Biomedical subjects
Publications and source records attributed to M L Stoller.
We report the first case of localized, unilateral, idiopathic retroperitoneal fibrosis encasing the left renal vein, which resulted in secondary renal vein hypertension. The patient presented with sudden and dramatic gross hematuria. Surgical release and excision of the surrounding localized retroperitoneal fibrosis resulted in prompt resolution of the hematuria.
OBJECTIVES: Obesity increases the risk of developing chronic medical conditions such as diabetes mellitus, hypertension, and coronary artery disease. We performed a retrospective review of a large data base on urinary stones to determine if differences are found in urine and serum chemistries among obese and nonobese stone-forming patients. The effect of body weight on stone recurrence among urinary stone formers was also determined. METHODS: A national data base containing serum biochemical profiles, 24-hour urine specimens, and standardized questionnaires was retrospectively evaluated from 5942 consecutive patients with urinary stone disease. Stone-forming patients were classified by body weight: nonobese men, less than 100 kg and nonobese women, less than 85 kg; intermediate men, 100 to 120 kg and intermediate women, 85 to 100 kg; and obese men, more than 120 kg and obese women, more than 100 kg. RESULTS: Obese stone formers comprised 6.8% (n = 404) of the patient population. The mean weight in the nonobese and obese groups was 81 kg versus 134 kg, respectively, for men and 64 kg versus 112 kg, respectively, for women. Obese patients represented 3.8% of the male and 12.6% of the female population. Obese patients had increased urinary excretion of sodium, calcium, magnesium, citrate, sulfate, phosphate, oxalate, uric acid, and cystine; obesity was associated with increased urinary volumes and urine osmolality compared with the nonobese patients. Obese men had increased concentration of urinary sodium, oxalate, uric acid, sulfate, and phosphate when corrected for urinary volume. Obese women had increased concentrations of sodium, uric acid, sulfate, phosphate, and cystine. The mean number of stone episodes in nonobese versus obese men was similar (3.55 and 3.56), whereas mean stone episodes were 2.93 and 3.38 (P = 0.045) for nonobese versus obese women. CONCLUSIONS: Among known stone formers, obesity is associated with unique changes in both serum and urinary chemistries. These changes are associated with an increased incidence of urinary stone episodes in obese women but not in obese men.
Bladder calculi account for 5% of urinary calculi and usually occur because of foreign bodies, obstruction, or infection. Males with prostate disease or previous prostate surgery and women who undergo anti-incontinence surgery are at higher risk for developing bladder calculi. Patients with SCI with indwelling Foley catheters are at high risk for developing stones. There appears to be a significant association between bladder calculi and the formation of malignant bladder tumors in these patients. Transplant recipients are not at increased risk for developing vesical calculi in the absence of intravesical suture fragments and other foreign bodies. Patients who undergo bladder-augmentation procedures using a vascularized gastric patch appear to be protected from vesicolithiasis, perhaps by the acidic environment. Ileum and colon tissues, however, are colonized by urease-producing organisms, producing an alkaline pH that promotes stone formation. Children remain at high risk for bladder-stone development in endemic areas. Diet, voiding dysfunction, and uncorrected anatomic abnormalities, such as posterior urethral valves and vesicoureteral reflux, predispose them to bladder-calculus formation. Finally, there are a number of techniques and modalities available to remove bladder stones. Relieving obstruction, eliminating infection, meticulous surgical technique, and accurate diagnosis are essential in their treatment.
OBJECTIVE: To assess drainage through spiral-ridged and smooth-walled JJ ureteric stents (designed to ensure upper tract drainage) and thus determine whether drainage preferentially occurs around rather than through the spiral-ridged stent, promoting renal flow and potentially facilitating the passage of urinary stone fragments. Materials and methods A mechanical ureteric model was constructed to mimic the funnel characteristics of the renal pelvis. A motor pump was used to help simulate respiratory and skeletal movement, resulting in differential motion between the intraluminal stent and the surrounding ureteric wall. Tubes of varying internal diameters were used to simulate different sizes of ureter. Flow rates of standard 7 F smooth-walled stents were compared with 7 F spiral-ridged stents with and without occluded lumens, and with and without standardized excursions. RESULTS: Extraluminal flow (mean rates) with and without movements simulating respiratory excursions were significantly higher with the spiral stent for all stent diameters evaluated. All flow rates increased as the ureteric diameter increased. Total flow past the spiral stent was significantly greater than flow with the smooth-walled stent under all conditions tested. Flows measured around the spiral stent under conditions of excursion were the highest of all categories, 20-fold higher than in smooth-walled, closed, stationary stents. CONCLUSION: Spiral-ridged JJ stents provided substantially greater flow in this in vitro model. Extraluminal flow was markedly increased with the spiral-ridged configuration. The difference in flow rates was more pronounced at the smaller pseudo-ureteric tube diameters, simulating dimensions found in clinical practice. The flow rate also was increased when the central lumen remained open, and was greater still when there was dynamic excursion with respiratory movements.
