Caliceal Group Research Articles

Kidney collecting system anatomy applied to endourology - a narrative review.

To evaluate the surgical anatomy of the kidney collecting system through a narrative review of the literature, highlighting its importance during diagnosis and its approach during surgical procedures for the treatment of renal stones. We carried out a review about the anatomy of the kidney collecting system. We analyzed papers published in the past 40 years in the databases Pubmed, Embase and Scielo, and we included only papers in English and excluded case reports, editorials and opinions of specialists. Renal collecting system could be divided in four groups: A1 - kidney midzone (KM), drained by minor calyx that are dependent on the superior or the inferior caliceal groups; A2 - KM drained by crossed calyx, one draining into the superior caliceal group and another draining into the inferior caliceal group; B1 - KM drained by a major caliceal group independent of both the superior and inferior groups; and B2 - KM drained by minor calyx entering directly into the renal pelvis. Some details and anatomic variations of the collecting system are related to clinical and radiological aspects, particularly perpendicular calyces, interpyelocalyx space, position of calyces in relation to renal border, classification of the renal collecting system, infundibular diameter and the angle between the lower infundibulum and renal pelvis. The knowledge of intra-renal collecting system divisions and variations as the angle between the renal pelvis and lower infundibula, position of the calices in relationship with renal edge and the diameter and position of the calyces are important for the planning of minimally invasive renal surgeries.

Stone Free Rate of Lower Pole Calyceal Stone Versus Other Calyces in Retrograde Intrarenal Surgery

Background: Miniaturization of endoscopic instruments has gained wide popularity in the treatment of renal calculi. Retrograde intra-renal surgery (RIRS) and laser in combination has already proven their superiority when compared to other modalities in the treatment of renal calculi. This study was conducted to assess the stone-free rate (SFR) of lower pole calyceal stone versus other pole calyces in RIRS. Methods: This retrospective study analyzed the stone free rate of lower pole calyx stone versus other pole calyces in retrograde intra renal surgery (RIRS) adults above 15 years of age from March 2021 to February 2022 at Chitwan Medical College and Teaching Hospital, Nepal. The stone-free rate was assessed descriptively on post operative complications, stone size, operative time, hospital stay, and need for the second procedure. Results: A total of 62 patients underwent retrograde intrarenal surgery. The mean age of the study population was 38.41 ± 10.54years in the lower caliceal group against 39.09 ±13.53 years with p value of 0.829.The mean hounsfield of lower caliceal stone was 1023.31±252.96 to that of other caliceal stones 1004.00±349.22 with p value of 0.806. The sizes of the stones were 11.07±2.10 mm in lower caliceal stones versus 10.67±2.51mm in other caliceal stones with p value of 0.507. The duration of operation time in 1st group was 63.82±23.57minutes to that of 65.93±28.96 in 2nd group with p value of 0.756. The hospital stay in lower caliceal stones were 6.13±1.43days to that of other caliceal stones 5.87±0.99 with significant p value of 0.412. There were no major complications in both arms. The stone free rate was 25 (86.2%) in lower caliceal stones as compared to 31(93.93%) in other caliceal stones with no significant p value of 0.405. Conclusions: Retrograde intrarenal surgery is a better procedure that continues to undergo significant advancements. It is a technically safe and effective procedure for the treatment option for treating the lower pole calyx calculus with optimal post-surgical morbidity and stone-free rate.

Definition and Unfavorable Risk Factors of Trifecta in Mini-Percutaneous Nephrolithotomy.

