Efficiency Quotient Research Articles

Field Assessment for Initial Preparation of Net Zero Building Certification for The Universitas Multimedia Nusantara (UMN) Building: A Case Study On Visual Comfort in C and D Tower

Ensuring optimal physical comfort, the need for a comprehensive evaluation of the performance of building systems was established. This investigation endeavors to meticulously scrutinize illuminance and light power density metrics across distinct temporal segments (morning, noon, afternoon, and night), as well as the dynamism of daylighting and artificial lighting presence within Tower C and D of Universitas Multimedia Nusantara (UMN). Noteworthy for their incorporation of double skin façades, these edifices serve as focal points of inquiry. The empirical findings reveal that illuminance levels within classrooms and offices, irrespective of natural or artificial lighting, consistently fall short of the prescribed 350 lux threshold based on SNI across most floor levels. The efficacy of the double skin façade manifests in a discernible attenuation, diminishing illuminance ingress to the building by approximately 50%, and precipitously by up to 90% about window fixtures. Furthermore, the analysis of light power density underscores an energy efficiency quotient hovering around 60%. These empirical insights are intended to serve as a foundational resource for guiding the initiation of Net Zero Healthy Greenship certification endeavors.

The Efficiency of Extracorporeal Shock Wave Lithotripsy (ESWL) in the Treatment of Distal Ureteral Stones: An Unjustly Forgotten Option?

IntroductionThe optimal management of distal ureteral stones remains a matter of debate since current guidelines favor ureteroscopy over extracorporeal shock wave lithotripsy (ESWL). We aimed to evaluate the efficiency of ESWL for distal ureteral stones and to identify factors that affect treatment outcomes.Materials and methodsThe retrospective study included records of 115 patients with distal ureteral stones, 5 mm to 18 mm in size, undergoing 223 ESWL sessions as an outpatient procedure. Early fragmentation and three-month follow-up stone-free rate (SFR) was assessed through radiographic imaging. Treatment was successful if there were no residual fragments or they were ≤4 mm, three months after the last session.ResultsThe mean ±standard deviation (range) stone size was 9.68 ±3.10 (5.00-18.0) mm. The mean body mass index (BMI) was 24.3 ±2.67 (18.4-29.8) kg/m² with a significant correlation between BMI and stone size (r2 =0.324, p <0.001). Patients underwent ESWL an average of 1.7 ±1.36 times (1-5), while 68 patients (59.1%) became stone-free after one session. The overall SFR was 82.6%; for patients with stone sizes ≤10 mm and >10 mm, it was 99% and 9.4%, respectively. Cumulative SFR after the second session was 77%. In 20 (17%) patients the treatment was a failure. Complications occurred in 10.4%, while auxiliary procedures were needed in 8.7% of cases, both significantly affected by the stone size (p <0.001). The efficiency quotient (EQ) was 0.76. Treatment outcome was significantly different depending on stone size, BMI, number of sessions, complications, and auxiliary procedures (p <0.001, p =0.022, p <0.001, p <0.001, p <0.001, respectively). Univariate regression analysis identified stone size and BMI as significant predictors of treatment outcome (odds ratio (OR) 3.84, 95% confidence interval (CI): 2.31-8.97, p =0.001, and OR 1.25, 95% CI: 1.04-1.54, p =0.024, respectively).ConclusionsExtracorporeal shock wave lithotripsy continues to be a safe and effective option for managing simple calculi in distal ureters with a diameter of ≤10 mm. The stone size and BMI remain significant predictors of treatment outcome.

Comparative effectiveness of high-power holmium laser lithotripsy for pediatric patients with kidney and ureteral stones

The comparative effectiveness of high-power laser technology for kidney stone surgery in pediatric patients is poorly understood. We compared outcomes for the 120W Holmium:yttrium-aluminum-garnet (Ho:YAG) laser with MOSES technology to 30W Ho:YAG laser for pediatric patients undergoing ureteroscopy with laser lithotripsy for kidney and ureteral stones. We evaluated the outcomes of the new MOSES laser technology as compared to low-power Ho:YAG lasers commonly used for kidney stone treatment in the pediatric population. We performed a retrospective cohort study of 131 consecutive patients aged 1-18 years who underwent ureteroscopy and laser lithotripsy for renal and ureteric calculi at a large freestanding children's hospital between 2013 and 2020. The primary outcome was the efficiency quotient, which incorporates stone clearance, auxiliary procedures, and retreatment rates. Outcomes were compared between groups using Chi-square or Fisher's exact tests and multivariable regression. A sensitivity analysis was performed extending the age limit to ≤21 years. Outcomes are summarized in the table below. Median age of the cohort was 14 years with 53% of patients being female. MOSES laser had a higher efficiency quotient and was associated with a lower odds of post-operative emergency department visits (OR 0.2, 95% CI 0.0-1.0; p=0.047). Operative time was similar. In the sensitivity analysis of patients ≤21 years, the statistical significance with fewer emergency department visits was lost and the efficiency quotient was lower. Our results show that stone clearance is similar between the 120W MOSES and 30W Ho:YAG lasers. However, there are indications that high-power laser lithotripsy is more efficient due to fewer auxiliary procedures and a reduction in retreatment. In addition, higher power lasers were associated with fewer emergency department visits. The benefits appear to be greater among children ≤18 years. These exploratory findings are important for pediatric patients due to the requirement for general anesthesia for each procedure and their associated impact on children and their caregivers. High-power laser lithotripsy may be more efficient than lower power laser lithotripsy, which is driven by the fewer auxiliary procedures and reduction in retreatment particularly among youth ≤18 years old.