BACKGROUND AND PURPOSE: Increasing evidence suggests that Randall's plaques contribute to the pathogenesis of urinary stone formation. The purpose of our study was to evaluate the urinary risk factors of stone patients who underwent endoscopic mapping of their calices for Randall's plaques. PATIENTS AND MATERIALS: Patients (N = 143) having endoscopic procedures to remove upper tract calculi or for other purposes underwent mapping of their calices for Randall's plaques. Plaque incidence and pattern were correlated with the stone composition and urinary risk factors found on subsequent metabolic evaluation. RESULTS: Papillary plaques were found more commonly in patients having calcium oxalate stones than in patients with other stone types and patients without a history of stones. Papillary plaque incidence and pattern did not correlate with any specific urinary risk factor; however, patients with plaques tended to exhibit a higher incidence of all risk factors. Plaque severity tended to be greater in patients exhibiting hypercalciuria. CONCLUSIONS: Randall's plaques are found most frequently in patients with calcium oxalate stones and are most important in the pathogenesis of calcium oxalate nephrolithiasis. Stone patients with papillary plaques are more likely to exhibit abnormalities in their urinary milieu than are patients without papillary plaques.
PURPOSE: Historically, aggressive surgical exploration of renal fistulae has been associated with a 20% nephrectomy rate. We evaluated the role of minimally invasive techniques in the management of urinary fistulae. MATERIALS AND METHODS: A retrospective review identified 10 renal fistulae in nine patients. Six renal-cutaneous, two renal-colonic, and two renal-pleural fistulae were referred for evaluation and treatment. RESULTS: Five men and four women (mean age 54 years, range 32-76) were referred to the University of California, San Francisco Urinary Stone Center from 1988 to 1996. Of the six renal-cutaneous fistulae, four were spontaneous and two were iatrogenic. The iatrogenic fistulae occurred after an open pyelolithotomy (1) and a renal exploration performed after extracorporeal shock wave lithotripsy (1). The spontaneous fistulae resulted from obstructing calyceal calculi (2), infundibular stenosis (1), and obstructed nephrostomy tube (1). The two renal-colonic fistulae resulted from percutaneous nephrolithotomies, and the two renal-pleural fistulae developed after renal surgery. Eight of 10 fistulae resolved with minimally invasive endoscopic techniques and relief of urinary obstruction. One nephrectomy was performed for a small nonfunctioning kidney after failed open pyelolithotomy. One patient refused all treatment and the fistula resolved spontaneously. CONCLUSIONS: Conservative management of both spontaneous and iatrogenic renal fistulae is possible by relieving urinary obstruction and using minimally invasive endoscopic techniques. Low nephrectomy rates can be expected using these methods.
Cystinuria, a renal tubule disease affecting urinary cystine excretion with or without kidney stone formation, previously was mapped to chromosome region 2p.21. Mutations in the gene SLC3A1 or NBAT, the reported candidate gene for cystinuria at 2p.21, have been demonstrated in individuals with the autosomal recessive Type I cystinuria phenotype. Recently, the Type III cystinuria phenotype was mapped to chromosome region 19q13.1. Here we report a kindred of 39 persons in two families of cystinurics, Types II and III, that support linkage to 19q13.1 and exclude 2p.21. Based on a dominant model of inheritance, two-point analysis of the entire pedigree produced a maximum lod score (Z(max)) of 3.82 at marker D19S425. Multipoint analysis yielded a lod score of 4.96 at this marker, and a resultant lod score of 5.90 using a codominant model of inheritance. Furthermore, a candidate gene interval of 8.9 cM, flanked by markers D19S225 and D19S223, was obtained using multipoint and haplotype analyses. Thus, this kindred demonstrates the linkage of Type II cystinuria to 19q13.1 and confirms the linkage of Type III cystinuria at 19q13.1 while excluding the marker D19S225 that was previously included in the critical interval.
