Kidney Ureter Bladder Research Articles

Seed migration after transperineal interstitial prostate brachytherapy with I-125 free seeds: analysis of its incidence and risk factors

The purpose of this study was to evaluate the incidence and predictors of seed migration after transperineal interstitial prostate brachytherapy. From March 2007 to March 2011, 121 patients with stage T1-T2 prostate cancer underwent transperineal interstitial prostate brachytherapy. Pre-planning was performed 3 weeks prior to implantation, and the implants were inserted using the standard parallel needle insertion technique. All patients underwent a series of radiographs [chest radiography, kidney-ureter-bladder (KUB) radiography, and a CT scan] to assess whether seed migration had occurred on postoperative days 1 and 30, and 12 months. Seed migration occurred in 31 (25.6 %) of 121 patients. A total of 51 of 7,883 (0.65 %) implanted seeds migrated. Migration was detected on postoperative day 1 in 16 patients, day 30 in 13 patients and at 12 months in 4 patients (migration occurred at different times in 2 patients). The migrated seeds were found in the lungs, pelvis, heart, mediastinum, kidney, inguinal canal, liver and sacrum. The number of needles was a statistically significant factor in seed migration. The seeds migrated to many organs. No decrease in the dose administered to the prostate or adverse effects associated with seed migration were noted.

Predictive Value of Attenuation Coefficients Measured as Hounsfield Units on Noncontrast Computed Tomography During Flexible Ureteroscopy with Holmium Laser Lithotripsy: A Single-Center Experience

To assess the utility of attenuation coefficients as predictors of surgical outcome after a single flexible ureteroscopy (URS) with holmium laser lithotripsy. Many reports indicate that the efficacy of extracorporeal shockwave lithotripsy (SWL) can be predicted by the target's radiofrequency attenuation, measured as Hounsfield units (HUs) on noncontrast CT (NCCT). Studies of flexible URS, however, have not assessed the predictive value of attenuation coefficients on NCCT. Patients with renal stones who were treated by flexible URS with holmium laser lithotripsy between December 2009 and October 2011 at a single institute were retrospectively evaluated. Stone-free (SF) status was determined by kidneys-ureters-bladder (KUB) radiography at postoperative month 3. Correlations of possible predictors with SF status were analyzed using a logistic regression model. The comparison between groups with low and high HUs was examined using the Mann-Whitney U test. There were 219 eligible procedures. According to the logistic regression model, the maximum attenuation coefficient (P=0.105) and average attenuation coefficient (P=0.175) did not significantly, independently predict SF status. Fragmentation efficiency was significantly different between cases with low and high attenuation coefficients (P=0.001). In groups with less than 20.0-mm diameter stones, overall operative time (P<0.001 and P=0.001) and the time from starting fragmentation (P<0.001 and P=0.002) were significantly high in both attenuation groups. In groups with stones greater than 20.0 mm diameter, the two definitions of operative time revealed no differences between the low and high attenuation groups. The retrospective study design was the major limitation of this study. We found that both the maximum and average attenuation coefficients on NCCT are significantly related to the fragmentation efficiency. In addition, this study showed that, in patient groups with stone a burden <20.0 mm in diameter, both the maximum and average attenuation coefficients were significantly predictive of operative time.

Prevalence of hip pathology in patients over age 50 with spinal conditions requiring surgery

Background:The objective of this study was to evaluate of prevalence of co-existing spine and hip disease using initial screening kidney–ureter–bladder (KUB) radiograph in patients over 50 who underwent spinal surgery.Materials and Methods:The study subjects were 388 patients (male: female=117:271; mean age 62.0 years) who underwent spinal surgery between 2008 and 2010. We retrospectively reviewed the initial KUB radiographs used to diagnose the spine and hip disease. Depending on the extent of acetabular and hip joint visualization in KUB, we divided the subjects into three groups: Acetabulum, hip joint, and femoral neck visualization. The hip visualization rate was also assessed with respect to patient height. χ2 and logistic regression test were used for statistical analysis.Results:126 (32.5%) cases had significant hip pathology including hip osteoarthritis (Kellgren/Lawrence grade 3 in 123 cases, grade 4 in 3 cases) and avascular necrosis (1 case each of Ficat stage IIA and IIB), and 8 cases had other morphologic abnormalities. Regarding acetabulum–hip visualization in KUB, 7 (1.8%) cases had acetabulum visualization only, 16 (4.1%) had hip joint visualization, and 365 (94.1%) had femoral neck including lesser trochanter visualization. Patients were categorized into four groups according to height (less than 150 cm, 150–159 cm, 160–169 cm, greater than 170 cm). The hip visualization rates differed significantly among these four groups (P<0.05).Conclusions:The prevalence of discernible hip pathology in patients who underwent spinal surgery was 32.5%. Hip joint visualization was excellent (98.2%) in KUB radiographs. Hence, spinal surgeons should pay attention to hip pathology in surgically indicated spinal patients.

