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PubMed1982

Urinary calculi in children.

Forty-seven cases of urinary calculi were seen, in children from the Western Galilee region, in the last thirteen years. This disease was found in very high frequency in Oriental Jewish children, as well as in Arab children (0.29/1,000 and 0.26/1,000, respectively), and is rare in Jewish children of Ashkenazic European origin (0.04/1,000). These facts were known from previous studies. The striking finding in this survey was the high family incidence of urinary calculi. In 21 of 47 cases from this series one or more family members (up to second cousins) were affected by the same disease. The etiology of "idiopathic" urinary calculi in cases in which no metabolic defect is found was never clearly established. This study suggests that hereditary factors have great importance in a population with a high incidence of this disease.

Adolescent↗

PubMed1985

Dissolution of uric acid calculi with intravenous 1/6 molar lactate.

The use of intravenous 1/6 molar sodium lactate for dissolution of uric acid calculi is reported in 4 patients. All presented with a urine pH of 5. The calculi were located in the proximal ureter in 2 patients and in the renal pelvis in the other 2 patients. After infusion of 1/6 molar lactate, rapid alkalinization of the urine to pH 8 was achieved and maintained. The mean time required for dissolution of the calculi was 6.2 days precluding the need for surgical intervention. The mechanism of action of lactate is oxidative conversion to bicarbonate, providing a sustained alkaline urine. While our patients experienced no metabolic complications, one should monitor serum electrolytes, blood pressure, and fluid balance, particularly in cardiac-compromised patients.

Aged↗

PubMed1989

ESWL monotherapy for large-volume renal calculi: efficacy and morbidity.

We assessed the efficacy and morbidity of extracorporeal shock-wave lithotripsy (ESWL) monotherapy in the treatment of 25 consecutive patients with large-volume renal calculi (surface area greater than or equal to 5.0 cm2). Eighteen of the calculi were infection (struvite) stones and 7 were sterile stones. In 21 cases internal ureteral stents were positioned before ESWL, but no patient underwent pretreatment percutaneous nephrostomy (PCN) or percutaneous nephrostolithotomy (PNL). An average of 2.1 procedures including ESWL, PCN, or ureteral interventions were required to achieve a stone-free renal collecting system and ureter, or residual stone particles less than 4 mm in diameter confined to the renal collecting system. Sixty percent of the patients required no ancillary procedures after ESWL. There were no differences in the mean duration of hospitalization, need for post-treatment ancillary procedures, time to clearance of ureteral fragments, and incidence of residual stone particles among patients with infection and sterile stones. Of 23 patients observed greater than three months (mean 10.9 mos) after ESWL, 43 percent had residual stone particles in the renal collecting system. Expansion of these particles or stone recurrence in the absence of residual particles has not been observed. We conclude that large volume renal calculi may be managed effectively and safely with ESWL monotherapy.

Adult↗

PubMed1991

ESWL treatment with ventral shock-wave application: therapy of iliac and distal ureteral calculi.

Because of the interposition of bony structures, extracorporeal shock-wave lithotripsy (ESWL) of middle or iliac ureteral calculi is not feasible in the conventional supine position. By a slight modification of the patient's couch allowing the prone positioning of the patient, 22 patients with calculi covered by bony structures were thus treated. The success rate of 95 percent without complications is promising and renders ESWL therapy as an alternative to ureteroscopic extraction of mid and iliac ureteral calculi.

Humans↗

PubMed2004

Refinements in treatment of large bladder calculi: simultaneous percutaneous suprapubic and transurethral cystolithotripsy.