Обґрунтування комплексного підходу до модернізації систем централізованого теплопостачання і теплоспоживання населених пунктів

The purpose of the article is to substantiate the feasibility of an integrated approach to the implementation of measures for the restoration and modernization of housing stock and heat supply objects. On the conditional example of heat supply of a heated quarter (which means a small number of residential buildings to be heated, a local boiler room and local distribution heat networks), various modernization options are considered: separate thermal modernization of buildings, modernization of heating networks, modernization of the boiler room, and options for simultaneous modernization of all elements of the chain: production-supply-consumption of heat energy (complex modernization of the heated district). It is proved that precisely a comprehensive modernization, which involves a simultaneous production, coordinated in terms of time and volumes, supply and consumption of heat, is an effective instrument for improving efficiency in the sphere of heat supply and heat consumption. The complexity of modernization in this example involves thermal modernization of buildings in the heated district (with a decrease in heat consumption by 40%) with the simultaneous modernization of heat transmission networks (with a decrease in heat loss when supplied from 20% to 5%) and modernization of the boiler room (with an increase in the efficiency quotient of boiler equipment from 88% to 93%). The implementation of such a project is economically feasible for all participants: consumers reduce the cost of paying for heat supply services by 49%, and the supplier and producer of heat with a slight (up to 6%) increase in heating tariffs provide break-even activities and receive a larger investment resource in the form of a larger amount of depreciation. At the national level, the proposed mass complex modernization of heated districts can almost halve the consumption of natural gas by municipal heat and power engineering and to the same extent reduce emissions of harmful substances into the atmosphere. In addition, it becomes possible to significantly reduce the amount of subsidies from the budget for the payment of housing and communal services by the population.

Which frequency is better for pediatric shock wave lithotripsy? Intermediate or low: a prospective randomized study.

Shock wave lithotripsy (SWL) is the first option in the treatment of pediatric kidney stones; however, optimal frequency is still uncertain. The aim of this study was to compare low frequency [60 shocks per minute (SWs/min)] and intermediate frequency [90SWs/min] in terms of lithotripsy success, complications, cardiac arrhythmia, anesthesia time, secondary procedures, and efficiency quotient (EQ) in children. Seventy-eight consecutive children who received SWL for radiopaque renal stones between July 2016 and January 2020 were randomly divided into two groups: Group 60 (SWL frequency: 60 SWs/min) and Group 90 (SWL frequency: 90 SWs/min). After exclusion (remaining 71 children), Group 60 (n = 38) and Group 90 (n = 33) were compared using univariate analysis. The median age of children (37 girls, 34 boys) was 5 (1-16) years. Patient demographics and stone features were similar between the groups. Success rate after the last SWL session was 81.6% (n = 31) for Group 60 and 87.9% (n = 29) for Group 90 (p = 0.527). Stone-free rate after the first, second, and third sessions was 42.1%, 18.4%, and 21.1% for Group 60 and 48.5%, 27.3%, and 12.1% for Group 90, respectively. Additional treatment rate was similar between the groups. In Group 60, the EQ was 57.83, and it was 64.07 in Group 90. Median total anesthesia time was significantly longer in Group 60 (74.5min) than in Group 90 (32min; p < 0.001). Intermediate frequency and low-frequency pediatric SWL have similar success rates; however, intermediate-frequency SWL has a shorter anesthesia time.

Comparison of Efficiency and Safety of Retrograde Intrarenal Surgery and Micropercutaneous Nephrolithotomy in Pediatric Kidney Stones Smaller than 2 cm: A Prospective Cohort Study.

Objective: To compare the safety and efficacy of two minimally invasive surgical techniques used for pediatric stone disease: retrograde intrarenal surgery (RIRS) and micropercutaneous nephrolithotomy (micro-PCNL). Materials and Methods: A prospective study was designed to include children aged <15 years with a single stone <20 mm. Sixty-four patients were assigned to undergo either an RIRS or a micro-PCNL (1:1 ratio). Demographic parameters, stone size, location, operative data, complications, stone-free status, and efficacy quotient were compared. Results: Due to anatomic considerations, seven patients were shifted to the micro-PCNL arm, thus resulting in 39 micro-PCNLs performed vs 25 RIRS in the end. Because of the deviation from planned surgery that was significantly higher in the RIRS group (p = 0.011), the analysis was done in a prospective cohort comparison. Stone-free rates were similar for micro-PCNL and RIRS groups (80% vs 82.2%). The operative (median 60 vs 90 minutes, p < 0.001), fluoroscopy (median 15 vs 30 seconds, p = 0.004), and lithotripsy times (median 15 vs 25 minutes, p = 0.007) were shorter in the RIRS group. However, despite the larger stone size, the efficiency quotient was significantly higher in the micro-PCNL group (82.1% vs 54.1%; p = 0.009). None of the patients experienced significant hematuria requiring blood transfusion, as well as no ureteral orifice obstructive complication was detected within the follow-up period. Conclusion: RIRS and micro-PCNL techniques in children have similar stone-free and complication rates. The operative, fluoroscopy, and lithotripsy times were shorter, deviation from the planned surgery, and the number of sessions under anesthesia was higher in the RIRS group. Despite the larger stone size, efficacy quotient was significantly higher in the micro-PCNL group.