The Most Reliable Preoperative Assessment of Renal Stone Burden as a Predictor of Stone-free Status After Flexible Ureteroscopy With Holmium Laser Lithotripsy: A Single-center Experience

To examine which parameters should be measured to preoperatively determine the stone burden as predictors of stone-free (SF) status after a single flexible ureteroscopy (URS). Although several stone parameters reportedly influence the outcome of treatment for urinary stones, the most reliable indicators of stone burden remain unclear. Patients with renal stones treated by flexible URS with holmium laser lithotripsy between October 2009 and December 2011 at a single institute were retrospectively evaluated. The SF status was determined by kidney-ureter-bladder (KUB) films at postoperative day 1. Correlations of possible predictors with the SF status were analyzed using a logistic regression model. According to the univariate analysis, the following variables were significantly associated with failed treatment: number of stones (P = .001), cumulative stone diameter (CSD) (P < .001), stone surface area (SA) (P < .001), stone volume (P < .001), and presence of lower pole calculi (P = .008). According to the multivariate analysis, the stone volume (P < .001) and the CSD (P = .015) were found to be independent predictors of SF status. The SA (P = .598) had no significant independent influence on the SF status. Among the several parameters regarding the renal stone burden, the stone volume determined by noncontrast computed tomography and the CSD of the KUB were significantly and independently inversely related to the success rate of URS. Among the 3 parameters of stone burden, the SA was found to have a lower clinical utility and priority as a predictor of a SF status after URS.

Stone area and volume are correlated with operative time for cystolithotripsy for bladder calculi using a holmium: yttrium garnet laser

This study investigated the correlation between the operation time and the stone size as determined by multiple modalities and the computed tomography (CT) densities of bladder calculi using holmium: yttrium garnet (Ho:YAG) laser lithotripsy. A total of 68 patients underwent cystolithotripsy from March 2010 to October 2011. Thirty-six of these patients underwent cystolithotripsy using a Ho:YAG laser for bladder calculi by a single surgeon. The stone size was assessed by six modalities: sum of the stones' diameters: stone burden; maximum stone's diameter; number of stones; sum of the area using axial CT; sum of area using kidney-ureter-bladder (KUB) films; and volume using CT. In addition, the stone's CT density was measured by: the mean CT density of the maximum stone's whole area; maximum CT density of the maximum stone's whole area; and mean CT density of the maximum stone's center area. Correlations between the operation time and the stone size and the stone CT density were assessed. A total of 36 patients (30 male and six female) who underwent cystolithotripsy using a Ho:YAG laser for bladder calculi were enrolled in this study. Spearman correlation showed that the area and volume were strongly correlated with the operative time. The multipliers between the stone size and stone CT density showed no advantages based on the stone area or volume alone. The area and volume of the stones correlated more closely with the operation time than the stone burden for bladder calculi lithotripsy using a Ho:YAG laser.

Comparison of conventional radiography combined with ultrasonography versus nonenhanced helical computed tomography in evaluation of patients with renal colic

The aim of this study is to determine whether kidneys ureters bladder X-ray (KUB) film combined with ultrasound (US) can be effectively used in evaluation of renal colic and miss stones with clinically significant size identified on nonenhanced computed tomography (NECT) in patients with urolithiasis. This retrospective study evaluated the clinical and radiological records of 300 patients at our institution undergoing KUB and/or US and/or NECT for the evaluation of renal colic from June 2007 to December 2010. Of patients with negative findings on KUB and/or US, 22 had renal stones on NECT (mean size 4.4 mm, range 3-8), 3 had lower ureteral stone (mean size 3.3 mm, range 2-5). In patients with isolated suspicious renal ectasia without stone image, two had renal stone on NECT (mean size 4 mm, range 2-6), 5 had upper ureteral stone (mean size 4.4 mm, range 4-6), 7 had middle ureteral stone (mean size 3.7 mm, range 3-4) and 14 had lower ureteral stone (mean size 4 mm, range 2-6). The cost-effective and almost radiation-free combination of KUB and US should be preferred for diagnosis of urolithiasis, as it detects most of the ureteral and renal calculi which are clinically significant.