Objectives: In performing mini-percutaneous nephrolithotomy (PCNL), we aimed at achieving the trifecta of stone-free status and no complications in a single treatment session. We analyzed our experience to determine negative predictors for achieving these three-fold goals. Patients and Methods: The data of all consecutive patients who underwent tubeless mini-PCNL between July 2015 and March 2020 in two hospitals were retrospectively reviewed. Stone-free was defined as no residual stones. Complications were recorded and graded according to modified Clavien classification. Patients were divided into two groups according to the outcome (trifecta and non-trifecta). Factors affecting the outcome were compared between both groups by using univariate and multivariate analyses to detect independent unfavorable risk factors. Results: The study included 944 patients with mean age 40.2 years (standard deviation: 13.6). The stone-free rate after one session of mini-PCNL was 90.7%. Auxiliary procedures were needed in 14 patients (1.5%). Complications were observed in 76 patients (8.1%). Trifecta was achieved in 792 patients (84%). Independent unfavorable risk factors in multivariate analysis were number of caliceal groups affected by the stones (relative risks were 1.95 to 2.27 and 5.7 for one, two, and three caliceal groups respectively) and number of percutaneous tracts (relative risk was 2.2). Stone size and complexity were not significant predictors of missing trifecta in multivariate analysis. Conclusions: Mini-PCNL can achieve a high rate of trifecta (84%) for different stone sizes and complexities. Stones distribution in multiple caliceal groups and multiple tracts are the independent unfavorable risk factor.

Two-part silicone mold. A new tool for flexible ureteroscopy surgical training.

ABSTRACTIntroduction and objectives:Flexible ureteroscopy is a common procedure nowadays. Most of the training programs use virtual reality simulators. The aim of this study was to standardize the building of a three-dimensional silicone mold (cavity) of the collecting system, on the basis of polyester resin endocasts, which can be used in surgical training programs.Materials and Methods:A yellow polyester resin was injected into the ureter to fill the collecting system of 24 cadaveric fresh human kidneys. After setting off the resin, the kidneys were immersed in hydrochloric acid until total corrosion of the organic matter was achieved and the collecting system endocasts obtained. The endocasts were used to prepare white color two-part silicone molds, which after endocasts withdrawn, enabled a ureteroscope insertion into the collecting system molds (cavities). Also, the minor calices were painted with different colors in order to map the access to the different caliceal groups. The cost of the materials used in the molds is $30.00 and two days are needed to build them.Results:Flexible ureteroscope could be inserted into all molds and the entire collecting system could be examined. Since some anatomical features, as infundular length, acute angle, and perpendicular minor calices may difficult the access to some minor calices, especially in the lower caliceal group, surgical training in models leads to better surgical results.Conclusions:The two-part silicone mold is feasible, cheap and allows its use for flexible ureteroscopy surgical training.

Influence of the renal lower pole anatomy and mid-renal-zone classification in successful approach to the calices during flexible ureteroscopy.

The aim of this paper is to analyze if the anatomy type of the collector system (CS) limits the accessibility of flexible ureteroscopy (FUR) in the lower pole. We analyzed the pyelographies of 51 patients submitted to FUR and divided the CS into four groups: A1-kidney midzone (KM) drained by minor calices (Mc) that are dependent on the superior or on the inferior caliceal groups; A2-KM drained by crossed calices; B1-KM drained by a major caliceal group independent both of the superior and inferior groups, and B2-KM drained by Mc entering directly into the renal pelvis. We studied the number of calices, the angle between the lower infundibulum and renal pelvis, and the angle between the lower infundibulum and the inferior Mc. With the use of a flexible ureteroscope, the access attempt was made to all of lower pole calices. Averages were statistically compared using the ANOVA and Unpaired T test (p < 0.05). We found 14 kidneys of A1 (27.45 %); 4 of A2 (7.84 %); 17 of B1 (33.33 %); and 16 of B2 (31.37 %). The LIP was >90° in 31 kidneys (60.78 %) and between 61° and 90° in 20 kidneys (39.22 %). We did not find angles smaller than 60°. The group A1 presented 48 Mc and the UF was able to access 42 (87.5 %); the group A2 had 11 Mc and the UF was able to access 7 (63.64 %); the group B1 had 48 Mc and the UF was able to access 41 (85.42 %) and in group B2 we observed 41 Mc and the UF could access 35 (85.36 %). There was no statistical difference in the accessibility between the groups (p = 0.2610). Collecting system with kidney midzone drained by crossed calices presented the lower accessibility rate during FUR.

External Validation and Predictive Accuracy Assessment of Guy's Stone Score as a Preoperative Tool for Estimating Percutaneous Nephrolithotomy Outcomes.