Efficacy and Safety of Semi-rigid Ureteroscopic Lithotripsy (URS) for Proximal Ureteral Stone ≥10 mm

To evaluate the efficacy and safety of the semi-rigid URS with pneumatic lithotripsy for the treatment of large (>10 mm) proximal ureteral calculi. Cohort study. Section of Urology, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2010 to December 2018. All patients with single, radio-opaque unilateral proximal ureteral stones >10 mm were included in the study. Patients with urosepsis, pregnancy, solitary kidney, and indwelling JJ stent or prior percutaneous nephrostomy drainage were excluded. Patients without any visualisation of stone on abdominal X-Ray done at 4 weeks of the procedure were labelled as stone-free. One hundred and three cases with stones >10 mm and fulfilling the selection criteria were included. The mean age was 40.83 + 14.92 years. The mean stones size was 13.33 + 4.64 mm. The mean procedure time was 41.50 + 15.60 minutes. Indwelling JJ stents were placed in 49 (47.6 %) cases. The stone-free rate was 83.5% at four weeks with calculated efficiency quotient (EQ) of 0.72, using a standard equation. The overall complication rate was 27% with the majority being minor (Clavian-Dindo grade 1). Only one patient had urosepsis (MCG IV). Ancillary procedures were performed in 17 (16.5%) cases, most commonly the extracorporeal shock wave lithotripsy (ESWL) in 14 (13.5%) cases, followed by the secondary URS in 3 (2.9%) cases. Semi-rigid URS is an effective and safe procedure for the large proximal ureteral stones, with limited access to flexible instruments. Key Words: Ureteroscopy, Semi-rigid, Stone, Proximal, Clearance, Safety.

Treatment of Moderate-sized Kidney Stone with Third-generation Electromagnetic Shock Wave Lithotripter

BACKGROUND: The extracorporeal shock wave lithotripsy (ESWL) is a non-invasive method in the treatment of urinary tract stones and its discovery has led to a complete change in the therapeutic strategy for urolithiasis. Due to the low morbidity and excellent fragmentation of the stones, ESWL has proven to be an effective and non-invasive method in the treatment of renal stones.&#x0D; AIM: The aim of this retrospective study is to evaluate the efficacy and safety of the ESWL as a monotherapy in the treatment of moderate size kidney stones with stone area (SA) of 100–300 mm².&#x0D; MATERIALS AND METHODS: We made a retrospective study of 98 patients with moderate size kidney stones with SA of 100–300 mm², divided into two subgroups, into a group with a SA of 100–200 mm² and with 200–300 mm², treated with ESWL in the period of November 2018–December 2019. The patients were treated with a third-generation electromagnetic lithotripter (Lithoskop®, Siemens Medical Systems, Erlangen, Germany), with a source of electromagnetic shocks (Pulso™) and dual ultrasonographic/fluoroscopic system for detection of the stones. The stone location, size, maximum energy used, localization technique, number of shock waves, sessions, re-treatment rate, and additional procedures were reviewed. All the patients before the intervention had a complete laboratory and radiological examinations. Postoperatively, patients were monitored on the 1st, 30th, and 90th post-operative days.&#x0D; RESULTS: Ninety-eight patients with solitary kidney stone with a SA of 100–300 mm² were treated with ESWL. The study included 58 men (59.18%) and 44 women (40.81%). The average length and width of the stone were 15.47 ± 2.68 mm and 12.99 ± 2.83 mm, respectively. The average surface area of the stones in our series was 203.78 ± 72.85 mm². The mean number of treatments for the entire series of patients was 1.82 ± 0.91. The mean number of shock waves for the total series of patients was 3899.11 ± 40. The mean energy used for the overall patient series was 110106.17 ± 21489.61 mJ. The total re-treatment rate was 47.95%. The entire rate of additional procedures was 19.38%. The overall success rate (SR) in our study was 77.55%. The efficiency quotient for the upper-middle and lower calyx was 55.57, 57.15, and 30.81, respectively.&#x0D; CONCLUSION: ESWL is a safe and effective method in the treatment of renal stones, and we recommend as the first method in the treatment of moderate size kidney stone with a surface area of 100–300 mm². The treatment of each patient should be individualized and take into account all favored and non-favored factors that influence the decision to choose extracorporeal lithotripsy as a method of treatment of medium-sized stones.