OBJECTIVES: To present a combined endourologic approach to treat bladder calculi consisting of simultaneous percutaneous suprapubic and transurethral cystolithotripsy. METHODS: We report on a series of 12 consecutive patients with bladder stone burdens of 40 mm or greater. Percutaneous 30F access was obtained under cystoscopic control. Fragmentation and stone removal were performed simultaneously by two urologists using a Swiss lithoclast, holmium laser, and/or ultrasound lithotriptor through both percutaneous and transurethral routes. Suprapubic and transurethral catheters were placed postoperatively. RESULTS: Twelve patients with a median age of 66 years (range 33 to 80) were treated by simultaneous percutaneous suprapubic and transurethral cystolithotripsy. Six underwent transurethral resection of the prostate at the completion of stone clearance. The median stone size was 60 mm (range 40 to 80), and the median lithotripsy time was 56 minutes (range 45 to 70). The median postoperative hospitalization was 2.7 days (range 2 to 5), and complete stone clearance was achieved in all cases. One patient, who underwent concomitant transurethral resection of the prostate, developed urinary retention 1 week postoperatively and was successfully treated by temporary transurethral catheterization. One patient with a positive urine culture preoperatively developed fever on the first postoperative day and was treated with intravenous antibiotics according to the antibiogram results for 5 days. No other complications had occurred after a median follow-up of 10 months (range 3 to 15). CONCLUSIONS: Simultaneous percutaneous suprapubic and transurethral cystolithotripsy appears to be a safe approach for the management of large bladder calculi and may shorten the total fragmentation time. It can be combined with transurethral resection of the prostate without prolonging hospitalization. The simultaneous use of two modalities of stone fragmentation represents an effective and minimally invasive way of treating large bladder calculi.

Adult↗

PubMed2005

Comparative study of percutaneous access for staghorn calculi.

OBJECTIVES: To compare the success and complication rates of staghorn calculi treated through the upper pole calix, lower/middle calices, and multiple access. METHODS: Between January 1995 and December 2000, the records of 119 patients with staghorn calculi who underwent percutaneous nephrolithotomy were retrospectively reviewed. The mean stone burden was 6.9 cm. Of the 119 patients, 16 (13.4%) had upper pole access, 70 (58.8%) lower or middle calix access, and 33 (27.7%) multiple renal access. RESULTS: The stone-free rate was 80.0% for those in the lower/middle, 87.5% for those in the upper pole, and 84.8% for those in the multiple access group. Single access was performed in 72.3% and multiple access tracts in 27.7% of patients. The average operative time was 86.8 minutes in the upper pole, 139.1 minutes in the lower/middle pole, and 134.9 minutes in the multiple access groups. Extracorporeal shock wave lithotripsy was used in 4.2% of patients. The overall complication rate was 28.5% (25% in the upper pole, 21.4% in the lower/middle, and 45.4% in the multiple access group). Thoracic complications (pneumothorax and hydrothorax) occurred in 2 patients (1.7%), but only 1 patient had undergone supracostal access. Bleeding requiring blood transfusion was significantly greater in the multiple access group. The average hospital stay was 3.0 days for all patients. CONCLUSIONS: The success of percutaneous treatment of patients with staghorn calculi is highly related to optimal kidney access. The supracostal and multiple access approaches can be used, with a slight increase in the incidence of acceptable complications.

Humans↗

PubMed2006

Renal calculi presenting as hyperhidrosis in patient with spinal cord injury.

Renal calculi in the spinal cord injury population present a diagnostic dilemma for urologists. However, 7% of all patients with spinal cord injury will develop renal calculi. Undiagnosed stone disease can lead to significant morbidity and mortality in this population. This case demonstrates the subtlety of the presenting symptoms of renal calculi in the patient with spinal cord injury.

Adult↗

PubMed2006

Preventing retrograde stone displacement during pneumatic lithotripsy for ureteral calculi using lidocaine jelly.

