A review of the natural progression of medullary sponge kidney and a novel grading system based on intravenous urography findings.

PURPOSE: Medullary sponge kidney (MSK) is a developmental abnormality of the medullary pyramids of the kidney, characterised by cystic dilatations of the collecting ducts. We investigated a cohort of patients with MSK to gain further information about its presentation, clinical course and treatment required. We devised a grading system based upon findings at diagnostic intravenous urography (IVU) and established a relationship between severity of IVU findings and severity of disease. MATERIALS AND METHODS: The clinical notes and imaging of 29 patients with MSK were analysed. The severity of IVU findings was classified as follows: grade 1 (one calyx, unilateral), grade 2 (one calyx, bilateral), grade 3 (more than one calyx, unilateral) and grade 4 (more than one calyx, bilateral). RESULTS: The age range at diagnosis was 12-69 (mean 39), mean follow-up period was 12.7 years. Increasing grade of IVU findings correlated with more frequent symptomatic stone episodes (grade 1: 0.09 episodes per patient per year; grade 4: 0.34). Higher grade was also related to the number of hospital admissions (grade 1: 0.182 per patient per year; grade 4: 0.282) and the number of procedures required (either surgery or extracorporeal shock wave lithotripsy; grade 1: 0.0 interventions per patient per year; grade 4: 0.24). CONCLUSIONS: MSK presents over a wide age range and can cause long periods of intermittent episodes. Patients can be graded using a novel system based on IVU findings, which correlates with severity of disease. Management strategies such as intensity of follow-up can be modified using this grading.

A prospective randomized single-blind comparison of ureteral stents composed of firm and soft polymer.

PURPOSE: Ureteral stents are composed of different polymers and it is unclear if stent composition influences patient comfort. We compared the impact of stents composed of firm and soft polymer on patient health related quality of life. MATERIALS AND METHODS: A total of 130 patients requiring insertion of ureteral stents during the treatment of urinary calculi were randomized to receive a stent composed of firm (Percuflex, group 1) or soft (Contour, group 2) polymer. Patients were asked to complete the Ureteric Stent Symptoms Questionnaire, a validated instrument, at weeks 1 and 4 with the stent in situ and 4 weeks after its removal, this served as the main outcome measure. Additional assessments included difficulty in stent insertion and the need for early stent removal. RESULTS: There were 78 men and 38 women in total (61 in group 1 and 55 in group 2) with a mean age of 51 years (range 22 to 79) and no difference in age between the 2 groups (p = 0.9). Comparison of the results of the Ureteric Stent Symptoms Questionnaire survey at weeks 1 and 4 with stent in situ revealed no significant differences in the domain scores of urinary symptoms (p = 0.9 and p = 0.8), pain (p = 0.8 and p = 0.6) and general health (p = 0.6 and p = 0.4). Similarly, there were no differences in the number of days with reduced activities, work performance (p = 0.7) and sexual dysfunction between the 2 groups. A similar number of patients (8 and 7 in groups 1 and 2, respectively) required stent removal earlier than planned due to stent related symptoms. CONCLUSIONS: This randomized study showed no difference in the impact on patient quality of life between ureteral stents composed of firm or soft polymer.

Atraumatic retroperitoneal haemorrhage in a hydronephrotic kidney secondary to transitional cell carcinoma.

Retroperitoneal haemorrhage due to rupture of a hydronephrotic kidney has been described previously. There have only been two previous cases reporting retroperitoneal haemorrhage secondary to transitional cell carcinoma. We report two cases of spontaneous retroperitoneal haemorrhage in grossly hydronephrotic kidneys which had extensive transitional cell carcinoma present in the renal pelvis.

Evaluation of the clinical value of urinary NMP22 as a marker in the screening and surveillance of transitional cell carcinoma of the urinary bladder.

PURPOSE: To prospectively evaluate the clinical role of urinary NMP22 as a marker for transitional cell carcinoma of the urinary bladder in screening and surveillance settings. PATIENTS AND METHODS: Single voided specimens were obtained from 211 consecutive patients who presented for flexible cystoscopy. Of these, 96 patients presented with haematuria or irritative symptoms (screening), the remaining 115 were patients with known transitional cell carcinoma on follow-up (surveillance). The urine sample was used for urine microscopy, cytology and for measuring NMP22 levels. RESULTS: Bladder tumours were found in 16 of 96 (16.6%) patients in the screening group and 17 of 115 (15.6%) patients on surveillance. The NMP22 levels were significantly lower in patients with lower stage (Ta vs. T1-3), low grade (G1, G2 vs. G3, CIS) and papillary morphology. The optimum threshold for NMP22 obtained from the ROC curve was 4.75 U/ml, providing a sensitivity, specificity, positive predictive value and negative predictive value of 42.4, 85, 38.5 and 88.6%, respectively. Sensitivity and specificity were better in patients being screened than in those on surveillance. In both groups, urinary NMP22 had similar diagnostic characteristics as urinary cytology. CONCLUSIONS: Urinary NMP22 levels are significantly higher in patients with bladder tumour than in those negative for tumours, and test predictability improves with increasing stage and grade. The overall sensitivity for urinary NMP22 is similar to, but not superior to urine cytology. Our study suggests that the clinical role of urinary NMP22 as a diagnostic marker can be at best supportive only.