MP63-10 IMPACT OF URETERAL ACCESS SHEATH DIAMETER ON THE OUTCOMES OF FLEXIBLE URETEROSCOPIC STONE REMOVAL AS DETERMINED BY THE URETEROSCOPIC STONE EFFICIENCY QUOTIENT

INTRODUCTION AND OBJECTIVE: The use of a ureteral access sheath (UAS) during flexible ureteroscopy (URS) enhances pressure-flow dynamics within the collecting system, resulting in improved visualization and maintenance of lower intrarenal pressure. As the diameter of the deployed UAS increases, there is a concomitant improvement in irrigant flow and easier removal of larger stone fragments. We evaluated the impact of the largest diameter UAS (i.e. 16 Fr), on post URS computed tomography (CT) stone free rates (SFR) and herein introduce the concept of the ureteroscopic stone efficiency quotient (USEQ). METHODS: We reviewed our prospectively maintained database, and evaluated patients undergoing URS for renal calculi with the use of an 11 Fr, 14 Fr, or 16 Fr UAS. At the outset of each case, passage of a 16 Fr UAS was attempted; if the 16 Fr UAS did not pass easily, then the UAS was downsized to a smaller sheath. Patient demographics, stone parameters, procedure time, and postoperative CT scan results were recorded. SFR was defined as complete absence of stones. The USEQ was defined as: %SFR / operative time (minutes) X 100. We evaluated the outcomes of the three UASs using student’s T test, Chi square test, and logistic regression. RESULTS: Among 110 patients undergoing URS between January 2018 and June 2019, 56 patients with renal stones (65 renal units) had a postoperative CT. Mean aggregate stone size was 15±7 mm, number of stones 2.7±1.6, and stone density 711±430 HU. We deployed 11 Fr, 14 Fr, and 16 Fr UAS in 12%, 29%, and 59% of renal units, respectively. Stone parameters did not differ significantly among the three groups. Median time to patients’ postoperative CT was 39 days. The overall SFR was 55%. Using univariate analysis, the stone-free cohort had smaller aggregate stone size (13 vs. 18 mm, p=0.03) and fewer stones (2.2 vs. 3.2, p=0.01). The SFR for 16 Fr vs. 14 Fr was 58% and 63% (p=0.7) while the SFR for 16 Fr vs. 11 Fr was 58% and 25% (p=0.09). There were 3 (4.6%) UAS-induced high grade ureteral injuries noted as a split in the urothelium (post ureteroscopy lesion scale = 3, based on a 0-5 scoring system); all were treated with a ureteral stent. The use of 16 Fr UAS was associated with shorter operative time (92 minutes) compared to the 14 Fr UAS (139 minutes, p=0.03) and 11 Fr UAS (118 minutes, p=0.53). The USEQ was markedly improved with use of the 16 Fr UAS: 64 vs. 14 Fr: 45 vs. 11 Fr: 21. CONCLUSIONS: Use of a 16 Fr UAS vs. a 14 Fr or 11 Fr UAS reduced operative time without impairment of SFR while markedly augmenting the ureteroscopy stone efficiency quotient. Source of Funding: none

Miniature semi-rigid ureteroscopy with holmium-yttrium-aluminium-garnet laser vs shockwave lithotripsy in the management of upper urinary tract stones >1 cm in children

ABSTRACT Objective To compare the efficacy and safety of miniature semi-rigid ureteroscopy (URS) with holmium (Ho)-yttrium-aluminium-garnet (YAG) laser lithotripsy vs shockwave lithotripsy (SWL) for treating upper urinary tract (UUT) calculi >1 cm in children. Patients and methods Children with unilateral single UUT ureteric stones of >1 cm were prospectively enrolled in this study. Patients were randomly divided into two groups: Group 1, treated with SWL; and Group 2, treated with URS (6/7.5 F) and laser lithotripsy. The patients’ characteristics, stones demographics, operative time, adjunctive procedures, stone-free rate (SFR), re-treatment rate, and complications were statistically analysed and compared. Success was defined as stone-free status (no stone residual of ≥0.3 cm) at 1 month from the initial treatment without any auxiliary procedures. Results In all, 68 patients with UUT stones met our inclusion criteria. There were no significant differences between the two groups for patient or stone demographics. In Group 1, the SFR was 26/34 (76.4%) and in Group 2 it was 33/34 (97.1%) (P = 0.03). A total of 12 auxiliary procedures in Group 1 and two in Group 2 were needed to reach a 100% SFR (P = 0.014). There were no significant differences between the two groups for operative times, adjunctive procedures, number of complicated cases or complications of Grade ≥III (P = 0.65, P = 0.23, P = 0.77, and P = 0.62, respectively). Conclusion Miniature semi-rigid URS with Ho-YAG laser lithotripsy for UUT ureteric stones of >1 cm in children was more effective than SWL in terms of SFR and re-treatment rate, with no significant difference in the rate or grade of complications. Abbreviations EQ: efficiency quotient; KUB: plain abdominal radiograph of the kidneys, ureters and bladder; RCT: randomised controlled trial; SFR: stone-free rate; SWL: shockwave lithotripsy; URS: ureteroscopy; US: ultrasonography/ultrasound; URS: ureteroscopy; UUT: upper urinary tract; YAG: yttrium-aluminium-garnet

Study of the safety and efficacy of minimally invasive percutaneous nephrolithotomy in the management of large and complex renal stone

