Shock Wave Lithotripsy in Pediatric Stone Disease: A 15-Year Single-Center Experience with 2 Types of Lithotripters.

INTRODUCTION AND OBJECTIVES: We report our experience with pediatric shock wave lithotripsy (SWL) using two types of lithotripters: Dornier HM3 (HM3) and Dornier Lithotripter SII (DLS). STUDY DESIGN: We retrospectively reviewed the charts of children who underwent SWL between 2002 and 2016. Patients were divided into two groups based on the type of the lithotripter: during 2002-2009, we used the electrohydraulic HM3 lithotripter which was replaced in 2009 with the DLS electromagnetic lithotripter. Clinical and perioperative parameters were compared. RESULTS: Our cohort included 107 children who underwent SWL. Average age was 11.5 ± 5.1 years. Average stone size was 10.6 ± 4.9 mm. HM3 was used in 38% of children and DLS2 in 62% (n = 41 and 66, respectively). There were no significant differences in age, gender, stone size, or location between the groups. The total SFR did not differ statistically between HM3 and DLS (83% vs. 74%, p = 0.35). SFR after one SWL was higher with the HM3 (78% vs. 62%, p = 0.093). Re-treatment rate was 22% and 17% (HM3 vs. DLS, p = 0.61). Complication rates were low, with renal colic being the most common (HM3 10%, DLS 20%, NS). CONCLUSIONS: SWL in the pediatric population using the DLS showed good results with low complication rates that are equivalent to the gold standard HM3.

Laparoscopic Nephrectomy: Initial Case Report.

A tumor-bearing right kidney was completely excised from an 85-year-old woman using a laparoscopic approach. A newly devised method for intra-abdominal organ entrapment and a recently developed laparoscopic tissue morcellator made it possible to deliver the 190 gm. kidney through an 11 mm. incision.

Differences in renal stone treatment and outcomes for patients treated either with or without the support of a ureteral access sheath: The Clinical Research Office of the Endourological Society Ureteroscopy Global Study.

PURPOSE: To describe the differences in the treatment and the outcomes of renal stones treated with flexible ureteroscopy (URS) either with or without the support of a ureteral access sheath (UAS). METHODS: The Clinical Research Office of the Endourological Society URS Global Study involved the collection of prospective data from consecutive patients treated with URS at centers around the world over a 1-year period. Baseline characteristics, stone location, treatment details, postoperative outcomes and complications were recorded. Inverse-probability-weighted regression adjustment (IPWRA) analyses were conducted on outcome from patients treated with or without the use of a UAS to determine the impact on stone-free rates (SFRs). RESULTS: Of 2239 patients treated with flexible URS, 1494 (67 %) patients were treated with the use of a UAS and 745 (33 %) without a UAS. The IPWRA analyses conducted on 1827 patients with complete data and based on treatment and outcome models showed that if URS procedures were performed without the use of an UAS, the average stone-free rate would be 0.504 compared with 0.753 with a UAS. This average treatment effect of 0.248 was not significant (P = 0.604). Using IPWRA analysis on only the treated population in the estimations revealed no significant difference between using and not using a UAS (31 %; ATET: 0.311; P = 0.523). CONCLUSIONS: The study showed no difference in SFR when a UAS was used or not. Whereas UAS did not increase the risk of ureteral damage or bleeding, postoperative infectious complications were reduced.

Obstructive uropathy caused by retroperitoneal fibrosis presents as a late manifestation of sarcoidosis.

Obstructive uropathy in sarcoidosis can result from retroperitoneal involvement, retroperitoneal fibrosis (RPF), renal stones, or ureteral involvement. We report acute kidney injury (AKI) from obstructive uropathy because of RPF in a female patient, 2 years following the resolution of pulmonary sarcoidosis. We propose that RPF may occur in sarcoidosis even when a lag of years separates the presentations of the illnesses.

What happened to shockwave lithotripsy during the past 22 years? A single-center experience.