To externally validate Guy's stone score system and estimate its predictive accuracy. An analysis of 282 consecutive patients, who underwent a percutaneous nephrolithotomy, was performed. The association between Guy's stone score and several pre-, intra-, and postoperative parameters was assessed. A univariate and multivariate analysis was conducted to identify the independent predictors for stone-free rates. Area under the curve was used for predictive accuracy estimation. Stone burden, multiple stone locations, number of stones, number of implicated caliceal groups, and Guy's stone score were significantly associated with stone-free outcomes. The multivariate analysis showed that Guy's stone score, number of stones, and number of implicated caliceal groups are independent predictors of stone-free status. Receiver operating characteristic curve analysis revealed a significant predictive accuracy for the Guy's stone score. The present study externally validated Guy's stone score. Significant predictive ability combined with great predictive accuracy was found.

Lower pole anatomy and mid-renal-zone classification applied to flexible ureteroscopy: experimental study using human three-dimensional endocasts.

The aim of this study was to analyze the anatomy of the inferior pole collecting system and the mid-renal-zone classification in human endocasts applied to flexible ureteroscopy. 170 three-dimensional polyester resin endocasts of the kidney collecting system were obtained from 85 adult cadavers. We divided the endocasts into four groups: A1--kidney midzone (KM), drained by minor calices (mc) that are dependent on the superior or the inferior caliceal groups; A2--KM drained by crossed calices; B1--KM drained by a major caliceal group independent of both the superior and inferior groups; and B2--KM drained by mc entering directly into the renal pelvis. We studied the number of calices, the angle between the lower infundibulum and renal pelvis and the angle between the lower infundibulum and the inferior mc (LIICA). Means were statistically compared using ANOVA and the unpaired T test (p < 0.05). We found 57 (33.53 %) endocasts of group A1; 23 (13.53 %) of group A2; 59 (34.71 %) of group B1; and 31 (18.23 %) of group B2. The inferior pole was drained by four or more calices in 84 cases (49.41 %), distributed into groups as follows: A1 = 35 cases (41.67 %); A2 = 18 (21.43 %); B1 = 22 (26.19 %); and B2 = 9 (10.71 %). Perpendicular mc were observed in 15 cases (8.82 %). We did not observe statistical differences between the LIICA in the groups studied. Collector systems with kidney midzone drained by minor calices that are dependent on the superior or on the inferior caliceal groups presented at least two restrictive anatomical features. The mid-renal-zone classification was predictive of anatomical risk factors for lower pole ureteroscopy difficulties.

MP28-07 FLEXIBLE URETEROSCOPY TRAINING. NEW TOOL OF TWO-PART SILICONE MOLD (CAVITIES) BASED ON REAL HUMAN KIDNEYS ENDOCASTS

You have accessJournal of UrologyStone Disease: Surgical Therapy II1 Apr 2015MP28-07 FLEXIBLE URETEROSCOPY TRAINING. NEW TOOL OF TWO-PART SILICONE MOLD (CAVITIES) BASED ON REAL HUMAN KIDNEYS ENDOCASTS Bruno Marroig, Marco Pereira Sampaio, Luciano Favorito, and Francisco Sampaio Bruno MarroigBruno Marroig More articles by this author , Marco Pereira SampaioMarco Pereira Sampaio More articles by this author , Luciano FavoritoLuciano Favorito More articles by this author , and Francisco SampaioFrancisco Sampaio More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1230AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Flexible ureteroscopy is a common procedure nowadays. Most of the training programs use virtual reality simulators. The aim of this study was to standardize the building of a three-dimensional silicone mold (cavity) of the collecting system, based on polyester resin endocasts, which can be used in surgical training programs. METHODS A yellow polyester resin was injected into the ureter to fill the collecting system of 10 cadaveric fresh human kidneys. After setting off the resin, the kidneys were immersed in hydrochloric acid until total corrosion of the organic matter was achieved and the collecting system endocasts obtained. The endocasts were used to prepare white color two-part silicone molds, which after endocasts withdrawn, enabled an ureteroscope insertion into the collecting system molds (cavities). Also, the minor calices were painted with different colors in order to map the access to the different caliceal groups. RESULTS Flexible ureteroscope could be inserted into all molds and the entire collecting system could be examined. Some anatomical features, as infundibular length, acute angle, and perpendicular minor calices would difficult the access to some minor calices, especially in the lower caliceal group. CONCLUSIONS The two-part silicone mold is feasible, cheap and allows its use for flexible ureteroscopy surgical training. By the first time, it is presented a training-model made from actual intra-renal collecting system cavities after endocasts. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e313 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Bruno Marroig More articles by this author Marco Pereira Sampaio More articles by this author Luciano Favorito More articles by this author Francisco Sampaio More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Giant Calculus in the Ureteropelvic Junction: A Case Report