Background: Nephrolithiasis is highly prevalent across all demographic groups in the india and beyond, and its incidence rates are rising. In addition to the morbidity of the acute event, stone disease often becomes a lifelong problem that requires preventative therapy to diminish ongoing morbidity. Objective of this study to evaluate the safety and efficacy of minimally invasive percutaneous nephrolithotomy (PCNL) in the management of large and complex renal stone.Methods: This retrospective study includes 75 renal calculi patients with 100 renal units with large and complicated stone &gt;20 mm. Stones were classified into simple (isolated renal pelvis or isolated calyceal stones) or complex (partial or complete stag horn stones, renal pelvis stones with accompanying calyceal stones). Then various parameter like decrease haemoglobin, surgical complication, creatinine level, duration of surgery etc were compared between simple and complex stones patients by calculation p value using online student t test calculator. P value less than 0.01 considered as a difference of significance.Results: The mean stone size was 35.5±20.37 mm and mean operative duration was 60±35.3 min. In all, cases 60 (80%) were stone-free after the first procedure and another 10 needed an auxiliary procedure (5 second-look PCNL, 3 extracorporeal shockwave lithotripsy-ESWL, 2 ureterorenoscopy, and) to become stone-free, resulting in a 93.33% stone-free rate. Complications occurred in 9 procedures (12%).Conclusions: From this study, it would be concluded that Minimally invasive PCNL provided significantly higher stone-free rate and efficiency quotient for management of urinary calculi. Overall complications are usually observed in patients having intraoperative hypotension and increased intra operative time.

The "old" 15mm renal stone size limit for RIRS remains a clinically significant threshold size.

To investigate the performance of retrograde intrarenal surgery (RIRS) for the 1-2cm renal stone size range in comparison to smaller stones. From a data base of 3000 ureteroscopies between 2004 and 2014, 635 consecutive patients underwent RIRS for renal stones. Patients were divided to three groups according to their renal stone size (<10, 10-15, 15-20mm). Preoperative, operative, stone free rate (SFR) and follow-up data were analyzed and compared. The SFR for the three groups was 94.1, 90.1 and 85%, respectively. Patients with renal stone size above 15mm had a statistically significantly lower SFR. The efficiency quotient calculated for stones larger and smaller than 15mm was 83.9 vs. 91.8%, respectively (p<0.01). The mean operative time and hospital stay were longer for patients with renal stones larger than 15mm (73.6±29.9 vs. 53±19.4min, p<0.01 and 2.2±2 vs. 1.8±1.8days, p=0.031, respectively). Moreover, the complication rate was almost two times higher (10 vs 5.4%, p=0.08). Concomitant ureteral stones and older age were independent predictors of failure in the large stone group. While the overall SFR following RIRS for renal stones up to 2cm is generally high, the SFR for 15-20mm stones is significantly lower, with a longer operating time and hospital stay, and a higher complication rate.

Comparison of YAG Laser Lithotripsy and Extracorporeal Shock Wave Lithotripsy in Treatment of Ureteral Calculi: A Meta-Analysis

Objective: To evaluate the clinical efficiency and safety of ureteroscopy lithotripsy (URSL) with holmium laser technology and extracorporeal shock wave lithotripsy (ESWL) on ureteral calculi using systematic reviews. Methods: Randomized controlled trials and prospective controlled trials accorded with inclusion among PubMed Database, EmBase Database, Cochrane Library and China National Knowledge Infrastructure were collected. Review Manager 5.0 was adopted to estimate the effects of the results among selected articles. Forest plots, sensitivity analysis and bias analysis for the articles included were also conducted. Pooled estimate of risk ratios and standard mean difference (SMD) with 95% CIs were used as measures of effect sizes. Results: Finally 1,770 patients were included in the 14 studies, which eventually satisfied the eligibility criteria. The number of patients in URSL group and ESWL group were 885 and 885, respectively. The results of heterogeneity test suggested that complication events (RR 1.12 (95% CI 0.63-2.00), p = 0.70), hospital days (SMD = -0.08 (95% CI -1.14 to 0.98), p = 0.88) and efficiency quotient (RR 1.31 (95% CI 0.96-1.80), p = 0.09) were insignificantly different, while the stone-free rate (RR 1.15 (95% CI 1.06-1.26), p = 0.002) and operation time (SMD = -2.27 (95% CI -3.42 to -1.11), p = 0.0001) between ESWL and URSL were significantly different. Conclusion: Although both URSL and ESWL have its own advantages and drawbacks, URSL is relatively a more efficient and safe method to treat ureteric stones, since it has shorter operation time and a better stone-free rate.

