Extracorporeal Lithotripsy Research Articles

Hematoma escrotal como primera manifestación de hematoma retroperitoneal tras litotricia extracorpórea

We described the case of a patient who presented a large scrotal black discoloration 15 hours after successful extracorporeal lithotripsy of a proximal ureteral calculus. The patient did not present any other clinical symptoms as a sign of subcapsular haematoma.

Comparative Results of Shockwave Lithotripsy for Renal Calculi in Upper, Middle, and Lower Calices

To assess the results of shockwave lithotripsy (SWL) for renal calculi in upper, middle, and lower calices according to the stone burden. A series of 52 female and 66 male patients with a mean age of 47.8 years and isolated single caliceal stones who underwent SWL monotherapy were enrolled. Stone burden, stone location, number of sessions/shockwaves, and auxiliary procedures were noted for each patient. Stones were located in the upper, middle, and lower calices of 35, 43, and 40, patients respectively, with mean stone burdens of 81.4 mm2, 75.2 mm2, and 96.3 mm2, respectively. Patients were evaluated with intravenous urography, plain film, or ultrasonography. Success was determined 3 months after the last session. Re-treatment rates were calculated. The effect of anatomic factors on the success of treatment for lower-caliceal stones also was determined. The mean stone burden, median number of treatment sessions, and mean number of shockwaves were 84.2 mm2, 2, and 4344, respectively. The auxiliary procedure rate was 16.1%, and the re-treatment rate was 71.2%. Failure was noted in 26 patients (22%). The stone-free rates for stones in the upper, middle, and lower calices were 82.8%, 83.4%, and 67.5%, respectively (P = 0.14). The stone-free rates for stones <100 mm2 and 100 to 200 mm2 were 91.2% and 65.5%, respectively (P = 0.001). The efficiency quotient was 49.8, 44.8, and 32.5 for upper-, middle-, and lower-caliceal stones, respectively. Infundibular length (P = 0.006) and infundibular width (P + 0.036) were significant in determining the stone-free rate after treatment of lower-caliceal stones. We recommend SWL as the first choice for treatment of stones <200 mm2 in the upper and middle calices. Extracorporeal lithotripsy is one of the options for lower-caliceal stones <200 mm2 but has high re-treatment and auxiliary-procedure rates in these cases.

Critical Prospective Appraisal of Renal Morphology and Function in Children Undergoing Shockwave Lithotripsy and Percutaneous Nephrolithotomy

To assess the effect of shockwave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) on renal morphology and function in children undergoing therapy for upper-tract urolithiasis. Fourteen patients less than 13 years of age with renal or upper-ureteral calculi who were found suitable for primary SWL or PCNL were evaluated for alteration of renal morphology and function after treatment. Of the 18 renal units treated, SWL and PCNL were performed in 9 units each. The average stone size was 880.2 mm2 (range 110-3800 mm2; median 660 mm2). All children underwent ultrasonic estimation of renal length and parenchymal thickness, 99m technetium dimercaptosuccinic acid (DMSA) and 99m Tc-ethylene dicystine (EDC) scintigraphy, and glomerular filtration rate (GFR) estimation prior to intervention and at 3 and 6 months of follow-up. Extracorporeal lithotripsy achieved complete clearance in 8 renal units (88%), requiring an average of 6333 shockwaves and an average of 2.2 sessions per renal unit. The efficiency quotient was 42. Percutaneous surgery likewise achieved complete stone clearance in 88% of renal units, with three units requiring more than one tract. Mixed calcium oxalate monohydrate and dihydrate accounted for the majority of the stones. The mean preintervention GFR was 78.3 +/- 14.6 mL/min/1.73 m2 (median 82.5 mL/min/1.73 m2; range 54-98.6 mL/min/1.73 m2), whereas the mean GFR at 3 months was 78.95 +/- 14.4 mL/min/1.73 m2 (median 78.95 mL/min/1.73 m2; range 52-98 mL/min/1.73 m2). A marginal improvement of an average of 0.65 mL/min was noted. Split function EDC scans demonstrated improved drainage in five cases after intervention; the rest were unchanged. Preintervention DMSA scans revealed renal cortical scars in three children. None of the renal units had developed fresh scars at follow-up scans. None of the children developed new-onset hypertension, proteinuria, or alteration in renal size. In the present study, pediatric SWL and PCNL were not found to cause adverse renal morphologic or functional alteration. Stone clearance resulted in marginally improved function and better drainage.