INTRODUCTION: From 1985 to August 2007 we have performed 15,324 shockwave lithotripsy (SWL) treatments using the Dornier HM3 lithotripter. We studied trends in the characteristics of treatments and patients. PATIENTS AND METHODS: Patient data were recorded in a computerized database. Changes in characteristics of patients and stones treated during this period were reviewed. RESULTS: A total of 15,324 treatments were performed on 10,734 patients. The following trends were observed: (1) Stone size: A significant increase in the proportion of patients treated for stones up to 10 mm in diameter, no change for stone size of 10 to 20 mm, and a decrease in stones larger than 20 mm in diameter. (2) Stone location: A significant increase in the proportion of patients treated for proximal and distal ureteral calculi, whereas a significant decrease in those with renal pelvic and staghorn stones. (3) Auxiliary procedures: A significant increase in the use of perioperative procedures (stents or ureteral catheters) ranging from 20% during the mid-1980s up to 60% in the year 2007. (4) Presenting symptoms: A significant increase in the percentage of patients referred with pain and a significant decrease in the percentage of patients referred with signs of infection. (5) Repeat SWL: A total of 13% of the patients required a second SWL for the same stone within 90 days of the first procedure. (6) Complication rate: This rate was relatively low, ranging from 1% to 6% per year. CONCLUSIONS: The evolvement of endourological procedures and techniques resulted in a decreased referral of large kidney stones for SWL. Advanced diagnostic modalities increased the diagnosis of renal colic in patients presenting with pain, and consequently their referral rate and timing for SWL treatment. The use of stents increased because of referral of patients with obstructing stones and infection or for prevention of posttreatment obstruction.

Fever after shockwave lithotripsy--risk factors and indications for prophylactic antimicrobial treatment.

PURPOSE: To identify risk factors for fever after shockwave lithotripsy (SWL) and suggest guidelines for prophylactic antimicrobial treatment. PATIENTS AND METHODS: Between 1985 and 2007, a total of 15,324 SWL procedures were performed in our institution using the Dornier HM3 lithotripter. Because stone analyses were not available in the majority of patients, management of stones larger than 2 cm in diameter were excluded from this analysis to minimize the ratio of struvite stones as a possible cause for postprocedural fever. In this analysis, 11,500 SWL treatments were included. Clinical parameters before, during, and after treatments were prospectively registered using a computerized database. Potential risk factors for fever after SWL were evaluated. RESULTS: Fever >38.0 degrees C developed in 161 (1.4%) patients. The risk factors for fever after SWL were: A positive urine culture (P < 0.05), an indwelling nephrostomy tube or stent during the procedure (P < 0.001), lithotripsy of kidney or upper ureteral stones (P < 0.05) and preoperative symptomatic urinary tract infection (UTI) (P < 0.05) or sepsis (P < 0.05). Lithotripsy of mid and lower ureteral stones, stone size, and the use of ureteral catheters during the procedures were not associated with increased risk of fever after SWL. CONCLUSIONS: Fever (>38.0 degrees C) develops in only 1.4% of the patients undergoing SWL. Therefore, prophylactic antibiotic treatment is not indicated in all patients. Selective prophylactic treatment is recommended in patients who present with UTI, kidney or upper ureteral stones, and those for whom a nephrostomy tube or stent is necessary.

Urinary excretion of endothelin receptors ET A and ET B in hypertensive patients and normotensive subjects.

BACKGROUND/AIMS: Endothelin (ET)-1 is produced by most renal cell types. Renal tubular and vascular cells express both the ET receptors ET(A) and ET(B). Since significant amounts of ET-1 of renal origin were detected in human urine, urinary ET-1 has been used as an index for the capacity of renal ET-1 production. Here, we determine the existence of additional components of the intrarenal ET system, namely the ET(A) and ET(B) receptor subtypes, in the urine of normal and hypertensive subjects. METHODS: ET(A) and ET(B) receptors were detected in urine samples that were concentrated by TCA precipitation, Speedvac or ProteoSpin. RESULTS: Analysis of the human urine extracts revealed the existence of approximately 50 and 55 kDa of immunoreactive proteins, corresponding to ET(B) and ET(A), respectively, indicating that intact ET(A) and ET(B) are excreted in the urine of healthy subjects and hypertensive patients. Normotensive and hypertensive subjects had statistically comparable ET(B) excretion normalized to creatinine (0.58 +/- 0.16 vs. 0.83 +/- 0.17 microg/mg creatinine, respectively; p = 0.304). In contrast, ET(A) excretion was higher among hypertensive subjects (0.05 +/- 0.01 vs. 0.11 +/- 0.02 microg/mg creatinine; p = 0.0451). Immunostaining of ET(A) and ET(B) in the human urinary system revealed expression of both receptors, principally in tubular cells (mainly in medullary collecting ducts) and in the bladder urothelium, and ET(A) expression in the peritubular capillaries and arterioles. Urinary ET receptors closely and inversely correlated with indices of urine concentration, suggesting that their shedding is principally affected by urine flow. CONCLUSION: ET receptors are present in human urine, conceivably originating within the urinary system. Their excretion is principally affected by urinary concentration. It remains to be determined whether urinary ET(A)/ET(B) is of physiological/pathophysiological relevance.