Urinary lithiasis is an affection of high social impact associated with high costs. Its incidence varies from 1 to 15% in the general population and has a recurrence chance of 26-50%. We report one rare case of giant ureteral calculus in the ureteropelvic junction in a patient with complaints of left lumbar pain and recurrent urinary tract infection diagnosed in the outpatients‘ Urology clinics. Antibioticotherapy was instituted and complementary tests were done. The abdomen x-ray showed a large opacity in the left kidney topography, and the computed tomography evidenced a giant left ureteral calculus associated with a large ureteropelvic junction dilation and grade III hydronephrosis. An ureterolitothomy was performed and evidenced a calculus of 9.5x6.5cm and weighting 347g. The patient became well after the surgery, and a pyelogram evidenced dilation of both caliceal groups and left ureter, without any calculus. Urinary lithiasis should be early diagnosed and treated in order to avoid severe complications as the presented here.DOI: http://dx.doi.org/10.3329/jom.v15i1.19884 J Medicine 2014; 15: 91-93

MP7-02 PRE-OPERATIVE FAT DENSITY CHARACTERISTICS FROM COMPUTED TOMOGRAPHY IMAGING IS PREDICTIVE OF EASE OF PERINEPHRIC FAT DISSECTION AT TIME OF PARTIAL NEPHRECTOMY

INTRODUCTION AND OBJECTIVES: To determine whether renal papillae density using attenuation measurement (HU) on noncontrast Computed Tomography (CT) can predict the development of urinary calculi in stone free patients as well in recurrent stone formers and its role in predicting any associated urinary metabolic abnormality. METHODS: In this study we compared renal papillae density using attenuation measurement (HU) on noncontrast Computed Tomography (CT) in stone forming group (SFG) (first time stone formers and recurrent stone formers) with the healthy stone free control group (CG). The SFG inclusion criteria were active stone disease (unilateral or bilateral) diagnosed by abdominal computed tomography. Prospective living kidney donor without active or past history of stone disease formed CG. Papillae tip attenuation was measured using noncontrast CT. Mean Hounsfield density (HU) of 3 caliceal group was calculated for each kidney. 24 hours urinary metabolic evaluation was done wherever deemed necessary. Statistical analysis was done using student’s ttest. RESULTS: Total of 665 SFG and 104 CG patients met inclusion criteria. 343 patients had bilateral urolithiasis, 312 patients had unilateral urolithiasis, 52 were recurrent stone former and 38 patients having hyperoxaluria and hypercalciuria each. Mean HU of papillae of SFG was greater than that of CG (29.46 3.06 Vs 27.71 0.48; p 0.05) as was patients having Hyperoxaluria (29.80 2.15 Vs 29.46 3.06, p>0.05). CONCLUSIONS: Mean HU of renal papillae was significantly increased in patient with urolithiasis. This holds valid for papillae with or without calculi. There isnosignificant differencebetweenmeanHUof renal papillae density in patients having Hypercalciuria/Hyperoxaluria when compared with stone bearing patients with normal urinarymetabolic study.