Arterial Stents for Access and Protection of the Parotid and Submandibular Ducts During Sialoendoscopy

Sialoendoscopy has recently gained popularity as a minimally invasive alternative to ablative surgery for obstructive salivary duct disease resulting from stones and strictures. Sialoendoscopy has been performed in numerous patients with a high degree of success. 1 Nahlieli O. Baruchin A.M. Long-term experience with endoscopic diagnosis and treatment of salivary gland inflammatory diseases. Laryngoscope. 2000; 110: 988 Crossref PubMed Scopus (160) Google Scholar , 2 Marchal F. Dulguerov P. Becker M. et al. Submandibular diagnostic and interventional sialendoscopy: New procedure for ductal disorders. Ann Otol Rhinol Laryngol. 2002; 111: 27 Crossref PubMed Scopus (123) Google Scholar , 3 Katz P. New techniques for the treatment of salivary lithiasis: Sialoendoscopy and extracorporal lithotripsy: 1773 cases. Ann Otolaryngol Chir Cervicofac. 2004; 121: 123 Crossref PubMed Google Scholar However, damage or perforation of the duct during repeated manipulation of the endoscope and surgical instruments is a known complication. 1 Nahlieli O. Baruchin A.M. Long-term experience with endoscopic diagnosis and treatment of salivary gland inflammatory diseases. Laryngoscope. 2000; 110: 988 Crossref PubMed Scopus (160) Google Scholar , 2 Marchal F. Dulguerov P. Becker M. et al. Submandibular diagnostic and interventional sialendoscopy: New procedure for ductal disorders. Ann Otol Rhinol Laryngol. 2002; 111: 27 Crossref PubMed Scopus (123) Google Scholar , 3 Katz P. New techniques for the treatment of salivary lithiasis: Sialoendoscopy and extracorporal lithotripsy: 1773 cases. Ann Otolaryngol Chir Cervicofac. 2004; 121: 123 Crossref PubMed Google Scholar This can result in a false passage that may compromise the success of the procedure. The purpose of this study was to assess the feasibility of using cardiovascular stents to dilate and maintain access to the parotid and submandibular ducts during sialoendoscopy. The hypothesis was that stents would allow for easy instrumentation of the ducts with fewer traumatic injuries. To the best of our knowledge, this is the first report on the use of cardiovascular stents for this purpose.

Experiencia clínica y resultados en el tratamiento de 4402 pacientes con cálculos urinarios únicos con el litotritor extracorpóreo Dornier MFL-5000

To report the series of our Urology Department in the treatment of urinary stone disease with extracorporeal lithotripsy as well as the effectiveness of the Dornier lithotripter MFL-5000.6.602 patients were treated by extracorporeal lithotripsy during 12 years with a total of 17.120 sessions. We examined the treatment outcome of 4.402 patients with a solitary stone, accordingly to stone size and localization.There were no major complications and only 43 patients experienced "calle litiásica". We treated 4.402 stones. For all stones, independently of size and localization, 2615 (59.4%) were treated in one session, 801 (18.2%) required two sessions, 379 (8.6%) 3 sessions, 213 (4.8%) 4 sessions and 373 (8.4%) 5 or more sessions.The Dornier MFL-5000 lithotripter successfully treated urinary stone disease in patients of all age groups with a retreatment rate and number of sessions per stone similar to other studies, without analgesia or anesthetic procedures, except in the younger age group.