Extracorporeal shock wave lithotripsy in prepubertal children: 22-year experience at a single institution with a single lithotriptor.

PURPOSE: The sophistication of percutaneous nephrolithotomy and ureteroscopy challenges the efficacy of ESWL for urolithiasis in prepubertal patients. We evaluated our long-term experience with ESWL in these patients and determined its efficiency. MATERIALS AND METHODS: We retrospectively reviewed the charts of all prepubertal patients who underwent ESWL. We evaluated the need for tubing, the 3-month stone-free rate, the need for additional ESWL, and the effect of stone size and location, and cystinuria on the 3-month stone-free rate. RESULTS: Between 1986 and 2008, 119 males and 97 females with a mean age of 6.6 years who had urolithiasis underwent ESWL using the Dornier HM3 lithotriptor. We treated 157 children with renal calculi with an average +/- SD diameter of 14.9 +/- 8.9 mm, of whom 66 (42%) required a tube in the urinary system. The 3-month stone-free rate was 80% and 31 patients (19.7%) needed an additional procedure. Stone location did not affect the stone-free rate but stone size did. We treated 59 patients for ureteral stones with an average stone length of 9.5 +/- 4.8 mm, of whom 41 (69%) required tube insertion. The 3-month stone-free rate was 78% and 13 patients (22%) needed an additional procedure. The 3-month stone-free rate did not depend on stone location or size. The rate was 37.5% in patients with cystinuria and 82.5% in all others (p <0.0001). Six patients (2.8%) had complications. CONCLUSIONS: The 3-month stone-free rate after ESWL in prepubertal patients is 80% and 20% of patients require additional procedures. ESWL is most effective for kidney stones less than 11 mm. ESWL has inferior results for cystine stones compared to other calculi. Complications are rare.

Perioperative morbidity and mortality in 80 years and older undergoing elective urology surgery - a prospective study.

BACKGROUND AND PURPOSE: The number of octogenarians requiring surgery increases constantly. Data regarding perioperative morbidity and mortality in octogenarians is limited. Our aim was to assess surgery-related complications in octogenarians, undergoing urological surgery. PATIENTS AND METHODS: We prospectively collected data from octogenarians and a control group of younger patients undergoing an elective urological surgery in our institution. Recorded data included: age, gender, American Society of Anesthesiologists (ASA) score, co-morbidities, number of medications, operation extent, anaesthesia type, surgery duration and perioperative morbidity and mortality. RESULTS: Forty-seven octogenarians and 80 patients with a median age of 59 years (range 19-75) enrolled prospectively. Gender ratio, surgeries extent and median operative time were similar among groups. General anaesthesia was more prevalent in the control group. ASA classification and duration of hospitalization were significantly higher in octogenarians. The rate of intra-operative complications was significantly higher in the octogenarians group 6.38% versus 3.75% (p = 0.007), there was no significant difference in immediate post-operative and post-discharge complications among groups. One octogenarian patient died 2 days post-surgery, no death occurred in the control group. CONCLUSIONS: Octogenarians have higher rate of intra-operative morbidity, leading to longer hospital stay. More experienced surgeons and anaesthetists should be involved in the operation; and careful surgical technique, tapered anaesthesia and higher level of post-operative monitoring should be applied for patients in this age.

Role of bone regeneration and turnover modulators in control of fracture.