OBJECTIVES: Struvite calculus formation requires an alkaline urinary pH. An acidic urinary pH will dissolve struvite calculi and prevent recurrent struvite stone formation. Long-term urinary acidification has been unsuccessful. We sought to determine whether a gastric patch (with viable parietal cells) anastomosed to the renal pelvis could create an acidic urinary milieu. METHODS: A vascularized stomach patch (from the greater curvature) was anastomosed to the left renal pelvis in 15 female pigs. The right kidney was used as a control. The first 6 pigs were used to refine the surgical technique. The remaining 9 pigs were subjected to a formal gastropyeloplasty and followed up for 4 weeks. Urine was collected before and after stimulation with pentagastrin. Urine pH was measured from both kidneys in response to gastrin stimulation and oral intake. The kidneys, ureters, and bladders were examined for gross changes and histologic review. RESULTS: The 9 test animals had more acidic urine in the control kidney than in the gastropyeloplasty kidney. Pentagastrin had no significant impact on urinary pH. Hydroureteronephrosis and a concentrating defect were noted in the treated kidney. Histologic review revealed smooth muscle hyperplasia of the left ureter and viable parietal cells in the stomach patch. CONCLUSIONS: An animal model was developed to transfer a gastric patch to the renal pelvis. Hydronephrosis and ureteral dilation were associated with this gastric patch. We were unable to acidify the urine despite viable parietal cells in the transposed stomach segment. Further refinements of this concept may be successful in acidifying urine in the hope of preventing recurrent struvite nephrolithiasis.
OBJECTIVES: Preoperative autologous blood (AUB) donation has decreased patient exposure to allogenic blood (ALB) products and associated infectious risk. The risk of contracting hepatitis C and human immunodeficiency virus is 1 in 103,000 and 1 in 678,000, respectively, after receiving 1 U ALB. Elective surgical procedures require surgeons to offer preoperative AUB donation in California. Unused AUB is discarded. We report our use of AUB obtained for percutaneous nephrolithotomy. METHODS: A retrospective study of 144 consecutive patients who underwent 193 percutaneous nephrolithotomies between January 1994 and April 1998 at one of four teaching hospitals at the University of California, San Francisco was performed. Preoperative AUB donation, transfusion rates, hemoglobin levels, blood use, and costs were analyzed. RESULTS: Ninety-six units of blood were collected from 63 patients (44%) and were available for 70 procedures (36%). The overall transfusion rate per procedure was 7%, with 13 patients receiving a total of 24 U, 7 AUB and 17 ALB. Eighty-nine units (92.7%) of AUB were discarded, and the transfusion rate in donors and nondonors was similar. There was no significant difference in preoperative hemoglobin or operative blood loss between donors and nondonors. The 13 transfused patients had a lower preoperative hemoglobin ( 11.5 versus 12.8 g/dL; P = 0.029) and higher operative blood loss as measured by hemoglobin level (3.2 versus 1.6 g/dL; P <0.001). Blood bank charges for ALB and AUB were $ 119/U and $244 to $498/U, respectively, depending on transportation and thawing charges. CONCLUSIONS: Routine preoperative blood donation adds substantial cost for minimal benefit, given the low infectious risk of ALB and the two- to fourfold higher cost of AUB. In our series, women had an increased incidence of blood transfusion compared with men. AUB donation may provide peace of mind but is rarely used and is discarded 93% of the time.
Struvite calculi can be a debilitating affliction for which the cure is mainly surgical. If left untreated, infection-related calculi can cause failure to thrive, anemia, chronic renal insufficiency, renal failure and death. There has been much research aimed at non-surgical intervention and prevention of these calculi especially in this "non-invasive" era. The historic and current non-surgical treatment modalities of struvite calculi are discussed.
PURPOSE: Indinavir sulfate is an effective protease inhibitor of the human immunodeficiency virus type 1. Use is associated with a significant incidence of crystallization and stone formation in the urinary tract, and these calculi are not visible on plain radiographs. Previously all urinary stones, including uric acid and matrix, were believed to be radiodense on computerized tomography (CT). We conducted a retrospective study to evaluate the radiographic appearance of indinavir calculi. MATERIALS AND METHODS: Retrospective chart review of 36 patients taking indinavir sulfate and presenting with renal colic was performed with attention to presentation, urinalysis, radiographic evaluation and management. Specifically, imaging characteristics on CT were addressed. RESULTS: All patients complained of ipsilateral flank pain and 35 had nausea and/or vomiting. Of 30 patients with dysuria or urgency the majority had hematuria, and most had pyuria and/or proteinuria. No stones were visualized on abdominal radiography. Diagnosis was confirmed on 1 of 13 excretory urograms and 4 of 11 renal ultrasounds. None of 12 CT scans was diagnostic of renal lithiasis. CONCLUSIONS: Indinavir sulfate is a protease inhibitor with poor solubility and significant urinary excretion. Crystallization and stone formation are demonstrated in as many as 20% of patients taking the medication. Most patients present with flank pain, nausea or vomiting and hematuria. Previously CT was thought to identify all urinary calculi with clarity but it cannot reliably confirm the presence of indinavir calculi.
