Urinary tract stone deaths: data from the Australian and New Zealand Audits of Surgical Mortality.

OBJECTIVES: To analyse all mortalities related to surgery for urinary tract calculi in Australia from 1 January 2009 to 31 December 2018, and identify common causes, clinical management issues (CMIs), and areas for improvement. PATIENTS AND METHODS: All urological-related deaths reported to the Australian and New Zealand Audit of Surgical Mortality (ANZASM) from 2009 to 2017 were analysed. The Bi-National Audit of Surgical Mortality (BAS) database was interrogated for any involvement with renal, ureteric or bladder stones and all relevant associated data analysed. Any CMIs documented by the peer reviewers were recorded and compared to those in urology and all of surgery ANZASM data. RESULTS: Of 1034 total urological deaths, 100 (9.7%) were related to stones. The mean (range) age of patients was 74.4 (21-97) years; 95% of the patients underwent at least one procedure, with 45 (47.4%) of these being elective. Urinary sepsis was responsible for 49.5% of the deaths, with 20% dying of cardiac events. In all, 39% (37/95) of deaths were associated with CMIs, the most common considerations being delays in diagnosis or treatment, perioperative management and inadequate preoperative evaluation. This is a considerably higher percentage than the 26% recorded for the general urology and all surgery national data. Ureterorenoscopy at 54% (12/22) had the highest rate of CMIs. CONCLUSION: Death related to stone surgery represents only a small proportion of all urological surgical deaths, but generates more CMIs amongst ANZASM peer assessors. Results could be improved with more rapid diagnosis and treatment. Careful case selection and access to all treatment options are recommended.

Successful outcomes of endoscopic lithotripsy in completely bedridden patients with symptomatic urinary calculi.

Due to the aging population, the number of completely bedridden individuals is expected to increase, and such individuals are at high risk of developing urinary calculi. This retrospective study included 32 consecutive bedridden patients, who had undergone endoscopic lithotripsy between 2010 and 2019, and aimed to identify the treatment outcomes of endoscopic lithotripsy for bedridden patients. A total of 45 endoscopic lithotripsies were performed to treat stones (median cumulative diameter, 24 mm). The stone-free rate (SFR) < 4 mm and complete SFR (0 mm) were achieved in 81% and 63% of patients, respectively. Postoperatively, 10 patients (22%) developed symptoms of systemic inflammatory response syndrome, and three patients (7%) had bloodstream infections. Except for one patient (3%) having a retained ureteral stent ultimately died from septic shock, drainage tube-free discharge was achieved in all patients. The 2-year cumulative incidence of stone-related events, and overall mortality rate, were 18% and 27%, respectively. Endoscopic lithotripsy is well tolerated and is associated with a high success rate, even with severe comorbidities and a relatively large stone burden. Physicians should consider performing endoscopic lithotripsy in bedridden patients with symptomatic urinary calculi regardless of their relatively short life expectancy and the remote risk of perioperative mortality.

U-Shaped Association of Serum Uric Acid With All-Cause and Cause-Specific Mortality in US Adults: A Cohort Study.

BACKGROUND: In addition to the controversy regarding the association of hyperuricemia with mortality, uncertainty also remains regarding the association between low serum uric acid (SUA) and mortality. We aimed to assess the relationship between SUA and all-cause and cause-specific mortality. METHODS: This cohort study included 9118 US adults from the National Health and Nutrition Examination Survey (1999-2002). Multivariable Cox proportional hazards models were used to evaluate the relationship between SUA and mortality. Our analysis included the use of a generalized additive model and smooth curve fitting (penalized spline method), and 2-piecewise Cox proportional hazards models, to address the nonlinearity between SUA and mortality. RESULTS: During a median follow-up of 5.83 years, 448 all-cause deaths occurred, with 100 cardiovascular disease (CVD) deaths, 118 cancer deaths, and 37 respiratory disease deaths. Compared with the reference group, there was an increased risk of all-cause, CVD, cancer, and respiratory disease mortality for participants in the first and third tertiles of SUA. We further found a nonlinear and U-shaped association between SUA and mortality. The inflection point for the curve was found at a SUA level of 5.7 mg/dL. The hazard ratios (95% confidence intervals) for all-cause mortality were 0.80 (0.65-0.97) and 1.24 (1.10-1.40) to the left and right of the inflection point, respectively. This U-shaped association was observed in both sexes; the inflection point for SUA was 6 mg/dL in males and 4 mg/dL in females. CONCLUSION: Both low and high SUA levels were associated with increased all-cause and cause-specific mortality, supporting a U-shaped association between SUA and mortality.