Mechanical Lithotripsy of Pancreatic and Biliary Stones: Complications and Available Treatment Options Collected From Expert Centers

PD and common bile duct (CBD) stones often require mechanical lithotripsy (ML) at ERCP for successful extraction. The frequency and spectrum of complications is not well described in the literature. To describe the frequency and spectrum of complications of ML. A comprehensive retrospective review of cases requiring ML of large or resistant PC and/or CBD stones using a 46-point data questionnaire on type(s) of complication, treatment attempted, and success of treatment. The study involved 7 tertiary referral centers with 712 ML cases (643 biliary and 69 pancreatic). Overall incidence of complications were: 4-4% (31/712); 23/643 biliary, 8/69 pancreatic; 21 single, 10 multiple. Biliary complications: trapped (TR)/broken (BR) basket (N = 11), wire fracture (FX) (N = 8), broken (BR) handle (N = 7), perforation/duct injury (N = 3). Pancreatic complications: TR/BR basket (N = 7), wire FX (N = 4), BR handle (N = 5), pancreatic duct leak (N = 1). Endoscopic intervention successfully treated complications in 29/31 cases (93.5%). Biliary group treatments: sphincterotomy (ES) extension (N = 7), electrohydraulic lithotripsy (EHL) (N = 11), stent (N = 3), per-oral Soehendra lithotripsy (N = 8), surgery (N = 1), extracorporeal lithotripsy (N = 5), and dislodge stones/change basket (N = 4). Pancreatic group treatments: ES extension (N = 3), EHL (N = 2), stent (N = 5), Soehendra lithotriptor (N = 4), dislodge stones/change basket (N = 2), extracorporeal lithotripsy (ECL) (N = 1), surgery (N = 1). Perforated viscus patient died at 30 days. The majority of ML in expert centers involved the bile duct. The complication rate of pancreatic ML is threefold greater than biliary lithotripsy. The most frequent complication of biliary and pancreatic ML is trapped/broken baskets. Extension of ES and EHL are the most frequently utilized treatment options.

Management Strategies and Results for Severely Encrusted Retained Ureteral Stents

To review the management approach to and results of severely encrusted retained ureteral stents and analyze predictive risk factors. Medical records from January 1996 to March 2006 were reviewed for Double-J stent complications and their final outcome. A total of 876 stents were inserted in 784 patients for treatment of renal calculi with extracorporeal shockwave lithotripsy, ureteral calculi, after percutaneous nephrolithotomy, pyeloplasty, or injury to the ureter and kidney. Of these stents, 95 (10.84%) were found to be encrusted, and 26 (2.96%) were not only encrusted but retained as well. These patients, 21 men and 5 women with a mean age of 34 years (range 18-69 years), underwent one or more of the following procedures: cystolitholapaxy, retrograde ureteroscopic manipulation, intracorporeal or extracorporeal lithotripsy, percutaneous nephrolithotomy, and open surgical removal to make them stent free. The average duration of stent placement was 14 months (range 5 months-9 years). The encrustation was confined to the upper coil in 4 and the upper coil and body in 5. The lower coil and body in 8 and 9, respectively, were totally encrusted, of which 2 were fragmented as well. A total of 62 sessions of auxiliary procedures were required to render patients stent free. Four patients required percutaneous nephrolithotomy and one open removal. Encrustation and retention of a ureteral stent is a serious complication. Successful management of encrusted retained stents requires multimodality procedures along with proper record keeping of stent insertion and removal and patient counseling.

Preventing Migration of Stones During Fragmentation with Thermosensitive Polymer

To define a method of stabilizing stones during extracorporeal (SWL) and intracorporeal lithotripsy with a thermosensitive polymer. Using a thermosensitive polymer that is either a liquid or a gel, depending on the temperature, both calcium oxalate and plaster of Paris phantom stones were placed in the polymer gel or saline, and SWL was performed. Comparisons were made between the effectiveness of the fragmentation in the two media. Also, in-vivo studies using the polymer to prevent migration of ureteral stones were performed in swine. Electrohydraulic lithotripsy was used on a small stone implanted in the distal ureter with the polymer instilled proximally. Once in the ureter, the polymer converted to a gel. After completion of the procedure, the polymer was restored to a liquid form by infusion of cold saline and expelled from the ureter. Three of the pigs underwent treatment of the stone, convalesced for 7 days, and then had urine collections from both ureters to compare the glomerular filtration rates, fractional sodium excretion, urine/plasma creatinine ratio, and urine/plasma urea ratio on the treated and the contralateral (control) sides. The polymer did not enhance fragmentation when used with SWL but prevented stone migration in the in-vivo studies. The physiologic parameters were not significantly different on the treated and the control sides. The polymer was easily removed from the ureter by infusing cold water. The use of this thermosensitive polymer proximal to ureteral stones prevents migration and is not traumatic to the ureter.