MP7-01 CAN A NON CONTRAST COMPUTED TOMOGRAPHY FINDING PREDICT DEVELOPMENT OF URINARY CALCULI, CHANCES OF RECURRENT STONE DISEASE AND ASSOCIATED URINE METABOLIC ABNORMALITY – A REVIEW OF 655 PATIENTS

You have accessJournal of UrologyImaging/Radiology II1 Apr 2014MP7-01 CAN A NON CONTRAST COMPUTED TOMOGRAPHY FINDING PREDICT DEVELOPMENT OF URINARY CALCULI, CHANCES OF RECURRENT STONE DISEASE AND ASSOCIATED URINE METABOLIC ABNORMALITY – A REVIEW OF 655 PATIENTS Ankush Jairath, Arvind Ganpule, Jigish Vyas, Shashikant Mishra, Ravindra Sabnis, and Mahesh Desai Ankush JairathAnkush Jairath More articles by this author , Arvind GanpuleArvind Ganpule More articles by this author , Jigish VyasJigish Vyas More articles by this author , Shashikant MishraShashikant Mishra More articles by this author , Ravindra SabnisRavindra Sabnis More articles by this author , and Mahesh DesaiMahesh Desai More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.324AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To determine whether renal papillae density using attenuation measurement (HU) on noncontrast Computed Tomography (CT) can predict the development of urinary calculi in stone free patients as well in recurrent stone formers and its role in predicting any associated urinary metabolic abnormality. METHODS In this study we compared renal papillae density using attenuation measurement (HU) on noncontrast Computed Tomography (CT) in stone forming group (SFG) (first time stone formers and recurrent stone formers) with the healthy stone free control group (CG). The SFG inclusion criteria were active stone disease (unilateral or bilateral) diagnosed by abdominal computed tomography. Prospective living kidney donor without active or past history of stone disease formed CG. Papillae tip attenuation was measured using noncontrast CT. Mean Hounsfield density (HU) of 3 caliceal group was calculated for each kidney. 24 hours urinary metabolic evaluation was done wherever deemed necessary. Statistical analysis was done using student’s t- test. RESULTS Total of 665 SFG and 104 CG patients met inclusion criteria. 343 patients had bilateral urolithiasis, 312 patients had unilateral urolithiasis, 52 were recurrent stone former and 38 patients having hyperoxaluria and hypercalciuria each. Mean HU of papillae of SFG was greater than that of CG (29.46± 3.06 Vs 27.71±0.48; p < 0.0001). In unilateral urolithiasis mean HU of papillae of calculus bearing kidney was greater than that of non calculus bearing kidney (29.82± 6.14 Vs 28.17±2.04; p < 0.004) and mean HU of papillae of stone free kidney was greater than that of CG (28.17± 2.04 Vs 27.71±0.48; p < 0.01). Mean HU of papillae of recurrent stone former was greater than that of CG (29.3±2.10 Vs 27.71±0.48, p< 0.05). Mean HU of renal papillae of patients having Hypercalciuria was comparable with that of SFG (29.90±2.31 Vs 29.46±3.06, p>0.05) as was patients having Hyperoxaluria (29.80±2.15 Vs 29.46 ± 3.06, p>0.05). CONCLUSIONS Mean HU of renal papillae was significantly increased in patient with urolithiasis. This holds valid for papillae with or without calculi. There is no significant difference between mean HU of renal papillae density in patients having Hypercalciuria/Hyperoxaluria when compared with stone bearing patients with normal urinary metabolic study. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e65 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Ankush Jairath More articles by this author Arvind Ganpule More articles by this author Jigish Vyas More articles by this author Shashikant Mishra More articles by this author Ravindra Sabnis More articles by this author Mahesh Desai More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Study of the anatomic variations of the pyelocaliceal system

Introduction and PurposeMany are the anatomical variations of the pyelocaliceal system, which influence the arterial irrigation and venous drainage. This study adopted a classification given by Sampaio in “Anatomia Renal para Urologia”. The system is divided in: Type A‐I has the mesorenal region drained by chalices from the superior or inferior caliceal group. Type A‐II has the mesorenal region drained by crossed chalices from both superior and inferior caliceal groups. Type B‐I has the mesorenal region drained by an independent caliceal group. Type B‐II has small chalices that drain the mesorenal region directly to the renal pelvis. The study aims to describe the structure of the pyelocaliceal system and its variations. Compare findings with those found in literature.MethodsKidneys obtained from adults that belong to the Morphology Department of Faculdade de Ciênicas Médicas da Santa Casa de São Paulo were injected with resin through the ureter and later corroded by acid. Kidneys obtained from someone who had nefropathy were excluded.Results52 kidneys were obtained. 39.6% were type A‐I. 12.5% were type A‐II. 18.8% type B‐I and 29.2% type B‐II.ConclusionResults were similar to the ones found in Brazilian population studies. Many are the anatomic variations of the pyelocaliceal system and they must be considered especially involving surgical procedures.