PURPOSE: Urological complications in renal transplant recipients will become more common with increasing numbers of transplantations as well as increased graft survival secondary to improvements in immunosuppression. Urinary stone disease may be one of those complications. We determine the current incidence of urinary stone disease in renal transplant patients based on contemporary immunosuppressive regimens. MATERIALS AND METHODS: We reviewed the records of 1,730 renal and 83 pancreas/renal transplantations performed during the cyclosporine era and identified 8 recipients (0.4%) with urinary stone disease, including 3 with renal pelvic stones, 1 with multiple ureteral stones and 4 with bladder calculi. RESULTS: Treatment ranged from conservative observation to open pyelolithotomy, and included percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. The ureteral stones were removed with antegrade and retrograde ureteroscopy. The 4 bladder stones were treated with cystolithalopaxy. No case had significant permanent graft damage. Mean followup was 68.6 months. Mean serum creatinine was 1.5 mg./dl. (normal 0.5 to 1.3) at baseline and 2.38 after followup. CONCLUSIONS: While the incidence of upper tract urinary stone disease in renal (0.23%) and pancreas/renal (1.2%) transplant recipients is not statistically significant (p <0.45), the latter have significantly higher rates of bladder stones (4.8 versus 0%, p <0.001). The diagnosis of urinary stone disease in transplant recipients can be challenging because of the lack of symptoms but the treatment approach is the same as in the normal population.
Percutaneous renal surgery is continually being improved, refined, and embraced by urologists worldwide. With the advent of extracorporeal shock wave lithotripsy (ESWL), many percutaneous techniques have been abandoned or forgotten. We are learning, however, that ESWL is not a panacea for all urinary calculi and different methods need to be used to obtain stone-free patients. We discuss the history, anatomy, techniques, and specific problems and complications ofpercutaneous renal surgery specifically relating to renal stone disease.
PURPOSE: Adult ureteropelvic junction obstruction is increasingly managed with endoscopic techniques. Retrograde balloon cautery endopyelotomy is quick, requires minimal hospital stay and allows most patients a rapid return to work. The complication rate of retrograde balloon cautery endopyelotomy ranges from 13 to 34%, with vascular injury in 0 to 16% of patients. We report 5 uncommon complications, including 4 vascular injuries, that clinicians should be familiar with when using this technique. MATERIALS AND METHODS: We reviewed 52 retrograde endoscopic endopyelotomy procedures performed during a 5-year period. There were 5 uncommon complications. RESULTS: Accessory lower pole renal artery injuries occurred in 3 patients, 1 of whom presented 12 days after endopyelotomy. Embolization was successfully performed in all 3 cases and none had subsequent hypertension. In 1 case a right ovarian vein laceration was not evident on preoperative or postoperative angiography. Emergency post-embolization abdominal exploration revealed a 2 mm. injury to the right ovarian vein before entering the right renal vein close to the ureteropelvic junction incision. Nephrectomy and ovarian vein ligature were curative. In 1 case the electrocautery wire broke intracorporeally after firing, resulting in a bobby pin-like configuration. Successful removal was accomplished by twisting the catheter and wrapping the wire around the tip, enabling atraumatic removal. CONCLUSIONS: Retrograde balloon cautery endopyelotomy is an emerging technology with potential adverse outcomes. The complications we noted are complex and potentially life threatening. Awareness of these complications may help avoid poor outcomes and expedite appropriate treatment.