Do stones still kill? An analysis of death from stone disease 1999-2013 in England and Wales.

OBJECTIVES: To analyse the trends in the number of deaths attributable to urolithiasis in England and Wales over the past 15 years (1999-2013). Urolithiasis has an estimated lifetime risk of 12% in males and 6% in females and is not perceived as a life-threatening pathology. Admissions with urinary calculi contribute to 0.5% of all inpatient hospital stays, and the number of deaths attributable to stone disease has yet to be identified and presented. MATERIALS AND METHODS: Office of National Statistics data relating to causes of death from urolithiasis, coded as International Classification of Diseases (ICD)-10 N20-N23, was collated and analysed for the 15-year period from 1999 to 2013 in England and Wales. These data were sub-categorised into anatomical location of calculi, age, and gender. RESULTS: In all, 1954 deaths were attributed to urolithiasis from 1999 to 2013 (mean 130.3 deaths/year). Of which, 141 were attributed to ureteric stones (mean 9.4 deaths/year). Calculi of the kidney and ureter accounted for 91% of all deaths secondary to urolithiasis; lower urinary tract (bladder or urethra) calculi contributed to only 7.9% of deaths. The data revealed an overall increasing trend in mortality from urolithiasis over this 15-year period, with an increase of 3.8 deaths/year based on a linear trend (R(2) = 0.65). Overall, the number of deaths in females was significantly higher than in males (ratio 1.5:1, P < 0.001); kidney and ureteric calculi causing death had a female preponderance (1.7:1, female:male); whereas calculi of the lower urinary tract was more common in males (1:2.2, female:male). CONCLUSIONS: Stone disease still causes death in the 21st century in England and Wales. This trend of increasing deaths must be placed in the context of the concurrent rising incidence of urolithiasis in the UK and the number of stone-related hospital episodes. The primary cause of death relating to complications of stone disease for each individual case should be further investigated to facilitate prevention of complications of urolithiasis.

Bladder cancer in individuals with spinal cord injuries.

STUDY DESIGN: Prospective scoping review. OBJECTIVES: To conduct a scoping review of all the literature related to bladder cancer in individuals with spinal cord injuries (SCI). METHODS: Literature search of the databases Pubmed, CINAHL, ProQuest, PsychINFO and Scopus up to and including August 2012. Articles related to bladder cancer among SCI patients were identified, and data pertaining to epidemiology, risk factors, screening, prevention and management was reviewed and summarized. RESULTS: An association between bladder cancer and SCI was first reported in the 1960s, with some case reports suggesting an alarmingly high rate among SCI patients. More recent epidemiological studies have reported this risk to be substantially lower. However, bladder cancer in SCI patients tends to present at an earlier age and at a more advanced pathological stage than bladder cancer in the general population. Presenting symptoms may be atypical, and early recognition is important to improve prognosis with surgical resection. Several risk factors have been identified, including indwelling catheters, urinary tract infections and bladder calculi. Screening of SCI patients for bladder cancer is routinely recommended in many SCI management guidelines and by expert consensus; however, evidence for screening tools and protocols is lacking. CONCLUSION: Bladder cancer is a rare, and potentially lethal occurrence in SCI patients. Physicians need to have a high index of suspicion for bladder cancer, particularly among SCI patients managed with long-term indwelling catheters.

Histopathology and histomorphometry of the urogenital tract in 15-month old male and female rats treated neonatally with SERMs and estrogens.

