Cystic Calculi Research Articles

28. Lithotomy through the ages: Big stones, small stones and all the ways to cut them out

The first known specimen of urological interest was a vesicle calculi dated to 5000 BC, found by Elliot Smith in 1901, in an ancient tomb in Egypt. Since these ancient times, urolithiasis has been a condition which fascinated and frustrated the medical world, both in understanding of its etiology and in how to treat patients afflicted with such stones. 
 Medical management of urinary calculi has a complex and suspect past; when such therapies failed, as their mystical and unscientific approaches often did, patients sometimes resorted to more drastic and dramatic means such as lithotomy.
 Lithotomy was known since early times in India and Persia; when it was introduced to Europe is unclear. Writings by Susruta in India describe early forms of the procedure, and techniques were improved by Celsus of Rome (1st Century AD), remaining in use, largely unchanged until the eighteenth Century.
 Marianus Sanctus (1490-1550) described a technique, the “grand appareil” which superseded the Celsus method, and other approaches by Franco (1500-1570), Jacques de Beaulieu (1651-1714), Johann Rau (1658-1709) and William Cheselden (1688-1752) gained and lost dominance over the centuries.
 Perhaps most interesting about lithotomy was the development of the tools used in its practice. From the beginning, the various knives, forceps, dilators and sounds became ever more complicated, intricate and gruesome looking, resembling more the armamentarium of a torture master than the curative tools of a physician. 
 As endoscopic techniques began and evolved, the necessity to make large incisions for stone removal decreased. Nonetheless, the approaches and instrumentation used to treat bladder stones helped shape the practice of urology and contributed to the continuing goal of minimizing invasion of the patient while still providing effective treatment of stone disease and other genitourinary problems. 
 Murphy LJT. The History of Urology. Springfield, Ill.: Charles C. Thomas, 1972.
 Chevalier RL. Kidney and urologic disorders in the age of enlightenment. Am J Nephrol 1994; 14(4-6):461-6.
 Herman, JR. Urology; a view through the retrospectroscope. Hagerstown, Md.: Harper & Row, 1973.

Postcholecystectomy Syndrome in the Laparoscopic Era

sWe describe the management of a cystic duct remnant calculus in a 45-year-old male patient who had undergone a laparoscopic cholecystectomy and re-presented with abdominal pain and jaundice. Magnetic resonance cholangiopancreatography was utilized to confirm the diagnosis of an impacted calculus within the remnant cystic duct along with several small retained common bile duct stones. Four sequential endoscopic procedures successfully removed all retained common bile duct calculi to alleviate the biliary obstruction; however, we were unable to treat the cystic duct remnant calculus endoscopically. The patient finally underwent successful laparoscopic excision of a 2.5-cm cystic duct remnant containing its impacted calculus. It remains unclear if cystic duct remnant calculi may become more prevalent as a cause of postcholecystectomy syndrome in future due to the large numbers of laparoscopic cholecystectomies performed in the past 2 decades.

Laparoscopic‐Assisted Cystotomy for Urolith Removal in Geldings

To describe a technique for laparoscopic-assisted removal of cystic calculi in geldings and report outcome. Clinical report. Four geldings with cystic calculi. Laparoscopic-assisted cystotomy and urolith retrieval was performed in 4 anesthetized geldings positioned in dorsal recumbency. With a laparoscope portal located at the umbilicus, the abdomen was insufflated and then the surgical table was tilted (30 degrees head-down position) before an instrumental portal was created parallel and 2-3 cm medial to the left external inguinal ring. Laparoscopic grasping forceps were inserted to grasp the cranial aspect of the bladder and elevate it to the ventral abdominal wall. With the instrumental portal as mid-point, the parainguinal skin incision was longitudinally extended cranial and caudal (approximately 8-10 cm) to accommodate the size of the urolith. The apex of the bladder was exteriorized and sharply incised, the urolith extracted, and after cystotomy closure, the bladder was repositioned. The mini-laparotomy and trocar incisions were closed in layers. There were no intra- or post-operative complications. All horses had minor incisional swelling for 3-4 days. No signs of abdominal or incisional pain were observed. Hematuria and slight stranguria occurred until the 3rd or 4th day. Surgical time (skin incision to skin closure) was 35-40 minutes. On long-term follow-up (up to 12 months) no recurrence of clinical signs associated with cystic calculi occurred. Uroliths (6-8 cm diameter) can be removed by laparoscopic-assisted cystotomy in geldings. Laparoscopic-assisted cystotomy combines the advantages of the parainguinal laparocystotomy with laparoscopic technique for removal of cystic calculi while avoiding their disadvantages.