Aspectos esenciales de los sistemas robóticos urológicos

Most advances in Surgery can now be seen to have been preceded by the invention of new instruments. Conventional surgery progressed as new instruments became available. Transurethral resections became routine following the introduction 80 years ago of the resectoscope: a highly revolutionary instrument at that time. Ureterorenoscopes and nephros- copes opened new windows of opportunity for urologists. When the therapeutic potential of extracorporeal lithotripsy, was first mentioned in the literature most surgeons thought it was mere science-fiction fantasy. Very soon however, this new technique, the fruit of close collaboration between urologists and engineers, became a common-place reality. Laparoscopy met with similar disbelief and the early applications gave rise to controversy and even consternation, yet only a few years later most of our urological surgical procedures have adopted this technique. At the beginning of the 20th century the astounding advances in engineering led many to forecast that before its end those systems might mimic human intelligence. However, many attempts to construct a rational thinking device revealed that even today this ambitious project was a still an unattainable dream. Consequently, attempts to design an autonomous urological surgical robot that might carry out unsupervised transurethral resections were unfruitful because the inherent and unpredictable complexity of surgical procedures obliges close and rigorous control by the surgeon. This important limitation led to the creation of 'master-slave' systems similar to those designed by our team in 1998 for transurethral resection. These are relatively simple tools and are infinitely safer than autonomous robots because they aim to effectively help the surgeon rather than replace him. The oft-repeated argument about whether or not a robot might ever replace the surgeon now has little sense because today it is merely a tool, an instrument for the surgeon's hands. The devices available today lack the all-important tactile feedback and to use them effectively, the surgeon is obliged to serve a new and arduous apprenticeship and the learning curve is unavoidably steep. Consequently, many prestigious authors understandably feel unable to recommend their use. Our accumulated experience with master-slave manipulators stimulates us to confidently predict that sooner than later, whether we like it or not, surgical robots will evolve to become indispensable tools that enhance the surgeon's skill, precision and speed in many surgical procedures.

Primary Ureteroscopy for Distal-Ureteral Stones Compared with Ureteroscopy after Failed Extracorporeal Lithotripsy

We reviewed our experiences with ureteroscopic pneumatic lithotripsy (URS-PL) for the treatment of distal-ureteral stones and investigated whether failed extracorporeal shockwave lithotripsy (SWL) is a limiting factor for the ureteroscopic procedure. We retrospectively studied the medical records of 375 patients treated with URS-PL from January 1999 to September 2005 in our clinic. Of these patients, 213 were treated with URS-PL primarily (group 1), whereas the remaining 162 patients had undergone SWL unsuccessfully before URS-PL was performed (group 2). We used 9F or 9.5F rigid instruments and the Vibrolith (Elmed, Ankara, Turkey). In group 1, 206 patients (96.7%) were treated successfully with URS alone, as were 155 patients (95.6%) in group 2. Impacted stones were observed in 21 patients in group 1 (9.85%) and in 57 patients in group 2 (35.1%). The average operating time was 33.19 +/- 9.039 minutes in group 1 and 57.42 +/- 8.757 minutes in group 2. The stone-free rates of the two groups were significantly different on the first postoperative day, but this difference decreased to an insignificant level at the end of the first month. When SWL fails, URS-PL is as safe and effective as primary URS. Pneumatic lithotripsy also seems to be effective for impacted stones.

Improvement of stone comminution by slow delivery rate of shock waves in extracorporeal lithotripsy