In this study, two selective estrogen receptor modulators (SERMs), tamoxifen (TAM) and toremifene (TOR) or two estrogens, ethinylestradiol (EE) and diethylstilbestrol (DES) were administered to newborn male and female Sprague-Dawley rats (days 1-5) to investigate the occurrence of developmental abnormalities in the adulthood. The compounds were dosed (s.c.) at an equimolar dose of 24.9 micromol/kg. During the follow-up period, mortality occurred mainly in DES-treated male rats (3/4), associated with obstructive urinary calculi and suppurative renal inflammation in 2/3 rats. Similar lesions were not evident in other groups. At the age of 15 months, the animals were necropsied and organs were collected for histopathology and histomorphometry. Treatment-related abnormalities were restricted to the reproductive organs. Chronic prostatitis and epithelial abnormalities in the vas deferens were observed in all treatment groups. The columnar epithelium of vas deferens showed hyperplasia and development of subepithelial glandular structures resembling epididymal cysts reported in humans exposed in utero to DES. Testicular atrophy was observed especially in estrogen-treated rats. Mainly in SERM-treated female rats, the uterus showed luminal dilation or obstruction, loss of endometrial glands and myometrium disorganization including foci of muscular disruption. TOR-treated female rats showed polyp-like nodules (incidence 4/15) and a high incidence (9/15) of a simple cuboidal epithelium in cervical regions normally occupied by multilayered epithelia. In conclusion, the vas deferens is a main target organ following neonatal administration of SERMs and estrogens. In addition, female rats were significantly more susceptible to SERM treatment than to treatment with estrogens.

Prognostic factors effecting on recurrence of urinary stone disease: a multivariate analysis of everyday patient parameters.

INTRODUCTION: Since comprehensive urometabolic analyses are currently more preferred for the patients with recurrent stones and with high risk of stone recurrence, we have tried to determine simple patient data increasing stone recurrence to limit sophisticated analyses to certain cases at least in particularly deprivation districts. MATERIALS AND METHODS: For the study 173 with first-time or recurrent urinary stone were taken. After stone treatment, various empirical metaphylaxis methods were counselled to the patients. The parameters evaluated were (a) age at onset of the disease, (b) gender, (c) urinary pH and (d) specific gravity, (e) serum calcium and (f) uric acid, (g) stone burden, (h) side, and (i) location, (j) treatment modality and (k) recurrence history. New stone formation or growing of the existing stone was considered as stone recurrence. In statistics, independent samples t, chi-square test, Kaplan-Meier, Log rank and Cox regression tests were used. RESULTS: The mean age was 35 years. The male to female ratio was 88/85. Recurrence occurred in 49 (28%) cases at a mean of 30 months. Stone burden was significantly larger in patients with recurrent stone. In subjects treated with open surgery and with previous recurrence history, stone recurrence rate was significantly higher. In survival analyses, higher serum calcium level, larger stone burden, renal stones and previous recurrence influenced stone prognosis poorly. However in multivariate analysis, none of them was the most significant independent factor. CONCLUSIONS: According to our study, detailed urometabolic analyses may be somewhat reserved for the patients with ordinary factors increasing risk of stone recurrence including relatively high serum calcium level, large stone burden, upper urinary stone, history of recurrence and open surgery. As a result, it has been thought that the stone risk evaluation guiding detailed laboratory examination may be partially performed with first-line clinical data under limited conditions.

Urolithiasis in rats consuming a dl bitartrate form of choline in a purified diet.

Urolithiasis appeared in rats maintained to study the effects of nutrients and methylmercury on development and aging. After a year, the mortality rate was approximately 10%, and by 2 years, it had increased to nearly 30%. Clinical signs and urinary tract pathology were examined as a function of diet, duration on diet, gender, methylmercury exposure, genetics, and other potential risk factors by using survival analyses and qualitative comparisons. Urolithiasis in female rats appeared 15 weeks after beginning a purified diet and after 5 weeks for male rats. After 97 weeks, the mortality rate of female rats was 22% and for male rats was 64%. Lifetime urolithiasis-associated mortality was about 2% in a group of rats that consumed the contaminated diet for < 30 weeks. No urolithiasis occurred in siblings or cohorts of the rats described here that were maintained on a standard rodent chow containing choline chloride. Urolithiasis was traced to racemic, rather than levo-, bitartaric acid in some purified diets shipped in 2001 and 2002. It is unknown when the impurity first appeared in the diet, so estimates of exposure duration are upper limits. Chronic methylmercury exposure increased vulnerability. Some families (dam + offspring) had multiple cases of urolithiasis, but probability models constructed to evaluate familial clustering revealed no evidence for a genetic predisposition to urolithiasis apart from gender. Removing racemic tartaric acid did not decrease mortality once rats had been on the diet for 20 to 30 weeks, but it helped when exposure duration was shorter.