Although most fractures heal in accordance with a highly regulated and well-known multistep process, 5%-10% of fractures result in delayed union or nonunion, causing morbidity, prolonged hospitalization, and economic cost for the individual and society. Ongoing research has improved our understanding of genes and molecules that are expressed during fracture healing. This knowledge has been translated into preclinical/clinical trials. Unfortunately, the success of most promising agents, and therefore most preclinically/clinically tested factors, is controversial and frequently disappointing. Taking advantage of our knowledge concerning the temporal events contributing to fracture healing, and as a result of our studies, we suggest that the application of several factors in sequence will intervene in different, crucial crossroads, accelerate remodeling, and result in an improved outcome. These factors will encompass stimulated recruitment and proliferation of stem cells to enlarge the progenitor pool, facilitate its differentiation into mature chondrocytes and osteoblasts, and stimulate cartilage resorption and its remodeling into bone by endochondral ossification--a process in which blood vessels, metalloproteinases, and osteoclasts work in concert to remodel immature bone into mature bone. The aim of this article is to highlight events that contribute to and drive the dynamic healing process in order to help clinicians to find successful, novel treatment protocols.

Hemorrhagic complications of minimally invasive urological surgeries, treated with selective endovascular embolization.

Minimally invasive urological procedures have gained in popularity and replaced open surgery in various urological procedures. Although considered minimally invasive, these procedures are not free from complications, and life-threatening hemorrhage may occur. Herein we describe 3 case series of patients who underwent minimally invasive urological surgeries that were complicated with bleeding. In all 3 patients we used super selective angiographic embolization to stop hemorrhage. Minimally invasive urological surgeries carry the risk of hemorrhage, and patients should be informed about this possibility. In hemodynnmic stable patients endovascular embolization allowed bleeding cessation with maximal preservation of the bleeding kidney tissue.

Antegrade pyelography versus unenhanced multidetector CT in the assessment of urinary-tract stones after percutaneous nephrostomy insertion: a prospective blinded study.

BACKGROUND AND PURPOSE: In patients with a percutaneous nephrostomy tube (PCN) inserted for symptomatic stone disease, antegrade pyelography is an accepted modality to assess the collecting system and residual stone status prior to PCN removal. Recently, unenhanced multidetector CT (UMDCT) has shown its superiority for the assessment of urinary-tract stones. Comparison of UMDCT with antegrade pyelography has never been done; hence, our aim was to compare the two methods for the assessment of urinary stones in patients with a PCN. PATIENTS AND METHODS: Between July 2004 and July 2005, we prospectively imaged 49 consecutive patients with known urinary-tract stone disease who had PCN (27 men and 22 women; average age 57 +/- 20 years; range 4-88 years). All patients underwent UMDCT and antegrade pyelography within 24 hours. Both examinations were prospectively and blindly evaluated by two attending radiologists for the presence, location, and size of urinary-tract stones. RESULTS: According to the findings of both imaging modalities, 18 patients were stone free, and 31 patients had urinary stones. In 20 of the latter 31 patients (64.5%), the urinary stones were diagnosed only by UMDCT. Antegrade pyelography missed renal as well as ureteral stones, with a significant mean size (5.1 x 6.2 mm, and 6 x 5.3 mm, respectively). Antegrade pyelography missed radiolucent (8/20) as well as radiopaque (12/20) stones. In 11 of the 31 patients (35.5%), urinary stones were diagnosed by both UMDCT and antegrade pyelography. The average size of these renal stones was 6 x 11 mm, and the mean ureteral stone size was 11 x 13 mm. In 64% (7/11), the stones were radiolucent and in 36% (4/11) radiopaque. There was no patient in whom urinary stones were diagnosed by antegrade pyelography but missed by UMDCT. CONCLUSIONS: Unenhanced multidetector CT is more accurate than antegrade pyelography via a PCN for the assessment of urinary-tract stones, with the advantage of reducing the risks of contrast injection side effects.

Shock wave lithotripsy for ureteral stones in elderly male patients.