The aim of this study was to investigate the effect of delivery rate of shockwaves (SW) on stone comminution and treatment outcomes in patients with renal and ureteral stones. Patients with radio-opaque stones in the upper urinary tract that were treated by extracorporeal shock wave lithotripsy (ESWL) were divided into two groups according to delivery rate (120 or 60 SW/min). The effective fragmentation after one ESWL session and treatment success at 3 months after ESWL was compared between the two groups. Of 134 patients (84 men and 50 women), 68 patients were treated at a fast rate and 66 were treated at a slow rate. Thirty and 38 patients in the fast rate group and 28 and 38 in the slow rate group had renal and ureteral stones, respectively. After one ESWL session, effective fragmentation was noted more often in the slow group (65.2%) than the fast group (47.1%) (P = 0.035), particularly for smaller stones (stone area <100 mm(2)) (P = 0.005) and renal stones (p = 0.005). However, there was no significant difference in treatment success at 3 months after ESWL between the two groups. In univariate logistic regression analysis, slow SW rate and smaller stones were significant factors for effective fragmentation after one ESWL session. In multivariate analysis, slow SW rate and smaller stones were also independent factors. Slow SW rate contributed to better stone comminution than fast rate, particularly for small stones and renal stones. ESWL treatment at a slow SW rate is recommended to obtain efficient stone fragmentation.

Extracorporeal renal lithotripsy: Evolution of residual lithiasis treated with thiazides

Objectives To analyze the evolution of residual lithiasis after renal extracorporeal shock wave lithotripsy (ESWL) and to show the prolonged efficacy of thiazides in the treatment of residual lithiasis in patients with calcium lithiasis. Methods We performed a longitudinal, analytical, 36-month study in 100 patients with residual calcium lithiasis after ESWL randomly distributed into two groups: 50 patients treated with placebo (controls, group 1) and 50 treated with hydrochlorothiazide, 50 mg/24 hr (group 2). All patients in both groups underwent imaging studies (simple radiography of the urinary tract and renal ultrasonography) and a metabolic urinary study. Results The percentage of global expulsion of lithiasis during the follow-up period was significantly greater (chi-square exponent = 19.938, P = 0.001) in the patients treated with thiazides (72%) than in the control group (36%), although a large number of patients in this group underwent new ESWL sessions. During the follow-up period, we performed ESWL on 42% of the patients in group 1 and 18% of group 2, a statistically significant difference (chi-square exponent = 6.881, P = 0.032). Conclusions The results of our study have shown that residual lithiasis progresses in 58% of patients undergoing observation, and new ESWL sessions will be necessary in 42%. We observed a significant relationship between the presence of a urinary lithogenic pattern and the progression of the residual lithiasis. The administration of thiazides stabilizes or reduces the growth of residual lithiasis and favors its spontaneous elimination, thus reducing the need for new sessions of ESWL. This effect of thiazides is highly significant in patients presenting with hypercalciuria.

Therapeutic ultrasound

The use of ultrasound in medicine is now quite commonplace, especially with the recent introduction of small, portable, and relatively inexpensive, hand-held diagnostic imaging devices. Moreover, ultrasound has expanded beyond the imaging realm, with methods and applications extending to novel therapeutic and surgical uses. Among these applications are tissue ablation, acoustocautery, lipoplasty, site-specific and ultrasound mediated drug activity, extracorporeal lithotripsy, and the enhancement of natural physiological functions such as wound healing and tissue regeneration. A particularly attractive aspect of this technology is that diagnostic and therapeutic systems can be combined to produce totally noninvasive, image-guided, bloodless surgery. This general lecture will review a number of these exciting new applications of ultrasound and address some of the basic scientific questions and future challenges in developing these methods and technologies for general use in our society. We shall particularly emphasize the use of high-intensity focused ultrasound (HIFU) in the treatment of benign and malignant tumors as well as the induction of acoustic hemostasis, especially in organs that are difficult to treat using conventional medical and surgical techniques. [Work supported in part by the NIH, NSBRI, ONR, and DARPA.]

Development of a urinary lithiasis localizer mechanism to couple ultrasound and extracorporeal lithotripsy equipment in canine model

Due to the evolution of extracorporeal lithotripsy equipment (ESWL) and presently, the fact that most part of the equipment does not present ultrasound to localize urinary calculi, a system that allows adapting ultrasound equipment to ESWL equipment was developed, disposing only of fluoroscopy. Thus, this equipment was developed and was tested in urinary stones in canine models, to check its precision in relation to fluoroscopy. Seven male dogs were utilized with the introduction, in the bladder through the ureteral route, of chalkstones, with initial localization by fluoroscopy, with a further ultrasound coincidence check localization of the vesical stones, being submitted to ESWL with a 3-hour, 21 days and 60 days follow-up after the procedure. Success of localization in all animals was verified presenting elimination of stones in the first micturitions, after ESWL. No complications were verified in those animals for 60 days. We verified that this equipment can lead to an update of the equipment that use only fluoroscopy, increasing in this way, their technical capacity in the treatment of urinary calculi, mainly in cases of non-radiopaque stones.