Validation of Randall's Plaque Theory Using Unenhanced Abdominal Computed Tomography

To determine whether nephrolithiasis is associated with radiographic changes in renal papillae. We performed a prospective study comparing papillae attenuation in a stone-forming group (SFG) and a healthy stone-free control group (CG). The SFG inclusion criteria were active stone disease diagnosed by abdominal computed tomography and stone analysis showing calcium composition. For the CG, we included living kidney donors without stone disease. Papillae tip attenuation was measured using nonenhanced computed tomography scans in Hounsfield units (HUs) for an area with a mean size of 0.1 cm(2). The mean density of the 3 caliceal groups was calculated for each kidney. Student's t test was used for statistical analysis, and the receiver operating characteristic curve was used to determine a threshold separating the CG and SFG. A total of 134 SFG and 134 CG patients met the inclusion criteria. The SFG and CG had similar demographic characteristics. Unilateral lithiasis was encountered in 92 patients (68.6%). The mean HU density of the papillae of the affected side in the SFG was significantly greater than in the CG (43.9 HU vs 33.9 HU, P = .001). No significant difference was seen between the affected and unaffected side in the SFG (43.9 HU vs 42.9 HU, P = .56). The receiver operating characteristic analysis showed an area under the curve of 0.91, with an optimal threshold at 40 HU and a specificity of 92% and a sensitivity of 91%. The density of the renal papilla significantly increased in the SFG in both the affected and the nonaffected kidneys compared with the CG. These findings suggest the presence of calcium deposits in the papillae, validating Randall's theory.

The Endovision Technique in Renal Percutaneous Lithotripsy

In order to achieve a safer percutaneous access to the kidney, even if not systematically, it is possible to combine the use of eco-fluoro-guided puncture with the endoscopic retrograde vision through flexible ureteroscopy. Our experience has been conducted in order to standardize the technique and highlight advantages and limitations. 26 patients (15 M-11 F), mean age 46 years, underwent flexible ureterorenoscopy as first percutaneous access for pyelic or pyelocaliceal stones. 20 cases were conducted in the prone and 6 in the supine position. We proceeded with the study of the caliceal topography and the choice of the calyx suitable for puncture, studying the orientation of the main axis of the papilla of the lower or middle group. Leaving the endoscopic instrument in place, we proceeded with the contrast injection and the eco-fluoro-guided puncture. The retrograde instrument followed the puncture and access dilatation. In 16 cases we identified a papilla of the lower caliceal group with a correct orientation for the renal puncture; in the other 10, we chose a papilla of the middle group, because it was more favorable. In 10 cases the puncture was made at the center of the papilla with its axis in favor; in 16 it was necessary to correct the puncture because the needle had penetrated the fornix (no. 14) or had punctured the other side of the calyx (no. 2). In 10 cases the puncture correction caused some bleeding, which required a careful washing in order to clear the field of vision and repeat the procedure; in other 6 cases, this was not possible: the Endovision procedure was interrupted and completed according to the conventional method. There was no difference in technique between the supine and the prone position. It is not always likely to find a papilla of lower calyx suitable to correct puncture. The Endovision technique is related to an inevitably blind moment linked to the displacement of the kidney, which is not followed by the flexible instrument, and to the limitations related to the visibility. The technique can be used both in the prone and supine position; chances are that it might not always be completed.