OBJECTIVES: To assess the efficacy of lubricating jelly instillation proximal to the upper ureteral calculi during lithotripsy on the prevention of retrograde stone displacement and the stone-free rate. METHODS: Thirty-four patients with upper ureteral calculi of less than 2 cm were randomized into two groups: jelly instillation (n = 16) and controls (n = 18). Ureteroscopy was performed using a 9.8F semirigid ureteroscope. A 5F ureteral stent was advanced beyond the stone. Lidocaine jelly (2 mL) was instilled, and lithotripsy was done with a Swiss Lithoclast. A 5F ureteral catheter was left in place for 24 hours, and patients were followed up at 24 hours with radiography of the kidneys, ureters, and bladder and at 2 weeks with intravenous urography. RESULTS: Both groups were comparable in terms of mean age and stone size. Stone or stone fragment migration occurred in 12.4% of the treatment group and 44.4% of the controls, statistically significantly different (P = 0.046). The stone-free rate was 93.7% and 83.3% in the treatment and control groups, respectively. The rates did not improve after 2 weeks, and the difference was not statistically significant between the two groups (P = 0.384). The mean operative time was also comparable between the two groups. CONCLUSIONS: Lidocaine jelly instillation proximal to the ureteral calculi during lithotripsy is an effective method to prevent retrograde stone displacement, but its effect on improving the stone-free rate was not significant in our study. Larger studies are needed to disclose more details about the efficacy of this method.

Adult↗

PubMed2003

Determination of calcium oxalate (mono- and dihydrate) in mixtures with magnesium ammonium phosphate or uric acid: the use of simultaneous thermal analysis in urinary calculi.

BACKGROUND: The human urinary calculi are mainly formed from calcium oxalate, magnesium ammonium phosphate hexahydrate (MAPH) and uric acid (UA) crystals. It is important for the physician and surgeon to distinguish the two types of hydrates of calcium oxalate, mainly mono- (COM, Whewellite) and dihydrate (COD, Weddelite). This is because COM stones are evacuated two times more frequently than COD, which sometimes needs to be extracted surgically. METHODS: Thermal analysis techniques, such as Differential Thermal Analysis (DTA) and Thermogravimetry (TG), are considered the best techniques for the characterization of the two hydrates of calcium oxalate. A simultaneous thermal analysis method (TG-DTA) was applied to determine the percentage of each hydrate (COM and COD) when present together, in the presence of MAPH or in the presence of UA. RESULTS: The results performed on 156 urinary calculi were as follows (according to the major component): 74.36%, 7.05% and 10.26% for calcium oxalate hydrate, UA and MAPH, respectively. The COD/COM ratios were 0.75 and 1.75, when they are present in mixtures with UA and MAPH, respectively. CONCLUSIONS: Fourier transform infrared (FTIR) and X-ray diffraction (XRD) have been used in urinary calculi analysis. Simultaneous thermal analysis TG-DTA would be an alternative method for quantitative determination of the two types of calcium oxalate in urinary stones.

Calcium Oxalate↗

PubMed1988

The tooth-root sign: a characteristic appearance of distal ureteric calculi.

Diagnostic accuracy in identifying calculi in patients with ureteric colic is poor. Lower ureteric calculi may be confused with other pelvic calcific opacities. A characteristic appearance of some larger lower ureteric calculi is described and likened to the root of a tooth. It is hoped that the tooth-root sign will be of assistance in the diagnosis of distal ureteric stones.

Humans↗

PubMed1997

Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association.

PURPOSE: The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data. MATERIALS AND METHODS: The panel searched the MEDLINE data base for all articles related to ureteral calculi published from 1966 to January 1996. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative treatments of ureteral calculi. RESULTS: The data indicate that up to 98% of stones less than 0.5 cm. in diameter, especially in the distal ureter, will pass spontaneously. Shock wave lithotripsy is recommended as first line treatment for most patients with stones 1 cm. or less in the proximal ureter. Shock wave lithotripsy and ureteroscopy are acceptable treatment choices for stones 1 cm. or less in the distal ureter. CONCLUSIONS: Most ureteral stones will pass spontaneously. Those that do not can be removed by either shock wave lithotripsy or ureteroscopy. Traditional blind basket extraction, without fluoroscopic control and guide wires, is not recommended. Open surgery is appropriate as a salvage procedure or in certain unusual circumstances.

