine placement of a ureteral stent following uncomplicated ureteroscopy for distal ureteral calculi is necessary.

Ureteroscopy with intravenous sedation for treatment of distal ureteral calculi: a safe and effective alternative to shock wave lithotripsy.

PURPOSE: We evaluated the safety, efficacy and patient tolerance of ureteroscopy with intravenous sedation for treatment of distal ureteral calculi. MATERIALS AND METHODS: Ureteroscopy with intravenous sedation was performed in 68 patients, with small distal ureteral calculi requiring treatment and in 2 with middle or upper third ureteral calculi. Intravenous sedation and analgesia were achieved with a combination of fentanyl and midazolam. Balloon dilation of the ureter was performed in 38 patients. Ureteroscopy was performed with a 6F rigid ureteroscope. RESULTS: Stone removal was successful in 66 patients (97%). There were no ureteral perforations in patients undergoing successful stone removal and no complications related to intravenous sedation. Tolerance of the procedure was good in 81% of the patients (including 72% of 36 men and 94% of 32 women undergoing ureteroscopy for distal ureteral calculi) and fair in 19%. CONCLUSIONS: In select patients with small distal ureteral calculi ureteroscopy offers a safe, effective and well tolerated alternative to shock wave lithotripsy.

Intracorporeal phenylephrine in the treatment of priapism.

PURPOSE: The effectiveness and complications of intracorporeal phenylephrine without aspiration or irrigation as a treatment for priapism were assessed. MATERIALS AND METHODS: Nine consecutive patients who presented with priapism were treated with 0.5 mg. phenylephrine diluted in 2 cc normal saline injected directly into the corpus cavernosum. Blood pressure and pulse were measured before and after injection, and monitored every 15 minutes. If no detumescence was noted after 15 minutes the injection was repeated. Neither penile blood aspiration nor irrigation was performed. RESULTS: Of 9 patients 8 responded with detumescence. The number of injections required ranged from 1 to 6. No changes in blood pressure, heart rate or side effects were observed. CONCLUSIONS: We believe that this is a safe and effective method for treatment of priapism. Routine initial aspiration or irrigation of the corpora before intracorporeal injection of alpha-adrenergic agents does not appear to be necessary.

Fournier's gangrene: nine cases of necrotizing infection of the male genitalia.

Between 1989 and 1993, nine patients with Fournier's gangrene presented to our institution. The mean patient age was 66 years. The source of infection was dermal in five cases, urethral in three cases and rectal in one case. Potential contributing factors included diabetes mellitus in six cases, alcohol abuse in four cases and drug-induces immunosuppression in two cases. In every patient, tissue cultures revealed mixed aerobic and anaerobic infections. All patients were treated initially with aggressive surgical debridement and culture-specific intravenous antibiotics. One patient required multiple debridements. Reconstruction by split-thickness skin grafts was performed in eight cases and one healed by secondary intention. There were no deaths due to progressive infection. The mortality rate was 11% with six month follow-up. The favorable outcome of patients in this series supports the current recommendation for early, aggressive surgical debridement and culture-specific, intravenous antibiotic therapy.

Asymptomatic microscopic hematuria.

The detection of microscopic hematuria on routine urinalysis in a patient with no urological symptoms presents the urologist with a management dilemma. Many authors1-6 have recommended intravenous pyelography (IVP) or renal ultrasound, and cystourethroscopy as the minimum investigation in all patients with this finding. While recognizing that microscopic hematuria may represent an early sign of a life threatening but curable urological cancer, urologists are also aware that a full urological investigation in most of these patients will not detect a life-threatening lesion. Under these circumstances, it is understandable that the urologist may be reluctant to subject every patient asymptomatic microscopic hematuria to an IVP and cystourethroscopy. Factors that may influence the urologist include the recognition that a certain number of erythrocytes (RBCs) in the urine may be accepted as within normal limits, and associated elements in the urine such as protein, or red cell or granular casts suggest a glomerular as opposed to a urological cause for the hematuria. The purpose of this review is to clarify our understanding of the normal limits of microscopic hematuria, to review recently introduced techiniques that may be helpful in determining that the hematuria is of glomerular origin, and to examine the data on which recommendations for patients investigation is advisable, it is necessary to address the question of which investigation are most appropriate, and whether under any circumstances, any investigations can be safely omitted.