INTRODUCTION: Age has never been considered as a factor in the treatment of ureteral stones, but elderly male patients may suffer from concomitant illnesses that may affect SWL results, such as voiding difficulties and musculo-skeletal and cardio-vascular disorders. The aim of this study was to assess the success rate and complications of shock wave lithotripsy (SWL) for all size and location ureteral stones in patients older than 70 years of age. PATIENTS AND METHODS: We retrospectively reviewed the charts and radiology films of all patients who had undergone SWL for ureteral stones with the HM3 lithotriptor and compared the results of patients younger than 70 years to those older than 70 years. RESULTS: During 2000-2003, 238 consecutive male patients (23 older than 70 years) underwent SWL under regional anesthesia for all size and locations ureteral stones. Stone sizes, locations, opacity, and pre-operative drainage procedures matched in both groups. The overall stone-free rate was 91% for both groups. Complications were recorded in 1% of the older patients and 3.7% of the younger ones. No treatment-related mortality was recorded. CONCLUSIONS: Age itself has no effect on the success rate of SWL with the HM3 lithotripter for ureteral stones. In general, SWL treatment showed a high success rate with minimal morbidity and no treatment-related mortality.

Extracorporeal shock wave lithotripsy for large ureteral stones using HM3 lithotriptor.

PURPOSE: We assessed the efficacy of extracorporeal shock wave lithotripsy for large (more than 10 mm) ureteral calculi with the unmodified Dornier HM3 lithotriptor. MATERIALS AND METHODS: A total of 96 consecutive patients with large ureteral stones were treated with shock wave lithotripsy using an unmodified HM3 lithotriptor. Patients, stone characteristics, preliminary treatment before shock wave lithotripsy, additional procedures after shock wave lithotripsy, complications and clinical outcomes were assessed. RESULTS: Between 2000 and 2003 a total of 96 patients (75 males, 21 females, mean age 51 years [range 16 to 81]) with large ureteral stones underwent shock wave lithotripsy. Average stone size was 14 mm (range 10 to 22), 90 stones were calcified, and 66 stones were located in the upper ureter, 20 in the mid ureter and 10 in the distal ureter. A total of 77 (80.2%) patients underwent a single shock wave lithotripsy session, 18 (18.7%) underwent 2 sessions and 1 (1.1%) patient underwent 3 sessions. The overall stone-free rate was 86.5% (83 patients). Complications occurred in 10 (10.4%) patients. Shock wave lithotripsy failed in 13 (13.5%) patients who were successfully treated with ureteroscopy. CONCLUSIONS: Our data show that shock wave lithotripsy for large ureteral stones along the entire ureter with the unmodified HM3 lithotriptor has a high success rate with minimal morbidity. We recommend it as first line treatment.

A review on hematuria in children.

Asymptomatic hematuria is very common in pediatric and adolescent patients. In contrast to painless hematuria in adults, the differential diagnosis and investigative modalities in the pediatric population is vastly different. This article presents the major diseases that may cause hematuria in children and suggests an evaluation algorithm for the pediatric urologist.

[Hematuria in children].

A symptomatic hematuria is very common in pediatrics and adolescence. In contrast to painless adult hematuria, the differential diagnosis and investigative modalities in the pediatric population is vastly different. This article presents the major diseases that may cause hematuria in children and suggests an evaluation algorithm for the pediatric urologist.

Inflamation of the testis and epidididymis in an otherwise healthy child: is it a true bacterial urinary tract infection?

PURPOSE: The exact etiology of acute gonadal inflamation (EO) in children is unknown. Bacterial infection and underlying urological abnormalities are thought to be the main causes, and hence antibiotic treatment and further invasive urinary tract imaging studies are usually recommended. The purpose of this study was to assess the role of bacterial infection in pediatric acute EO. MATERIALS AND METHODS: We retrospectively searched our electronic medical archive for children under the age of 18 years with the diagnosis of acute EO between 1997 and 2002. Patients' charts were retrieved and reviewed for clinical and laboratory data. RESULTS: During 1997-2002, 193 patients with acute EO were treated. There were two subgroups according to the results of urinary cultures: 182 children (94.3%) had negative urine cultures and 11 (5.7%) had positive cultures. In the negative culture group the mean age was 9.8+/-3.2 years (0.5-17). Medical history for urological disease was negative in all patients. Presenting symptom was scrotal pain in 165 (90.7%), and only three patients (1.6%) had accompanying urinary symptoms. Physical examination was normal besides tender gonad. Urinalysis was completely normal in 169 (92.9%) patients. Scrotal Doppler ultrasound (US) demonstrated non-specific inflammatory process in 146 patients (80%), in nine (5%) torsion of the appendix testis was documented and in 27 (14.8%) scrotal US was normal. Follow up was available in 40% all of whom had an uneventful recovery with normal physical examination. In the positive culture group of 11 patients, the mean age was 11+/-6.7 years (3 months to 16 years), and eight patients (73%) had a known congenital urological abnormality. Presenting symptom was pain in five (45.4%) and pain with swelling in six (55.6%). Accompanying dysuria, frequency and urgency occurred in eight (72.7%) patients. Urinalysis was abnormal in 10 (90.9%). US demonstrated increased blood flow to the gonad in 10 (90.9%). CONCLUSIONS: Negative history for urological disease, absence of urinary symptoms and normal urinalysis make the diagnosis of bacterial EO unlikely. In this setting, once testicular torsion was excluded, there is no justification for antimicrobial treatment or further imaging of the urinary tract.