Retroperitoneal iaparoscopic ureterolithotomy for impacted upper-ureteral calculi: a report of 42 cases

The clinical data of 42 patients with impacted upper-ureteral calculi undergoing retroperitoneal laparoscopic ureterolithotomy (RPLU) from January 2008 to December 2010 were retrospectively analyzed.RPLU was successfully performed in 40 cases,and simultaneous laparoscopic electrocoagulation ablation was also performed in 11 cases complicated with ureteral inflammatory polyps.No massive bleeding occurred during the operations.The stone-free rate 3 d after operation was 100％,and no stone left as reviewed by kidney ureter bladder X-ray (KUB) and B-ultrasonography.During the follow-up of 3 to 24 months (mean 11 months),40 cases showed no stone recurrence and no ureteral stricture in KUB and B-ultrasonography.The hydronephrosis of all RPLU patients relieved.Results indicate that RPLU is a safe and effective minimally invasive operation for treatment of impacted upper-ureteral calculi. Key words: Laparoscopy; Ureteral calculi

Encrusted Ureteral Stent Retrieval Using Flexible Ureteroscopy with a Ho: YAG Laser

A 23-year-old female had bilateral ureteral stents placed due to bilateral renal stones and hydronephrosis. The bilateral ureteral stents were changed every 3 months. A kidney ureter bladder (KUB) film showed left encrustation along the ureteral stent thus necessitating removal; however, the ureteral stent could not be removed cystoscopically. The ureteral stent was, therefore, extracted using flexible ureteroscopy (URS) with a holmium (Ho): yttrium aluminum garnet (YAG) laser.

Noncontrast multidetector-row computed tomography scanning for detection of radiolucent calculi in acute renal insufficiency caused by bilateral ureteral obstruction of ceftriaxone crystals

Noncontrast computed tomography (CT) has great advantage with higher sensitivity and more clear modalities in detecting urinary tract radiolucent calculi in patients with acute renal insufficiency (ARI) compared to other image diagnosis approaches. We report two cases (female, 28 years old; male, 39 years old) with persistent flank pain and acute anuria after the administration of ceftriaxone (4.0 g daily) for 2 days intravenously. No abnormality was found in the kidney-ureter- bladder (KUB) areas with plain abdomen X-rays. A diagnosis of bilateral hydronephrosis was made by ultrasound examination in both cases. Serum creatinine levels reached up to 257 and 810 μ mol/L (normal serum creatinine level is 40-130 μ mol/L), respectively. Vague density spots were noticed in the pelvis with noncontrast multidetector-row CT (MDCT) scanning. However, distinguishable clusters of high-density shadows were seen in pelvic areas with maximum intensity projections (MIP, CT values in 30-128 HU). Ceftriaxone crystal calculi were found on both sides of distal ureters under endoscopy. Renal function recovered in both patients after double-J ureteral stents were installed. Out results demonstrated that noncontrast MDCT scanning and MIP reconstruction as an effective diagnostic tool could provide clear images in detection of radiolucent calculi in urinary tract when conventional X-rays image are not suitable in the patients with obstructive anuria and ARI of unknown origin.