MP54-18 EMERGENCY EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (EESWL) FOR ACUTE RENAL COLIC DUE TO URETERAL STONES

You have accessJournal of UrologyStone Disease: Shock Wave Lithotripsy1 Apr 2016MP54-18 EMERGENCY EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY (EESWL) FOR ACUTE RENAL COLIC DUE TO URETERAL STONES Paolo Umari, Stefano Bucci, Michele Rizzo, Nicola Pavan, Giovanni Liguori, Diego Marega, and Carlo Trombetta Paolo UmariPaolo Umari More articles by this author , Stefano BucciStefano Bucci More articles by this author , Michele RizzoMichele Rizzo More articles by this author , Nicola PavanNicola Pavan More articles by this author , Giovanni LiguoriGiovanni Liguori More articles by this author , Diego MaregaDiego Marega More articles by this author , and Carlo TrombettaCarlo Trombetta More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.588AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The aim of this study is to understand the role of extracorporeal shockwave lithotripsy (ESWL) as first-line treatment in patients with acute renal colic due to obstructive ureteral stones. METHODS We prospectively studied 70 patients presenting with their first episode of ureteric colic undergone extracorporeal shockwave lithotripsy (ESWL) over a 14 months period. Patients were randomized to emergency ESWL within 12 hours (eESWL group) or deferred ESWL until 20 days (dESWL group). Inclusion criteria were: acute renal colic, ureteral radiolucent or hyperechogenic stones from 5 to 20mm, no urinary infection or acute renal failure. Follow up included ultrasound or CT-scan at 24 hours, 7 days, 1 and 3 months. When it was necessary, repeated ESWL (re-ESWL) or ureteroscopy (URS) was performed. Preoperative and postoperative data between the two groups were compared and stone free rate (SFR) and efficiency quotient (EQ) were evaluated. Analyses were performed using SAS (9.3 version) statistical software. RESULTS 36 patients from eESWL group and 34 patients from dESWL group were well matched for age, gender, BMI and clinical and pathological characteristics. The mean patient age was 48.7 (range 24-81). Mean stone size was 9,8 mm (range 5-20mm). 25 stones (35.7%) were located in the upper and 45 (64.3%) in the distal ureter. Mean ESWL energy was 19,2 kV (range 14-24kV) and mean number of shock waves was 2650 (range 1000-3600). ESWL treatment lasted on average 44 minutes (range 17-60 minutes). All the procedures were conducted at the frequency of 1 Hz. No treatment was interrupted because of poor tolerance. Patients in the dESWL group spent more time in the hospital (2.21 vs 1.36 days) and the complication rates were paragonable in both groups (p<0.05). eESWL patients needs less auxiliary URS than dESWL patients, 11.1% vs 44.1% respectively and less re-ESWL 8.3% vs 32.4% respectively (p<0.05). The SFR at 24 hours was 52.8% and 11,8% in the eESWL and dESWL group respectively (p<0.05). The SFR at 3 months was 94.4% and 79.4% (p=0.07) and EQ was 79.1% and 57.5% in the eESWL and dESWL group respectively (p<0.01). CONCLUSIONS eESWL is a safe procedure and delivers high SFR even within 24 hours. It offers effective decompression of the collecting system and pain relief independently on the degree of hydronephrosis and especially in smaller stones (<10mm). It is able to reduce the number of auxiliary procedures and hospitalization. We believe that emergency timing of the precedure is of remarkably importance because of progressive development of ureteral edema and stone impactation. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e733-e734 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Paolo Umari More articles by this author Stefano Bucci More articles by this author Michele Rizzo More articles by this author Nicola Pavan More articles by this author Giovanni Liguori More articles by this author Diego Marega More articles by this author Carlo Trombetta More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extracorporeal shock wave lithotripsy (ESWL) versus percutaneous nephrolithotomy (PCNL) or retrograde intrarenal surgery (RIRS) for kidney stones.

Stones in the urinary tract are a common medical problem in the general population. At present, the great expansion in minimally invasive techniques has led to the decrease in open surgery. Extracorporeal shock wave lithotripsy (ESWL) has been introduced as an alternative approach which disintegrates stones in the kidney and upper urinary tract through the use of shock waves. Nevertheless, as there are limitations with the success rate in ESWL, other minimally invasive modalities for kidney stones such as percutaneous nephrolithotomy (PCNL) and retrograde intrarenal surgery (RIRS) are also widely applied. This is an update of a review first published in 2009. This review aimed to assess the effectiveness and complications of ESWL for kidney stones compared with PCNL or RIRS. We searched the Cochrane Renal Group's Specialised Register to 3 March 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. Randomised controlled trials (RCTs) assessing the use of ESWL compared to PCNL or RIRS for kidney stone management. Two authors independently assessed all the studies for inclusion. Statistical analyses were performed using the random effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). Five studies (338 patients) were included, four studies compared ESWL to PCNL and one compared ESWL with RIRS. Random sequence generation was reported in three studies and unclear in two. Allocation concealment was not reported in any of the included studies. Blinding of participants and investigators could not be undertaken due to the nature of the interventions; blinding of outcome assessors was not reported. Reporting bias was judged to be low risk in all studies. One study was funded by industry and in one study the number of participants in each group was unbalanced.The success of treatment at three months was significantly greater in the PCNL compared to the ESWL group (3 studies, 201 participants: RR 0.46, 95% CI 0.35 to 0.62). Re-treatment (1 study, 122 participants: RR 1.81, 95% CI 0.66 to 4.99) and using auxiliary procedures (2 studies, 184 participants: RR 9.06, 95% CI 1.20 to 68.64) was significantly increased with ESWL group compared to PCNL. The efficiency quotient (EQ; used to assess the effectiveness of procedures) higher for PCNL than ESWL; however EQ decreased when stone size increased. Duration of treatment (MD -36.00 min, 95% CI -54.10 to -17.90) and hospital stay (1 study, 49 participants: MD -3.30 days, 95% CI -5.45 to -1.15) were significantly shorter in the ESWL group. Overall more complications were reported with PCNL, however we were unable to meta-analyse the included studies due to the differing outcomes reported and the timing of the outcome measurements.One study compared ESWL versus RIRS for lower pole kidney stones. The success of treatment was not significantly different at the end of the third month (58 participants: RR 0.91, 95% CI 0.64 to 1.30). Mean procedural time and mean hospital stay was reported to be longer in the RIRS group. Results from five small studies, with low methodological quality, indicated ESWL is less effective for kidney stones than PCNL but not significantly different from RIRS. Hospital stay and duration of treatment was less with ESWL. Larger RCTs with high methodological quality are required to investigate the effectiveness and complications of ESWL for kidney stones compared to PCNL if there is any technological progress in the non-invasive elimination of the residual fragments. Moreover, further research is required for the outcomes of ESWL and RIRS in lower and non-lower pole studies including PCNL versus RIRS.