Humans↗

PubMed1995

Submucosal calculi: endoscopic and intraluminal sonographic diagnosis and treatment options.

After shock wave lithotripsy and endoscopic lithotripsy, occasionally a patient has persistent ureteral fragments associated with ureteral obstruction. After lithotripsy, stone fragments may be embedded in the ureteral mucosa, and they may become completely submucosal and associated with obstruction. Others may be hidden in iatrogenic ureteral outpouchings, while still others may be extruded from the ureter entirely. We present 20 patients who were referred after previous treatment failed to clear fragments or who had residual obstruction. The majority of patients had failed endoscopic fragment retrieval or shock wave lithotripsy and were referred with ureteral obstruction. All patients were reevaluated by repeated upper tract endoscopy with small diameter endoscopes. As an adjunct to ureteral endoscopy, a 6F, 20 MHz. ultrasound probe was placed transureterally to determine the depth and location of stones. A total of 15 patients in this series had hyperechoic foci with shadowing consistent with submucosal or periureteral stone fragments. A decision for treatment was based upon the location as noted by sonographic and fluoroscopic visualization of intramucosal and submucosal fragments. Calculi more than 4 mm. from the lumen were not removed without evidence of obstruction. Multiple, small (speckled) fragments embedded in the mucosa were often associated with subsequent stricture. Solitary fragments within the wall of the ureter could be removed with relief of obstruction. The risk of embedding calculi submucosally during lithotripsy should be recognized. Submucosal fragments causing obstruction should be removed endoscopically. Totally extruded calculi may be left in situ safely.

Adolescent↗

PubMed1999

Staghorn calculi in children: treatment with monotherapy extracorporeal shock wave lithotripsy.

PURPOSE: We evaluated the effectiveness of monotherapy extracorporeal shock wave lithotripsy (ESWLT) for treating children with staghorn calculi. MATERIALS AND METHODS: From February 1992 to December 1997, 11 boys and 4 girls 14 months to 13 years old (median age 4 years) presented to our institution with staghorn calculi. In these patients ESWL was performed using a Siemens Lithostar-ULTRA with ultrasound stone localization and with intravenous sedation or without anesthesia. Using the Puigvert method the frequency and energy of the shock waves delivered were increased progressively to desensitize cutaneous nerve receptors, making the procedure less painful and improving stone fragmentation. RESULTS: Overall stones resolved in 11 of the 15 patients (73.3%) after an average of 2 ESWL sessions. Of the 11 patients 7 were stone-free after only 1 session, 2 with fragments less than 5 mm. required no further intervention, and 2 required additional surgery, including percutaneous nephrolithotomy to remove large residual stone fragments in 1 and open renal surgery to remove a cystine staghorn calculus in 1. Ureteral stents were not required in any patients. One case of post-ESWL fever resolved promptly with antibiotics. CONCLUSIONS: ESWL using the Siemens Lithostar-ULTRA is simple, effective and safe primary treatment in children with staghorn calculi.

Adolescent↗

PubMed1997

Teleradiology in urology: comparison of digital image quality with original radiographic films to detect urinary calculi.