Studies on hepatoprotective and antioxidant actions of Strychnos potatorum Linn. seeds on CCl 4-induced acute hepatic injury in experimental rats

Strychnos potatorum Linn. seeds are used in the Indian traditional system of medicine for the treatment of hepatopathy, nephropathy, gonorrhoea, leucorrhoea, gastropathy, bronchitis, chronic diarrhoea, strangury, renal and vesicle calculi, diabetes and eye diseases. The present study describes the hepatoprotective and antioxidant activities of the seed powder (SPP) and aqueous extract (SPE) of Strychnos potatorum seeds against CCl 4-induced acute hepatic injury. Hepatic injury was achieved by injecting 3 ml/kg, s.c. of CCl 4 in equal proportion with olive oil. Both SPP and SPE at the doses 100 and 200 mg/kg, p.o. offered significant ( p < 0.001) hepatoprotective action by reducing the serum marker enzymes like serum glutamate oxaloacetate transaminase (SGOT) and serum glutamate pyruvate transaminase (SGPT). They also reduced the elevated levels of ALP and serum bilirubin. Reduced enzymic and nonenzymic antioxidant levels and elevated lipid peroxide levels were restored to normal by administration of SPP and SPE. Histopathological studies further confirmed the hepatoprotective activity of SPP and SPE when compared with the CCl 4 treated control groups. The results obtained were compared with Silymarin (50 mg/kg, p.o.), the standard drug. In conclusion, SPE (200 mg/kg, p.o.) showed significant hepatoprotective activity similar to that of the standard drug, Silymarin (50 mg/kg, p.o.).

Diagnosis and surgical management of ureteral calculi in dogs: 16 cases (1990–2003)

AIMS: To examine the clinical signs, laboratory and radiographic findings, surgical technique, ureterolith composition, and post-operative outcomes in dogs managed surgically for ureterolithiasis to determine whether surgical removal of ure-teroliths in dogs resulted in a positive clinical outcome. METHODS: The medical record database of a university veterinary hospital in Pennsylvania, USA, was searched for dogs that underwent surgery to remove obstructive ureteral calculi between 1990 and 2003. Records were reviewed for signalment, clinical history and examination findings, radiographic and laboratory test results, surgical technique, and ureterolith analysis. Follow-up information was obtained from telephone interviews with owners or referring veterinarians, or by reviewing the medical record of subsequent hospital visits. RESULTS: Sixteen dogs were included in this study; ten were neutered females, two intact females and four castrated males. Abdominal radiography revealed ureteral calculi in 14/16 dogs, renal calculi in 8/16, cystic calculi in 8/16, urethral calculi in 1/16, renomegaly in 6/16 and renal mineralisation in 5/16. Ure-terolith type included struvite in six dogs, calcium oxalate in five, calcium phosphate in one, and a mix of struvite, calcium phosphate and calcium oxalate in another. Compared to dogs with non-struvite ureteroliths, those with struvite ureteroliths had a higher pre-operative white blood cell (WBC) count (25.6, SD 7 vs 17.6, SD 6 x 103 cells/µl; p=0.046), and were more likely to have a purulent discharge from the ureteral incision noted at the time of surgery (p=0.015). Following discharge, 14/16 dogs were re-evaluated. Median survival time was 904 days (range 2–1,876). Two dogs required additional surgery on the urinary tract. Four dogs died or were euthanised because of azotaemia and clinical signs related to the urinary system or non-specific signs of illness (vomiting, lethargy) at 8, 90, 333 and 904 days post-operatively. CONCLUSIONS: Surgical management of ureteroliths was successful and resulted in good long-term survival in the majority of dogs examined in this small study population. Similar proportions of calcium oxalate and struvite ureteroliths were identified. CLINICAL RELEVANCE: The use of ure-teral surgery may increase as the frequency of diagnosis of ure-teroliths in dogs increases.