Beware! Fungal Urosepsis May Follow Endoscopic Intervention for Prolonged Indwelling Ureteral Stent

We present a 38-year-old lady with a prolonged indwelling ureteral stent that had been placed for pain relief after development of Steinstrasse following extracorporeal lithotripsy for a 2.5-cm left renal calculus. The patient developed candidal urosepsis within 6 hours after ureteroscopy and percutaneous nephrolithotomy (PCNL) for the removal of residual fragments. She subsequently recovered on systemic antifungal therapy in the form of intravenous amphotericin B and achieved complete stone clearance after repeat ureteroscopy and PCNL. Fungal urosepsis is known to complicate the postoperative course in chronically debilitated patients with poor nutritional status or those with diabetes or other significant comorbities. To our knowledge, this is the first reported case of a patient with no significant comorbities developing fungal urosepsis after endoscopic intervention for a long-term indwelling ureteral stent.

Subcapsular renal hematoma after shock wave lithotripsy

76-year-old man presented to our Emergency Departent with a chief complaint of right flank pain. The atient stated that he had a history of a kidney stone and hat 3 h prior he had undergone extracorporeal shock ave lithotripsy (ESWL) of the right kidney. Before the rocedure the patient reported only mild pain in the ank, but since the procedure his pain had become much ore severe. The patient denied nausea, vomiting, chest ain, or shortness of breath. He had no fevers and denied ematuria. His past medical history was significant for iabetes mellitus, coronary artery disease, and emphyema in addition to nephrolithiasis. His medications inluded insulin, aspirin, rofecoxib, Glucophage, clopiogrel, and cetirizine. Physical examination revealed an elderly man in modrate distress due to pain. Vital signs were: temperature 6.4°C (97.6°F), blood pressure 123/66 mm Hg, heart ate 65 beats/min, and respiratory rate 18 breaths/min. he heart was regular without murmurs and lungs were lear to auscultation. The abdomen was soft and nonender to palpation. There was no hepatosplenomegaly. ack examination revealed right flank percussion tenderess at the costovertebral angle. No bruising was present. he remainder of the physical examination was normal. The patient received morphine 8 mg i.v. for pain. aboratory studies revealed hemoglobin of 13.1 g/dL nd a white blood cell count of 14 K/UL. Urinalysis was ignificant for 100–150 red blood cells. Due to continued

Clinical Insignificant Residual Fragments (CIRF) after Extracorporeal Lithotripsy: Implications and Treatment

The stone-free status depends on the appropriate selection of the urologic treatment according to the stone and excretory tract characteristics, and/or to the patient parameters. Although the gold standard for the treatment is the stone-free status, the authors believe that the presence of non-infected, nonobstructive, asymptomatic residual fragments, smaller than 4–5 mm, can be treated with an adequate medical therapy in order to prevent stone growth. Further urological treatment is recommended if the clinical indications for stone removal persist.