[Shock wave lithotripsy for ureteral stones--single institute experience in 661 consecutive cases].

INTRODUCTION: Optimal treatment for ureteral stones is still controversial. The main retreatment options include ureteroscopy and shock wave lithotripsy (ESWL). The study aimed to assess the efficacy of ESWL using the unmodified HM3 lithotripter (Dornier Medical Systems) to achieve stone-free status in patients with ureteral calculi, regardless of stone size and location along the ureter. MATERIAL AND METHODS: We retrospectively reviewed the charts and radiology studies of all patients who had ESWL for ureteral stones. Following ESWL with the HM3 lithotripter, patients had imaging examinations performed after 1 and 3 months, and thereafter, according to the residue status of the stones. RESULTS: During the years 1998-2003, 661 patients underwent ESWL for ureteral stones. The mean age was 51 years (range: 4-85 years) and the average stone size was 8 x 10 mm (range: 3-30 mm). Forty percent of the patients had upper ureteral calculi, 17% mid and 43% lower ureteral stone. Overall stone-free status was 93.6%. According to stone location, the success rate for upper ureteral calculi was 93.6%, and 93.6% and 95.5% for mid and lower ureteral stones. Complications were recorded in 28 (4.2%) patients, 20 had acute urinary tract infection treated with i.v. antibiotics, and 8 had renal colic treated conservatively. CONCLUSIONS: Our data shows that ESWL using HM3 lithotripter for ureteral stones at any level and size has a high success rate with minimal morbidity. ESWL using the HM3 lithotripter is our preferred treatment of choice for ureteral calculi.

Urothelial cancer of the renal pelvis in percutaneous nephrolithotomy patients.

INTRODUCTION: The association between staghorn calculus of the kidney long-standing and urothelial tumors of the renal pelvis is well documented. We describe 3 patients with urothelial cancer in a kidney who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Retrospective analysis of our series of more than 500 PCNLs revealed 3 patients in whom urothelial cancer of the renal pelvis was diagnosed during or following percutaneous stone removal. Preoperative assessment included IVP, renal sonography and renal scan using DTPA in all 3 patients, and CT in 2 patients. Imaging did not raise the suspicion of a neoplastic lesion. RESULTS: All patients had a long history of urolithiasis and urinary infections. No patient was diagnosed preoperatively. One patient was diagnosed postoperatively, when a CT demonstrated a renal lesion. The second patient underwent simple nephrectomy due to a non-functioning kidney, and the tumor was found on pathological analysis. In the third patient, biopsies were taken from a suspicious-looking tissue in the renal pelvis during the PCNL session. All patients had transitional cell carcinoma: 1 associated with sarcomatoid features and 1 with squamous carcinoma. They all died from metastatic disease 2-19 months after the diagnosis of urothelial cancer. CONCLUSIONS: The preoperative diagnosis of urothelial cancer in patients with staghorn stones is difficult due to the existing stone and inflammation. Since the prognosis of urothelial cancer is extremely poor, biopsies of the renal pelvis, obtained directly through the nephroscope during the PCNL session, may be the only key for early diagnosis and treatment. A high index of suspicion should be raised when patients suffering from infected staghorn calculi are encountered, and such intraoperative biopsies should be considered.