PURPOSE: Teleradiology systems are now being evaluated as a mechanism to provide rapid, accurate and cost-effective diagnostic radiographs to off-site physicians. Little data are available on the role and safety of teleradiology in urology. To address these issues a personal computer based system was developed to assess the diagnostic accuracy and ease of use of transmitted digital images when evaluating for urinary calculi. MATERIALS AND METHODS: A total of 100 plain abdominal scout films from excretory urograms performed during acute urological referrals was digitized on a laser scanner. The 10 megabyte files were transferred over public telephone lines and written to compact disks. The images were viewed on a 1280 x 1640 resolution monitor using "Imager-3D" software run on a 133 MHz. pentium personal computer with 32 megabytes of random access memory. Two faculty urologists and 2 urology fellows each looked at 50 original radiographs and 50 digital images. Diagnostic interpretations of the presence and location of calculi were recorded, and confidence in the diagnosis, assessment of image quality and diagnostic difficulty were scored using a numerical scale. RESULTS: The accuracy for all readers was 86.5% for plain radiographs and 81.5% for digital images (p >0.2). There was no statistical difference between faculty and fellows. Diagnostic accuracy did not differ between plain films and screen images when the results were assessed with respect to image quality, diagnostic difficulty or the reader confidence in the diagnosis (p >0.1). Compared to plain films, more screen images were classified as lower image quality (60 versus 40%) and the diagnostic confidence was lower (low and medium grade 50 versus 35%), although this did not interfere with diagnostic accuracy. CONCLUSIONS: These data imply that a high quality affordable teleradiology system is effective and accurate compared to plain films for assessing urinary calculi.

Humans↗

PubMed2002

Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients.

PURPOSE: We assessed the effectiveness and safety of holmium:YAG laser lithotripsy for managing upper urinary tract calculi in a prospective cohort of 598 patients. MATERIALS AND METHODS: Ureteroscopic holmium:YAG laser lithotripsy was performed in 598 patients between 1993 and 1999. Calculi were located in the distal ureter in 39.6% of cases, mid ureter in 18.6%, proximal ureter in 32.4% and kidney in 9.4%. Patients were treated on an outpatient basis with various flexible and semirigid endoscopes. Of the cases 59% were referred as previous treatment failures. Patients were assessed 6 to 12 weeks postoperatively with repeat plain x-ray and ultrasound or excretory urography for late obstructive complications. RESULTS: The overall stone-free rate was 97%. As stratified by location, the stone-free rate was 98% in the distal ureter, 100% in the mid ureter, 97% in the proximal ureter and 84% in the kidney. Fragmentation was incomplete in 6% of cases and secondary intervention was required in 6%. The overall complication rate was 4%. New onset ureteral stricture developed postoperatively in 0.35% of patients. CONCLUSIONS: Holmium:YAG laser lithotripsy is a highly effective and safe treatment modality for managing ureteral and a proportion of intrarenal calculi on an outpatient basis. The effectiveness and versatility of the holmium laser combined with small rigid or flexible endoscopes make it our modality of choice for ureteroscopic lithotripsy.

Adolescent↗

PubMed2001

Ureteral stenting after ureteroscopy for distal ureteral calculi: a multi-institutional prospective randomized controlled study assessing pain, outcomes and complications.

PURPOSE: We compare postoperative pain, stone-free rates and complications after ureteroscopic treatment of distal ureteral calculi with or without the use of ureteral stents. MATERIALS AND METHODS: A total of 113 patients with distal ureteral calculi amenable to ureteroscopic treatment were prospectively randomized into stented (53) and unstented (60) groups. Stones were managed with semirigid ureteroscopes with or without distal ureteral dilation and/or intracorporeal lithotripsy. Preoperative and postoperative pain questionnaires were obtained from each patient. Patients with stents had them removed 3 to 10 days postoperatively. Radiographic followup was performed postoperatively to assess stone-free rates and evidence of obstruction. RESULTS: Six patients randomized to the unstented group were withdrawn from the study after significant intraoperative ureteral trauma was recognized, including 3 ureteral perforations, that required ureteral stent placement, leaving 53 with stents and 54 without for analysis. Patients with stents had statistically significantly more postoperative flank pain (p = 0.005), bladder pain (p <0.001), urinary symptoms (p = 0.002), overall pain (p <0.001) and total narcotic use (p <0.001) compared to the unstented group. Intraoperative ureteral dilation or intracorporeal lithotripsy did not statistically significantly affect postoperative pain or narcotic use in either group (p >0.05 in all cases). Overall mean stone size in our study was 6.6 mm. There were 4 (7.4%) patients without stents who required postoperative readmission to the hospital secondary to flank pain. All patients (85%) who underwent imaging postoperatively were without evidence of obstruction or ureteral stricture on followup imaging (mean followup plus or minus standard deviation 1.8 +/- 1.5 months), and the stone-free rate was 99.1%. CONCLUSIONS: Uncomplicated ureteroscopy for distal ureteral calculi with or without intraoperative ureteral dilation can safely be performed without placement of a ureteral stent. Patients without stents had significantly less pain, fewer urinary symptoms and decreased narcotic use postoperatively.