Evolution of shockwave lithotripsy (SWL) technique: a 25-year single centre experience of >5000 patients.

To assess the impact of various treatment optimisation strategies in shockwave lithotripsy (SWL) used at a single centre over the last 25 years. In all, 5017 patients treated between 1989 and 2013 were reviewed and divided into groups A, B, C and D for the treatment periods of 1989-1994 (1561 patients), 1995-2000 (1741), 2001-2006 (1039) and 2007-2013 (676), respectively. The Sonolith 3000 (A and B) and Dornier compact delta lithotripters (C and D) were used. Refinements included frequent re-localisation, limiting maximum shocks and booster therapy in group B and Hounsfield unit estimation, power ramping and improved coupling in group D. Parameters reviewed were annual SWL utilisation, stone and treatment data, retreatment, auxiliary procedures, complications and stone-free rate (SFR). The SFR with Dornier compact delta was significantly higher than that of the Sonolith 3000 (P < 0.001). The SFR improved significantly from 77.58%, 81.28%, 82.58% to 88.02% in groups A, B, C, and D, respectively (P < 0.001). There was a concomitant decrease in repeat SWL (re-treatment rate: A, 48.7%; B, 33.4%; C, 15.8%; and D, 10.1%; P < 0.001) and complication rates (A, 8%; B, 6.4%; C, 4.9%; and D, 1.6%; P < 0.001). This led to a rise in the efficiency quotient (EQ) in groups A-D from 50.41, 58.94, 68.78 to 77.06 (P < 0.001).The auxiliary procedure rates were similar in all groups (P = 0.62). In conclusion, improvement in the EQ together with a concomitant decrease in complication rate can be achieved with optimum patient selection and use of various treatment optimising strategies.

Single-Center Experience With the Dual-Focus Storz Modulith SLX-F2 Lithotripter: A Retrospective Study

Background: To calculate the modified efficiency quotient of the mobile Storz Modulith SLX-F2 lithotripter, to identify factors determining clinical succes rate and to identify complications and limitations with this device. Comparison of the results with reported data from other institutions for the same machine and other types in the peer review literature will be made. Methods: The study design is a retrospective chart review. Inclusion criteria include male and female and patients who were treated in the Texas Tech University Health Sciences Center for urinary calculi with the Storz Modulith SLX-F2 lithotripter between September 2006 and June 2011. During this period, 447 patients with single stones were treated, and 10 patients with radiolucent stones and 21 patients with incomplete follow-up were excluded. The patients were followed up with plain radiography and/or renal ultrasound to assess the clinical succes rate. Univariate and multivariate analyses were performed to identify the factors determining the clinical success rate. Results: Follow-up was complete for 416 patients. Mean age was 46.1 ± 14.4 years. The mean numbers of shock waves given were 2,457 and 2,838 for renal and ureteral stones, respectively. Mean stone sizes were 9.3 ± 4.5 mm and 9.7 ± 4.9 mm for renal and ureteral stones, respectively. Mean body mass index was 30.5 ± 7.04 kg/m 2 . The overall clinical success rate after one ESWL treatment was 84.6% (85.4% and 83.6% for renal and ureteral stones, respectively). The modified efficiency quotient was 0.69. On univariate analysis, clinical success rate was associated with smaller stone size ( &lt; 10 mm, P = 0.016), and absence of a ureteral stent (31.7% vs. 10.5%; P = 0.0002). Presence of lower calyx stones (P = 0.04) was a negative predictor of clinical success. On multivariate analysis, lower calyx stones, smaller stone size and the absence of a ureteral stent continued to be significant determinants of clinical success status. All complications were minor with a complication rate of 4.3%. Conclusions: The mobile Storz Modulith SLX-F2 lithotripter is clinically effective in the management of solitary renal and ureteral stones. It has an adequate modified efficiency quotient combined with a favorable safety profile. Major advantages are the increased treatment depth in combination with exceptionally high weight limit and a dual-focus system. World J Nephrol Urol. 2014;3(1):7-17 doi: http://dx.doi.org/10.14740/wjnu111w