Extra-anatomic stents in ureteric obstruction: experience and complications.

OBJECTIVE: To assess the role of extra-anatomic stents (EAS) as a means of urinary diversion in patients with ureteric obstruction secondary to malignancy. PATIENTS AND METHODS: The technique for inserting EAS in patients with ureteric obstruction was described previously; to date, 13 patients (seven women and six men, mean age 45.3 years, range 22-78) have been treated. All patients had ultrasonographic evidence of hydronephrosis and/or significant biochemical evidence of renal impairment. Patients had advanced malignancy and one patient an abdominal aortic aneurysm. RESULTS: Urinary diversion was successful in all patients; two survived for more than 1 year, with stent changes at 6-monthly intervals. In three patients the stents were replaced by percutaneous nephrostomies because of problems with leakage or infection. The remaining patients died with functioning EAS in situ. CONCLUSIONS: In patients with ureteric obstruction secondary to malignancy or medical conditions excluding them from more invasive surgery, EAS provide a further therapeutic option instead of a permanent nephrostomy, which has associated inherent problems. This technique is not without potential problems and careful selection of patients remains vital in this difficult area.

Reversal of female sterilisation experience in a district general hospital.

Forty-five women who had microsurgical reversal of tubal sterilisation in New Cross Hospital Wolverhampton, between January 1986 and December 1992, were analysed to determine the success rate and the influencing factors. These women were followed-up until September 1994. More than 80% of the women were sterilised before the age of 30, and more than 80% sought reversal because of change of relationship. The overall pregnancy rate was 57.8% (intrauterine 51.1%, ectopic 6.7%). There were 17 (37.8%) live births. Intrauterine pregnancy rate was 100% (6/6) for the reversal of previous Filshie clip sterilisation, 50% (17/34) for previous Falope ring application and 0% (0/5) for previous Pomeroy method (P < 0.001). Analysis according to the site of anastomosis showed that the isthmic-isthmic anastomosis had an intrauterine pregnancy rate of 87.5% (7/8), isthmic-ampullary: 48.4% (15/31) and ampullary-ampullary: 16.7% (1/6), (P < 0.02). Sterilisation-reversal interval had no significant influence on the intrauterine pregnancy rate.

Maternal plasma concentrations of beta-lipotrophin, beta-endorphin and gamma-lipotrophin throughout pregnancy.

Plasma beta-LPH, beta-EP and gamma-LPH concentrations were measured by radioimmunoassay in 10 pregnant women from 12 weeks gestation until term and in nine women in the early follicular phase of the cycle. There was a progressive and significant rise in the concentration of all three peptides throughout pregnancy and by 32 weeks the concentrations of beta-LPH and beta-EP were greater than the corresponding concentrations in the follicular phase: gamma-LPH was greater than in the follicular phase by the end of pregnancy in those women who were delivered after 40 weeks. The ratio of beta-LPH to gamma-LPH did not change significantly throughout pregnancy, but there was a progressive fall in the beta-LPH/beta-EP ratio. The possible presence of a 'big LPH' to explain this finding is discussed.

Maternal and cord plasma concentrations of beta-lipotrophin, beta-endorphin and gamma-lipotrophin at delivery; effect of analgesia.

Maternal venous plasma concentrations of beta-LPH, beta-EP and gamma-LPH were compared in (i) patients undergoing vaginal delivery, 11 with an epidural block and 13 with pethidine and nitrous oxide or no analgesics; (ii) patients delivered by caesarean section, 7 under epidural block and 8 under general anaesthesia. Patients delivered by either method under epidural block had significantly lower levels of all three peptides than those receiving no epidural. There were significant negative correlations between umbilical vein beta-LPH, beta-EP and gamma-LPH concentrations and umbilical artery pH and positive correlations between beta-LPH and beta-EP but not gamma-LPH and cord PCO2 in 29 patients. There was no relation between cord levels of any of the three peptides and the method of analgesia or the route of delivery. Although concentrations of all three peptides were closely correlated to one another in either maternal or cord plasma, there was no relationship between maternal and fetal levels.