[Medical and ecological assessment of climate effects on urolithiasis morbidity in population of Primorsky territory]. / Mediko-ékologicheskaia otsenka vliianiia klimata na zabolevaemost' mochekamennoi bolezn'iu naseleniia Primorskogo kraia.

The article presents medicoecological estimation of quantitative relations between monsoon climate and urolithiasis primary morbidity in the Primorsky Territory. Quantitative estimation of the climate was performed by V. I. Rusanov (1973) who calculated daily meteorological data for 1 p.m. throughout 1991-1999. Primary urolithiasis morbidity for this period of time was provided by regional health department. The data were processed by methods of medical mapping and paired correlation analysis. In the Territory, mapping revealed the same location of the zones with high frequency of discomfortable weather of class V and VI causing chilblain in positive air temperatures and zones with elevated primary urolithiasis morbidity in children and adults. Correlation analysis confirmed mapping results and determined significant negative correlations between frequency of relatively comfortable moment weather classes II-IV and morbidity of children and adults, positive correlation between frequency of discomfortable class VI and adult morbidity. Thus, high frequency of days per year with discomfortable classes of moment weather in low positive air temperatures may be one of the factors of urolithiasis risk in population of the Primorsky Territory. Climatic factors should be taken into consideration in planning primary prophylaxis of this disease in the Primorsky Territory.

Long-term outcome of paediatric patients with hereditary tubular disorders.

BACKGROUND: An increasing number of children with hereditary tubular disorders (HTD) reach adult life due to diagnostic and therapeutic advances which results in growing need to manage these patients by adult centres. Data on the prevalence and the late clinical problems of these patients are limited. METHODS: We observed 177 paediatric patients with isolated or complex HTD between 1969 and 1994. The median age at the time of diagnosis was 3 (range 0-18) years and the median observation period 10 (range 1-43) years. The long-term outcomes with respect to renal function, bone disease, and body growth were analyzed. RESULTS: The prevalence of HTD was 3.2% of all patients observed in our renal unit and 14% of those patients with chronic renal failure and/ or end-stage renal disease. The three most frequent disorders observed were nephropathic cystinosis (n = 34), X-linked hypophosphataemic rickets (n = 26), and idiopathic hypercalciuria (n = 17). At the last observation, 12% of the patients with isolated HTD and 30% of those with complex HTD had developed preterminal chronic renal failure; end-stage renal disease was observed in 5 and 25%, respectively (p < 0.001). Progressive disease occurred mainly in patients having cystinosis, primary hyperoxaluria, the syndrome of hypomagnesaemia/hypercalciuria, primary Fanconi syndrome, Fanconi-Bickel syndrome, and methylmalonic aciduria. Nephrocalcinosis was found in 42%, urolithiasis in 14%, bone deformities and/or fractures in 28%, and other extrarenal alterations in 29% of all patients. The median body height at last observation was 2.0 SD below the normal mean (range from -10.4 to +2. 6), and the adult height was subnormal in 48% of 67 grown-up patients. Growth retardation was more severe in complex than in isolated HTD. The mortality decreased from 17% in 1969-1981 to 12% in 1982-1994. CONCLUSION: Although HTD are rare nephropathies, their frequently progressive course associated with extrarenal complications requires the attention of nephrologists beyond the paediatric age.

[The surgical outcomes in complicated urolithiasis]. / Iskhody khirurgicheskogo lecheniia oslozhnennoi mochekamennoi bolezni.