Management of post cholecystectomy Mirizzi′s syndrome

Various strategies have been proposed for the management of retained calculi within the biliary tree following cholecystectomy. We present a unique case of a cystic duct remnant calculus causing Mirizzi syndrome, only the fourth such case of its kind. An open procedure was planned, however the calculus was eventually extracted endoscopically. The pathophysiology and management of Mirizzi syndrome and retained calculi within the cystic duct remnant are discussed along with the merits of a minimally invasive approach.

Polypoid cystitis in 17 dogs (1978-2001).

Polypoid cystitis is a rare disease of the urinary bladder in dogs characterized by inflammation, epithelial proliferation, and development of a polypoid mass or masses without histopathologic evidence of neoplasia. Medical records of 17 dogs with polypoid cystitis were reviewed to determine the clinical and laboratory features of this disorder and to assess treatment and outcome. Most affected dogs (15/17) were female and presented for evaluation of hematuria or recurrent urinary tract infection (UTI). Proteus spp were the most common bacterial isolates (12/52 or 23.1%) identified when all urine samples obtained for culture at any time during the course study were considered. Other commonly isolated organisms included Escherichia coli , Staphylococcus spp, and Enterococcus spp. Several dogs (7/17) also had cystic calculi at some time during the course of their disease. Most of the masses (11/14) were located cranioventrally in the bladder as opposed to transitional cell carcinoma, which has a predilection for the bladder neck or trigone area. It is unknown whether persistent or recurrent UTI predisposes to polyp formation or if polyps predispose to UTI. Surgery and removal of all polyps was the most efficacious treatment in dogs of this study. The question of whether or not polyps represent preneoplastic lesions remains unanswered and constitutes an area for future investigation.

Retained gallbladder/cystic duct remnant calculi as a cause of postcholecystectomy pain.

Pain following cholecystectomy can pose a diagnostic and therapeutic dilemma. We reviewed our experience with calculi retained in gallbladder and cystic duct remnants that present with recurrent biliary symptoms. Over the last 6 years, seven patients were referred to us for the evaluation of recurrent biliary colic or jaundice. There were four men and three women ranging in age from 35 to 70 years. All seven had biliary pain similar to the symptoms that precede cholecystectomy; two of them also had also associated jaundice and one had pancreatitis. The time from cholecystectomy to onset of symptoms ranged from 14 months to 20 years (median, 8.5 Years). Four had undergone laparoscopic cholecystectomy and three had had an open cholecystectomy; none had an operative cholangiogram. Five of seven underwent diagnostic endoscopic retrograde cholangiography (ERC), which revealed obvious filling defects in the cystic duct or gallbladder remnant. The final patient was diagnosed by laparoscopic ultrasound after eight negative radiographic studies. Four patients underwent laparotomy and resection of a retained gallbladder and/or cystic duct. Two patients were treated with extracorporeal shock-wave lithotripsy (ESWL); one of them also required endoscopic biliary holmium laser lithotripsy. One patient underwent successful repeat laparoscopic cholecystectomy. There were no treatment-related complications. At a median follow-up of 11.5 months, all have achieved complete stone clearance and are asymptomatic. Retained gallbladder and cystic duct calculi can be a source of recurrent biliary pain, and a heightened suspicion may be required to make the diagnosis. This entity can be prevented by accurate identification of the gallbladder-cystic duct junction at cholecystectomy and by routine use of cholangiography. A variety of therapeutic options can be employed to obtain a successful outcome.

Dorsally Recumbent Urinary Endoscopic Surgery

Laparoscopic cystotomy is the method of choice for treatment of a cystic calculus in the horse. The main advantage of this procedure over others is the excellent ability to view and gain operative access to the urinary bladder. This article describes the procedure, including techniques, instrumentation, preoperative and postoperative care, and complications.

Laparoscopic removal of cystic calculi

Laparoscopic removal of cystic calculi

Urine spraying in cats: presence of concurrent disease and effects of a pheromone treatment

Thirty four spraying cats, belonging to 24 households, had a complete physical examination, CBC, blood biochemistry panel, urinalysis, urine culture, urine cortisol:creatinine analysis and abdominal radiographs. Diagnostic procedures revealed some abnormalities and/or crystalluria in 13 patients (38%). Seven (20%) of these cats had medical conditions involving the urogenital system (renal calculi, renal failure, cystic calculi, bacterial urinary infection or cystitis associated with the presence of ammonium biurate crystalluria). The other six had crystalluria. A synthetic analogue of feline cheek gland pheromones (Feliway™, Sanofi Sante Nutrition Animale, Abbott Laboratories) was then evaluated as a treatment of urine spraying. The study was done on all 34 cats but complete data was obtained for only 22 cats belonging to 19 out of the 24 households. Nine of these cats had abnormalities and/or crystalluria. The results were highly significant: 14 households (74%; 95% confidence interval 49–91%) reported a decrease of spraying frequency.