Endoscopic Treatment of Chronic Pancreatitis: Long-Term Results

Endoscopic pancreatic stenting is nowadays considered to be the first intent therapeutic approach in case of painful chronic pancreatitis with dilation of the main pancreatic duct (MPD). While short-term effects of this treatment have been well evaluated and are satisfactory, long-term results are still uncertain. Definitive pancreatic stenting with exchange on demand could be the solution to prevent pain recurrence. Long term results of definitive stenting were analyzed from a series of 40 patients. Methods: 40 consecutive patients treated by endoscopic stenting because of a MPD dilation were followed for at least 60 months. The multihole plastic 10F stent was inserted till the tail of the pancreas, once the vacuity of the MPD was obtained following pancreatic sphincterotomy, pancreatic duct stenosis dilation, stone extraction and if necessary extracorporeal lithotripsy (11 cases). Follow-up was ensured by annual CT or MRCP, and liver tests. Results: 19 patients (47%) still have the stent in place without pain. In this group of patients, the mean frequency of stent exchange was 0.84:10 patients had had no stent exchange. In 9 cases, surgical pancreatic bypass or resection was finally performed: in 5 cases because a symptomatic main bile duct stenosis occurred (biliary and pancreatic bypasses), in 3 cases because of a perisplenic abcess following stent obstruction in patients who presented initially an associated stenosis of the caudal MPD (left splenopancreatectomy with wirsungo-jejunal anastomosis), in one case because a pancreatic carcinoma occurred (Whipple resection). In 2 cases, the stent migrated without pain recurrence. Finally 10 patients died for causes not related to the treatment or to the chronic pancreatitis (6 deaths related to the alcohol-tobacco abuse). Conclusion: Long-term follow-up demonstrates that in 3/4 of cases, endoscopic treatment by definitive pancreatic stenting is sufficient: ½ of the patients have no more pain or ¼ died from other diseases. The more severe complication is perisplenic abcesses in patients who has initially an associated caudal MPD stenosis despite stenosis was crossed by the stent. This associated stenosis could a better indication for initial surgical resection. The prognosis of the patients is mainly related to the alcohol-tobacco abuse than to the chronic pancreatitis itself.

Ureterolitotomia laparoscópica de un cálculo de uréter iliaco olvidado durante más de ocho años

IntroductionLaparoscopic ureterolithotomy recently rises as a new option in the treatment of ureteral calculi, particularly those of the greatest size, hardness or impactation. We describe such an indication to resolve a case of forgotten for more than eight years and severely obstructive ureteral stone. Patient and methodA 64 years-old male received extracorporeal shock wave lithotripsy for a right distal ureteral stone and, simultaneously, a left impacted iliac ureteral calculi was discovered, at the confluence of an incomplete duplication of the ureter, for which treatment was recommended, but deferred by the patient. Eight years after, the same stone caused a massive dilatation with poor function of the upper pole moiety and slightly preserved function of the lower pole moiety of the left kidney. Two intents of retrograde ureteroscopy failed because of impossibility to reach the stone. Transperitoneal laparoscopic ureterolithotomy was performed in lateral decubitus position, with double J in place and three 10 mm ports. After identification of the dilated ureter, an V-shape ureterothomy was made and the stone mobilized and extracted. The ureter was stented and the ureterothomy closed with intracorporeal suture. The patient had a postoperative stage of four days and a mild functional recovery. DiscussionIf the usual treatment options (extracorporeal lithotripsy and ureteroscopy with intracorporeal lithotripsy) failed, then laparoscopic ureterolithotomy is less invasive than open ureterolithotomy. However, the indications of laparoscopic ureterolithotomy are restricted because substantial laparoscopic experience is needed to cope with possible technical difficulties.

Papel de las tiazidas en la profilaxis de la litiasis cálcica recidivante

ObjectiveTo show the prolonged efficacy of thiazides in the prophylaxis and treatment of recurrences in patients with calcium oxalate and phosphate lithiasis. MethodsA randomised prospective study is conducted, with a three-year follow-up, in 150 patients diagnosed with recurrent calcium lithiasis. The patients are divided into three groups: A) 50 cases subject to observation with no treatment, B) 50 cases treated with 50 mg/day of hydrochlorothiazide, and C) 50 cases treated with 50 mg of hydrochlorothiazide and 20 mlEq of potassium citrate/day. Each group is subject to a renal study with imaging techniques and a urinary metabolic study at baseline, 12, 24 and 36 months. ResultsThe patients treated with thiazides (Groups B and C) obtain a significant reduction in lithiasis recurrence compared with the control group (Group A). The most common abnormality found in the metabolic study was hypercalciuria, 52% of cases; 16% present a mixed lithogenic pattern. The number of recurrences and need for new sessions of extracorporeal lithotripsy in patients with hypercalciuria treated with thiazides is significantly smaller than in Group A (p=0.003) ConclusionsWe observe a significant relation between lithogenic pattern and lithiasis recurrence. Thiazides help us to control lithogenic factors and recurrences in patients with calcium lithiasis. This effect is prolonged and significant in patients with hypercalciuria.