Editorial Comment

The authors of this study randomized patients with radiopaque, non–lower-pole kidney stones 5-20 mm to adjuvant tamsulosin, nifedipine, or placebo after 4000 shocks of shock wave lithotripsy (SWL) fragmentation and no ureteral stent. They defined success as kidney ureter bladder completely stone free or clinically insignificant stone fragments ≤4 mm at any time during their patients' weekly follow-ups. The authors included in their analysis any patient with at least 1 follow-up and performed an renal ultrasound at day 30 for all patients who remained in the study (82%). Overall, they found no significant difference (P = .118) in success rates among the 3 groups. By subgroup analysis, tamsulosin and nifedipine increased success rates for stones ≥10 mm (P = .024), with both drugs having higher adverse event rates compared with placebo. Overall, the study results seem valid, the patients seem to be well stratified, and the authors have taken a number of steps to decrease bias. The stone community is in sore need for these types of trials, and the authors are to be congratulated for the study completion and for their diligence. Adjuvant Tamsulosin or Nifedipine After Extracorporeal Shock Wave Lithotripsy for Renal Stones: A Double Blind, Randomized, Placebo-controlled TrialUrologyVol. 78Issue 5PreviewTo evaluate the effects of the adjuvant use of tamsulosin or nifedipine after extracorporeal shock wave lithotripsy for nonlower pole kidney stones 5-20 mm in size. Full-Text PDF ReplyUrologyVol. 78Issue 5PreviewWe appreciate and fully agree with the statements made in the Editorial Comment. We would just point out that only nifedipine was associated with significantly more side effects than placebo. Full-Text PDF

Reply

We appreciate and fully agree with the statements made in the Editorial Comment. We would just point out that only nifedipine was associated with significantly more side effects than placebo. Editorial CommentUrologyVol. 78Issue 5PreviewThe authors of this study randomized patients with radiopaque, non–lower-pole kidney stones 5-20 mm to adjuvant tamsulosin, nifedipine, or placebo after 4000 shocks of shock wave lithotripsy (SWL) fragmentation and no ureteral stent. They defined success as kidney ureter bladder completely stone free or clinically insignificant stone fragments ≤4 mm at any time during their patients' weekly follow-ups. The authors included in their analysis any patient with at least 1 follow-up and performed an renal ultrasound at day 30 for all patients who remained in the study (82%). Full-Text PDF

Abdominal Lump in an Old Woman

An 89-year-old woman presented to our emergency department with persistent epigastralgia and vomiting for 2 days. She was afebrile and mildly tachycardiac (pulse rate 101 beats/min). Physical examination revealed a masslike lesion beneath the umbilicus (Figure 1). Blood tests showed leukocytosis (WBC count 21,600/μL; neutrophil 96%). Kidney ureter bladder abdominal radiograph revealed a small bowel gas collection with a large radiopacity in the lower abdomen.

Urologist-operated ultrasound and its use in urological outpatient clinics.

Introduction:Ultrasonograghy plays an important role in the evaluation of urinary tract disorders in cases of medical or surgical renal disorders, because of its lower cost, availability, and lack of ionizing radiation and because with it there is no need for contrast material injection or ingestion. It needs no intervention or preparation and specifically can differentiate between the multiple causes of flank pain. Urologist-operated sonography is a quick, cost-effective, and time-saving modality for both the physician and patient for obtaining first or final diagnosis. Based on its results, patients can be selected for appropriate management and further assessment.Materials and methods:The efficacy of ultrasound examination by a trained urologist in the differentiation of urological emergencies admitted in a district private clinic was studied. Between April 2008 and April 2010, a total of 724 patients (1448 renal units) had renal ultrasound performed by a trained urologist on acute admission. The sonographic findings were compared with subsequent definitive radiological investigations performed as needed, such as KUB (kidney, ureter, bladder) or IVP (intravenous pyelogram). Patient satisfaction and permission for ultrasonography were evaluated by oral consent. Loin pain was the presenting symptom in 45% of the patients (n = 326 cases).Results:Diagnosis was achieved in 96% of patients. Further evaluations were requested as needed in suspicious cases. If any hydronephrosis was detected and patients’ history and/or complaints were suggestive of renal or ureteral stones, an outpatient KUB was requested. For more complex situations, IVP was the next option. Abnormal findings were recorded in 184 cases (25.5%). Mild to moderate unilateral hydronephrosis with or without hydronephrosis was the most common finding observed sonographically. The sensitivity of our ultrasonography evaluation was 99.7%.Conclusion:Office urologist-operated sonograghy may supplement the information available through routine history, physical examination, and laboratory studies. Our study shows that urological trainees can use ultrasound with high levels of accuracy, thereby improving patient management with a high level of patient satisfaction.