Humans↗

PubMed2001

Gastric patch pyeloplasty: development of an animal model to produce upper tract urinary acidification for treating struvite urinary calculi.

PURPOSE: Struvite calculi form in an alkaline environment created by urease producing uropathogens. We developed a viable upper tract urinary acidification model by performing gastric patch pyeloplasty in the rabbit. This model produces urinary acidification sufficient for the treatment and prevention of struvite renal calculi. We evaluated the physiological, metabolic and surgical outcomes. MATERIALS AND METHODS: gastric segment was harvested based on branches of the left gastro-epiploic artery. The flap was folded along the transverse axis and the adjacent edges were closed. The mouth of this reconfigured pouch provided optimal dimensions for anastomosis with the diminutive renal pelvis. Half of the rabbits were treated with internal stenting and H-2 blockade. Urinary pH was assessed by weekly cage collection and direct collection from the cannulated ureters. Urine culture was done, and serum gastrin and electrolytes were assessed at regular intervals. The rabbits were sacrificed at 3 to 26 weeks. Histological examination was routinely performed. RESULTS: A total of 15 rabbits were available for complete assessment. Sustained urinary acidification was produced in 7 animals (47%) with a mean pH decrease of 2.27. In another 2 rabbits (13%) the urine was initially acidic but subsequently became alkaline due to ureteral obstruction. Electrolytes and gastrin were unchanged in these rabbits and urine culture was positive in 2. Histological testing revealed nonspecific inflammatory changes of the renal pelvis. Anastomotic complications were the most common surgical complication and the most common cause of failed acidification. The cohort treated without stents and H-2 blockade was at significantly greater risk for anastomotic leakage. CONCLUSIONS: Gastric patch pyeloplasty may significantly increase urinary acidity in the rabbit model without altering the serum electrolyte balance or gastrin level. The procedure utilizes common techniques of reconstructive urology and may be possible with laparoscopy. Further study is required to assess the in vivo effect of this procedure for treating and preventing upper tract struvite calculi.

Animals↗

PubMed1994

Selective minimally invasive management of calculi in patients with urinary diversions.

We evaluate the efficacy of selectively applied minimally invasive management of calculi in 30 patients with urinary diversions (ileal/jejunal conduit in 23, cutaneous ureterostomy in 2, nonrefluxing colon conduit in 4 and ureterosigmoidostomy in 1). Upper tract calculi in 38 renal units were managed with extracorporeal shock wave lithotripsy or endo-urologically. Patients were divided into 3 treatment groups determined primarily by stone size and location: group 1-25 renal units with a mean stone burden of 1.78 cm.2 treated with extracorporeal shock wave lithotripsy alone, group 2-7 renal units with a mean stone burden of 12.75 cm.2 treated with percutaneous nephrostolithotomy alone and group 3-6 renal units with a mean stone burden of 19.03 cm.2 treated with a combination of both procedures. Stone-free results were 92%, 100% and 67% in groups 1 to 3, respectively. Total hospital stay averaged 4.3, 11.1 and 13.7 nights, while complications occurred in 1, 3 and 2 patients, respectively. We conclude that selective application of contemporary techniques for minimally invasive management of calculi in patients with a urinary diversion can provide acceptable results, even with progressively large and complex stone burdens, and that these results will be equivalent to those achieved in patients without urinary diversion.

Adult↗