The excretory urogram bowel preparation--is it necessary?

A prospective randomized study was undertaken to determine whether prior bowel preparation improves the diagnostic quality of the excretory urogram. From August 1986 to May 1987, 107 outpatients having an excretory urogram on an elective basis were randomized into 3 groups: group 1 received castor oil, group 2 received x-ray preparation and group 3 received clear fluids 24 hours before the study. The quality of the bowel preparation and the excretory urogram was graded separately on a scale of 1 to 5. More than 71 per cent of the bowel preparations were graded as 4 (very good) or 5 (excellent) and more than 91 per cent of the films were graded as 4 or 5 in all 3 groups. The quality of the excretory urogram was graded as 5/5 in a greater number of group 3 cases. Patients reported a high incidence of side effects from both bowel preparations, while no adverse effects were reported from those in group 3. The administration of a bowel preparation compared to that of clear fluids alone made no difference to either the quality of the bowel preparation or the diagnostic quality of the film.

Haematuria following a marathon run: source and significance.

Urine specimens were obtained from 98 runners before and immediately after running a half (21 km) or full (42 km) marathon. Specimens were examined for the presence of proteinuria, haematuria and whether the erythrocytes were normomorphic or dysmorphic as determined by phase contrast microscopy. Proteinuria occurred in 35% of those running the half and 69% running the full marathon. Haematuria with or without proteinuria occurred in 21% running the half and 22% running the full marathon. In runners with haematuria, dysmorphic erythrocytes were found in 30% of the half and 81% of the full marathon group. No urinary abnormalities were found on repeat examination 4 to 12 weeks after the run. These results suggest that non-glomerular bleeding, possibly from bladder contusions, predominates at shorter distances. With greater distances glomerular bleeding occurs. These abnormalities disappear with rest and do not appear to signify underlying urinary tract disease.

Rigid transurethral ureteroscopy.

Since March 1984 we have performed ureteroscopy in 58 patients. The indications were ureteric calculi in 49 cases and dilatation of ureteric strictures, evaluation of unexplained haematuria, evaluation of ureteric filling defects and the insertion of ureteric stents in the remainder. Stone removal was successful in 33 patients (67%). We have found rigid ureteroscopy to be a time-consuming procedure with a high risk of minor injury, but long-term complications are uncommon and we believe that rigid ureteroscopy should be the procedure of choice for the management of calculi in the lower and middle thirds of the ureter.

Retrograde nephrostomy: experience with 2 techniques.

An attempt was made to establish a percutaneous nephrostomy in 47 consecutive patients using retrograde techniques. In all patients the Lawson nephrostomy system was used first. A steerable guide wire is used to position a polytetrafluoroethylene (Teflon) catheter in a suitable calix. A penetrating wire then is passed through the catheter and advanced to the skin. The catheter then is advanced over the wire to the abdominal wall and locked to the wire. Traction on the wire advances the catheter to the skin to establish the nephrostomy tract. If the Lawson system could not be used successfully, the Hunter-Hawkins nephrostomy system was used. Of the patients studied 3 required bilateral nephrostomy and 1 required 2 nephrostomies in the same kidney, for a total of 51 attempted procedures. Of the 51 attempts 49 (96 per cent) were successful. Nephrostomy was done for stone removal in 46 cases and was successful. The Lawson system was used successfully in 43 of the 49 successful nephrostomies (88 per cent). The Hunter-Hawkins system was successful in the remaining 6 patients. The mean duration of the nephrostomy procedure was 45.9 minutes and the mean fluoroscopy time was 2.7 minutes. No patient suffered any complication related to the nephrostomy insertion. Retrograde nephrostomy is a quick, safe procedure that requires little radiation and is well suited to the undilated collecting system.

Urinary citrate excretion in normal persons and patients with idiopathic calcium urolithiasis.