PURPOSE: The present study investigated the effects of noxious stimulation of the lower urinary tract on neuronal fos protein expression in the spinal micturition center of rats and also examined the effects of electroacupuncture (EA) on fos expression induced by noxious stimulation of the lower urinary tract. MATERIALS AND METHODS: Experiments were conducted on 21 female Sprague-Dawley rats divided into four groups. Group 1 rats (n = 5) served as normal controls. Group 2 rats (n = 5) received EA at the Sanyinjiao acupoint. Group 3 animals (n = 6) were catheterized through the urethra and instilled with 1% acetic acid, and group 4 (n = 5) animals received EA 1 hour before 1% acetic acid instillation. All animals underwent arterial perfusion, laminectomy, and spinal cord removal. Spinal cords were sectioned and processed for immunohistochemical staining for fos protein. RESULTS: No fos protein was detected in any spinal neurons in normal control animals, and either none or few (0 to 4 cells/section) fos-immunoreactive (fos-IR) cells were seen in animals treated with EA. Noxious stimulation of the lower urinary tract with 1% acetic acid drastically increased the number of fos-IR neurons (30 to 127 cells/L6 section, mean 76.17+/-13.98; 28 to 77, cells/S1 section, mean 59+/-8.30; 7 to 35 cells/S2 section, mean 19.83+/-4.10). However, EA administered 1 hour before 1% acetic acid instillation significantly decreased the number of fos-IR neurons resulting from chemical irritation (0 to 50 cells/L6 section, mean 19.8+/-9.33; 0 to 47 cells/S1 section, mean 13.2+/-9.12; 0 to 37 cells/S2 section, mean 13.6+/-7.31). CONCLUSIONS: Our study demonstrates that bladder instillation with 1% acetic acid induces fos protein expression in the spinal micturition center of the rat and that electroacupuncture can reduce this expression. These results suggest a link between electroacupuncture and reduction in spinal neuronal cell activity.
PURPOSE: Papillary "Randall's plaques" are theorized to act as nidi for urinary stone formation. The aim of this study was to document the presence, pattern and distribution of Randall's plaques in patients undergoing endoscopic procedures for urinary stone disease. MATERIALS AND METHODS: Patients undergoing either ureteroscopy or percutaneous nephroscopy for removal of urinary stones underwent endoscopic mapping of accessible calices. These patients were compared to a smaller group of patients undergoing endoscopic procedures for conditions unrelated to urinary stone disease. In patients found to have papillary plaques the presence, location and pattern of plaques were recorded. Plaque formation was correlated with patient age and sex, and primary composition of extricated stone. RESULTS: Endoscopic evidence of papillary Randall's plaques was found in 74% of 57 patients having ureteroscopic (21) or percutaneous (36) stone removal. Of 7 patients having endoscopic procedures for conditions unrelated to urinary stone disease 3 (43%) had evidence of papillary plaques. Plaques were found uniformly throughout all calices and most commonly diffusely scattered over the papillary surface. There was no correlation between patient age or sex and the presence of plaques. The incidence of plaques varied with the primary composition of extracted stones, and was 100% for calcium phosphate and uric acid, 88% for calcium oxalate, 33% for cystine and 20% for struvite. The incidence of papillary plaques was significantly more common in patients with calcium oxalate (88 versus 43%, p = 0.023) and calcium phosphate stones (100 versus 43%, p = 0.009) than patients without a history of urinary stone disease. CONCLUSIONS: The endoscopic incidence of papillary Randall's plaques in patients with urolithiasis varies with the primary composition of formed urinary stones. Randall's plaques are found in the majority of patients with calcium urinary stone disease. Our findings suggest that the presence of papillary plaques is associated with calcium nephrolithiasis and may contribute to the pathogenesis of calcium urinary stones.
PURPOSE: We define the differences between geriatric patients with urinary stone disease compared to a younger cohort. MATERIALS AND METHODS: A data base, including serum biochemical profiles, 24-hour urinalyses and standardized questionnaires, was retrospectively evaluated from more than 6,000 consecutive patients with urinary stone disease. RESULTS: Geriatric stone formers comprised 12% (721) of all stone patients. Two-thirds of these elderly patients had aberrant urinary values and 29% had isolated hypocitraturia compared to 17% in the younger group. Of geriatric stone forming patients 76% had recurrent urinary stones (mean 3.5 stone episodes), which was similar to the younger comparable group (77%, mean 3.3 stone episodes). The severity of urinary stone disease was similar between the 2 groups based on the need for urological intervention. Geriatric stone patients, in general, experienced the first stone episode later in life (after age 50 years) compared with younger patients. Elderly patients had an increased incidence of uric acid stones, but had a similar incidence of struvite calculi. Geriatric stone patients underwent parathyroid surgery more frequently (2.7 versus 0.7%). Geriatric stone forming patients rarely had renal failure. CONCLUSIONS: The incidence, recurrence and severity of recurrent urinary stone disease were similar between geriatric and younger stone forming patients. Geriatric stone patients had an increased incidence of isolated hypocitraturia, uric acid calculi and previous parathyroidectomy. The geriatric stone population is not merely an extension of younger stone forming patients presenting at an older age. Rather, geriatric patients commonly experience the first symptomatic stone episode later in life.