Amitriptyline treatment for severe recurrent idiopathic cystitis in cats

Objective To evaluate the safety and efficacy of amitriptyline hydrochloride in the treatment of severe recurrent idiopathic cystitis (IC) in cats. Design Prospective study. Animals 15 cats with IC that failed to respond to other treatments. Procedure Each cat received 10 mg of amitriptyline, PO, every 24 hours in the evening for 12 months or until signs recurred. Urinalysis, CBC, serum biochemical analysis, urine bacteriologic culture, and cystoscopy were performed initially, and after 6 and 12 months in responders. Severity scores of owner-observed signs of lower urinary tract (bladder and urethra) disease were recorded. Results During the first 6 months of treatment, 11 of the 15 cats had no owner-observed signs of lower urinary tract disease. During the next 6 months, 9 of 15 cats remained free of signs of cystitis. Despite clinical improvement, cystoscopic abnormalities persisted in all cats at the 6- and 12-month evaluations. Hematuria and proteinuria were decreased at the 12-month evaluation compared with the initial evaluation. Two of 15 cats initially appeared somnolent after amitriptyline treatment. Of 9 cats completing the study, 7 had increased body weight and 8 had decreased coat quality compared with the initial evaluations. Four cats developed small cystic calculi during the first 6 months of the study. Serum biochemical or hematologic abnormalities were not detected during the study. Clinical Implications Amitriptyline treatment successfully decreased clinical signs of severe recurrent IC in 9 of 15 cats treated. Somnolence, weight gain, decreased grooming, and transient cystic calculi were observed during treatment in some cats. (J Am Vet Med Assoc 1998;213:1282-1286)

Medical management of urinary calculi in a stallion with breeding dysfunction

Management of urolithiasis in horses varies depending on the size and number of calculi, their location in the urinary tract, sex of the patient, and availability of surgical facilities. The recommended method for removal of cystic calculi in stallions and geldings is surgery; however, medical treatment consisting of lavaging the bladder and administering antibiotics and antiinflammatory drugs may be successful if the calculi are small.

Clinical evaluation of cats with nonobstructive urinary tract diseases

Objective To identify the underlying cause of clinical signs in cats with non obstructive diseases of the bladder and urethra. Design Prospective case series. Sample Population 109 cats examined by the urology service of The Ohio State University's veterinary teaching hospital because of stranguria, hematuria, pollakiuria, or urination in inappropriate locations. Procedure History was obtained and a CBC, serum biochemical analyses, serologic tests for FeLV and feline immunodeficiency virus, urinalysis, bacterial culture of urine, and contrast radiography or urethrocystoscopy (females only) were performed. Results 16 cats had cystic calculi: 8 had struvite uroliths, 7 had calcium oxalate uroliths, and 1 had a urolith of unknown composition in conjunction with an anatomic defect. Anatomic defects, including diverticulae, urethral strictures, and a malpositioned urethra, were identified in 12 cats. A urinary tract infection was identified in 1 cat, and neoplasia was diagnosed in 2. One of the cats with neoplasia also had a struvite urolith. The remaining 80 cats did not have an anatomic defect, urolith, or tumor. Ten of these cats also did not have radiographic or cystoscopic abnormalities and were presumed to have a behavioral disorder. The remaining 70 cats had radiographic or cystoscopic abnormalities, and idiopathic cystitis was diagnosed. In 14 of the cats with idiopathic cystitis, results of a urinalysis were normal. Cats with idiopathic cystitis were significantly more likely to eat dry food exclusively (59%) than were cats in the general population (19%). Clinical Implications Results suggest that idiopathic cystitis occurs commonly in cats with stranguria, hematuria, pollakiurfa, or inappropriate elimination and is associated with consumption of dry foods. Contrast radiography or cystoscopy is necessary for differentiating idiopathic cystitis from behavioral disorders in some cats. (J Am Vet Med Assoc 1997;210:46–50)