Complicated nephrolithiasis and ureterolithiasis were surgically treated in 87 and 79 patients aged 18-80 years, respectively. Of them elderly patients constituted 62%. Unilateral calculi occurred in 90.9%, coral calculi in 21 patients. Of 195 complications observed acute purulent pyelonephritis (PP) developed in 150 patients. It proved to be the most threatening and frequent complication. Therapeutic policy and choice of surgery were decided upon with consideration of the stone location, anatomic and functional status of the kidneys, preexisting somatic pathology, age of the patient. Because most severe pyelonephritis was reported in patients with nephroliths and prepelvic ureter, these patients have undergone nephrectomy most often (47%). Conservative surgery has been performed in 53%, pyelolithotomy without renal drainage in 9 (5.4%) patients with non-destructive pyelonephritis. Calculous pyodestructive pyelonephritis should be treated early according to the scheme: cleaning of the purulent foci, removal of the stone and nephrostomy. Used in 23 (13.9%) patients, this scheme failed (lethal outcome) only once. PP in patients with ureteroliths required two-stage treatment. Early nephrostomy (stage 1) preserved the kidney and prevented septic complications in 37 patients. Extracorporeal lithotripsy of ureteroliths (stage 2) is beneficial in clinically cured pyelonephritis and is indicated only in functioning nephrostomy. Conventional ureterolithotomy is valid in cicatricial ureteral stenosis in need of plastic surgery. Renal drainage and surgical elimination of the obstruction in the urinary tracts or on-demand nephrectomy resulted in a 90.4% cure. Hospital lethality in septic complications of calculous PP was 9.6%.

[The incidence of urolithiasis (based on autopsy data from the Donetsk Province Clinical Hospital)]. / Chastota mochekamennoi bolezni (po sektsionnym dannym Donetskoi oblastnoi klinicheskoi bol'nitsy).

Autopsy data indicate that urolithiasis is found in 3.6% of 100 autopsies, most frequently in men (62 cases) over 40 years of age. In 2/3 of patients the length of the disease was under 8 years, rarer over 15 years. In most cases renal involvement was bilateral (72 patients). In more that 70% two or three operations were performed. A pathogenetic relationship was found between urolithiasis and malformations of the kidneys and ureters, urinary stasis in disorders of innervation of lesser pelvis organs, hyperplasia of the prostate and disorders of the mineral metabolism.

[Frequency, localization and associated disorders in urinary calculi. Analysis of 1671 autopsies in urolithiasis]. / Frequenz, Lokalisation und Begleiterkrankungen der Harnsteine. Analyse von 1671 Urolithiasis-Obduktionen.

In the area of Rügen-Stralsund a maximum value of urolithiasis and cholelithiasis was found. In 27,133 autopsies the frequency of urolithiasis was 6%. Obesity, hypertension and diabetes mellitus may increase the tendency of cholelithiasis patients to develop additional urolithiasis. Ureteral and urinary bladder calculi are more frequently among male patients. In cases with benign prostatic hyperplasia the incidence of urolithiasis was not higher than in female patients. In the autopsy material multiple calculi and bilateral cases occur more frequently. Hypertension and increased heart weight did occur more frequently in patients suffering from oxalate lithiasis. Some of the calculi may develop in the terminal age of life.

An outbreak of avian urolithiasis on a large commercial egg farm.

A significant outbreak of avian urolithiasis was observed on a large commercial egg farm. From the initial outbreak site (a single laying house), the incidence of urolithiasis slowly spread in the ensuing months to numerous other laying houses. Increasing mortality associated with urolithiasis commenced during late growout to early lay and then leveled off when egg production peaked. At the height of the outbreak, mortality was typically 0.5% per week; 75% of this mortality was due to urolithiasis. The clinical and pathologic features of this condition are described. Both infectious bronchitis virus (IBV) and fowl adenoviruses were isolated from organ homogenates of sampled birds. A clone of the IBV strain was found to induce nephritis in specific-pathogen-free white leghorns.

The management of upper urinary tract calculi in spinal cord damaged patients.

The management of upper urinary tract calculi in 49 patients in the Mersey Regional Spinal Injuries Centre was reviewed retrospectively. Morbidity in nine patients was increased by either delay in operative intervention (5 cases) or inadequate follow up evaluation (4 cases). Earlier active treatment using modern endourological techniques and lithotripter technology is encouraged. A clinical algorithm incorporating these new techniques is shown.

Incidence, Prevalence and mortality of urolithiasis in the German Federal Republic.

Two nationwide surveys were conducted in the German Federal Republic. An incidence of 0.54% and a prevalence of 4% were registered. The ratio of men to women for incidence was 2:1 and for prevalence 1:1. Stone prevalence increased from 1.28% to 6.79% with increasing age. The occupational groups mostly affected were pensioners (34.3%), housewives (23.5%) and employees (16.9%). In cities the prevalence rate was higher than in rural areas. In recent years the mortality rate had decreased.