The 24-hour urinary excretion of citrate was measured in 83 normal persons and in 132 consecutive patients with idiopathic calcium urolithiasis, uninfected urine, and normal renal function. The urinary excretion of citrate in normal men was not significantly different from that in normal women (P greater than 0.05). There was a significant (P less than 0.001) increase of urinary citrate excretion with increasing age in normal persons. No increase of urinary citrate excretion with age was demonstrated in stone formers. There was no statistically significant difference between active and inactive stone formers in regard to regression of the citrate/calcium ratio or the citrate/uric acid ratio, and there was no difference in these ratios between men and women considered separately or in subgroups by hypercalciuria or hyperuricuria or by individual age. Hypocitraturia was found in 29.2% of patients with idiopathic calcium urolithiasis. No relationship could be demonstrated between the 24-hour urinary excretion of citrate and severity of stone disease before presentation at our clinic or the frequency of stone growth or new stone formation at follow-up. Twenty-two of 35 patients with hypocitraturia had multiple urinary citrate measurements. In 15 of these 22 patients, at least one normal urinary citrate measurement was obtained. Further prospective study is required to establish the value of urinary citrate determinations in patients consuming an uncontrolled diet in an outpatient setting.

Percutaneous removal of upper urinary tract calculi: experience with ultrasonic lithotripsy.

From October 1983 to March 1985, the authors removed upper urinary tract calculi percutaneously in 102 patients. In 89 patients, stones required disruption with an ultrasonic lithotriptor before removal. Fifty-two patients had a stone in the renal pelvis and 20 had calyceal stones only; 21 had stones at both sites and 9 had a stone in the upper ureter. Complete removal of all stone material was achieved in 67 of 68 patients with a solitary calculus, in 13 of 26 with multiple calculi and in 6 of 8 with ureteric calculi. Complications were minimal; three patients had pulmonary edema postoperatively as a result of excessive absorption of irrigating fluid, and one patient sustained a perforation of the descending colon. The mean postoperative hospital stay was 6.8 days and patients were able to return to work a few days after their discharge from hospital. Percutaneous stone removal is a safe and effective procedure and is the surgical procedure of choice for the removal of upper urinary tract calculi.

The stone clinic effect in patients with idiopathic calcium urolithiasis.

The "stone clinic effect" refers to the effect of encouraging a high intake of fluid and avoiding dietary excesses on stone formation and growth in patients with urolithiasis. To determine the extent of this effect we reviewed the clinical courses of 108 patients with idiopathic calcium urolithiasis and indeterminant metabolic activity. There was no evidence of stone growth or new stone formation (metabolic inactivity) after a mean followup of 62.6 months in 63 of the 108 patients (58.3 per cent), including 12 of 17 (70.6 per cent) with hypercalciuria and 7 of 15 (46.7 per cent) with hyperuricosuria. Comparison of initial and followup 24-hour urine volumes demonstrated a significant increase in patients who were metabolically inactive at followup (p less than 0.0005), while no increase was detected in patients who were metabolically active at followup. We recommend that specific drug therapy should not be given to patients with idiopathic calcium urolithiasis until the stone clinic effect has been evaluated.

The cytological diagnosis of prostatic carcinoma by transrectal fine needle aspiration.

During a 2-year period a prospective study was conducted, comparing the accuracy of transrectal fine needle aspiration with that of transperineal needle biopsy in the diagnosis of prostatic carcinoma. With increasing experience the accuracy of aspiration was found to be at least equal to that of biopsy. Blood cultures 1 hour postoperatively in 1 group and 5 minutes postoperatively in another revealed a low incidence of bacteremia. Our findings suggest that prostatic aspiration should be used more widely as the initial diagnostic procedure for suspected prostatic cancer.

Primary carcinoid of the testis with metastases.

A case of pure carcinoid of the testis is reported. The patient presented with metastatic carcinoid and the carcinoid syndrome 17 years after removal of the primary tumor. He died 2 years later. The long interval from initial orchiectomy to presentation with metastases strongly suggests that the original lesion was primary rather than metastatic. Only 2 cases have been reported to date in which an apparently pure primary testicular carcinoid developed metastases. In both of these cases the possibility that the testicular lesion itself was metastatic was not excluded.