A randomized controlled trial of nephrostomy placement versus tubeless percutaneous nephrolithotomy.

PURPOSE: We established whether totally tubeless percutaneous nephrolithotomy with no nephrostomy or ureteral stent is a safe management technique. MATERIALS AND METHODS: Patients were randomized to have a nephrostomy placed (group 1 control) or none (group 2 treatment). A total of 25 patients were randomized to each group. Cases were considered uncomplicated and suitable for randomization if there was no significant bleeding or residual stone load, the pelvicaliceal system was intact and there was no evidence of a residual ureteral stone. The primary outcome measure was length of stay, and secondary outcomes were analgesic requirements and postoperative complications such as bleeding, infection or ureteral obstruction. Hospital readmission rates and stone clearance rates were also recorded. RESULTS: Mean stone size was 21.6 vs 17.5 mm. There were no transfusions in either group. Hemoglobin change was 2.03 vs 1.18 gm/dl and mean creatinine increase was 0.029 vs -0.111 mg/dl. There were no differences in hemorrhage, infection and serum parameters. There were no readmissions in either group. Mean length of stay was 3.4 vs 2.3 days (p <0.05). CONCLUSIONS: This trial demonstrates that percutaneous nephrolithotomy without nephrostomy or stent is a safe and well tolerated procedure in selected patients. Length of stay was reduced with no major complications in either group. We believe that totally tubeless percutaneous nephrolithotomy may be considered an accepted standard of care for selected cases and it is possible to reserve placement of a nephrostomy tube or internal ureteral stent for specific indications.

Scintigraphic estimation of arterial and portal blood supplies to the liver.

A technique is described for the measurement of the relative magnitudes of the hepatic-artery and portal-vein components of liver perfusion, using a gamma camera and on-line computer system. This ratio is obtained from analysis of the time variation in liver activity on the first pass following bolus intravenous injection of a Tc-99m-labeled radiocolloid. The arterial and portal components are separated by their times of arrival at the liver. These arrival times are evaluated from activity time variations for spleen, left ventricle, and left kidney. Physiological validation of the technique was provided in a digestion study in which normal volunteers showed a significant increase in the portal-vein component 1 hr after a meal relative to the fasting situation. These results are compared with those from studies by other workers. The uncertainties and limitations of the technique are discussed and potential clinical uses suggested.

Diabetic cystopathy presenting as primary acute urinary retention in a previously undiagnosed young male diabetic patient.

Lower genito-urinary problems are part of the polyneuropathy of diabetes. Cystopathy affects 40%-85% of diabetic patients, although less than half are symptomatic. We report on a 42-year-old patient who was not known to be diabetic, and who presented to the urologists with primary acute urinary retention. His underlaying disease was detected by a test for random blood glucose. More common causes were excluded with careful clinical and radiological examinations. He was managed with insulin and self-catheterization. Diabetes should be considered as a differential diagnosis in relatively young men who present with unexplained acute urinary retention.

Non-invasive assessment of absolute values of hepatic haemodynamics using radiocolloid scintigraphy.

A non-invasive technique for the assessment of hepatic haemodynamics using radiocolloid imaging with a computer, in which absolute values of hepatic, mesenteric and splenic arterial effective blood flows were assessed, is described. The technique was carried out on ten volunteers, before and after a standard meal. After eating, total effective liver blood flow rose by 28% and the mesenteric arterial effective flow by 69%. Hepatic and splenic arterial effective flow were reduced.

Primary amyloidosis of urinary bladder.

Six cases of primary amyloidosis of the urinary bladder are reported. This is a rare clinical entity and is of interest to the urologist because it is usually confused with carcinoma. Conservative treatment is usually adequate, though long-term follow up is recommended.

Partial nephrectomy: an option in calculus disease?

Thirty-seven patients treated by partial nephrectomy for calculus disease between 1971 and 1986 were reviewed retrospectively. Of the 25 patients available for analysis, 20% developed immediate surgical complications, 20% had residual post-operative stone and 33% developed true ipsilateral stone recurrence during the period of follow-up. Our results from partial nephrectomy for calculus disease are compared with the results of treatment by percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy. It was concluded that partial nephrectomy should be reserved for situations where stone disease is associated with anatomical abnormalities which cannot be treated by the newer modalities of stone management.

Modified nephro-ureterectomy. Long-term follow-up with particular reference to subsequent bladder tumours.

Nephro-ureterectomy is the standard treatment for transitional carcinoma of the renal pelvis and caliceal system. In recent years a modification of the conventional two-incision technique has been described in which the intramural ureter is resected endoscopically and the remaining ureter is removed in continuity with the kidney through a single loin incision. Twenty-one patients had their renal pelvic tumours treated by this modified technique between 1970 and 1983. Of 16 patients available for analysis, 37.5% subsequently developed bladder tumours. It was concluded that this modified technique has no greater incidence of subsequent bladder tumour development than the conventional technique of nephro-ureterectomy, whilst giving considerable benefit to the patient.

Bromodeoxyuridine labelling of transitional cell carcinoma of the bladder--an index of recurrence?

Nineteen patients with newly diagnosed transitional cell carcinoma of the bladder consented to receive an intravenous bolus of bromodeoxyuridine (BrdUrd) 3 to 6 h prior to transurethral resection of bladder tumour. Routine paraffin embedded sections were stained with anti-BrdUrd monoclonal antibody in order to determine the S phase fraction of the bladder tumours and to correlate this with tumour grade, category and the development of recurrence during follow-up. BrdUrd labelling of nuclei was reliably detected in 100% of the tumours. The mean labelling index of Ta tumours (n = 8) was 3.14%; in T1 tumours (n = 7) it was 8.6% and in T2-3 tumours (n = 4) it was 16.4%. A similar correlation was found in association with tumour grade. The patients were followed up for a mean of 23 months (range 18-30). Seven of the 15 superficial tumours recurred during the period of follow-up. These tumours had a mean labelling index (at diagnosis) of 8.4%, whereas the tumours that did not recur had a mean labelling index of 3.4%. The in vivo determination of BrdUrd uptake in transitional cell carcinoma of the bladder may be useful in predicting which superficial tumours are likely to recur following resection and so rationalise both the time to follow-up and intravesical chemoprophylaxis.

Dynamic liver scanning in cirrhosis.

Dynamic liver scanning using 99mTc sulphur colloid has been used in assessing 41 patients with cirrhosis and the data compared with 33 control subjects. The mesenteric fraction (MF) was significantly reduced in cirrhotics (0.30 +/- 0.17) compared with controls (0.58 +/- 0.09), P less than 0.001. The liver: spleen ratio (L:S) was also significantly different (1.6 +/- 0.95 compared with 4.9 +/- 1.4), P less than 0.001. Those patients who had undergone a recent variceal bleed had values less than patients who had not bled. Dynamic scintigraphy may be of value in monitoring the progress of disease and response to treatment.