Slow vs Rapid Delivery Rate Shock Wave Lithotripsy for Pediatric Renal Urolithiasis: A Prospective Randomized Study

We compared slow vs fast shock wave frequency rates in disintegration of pediatric renal stones less than 20 mm. Our study included 60 children with solitary 10 to 20 mm radiopaque renal stones treated with shock wave lithotripsy. Patients were prospectively randomized into 2 groups, ie those undergoing lithotripsy at a rate of 80 shock waves per minute (group 1, 30 patients) and those undergoing lithotripsy at a rate of 120 shock waves per minute (group 2, 30 patients). The 2 groups were compared in terms of treatment success, anesthesia time, secondary procedures and efficiency quotient. Stone clearance rate was significantly higher in group 1 (90%) than in group 2 (73.3%, p = 0.025). A total of 18 patients in group 1 (60%) were rendered stone-free after 1 session, 8 required 2 sessions and 1 needed 3 sessions, while shock wave lithotripsy failed in 3 patients. By comparison, 8 patients (26.6%) in group 2 were rendered stone-free after 1 session, 10 (33.3%) required 2 sessions and 4 (13.3%) needed 3 sessions to become stone-free. Mean general anesthesia time was significantly longer in group 1 (p = 0.041). Postoperatively 2 patients in group 1 and 4 in group 2 suffered low grade fever (Clavien grade II). Significantly more secondary procedures (percutaneous nephrolithotomy, repeat shock wave lithotripsy) were required in group 2 (p = 0.005). The predominant stone analysis was calcium oxalate dihydrate in both groups. Efficiency quotient was 0.5869 and 0.3437 for group 1 and group 2, respectively (p = 0.0247). In children with renal stones slow delivery rates of shock wave lithotripsy have better results regarding stone clearance than fast delivery rates.

Critical Analysis of a New Generation Electrohydraulic Lithotripter: A Single Institution Experience with the Medispec E3000

The Medispec E3000(™) is a new generation electrohydraulic lithotripter with a wider focal width comparable to the Dornier HM3(™). We evaluate the efficacy of this machine for management of urinary stones at our institution by shockwave lithotripsy (SWL). There were 168 urinary calculi managed using the Medispec E3000 lithotripter over a 14-month period (10/2010-12/2011). During the first 6 months (10/2010-6/2011), a low power ramping protocol of 11-12-17 kV was used, and for the remaining 6 months (6/2011-12/2011), stones were managed with a higher power ramping protocol of 15-17-22.5 kV. A subanalysis of these groups was performed, as well as for stone location. The major end point was stone-free rate (SFR), defined as fragments <4 mm on follow-up imaging. Data were analyzed using the Fisher exact test and two-tailed Student t test. The study included 102 males and 66 females with an average age of 52.8 years. Mean stone size was 6.9 × 7.2 mm, which was significantly associated with SFR (P<0.0010). The overall SFR was 64.9%, with no significant difference between stones managed with the low power protocol (61.3%) and the high power protocol (70%). SFR varied by location across the upper pole (64.9%), midpolar area (57.1%), lower pole (68.4%), renal pelvis (79.2%), proximal ureter (66.6%), midureter (83.3%), and distal ureter (53.8%), but these differences were not significant (P=0.59). Efficiency quotient for the Medispec E3000™ was 54%. Overall, we achieved SFR of 64.9% in our initial experience with the Medispec E3000™. Optimizing treatment parameters may further improve success rates, and further outcomes follow-up may allow a more comprehensive evaluation of the lithotripter's overall efficacy.

Transrectal Ultrasonography-Guided Injection of Long-Acting Steroids in the Treatment of Recurrent/Resistant Anastomotic Stenosis After Radical Prostatectomy

Different techniques have been used for the treatment of patients with anastomotic stenosis after radical prostatectomy (RP). In this retrospective study, we analyzed our experience with urethral dilation and consecutive transrectal ultrasonography (TRUS)-guided injections of long-acting steroids in the scar area. We reviewed the records of patients who underwent RP in our department from 2002 to 2010 and presented to the outpatient clinics with symptomatic anastomotic stenosis. Patients were treated with: Urethral dilation, cold knife (CK) urethrotomy, transurethral resection (TUR) of stenosis and dilation/resection of the strictures with consecutive TRUS-guided injection of a long-acting steroid (dilation+TRUS-steroids). Patients remained under follow-up, which included the assessment of voiding and continence patterns, as well as cystourethroscopy. In 32 (10.8%) patients, symptomatic anastomotic stenosis was diagnosed. Initial urethral dilation succeeded in only 3 (10.3%) patients; thus, 29 remained with recurrent/resistant stenosis. Urethral dilation+TRUS-steroids was performed in 14 patients, while 8 patients underwent CK and in 7 TUR was performed. Patients in the dilation+TRUS-steroids group had lower re-treatment rates, and none of these patients became incontinent. Patients in the TUR group needed no re-treatment; however, they had the highest incontinence rate (57.1%). As a result, the highest efficiency quotient was in the dilation+TRUS-steroids with the lowest in the TUR group. Urethral dilation with consecutive TRUS-guided injections of steroids has the highest efficiency quotient and can be performed under local anesthesia with a low risk of incontinence.