An atypical cause of intestinal occlusion and hidronephrosis

We present the case of a 56-year-old male with a history of psoriasis and occasional arthritis treated with NSAIDs and corticosteroids. Onset was days before admission, presenting poor general conditions, symmetrical arthritis (elbows, wrists and interphalangeal joints) and sustained fever of 38.5 oC accompanied by progressive dyspnea at rest, no cough, expectoration or chest pain. The exploration observed widespread psoriasis lesions, arthritis of the elbows and wrists, and hypoventilation of the base of the lungs, with rhythmic heart sounds and a pleural rub. Analytically, the patient presented hemoglobin of 11.3 g/dl, WBC 14.8×103/μl, neutrophils 13.3x103/μl, lymphocytes 1×103/μl, platelets 298×103/μl, prothrombin time 58%, activated partial thromboplastin time: 57.9 s, C-reactive protein > 9 mg/dl, ESR 83 mm/1st hour and cardiac enzymes within normal values. The electrocardiogram showed sinus rhythm at 100 beats per minute, with an axis at +30o, with no evidence of the repolarization abnormalities or signs of ischemia. The chest x-ray showed grade III/V cardiac enlargement and pleural effusion. The echocardiogram showed moderate pericardial effusion without signs of tamponade or segmental hypomotility. A chest scan was requested, which confirmed the existence of pleural and pericardial effusion (Figure 1). Suspecting sepsis of respiratory origin, empirical antibiotic therapy with ceftriaxone was begun. Blood urine and sputum cultures for bacteria and Koch bacilli were serially taken and resulted repeatedly negative. The patient had an unfavorable clinical course, with persistent fever and intestinal ileus presented as abdominal distension, diffuse pain on palpation and fecaloid vomiting, with a progressive increase of acute phase reactants. Abdominal scan were performed (Figure 2) and significant expansion of the intestine, from sigma to the stomach, was observed without an evident cause of gastric obstruction. The right kidney showed dilated caliceal groups, with grade III hydronephrosis and dilation of the initial portion of the ureter. The colonoscopy was not objective because of stenosis. Reumatol Clin. 2010;6(2):115–116

Effectiveness of Three-dimensional Fluoroscopy in Percutaneous Nephrostomy: An Animal Model Study

To present, in an experimental study, an assessment of innovative digital fluoroscopy systems with three-dimensional (3D) reconstruction for use in endourologic applications. The experiment was performed in a pig model. We used 5 pigs. An obstructive uropathy model was created in the right kidney to dilate the urinary tract for group 1. Group 2 consisted of the nondilated left kidney. After selecting the tract on the 3D image, the lower caliceal group was punctured in the 2 kidneys under fluoroscopic control, to assess the efficiency of the 3D reconstruction when selecting the renal calix to be punctured. The 3D reconstruction system allowed us to obtain reconstruct the pelvis in three dimensions, isolated as the pelvis and renal parenchyma, as well as the adjacent bony relationships. In this study, the success rate was 100% for locating the selected renal calix. With this 3D reconstruction system, we were able to obtain a series of images that allowed for the study of the volume of the kidney, perfectly determining its renal calix distribution in the operating room. This enabled us to determine the precise delineation of the target calix. We, therefore, consider this new urologic application of fluoroscopy very useful in surgical planning for antegrade access of the upper urinary tract.

Use of Retroperitoneoscopic Intracorporeal Lithotripter in the Treatment of Nephrolithiasis in Children

PURPOSE The objective is to assess the efficacy of intracorporeal lithotripsy (StoneBreaker) by retroperitoneoscopical approach for treating pediatric struvita stones in the renal pelvis. MATERIAL AND METHODS We have treated two patients with unilateral pelvic struvita calculi using the StoneBreaker, a novel device, portable contact pneumatic intracorporeal lithotripter. The age at surgery was 2 and 4 years old. The patients presented with abdominal pain, nausea and vomiting and recurrent urinary tract infection due to Proteus and Pseudomona spp. Diagnosis was made by plain radiographs and renal ultrasonography. The calculi were located in renal pelvis and inferior caliceal group, with associated mild hydronephrosis. Retroperitoneoscopy was the minimally invasive method perfomed to access to the pelvic stone. Stone clearance was documented on a radiograph taken the day after the surgery. RESULTS 2 patients had retroperitoneoscopy approach by 3 ports. The size of the stones was 3 and 4,2 cm, respectively. Surgical technique is described. Lithotripsy was continued until stone fragmentation was sufficient to permit safe and easy removal of all fragments. Any evidencce of urothelial trauma was noted. The number of shocks required for successful clearance was 25 y 38, respectively. The renal pelvis was closed and a Penrose drain was left in the retroperitoneum. In the 2 patients a double-J stent was maintained postoperatively. The hospital stay was 3 days. Both patients (100%) became stone free. CONCLUSIONS The StoneBreaker appears to be an effective portable intracorporeal lithotripter that should plays an important role among endourological options for lithotripsy in children. Retroperitoneoscopy is an effective, minimally invasive, low-morbidity alternative to open nephrolitotomy for treatment of pelvicaliceal complex stones in the pediatric age.