Perineal urethrotomy for removal of cystic calculi in a gelding

Perineal urethrotomy for removal of cystic calculi in a gelding

Chronic hematospermia: Assessment by transrectal ultrasound

Objective. To evaluate transrectal ultrasound in the assessment of chronic hematospermia. Methods. Twenty-six patients aged between twenty-five and seventy-seven years (mean, 55.6 years) presenting with persistent hematospermia of an average duration of 10.2 months (range, 3 to 20 months) underwent transrectal ultrasound. Twenty-five asymptomatic men aged thirty-nine to eighty-two years (mean, 63 years) self referred to our institution seeking transrectal ultrasound as a screening method for prostate cancer and with no previous history of hematospermia were used as controls. Results. Significant sonographic findings not present in the control group were detected in 24 patients with hematospermia. These consisted of dilated seminal vesicles in 8, ejaculatory duct cysts in 4, ejaculatory or seminal vesicle calculi in 4, the presence of ejaculatory duct and seminal vesicle dilatation in 4, seminal vesicle cysts with ipsilateral renal agenesis and absence of the vas in 2, and an intraprostatic mullerian duct remnant in 2. Of the patients having biopsies, none was found to have malignancy. Conclusions. Transrectal ultrasound is the imaging modality of choice in the assessment of chronic hematospermia.

Cystic calculi surgery on a gelding

Cystic calculi surgery on a gelding

Dietary management of cystic calculi in a horse

Summary Principles in the dietary management of urolithiasis which have been successful in small animal cases were implemented in an equine case. This article describes the dietary management of a horse which repeatedly formed calcium carbonate cystic calculi. Treatment management included progressively decreasing the ration calcium content to reduce the intake of calcium. In addition, urinary tract infections were controlled and urinary acidification was used to inhibit calcium carbonate formation. Successful management was achieved by feeding a 0.2% calcium oat hay ration and administering 175 mg ammonium sulfate per kg body weight orally twice daily for 7 months which produced a urine pH of 5.0. There was no evidence of metabolic acid/base imbalances nor skeletal depletion of calcium. The horse has been free of cystic calculi for an additional 30 months while adequately maintained on a nutritionally balanced oat hay ration. Reducing dietary calcium intake and urine pH are possible management procedures in the horse with recurrent cystic calculi.

Percutaneous cholecystolithotomy: analysis of results and complications in 58 consecutive patients.

Percutaneous cholecystolithotomy was attempted in 58 consecutive patients. Patients were considered for percutaneous cholecystolithotomy only if they had symptomatic gallstones and a strong contraindication to surgical cholecystectomy. The procedure consisted of three parts: (a) initial percutaneous cholecystostomy, (b) tract dilation and stone removal, and (c) tract evaluation and tube removal. Local anaesthesia and intravenously administered analgesia were used in all procedures. Percutaneous cholecystolithotomy was successful in removing all of the stones in 56 patients (97%), including cystic duct calculi in 15 patients and common duct calculi in 10 patients. Major complications occurred in five patients (9%); in four cases, they were related to bile leakage after the cholecystostomy tube was removed. Thirty-day mortality was 3% (two patients). Advantages of percutaneous cholecystolithotomy include avoidance of general anesthesia and the ability to treat patients in any disease setting, including acute cholecystitis. Percutaneous cholecystolithotomy, although technically demanding, is an effective alternative to surgical cholecystectomy in elderly and debilitated patients.

Urolithiasis in 68 horses.

Medical records of 68 horses with urolithiasis were examined. Calculi were in the bladder in 47 horses, urethra in 11 horses, kidneys in 15 horses, and ureter in two horses. They occurred at several sites in six horses. Common clinical signs included hematuria, altered micturition (pollakiuria, dysuria, urinary incontinence), and tenesmus. Weight loss, possibly attributable to chronic renal failure and colic, was associated more commonly with renal and ureteral calculi. Weight loss also occurred in 13% of horses with cystic calculi only. In male horses, most cystic calculi were removed by perineal (ischial) urethrotomy under epidural anesthesia. Although there were few surgical complications with urethrotomy, seven of 15 horses with follow-up suffered recurrent urolithiasis.