How effective is extracorporeal shock wave lithotripsy of ureteral stones with Dornier Lithotripter S EMSE 220F-XXP? A prospective and preliminary assessment

To report our preliminary series with the Doli S EMSE 220F-XXP, the upgraded version of the previous Dornier Lithotripter S EMSE 220, for treatment of ureteral stones. Since July 2006, a total of 200 patients with ureteral stones were submitted to shock wave lithotripsy (SWL) with Doli S EMSE 220F-XXP. Mean stone size was 9.3mm (range 6-18mm). Ureteral stone location was proximal in 75, middle in 34, and distal in 91. Follow-up was carried out at 6weeks after the treatment, by means of kidney-ureter-bladder (KUB) film and ultrasound, or helical computed tomography (CT). The overall stone-free rate was 89.5%, and the effectiveness quotient was 80. Stratifying by stone site, the stone-free rate was 93.3, 67.6, and 94.5% for proximal, middle, and distal location, respectively. Mean number of sessions per patient was 1.14. Analgesia with intravenous ketorolac or tramadol was required in 42.5% of cases. No significant side-effects were recorded. The new Doli S EMSE 220F-XXP provides similar characteristics to the Doli S EMSE 220 in terms of safety and lack of major complications, when dealing with ureteral stones; the improvement in stone disintegration is particularly evident for distal location, for which the number of pulses and the intensity of treatment can be greatly increased and the upgraded power of the device can be widely applied.

The world’s heaviest ureteric calculus?

A 42-year-male presented with history of acute pain in the left lumbar area of 4 hours duration. There was no fever, pyuria or bacteruria on presentation, nor any history sug-gestive of urinary tract infection or stone disease in the past. However he had taken various over-the-counter analgesics in the past 10 years to relieve similar pain episodes.Physical examination was unremarkable. Hematological and biochemical parameters were within normal limits and urine culture was sterile. X-ray of the kidney-ureter-bladder (KUB) area revealed a 14 × 10 cm radio-opacity in the left lumbar area, overlapping the left sacro-iliac joint. Intravenous pyelogram (IVP) showed good excretion on both sides with gross hydroureteronephrosis (HDUN) on the left side due to a strange radiodense shadow in the left hemipelvis (Fig. 1). Contrast enhanced CT (CeCT) was done to ascertain the diagnosis – was it a foreign body; or DFDOFL?HGJURZWK RUDFDOFXOXVZLWKLQDGLYHUWLFXOXPRUdue to some ureterocoele. But the radiological dilemma persisted.Preoperative cystourethroscopy showed normal bladder PXFRVDDQGXUHWHULFRUL?FH+RZHYHUWKHLQWUDPXUDOSDUWRIWKHOHIWXUHWHUVHHPHG?OOHGXSIURPZLWKLQ>@$iFPUDGLRGHQVHRSDFLW\ZDVFRQ?UPHGXSRQAXRURVFRS\8QVXUHDERXWWKH?QDOSUHRSHUDWLYHGLDJQRVLVthe abdomen was opened with a midline vertical incision.The left ureter was found to be grossly dilated to the extent of 9 cm with a stony hard content within (Fig. 2). The

Small Bowel Obstruction Secondary to Strangulation Through a Defect in the Falciform Ligament After Blunt Abdominal Trauma in a Pediatric Patient

Obstruction caused by strangulation internal hernia secondary to incarceration within the falciform ligament, although rare, has been previously reported in the literature. These cases, however, were unrelated to trauma. We report on the first case in the pediatric literature of a strangulated internal hernia secondary to incarceration in the falciform ligament precipitated by blunt abdominal trauma. A 12-year-old girl presented to the emergency room less than 24 hours after sustaining a kick to the right upper quadrant. She described sharp, nonradiating, right-upper-quadrant abdominal pain, which was associated with nausea and vomiting. A KUB (kidney, ureter, bladder) view showed a paucity of bowel in the right upper quadrant with distended adjacent bowel. An ultrasound showed a small amount of abdominal ascites and a prominent liver. Computed tomography scan revealed a linear hypodensity at the tip of the right lobe of the liver, suggestive of a laceration. Moderate abdominal and pelvic ascites and multiple collapsed small-bowel loops with diffuse wall thickening and poor enhancement were seen in the right upper quadrant. Significantly, pneumatosis was noted, raising the question of obstruction/volvulus and/or bowel ischemia. An exploratory laparotomy revealed incarcerated small bowel herniated into a defect in the falciform ligament, which was resected. The defect was repaired. Seemingly trivial trauma may play a precipitating role in strangulation in a patient who already has a defect in the falciform ligament.