Multidetector-row computed tomography (MDCT) in patients with a history of previous urothelial cancer or painless macroscopic haematuria

The sensitivity and specificity of MDCT for depiction and localization of urothelial carcinoma (UC) was determined retrospectively. Axial and coronal four-row MDCT of the urinary tract (unenhanced, contrast-enhanced nephrographic, CT urography) was independently reviewed for UC by a radiologist (R1) and a urologist (R2), without other patient information, in 27 patients (22 male, five female; age, 72 +/- 11 years) with previous UC and/or painless macroscopic haematuria. Urinary tract segments included bladder, right and left upper, middle, and lower caliceal groups, renal pelvis, uretero-pelvic junction, upper, middle, and lower ureter. MDCT findings were corroborated by surgery, other invasive procedures, and 1-year follow-up, including MDCT, intravenous urography, and cystoscopy. Receiver-operating characteristic analysis was undertaken and the the area under the curve (AUC) calculated. Eighteen of 27 patients had evidence of UC (pTa, n = 3; pT1-pT3, n = 15; TNM 2002). Tumor was correctly located by both R1 and R2 in 17 patients (sensitivity, 94%; 95% confidence interval, 84-100%) and ruled out in seven (specificity, 78%; 95% confidence interval, 51-100%), with complete agreement. Each detected ten of 11 upper urinary tracts affected by UC. For 35 urinary tract segments with UC and 308 without, the AUC was 0.910 +/- 0.035 (R1) and 0.74 +/- 0.055 (R2), z = 2.4772, Bonferroni-corrected P = 0.022. MDCT depicts urinary tracts affected by UC with high sensitivity and substantial agreement between readers with different training.

V-02.05: Second-look flexible nephroscopy for restant caliceal stones

Access to all caliceal groups through a single percutaneous traject is difficult, if not impossible using the rigid nephroscopes. This study aimed to evaluate the efficiency of flexible nephroscopy during the second-look procedures for restant caliceal stones following percutaneous rigid approach.

Efficacy of extracorporeal shock wave lithotripsy for isolated lower caliceal stones in children compared with stones in other renal locations

Objectives To evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) monotherapy for isolated lower caliceal calculi in a pediatric age group and compare it with that for isolated middle/upper caliceal and renal pelvic calculi. Methods We retrospectively reviewed the data of 151 renal units in 126 children treated with ESWL for isolated caliceal and renal pelvic stones from March 1992 to February 2004. The stones were localized in the lower, middle/upper calices, and renal pelvis in 50, 26, and 75 renal units, respectively. The results were compared with respect to renal location and stone burden. Results The median patient age was 8 years (range 1 to 16). The median stone burden in the lower and middle/upper caliceal groups was significantly lower than in the renal pelvis group at 0.6, 0.6, and 1 cm 2, respectively ( P = 0.002). The overall stone-free rate was 62% for lower calices, 65.3% for middle/upper calices, and 80% for renal pelvis stones. For the group with a stone size greater than 2 cm 2, the stone-free rate decreased to 33% in both lower and middle/upper calices; however, it was almost the same in the renal pelvis (81.8%). A highly significant relation was found between the stone burden and number of sessions ( P <0.001), but none between the stone burden and stone-free rate. Conclusions In our study, ESWL was equally effective for stones in all locations. We recommend ESWL as the primary treatment of choice for stones less than 2.0 cm 2 in all caliceal locations. For the management of caliceal stones greater than 2.0 cm 2, prospective randomized trials comparing ESWL and percutaneous nephrolithotomy are necessary.