Extracorporeal shock wave lithotripsy under intravenous sedation for treatment of urolithiasis.

BACKGROUND: In contrast to treatment with oral or intramuscular analgesics, extracorporeal shock wave lithotripsy (E.S.W.L.) can be performed with patients under sedation too. Besides the advantage of increased shock energy, patients tend to have more constant breathing excursions and are more idle during treatment, potentially increasing the stone-free ratio (S.F.R.) after treatment. METHODS: This study presents the results of 310 patients who underwent 400 E.S.W.L. procedures under sedation, with a stationary lithotripter. RESULTS: After one procedure, the S.F.R. was 54.8% (170/310). A second treatment was successful in 42.1% (32/76), a third treatment in 21.4% (3/14). Therefore, 66.1% (205/310) of patients eventually became stone-free. Kidney stones were successfully treated in 65.4% (161/246), ureteral stones in 68.8% (44/64) of cases. Patients with stones ≤15 mm were successfully treated in 67.4% (194/288), patients with stones >15 mm in 50% (11/22) of cases. Considering each procedure individually, 45.3% (181/400) of procedures were successful after 3 weeks. Extending follow-up to 3 months is important, since 26.7% of stones (24/90) eventually still disappeared, increasing S.F.R. to 51.3% after one procedure. Complications occurred after 5.5% E.S.W.L.-procedures. CONCLUSIONS: E.S.W.L. is a well-tolerated, non-invasive procedure that produces reasonable stone clearance of both upper and lower urinary tract calculi. Performing the procedure whilst patients are intravenously sedated results in an acceptable S.F.R. Strong selection based on unfavourable factors could increase the chance on successful treatment and spare patients a pointless procedure. However, considering E.S.W.L.'s elegant nature, sometimes a more tolerant approach seems justifiable.

Effect of short-term outlet obstruction on rat bladder nerve density and contractility.

1 The present study was designed to investigate the relationship between innervation density and contractile responses to field stimulation and exogenous agonists at early time points after induction of bladder outlet obstruction (BOO) in rats. 2 When compared with sham-operated animals, 1, 3 and 7 days of BOO were associated with a 75%, 80% and 90% increase of bladder weight. Field stimulation caused a frequency-dependent increase in force of contraction. The force of contraction was reduced at each frequency in BOO rats with the greatest decrease after 1 day and a gradual but incomplete recovery thereafter. In contrast, contractile responses to ATP, carbachol and KCl were markedly reduced after 1 day of BOO and fully recovered after 7 days. The neurofilament staining was not altered by 1 day of BOO, but gradually decreased with increasing duration of BOO reaching the lowest levels after 7 days. 3 We conclude that impaired cellular contractility seems to underlie the early reductions of field stimulation-induced contraction, possibly reflecting surgical trauma of the tissue. However, at later time points a reduced nerve density, possibly reflecting a partial denervation, appears to be the main reason for impaired contractile response to field stimulation.

[Anticholinergics for overactive bladder: does subtype selectivity play a role?]. / Anticholinergika bei überaktiver Blase: Spielt Subtypselektivität eine Rolle?

Anticholinergics act in the treatment of overactive bladder by blocking muscarinic receptors of which five subtypes exist. Their desired effects occur via M(3) receptors, but a role for M(2) receptors is being discussed. Adverse effects such as dry mouth and constipation occur also via M(3) receptors, but M(2) and M(1) receptors can mediate side effects in the heart or on cognitive function, respectively. Therefore, an M(3)-selective drug such as darifenacin could theoretically be less effective but also have fewer cardiac or central nervous side effects. However, the limited available clinical data do not support a smaller efficacy or better general tolerability. The lack of adverse effects on cognitive function is well documented for darifenacin, but it cannot yet be determined definitively whether this discriminates it from other modern anticholinergics.