The role of emergency ultrasound for evaluating acute pyelonephritis in the ED

Background Controversy remains over the imaging method of choice for evaluating acute pyelonephritis (APN) in the emergency department (ED). Objective The aim of the study was to determine the efficacy of ultrasound in the diagnosis and management of patients presented to the ED with APN. Methods This was a retrospective study of prospectively collected data. A cohort of ED patients diagnosed as APN were prospectively registered, and their medical records were then retrospectively reviewed for the presence of complications (admitted >14 days, admission to intensive care unit, or received invasive procedures), significant abnormalities (hydronephrosis, polycystic kidney diseases, renal abscess, emphysematous pyelonephritis), and mild abnormalities (cysts, stones, swelling). Results The study included 243 patients. Most of the patients received one or more renal imaging studies (n = 206) and 39.5% of which were considered abnormal. The rates of significant abnormalities on different imaging methods were Kidney-ureter-bladder (KUB), 16.3%; emergency ultrasound (EUS), 39.6%; combination of KUB and EUS, 56.6%; and computed tomography, 58.8%. Factors contributed to complicated APN were elderly, male, a history of preexisting renal diseases, current use of catheters, previous renal calculi, and diabetes mellitus. Significant abnormalities can be identified by EUS in 61% of patients with complicated APN. In fact, the presence of significant sonographic abnormalities effectively diverted 34.3% of patients to receive surgical interventions (percutaneous nephrostomy, abscess aspiration, ureteroscopic stone manipulation, lithotripsy, or nephrectomy). Conclusion Structural abnormalities are not uncommon in ED patients with APN. Early assessment of these patients with EUS is likely to have a great impact on their diagnosis and management.

A huge bladder calculus causing acute renal failure

We present a 39-year-old man with repeated urinary tract infection and lower abdominal pain. Kidney-ureter-bladder (KUB) and IVU film showed a huge 450-g elliptical pelvic calculus that was surgically removed with excellent results. Surgical intervention by cystolithotomy or endoscopic cystolithotripsy can achieve satisfactory results. Bladder outlet obstruction should be treated simultaneously. Bladder stone is a common disease, but it is rare for such a calculus to be so large as to cause bilateral hydronephrosis. Close follow-up, however, is mandatory because the recurrence of urolithiasis is high in those patients with voiding problems and recurrent urinary infection. To the best of our knowledge, this is the largest bladder stone in a human male.

Emphysematous cystitis with perforation in a non-diabetic patient

An 82-year-old woman with a history of adenoid cystic carcinoma of the left lower lung, who had undergone surgery and radiotherapy in 1998, presented to our emergency department complaining of...

Clinical evaluation of urolithiasis in Crohn's disease

To investigate the characteristics of urolithiasis associated with Crohn's disease in a Japanese population. We studied 98 patients with Crohn's disease: 39 with urolithiasis and 59 without urolithiasis. Patients were treated at the Social Insurance Central General Hospital, or at the Toho University Omori, Ohashi, or Sakura Medical Centers. Calculi were more frequent in men (n = 30) than women (n = 9). Mean time from diagnosis of Crohn's disease to diagnosis of calculi was 8.8 years (range 0 to 22 years). Calculi were present on the right side in 19 patients and the left side in 19 patients. Stone were composed of calcium oxalate in nine patients, calcium oxalate and calcium phosphate in two patients, and ammonium urate in five patients. The rate of concurrent calculi was significantly higher in ileostomates. The probability of developing calculi was approximately eight times higher for patients with a urine pH of <or=6.0 than for those with a urine pH of >or=6.5. The rate of concurrent urolithiasis was higher in patients with a urine pH of <or=6.0, ileostomy, or two or more bowel resections. To prevent formation of calculi, Crohn's disease patients require regular urological examination including urinalysis, ultrasonography, and kidney ureter bladder X-ray.