Lower Calyx Research Articles

Fístula enterocutánea como complicación de nefrolitotomía percutánea en pacientes con cirugía bariátrica previa: presentación del caso y revisión de la literatura

Enterocutaneous fistula is a rare complication after percutaneous nephrolithotomy. Some situations are risk factors for it to occur, such as horseshoe kidney, retrorenal colon and chronic colonic dilation by several factors, among them late postoperative time after yeyunoileal bypass in morbid obesity treatment. 35-year-old female patient with a 2.5 cm calculus in the right renal pelvis. Late postoperative time after bariatric surgery using duodenal switch technique, and 55 kg lost till present. She undergone percutaneous nephrolithotomy (PCNL) with two punctures, one in the lower calyx, lost during dilation, and other in the upper calyx through which surgery was successfully carried out. During immediate postoperative time it enteric secretions were observed through the lower chalice puncture. Once the intraperitoneal lesion was removed, decision for conservative treatment was taken with fistula drainage, broadspectrum antibiotic therapy, fasting and total parenteral nutrition. The fistula debt ceased in the 8th postoperative (PO) day, when drain and nephrostomy tube were withdrawn and patient was discharged from the hospital on 10th PO day. On ambulatory follow up the patient is in good conditions. One case of enterocutaneous fistula after PNL presented in a patient in late postoperative time after yeyunoileal bypass. She was successfully treated by conservative therapy. Several authors point to chronic colonic distention and to great loss of retroperitoneal fat as causes for the increase of inadvertent colonic punctures in percutaneous renal access. The risk of complications with enterocutaneous fistula is significantly higher during the postoperatory in patients of bariatric surgery than in others.

1813 EVALUATION OF RISK FACTORS FOR PROGNOSIS OF TEMPORARY RENAL IMPAIRMENT AFTER SECONDARY EXTRACORPORAL SHOCK WAVE LITHOTRIPSY (ESWL) IN RENAL STONE TREATMENT

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopic or Percutaneous Stone Removal III1 Apr 20101813 EVALUATION OF RISK FACTORS FOR PROGNOSIS OF TEMPORARY RENAL IMPAIRMENT AFTER SECONDARY EXTRACORPORAL SHOCK WAVE LITHOTRIPSY (ESWL) IN RENAL STONE TREATMENT Christian Weißflog, Sven Oehlschläger, and Manfred Wirth Christian WeißflogChristian Weißflog More articles by this author , Sven OehlschlägerSven Oehlschläger More articles by this author , and Manfred WirthManfred Wirth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1738AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES ESWL as primary treatment of renal stone disease leads traceable (animal experiment, change of tubulary enzymes of human kidneys) to temporary renal impairment. The correlation between age, comorbidic factors (hypertension, diabetes, chronic ischaemic heart disease) and elevated levels of retention parameters is well known. With respect to different treatment opportunities (ureterorenoscopic stone extraction, ureterolithotomy) a predictable model to calculate renal impairment prior to ESWL would be of pathbreaking interest. This might lead to an alternative therapy without or with less renal impairment. METHODS 111 patients were examined with primary ESWL. 63 underwent immediate secondary ESWL. We analysed for age, sex, body mass index, body surface, stone location (side; upper, medium and lower calyx, ureteral stones excluded), creatinine and GFR prior (0) and after first (1) and second ESWL (2), prior stone treatment, hypertension, diabetes, chronic ischaemic heart disease, flouroscopy time for stone localisation, amount and intensity of shock waves, stone size, sonografic skin-stone-distance, renal stasis and in situ DJ-uretercatheter. RESULTS There was a non-significant decrease between GFR 0 vs. GFR 1. The significant decrease of GFR 0 vs. GFR 2 (p<0.01, table 1) was correlated with sex, age and arterial hypertension. Patients with decrease > 6 points in GFR after secondary ESWL, can be predicted with the logit sum model. The probability of decreased GFR has been calculated by summing up the regression-coefficients (table 2) and including it into the following formula of the logit transformation: p = exp(logit sum)/(1+exp(logit sum)), result in percent. table 1 - GFR mean ± SD (ml/min/1,73m2) prior to ESWL (0) 98,7±22,5 after 1. ESWL (1) 97,5±20,6(p<0,08) after 2. ESWL (2) 93,4±21,1(p<0,01) table 2 - variable regression-coefficient p Intercept -4.5125 creatinine prior to ESWL 0.0317 0.0309 GFR prior to ESWL 0.0446 0.0023 BMI -0.1538 0.0472 hypertension 1.2910 0.0076 CONCLUSIONS The study showed a significant decrease of GFR after secondary ESWL. Patients at risk can be predicted by using our evaluated statistic model. Those patients might profit of a conditioning of renal function or an optimized treatment of hypertension prior to ESWL. Dresden, Germany© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e703-e704 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Christian Weißflog More articles by this author Sven Oehlschläger More articles by this author Manfred Wirth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Extracorporeal Shock Wave Lithotripsy (Eswl) in Infant Urolithiasis Management

Purpose We evaluated the efficiency of ESWL in the treatment of urinary calculi in children under 2 years old. Material and Methods Forty five renal units of forty patients (29 boys, 11 girls, median age: 10 months range: 10 days- 24 months), were treated with ESWL for urolithiasis (median age: 13 months range: 3-24 months) under sedation. Stones were in lower calyx in 14, mid calyx in 15, upper calyx in 6, the renal pelvis,in 21, the proximal ureter in one patient. The mean stone burden was 76,8±55 mm 2 (16 - 247 mm 2 ).Efficiency of treatment is calculated with Efficiency quotient (EQ: stone-free% X 100/ (100% + %re-treatment rate+% auxiliary procedures) formula. Results 59 ESWL sessions (mean:1,33±0,67,range1-4) were performed. Stone free (SF) rate was 82,2% (37/45), clinical insignificant residual fragment (CIRF) rate was 17,7% and ESWL failure was not observed in any patients. Mean EQ was 0,64. There was no significant statistical association between the locations, size and the number of successfully treated calculi (table). SF CIRF Total Renal Units (n) 37 8 45 Median Age (months) 11 9 10 Mean Calculus Size (mm2) 77,76 72,62 76,8 Mean SWL Session 1.29 1.37 1.33 Mean Shock Number 1400 1375 1382 Mean Maximum Energy 1.59 1.4 1.53 Mean Average Energy 1 0,97 0,99 Calculus Localization (%) EQ Pelvis 85,7% 14,28% 0.69 21 Upper pole 83,3% 16,7% 0.63 6 Middle pole 80% 20% 0,50 15 Lower pole 78,6% 21,4% 0,58 14 Proximal ureter 100% 1 1 Conclusions ESWL is a safe and a very efficient treatment method in infant age group.All of the patients presented with a complete or partial response. Complete stone clearance was possible 82,2%. There was no marked difference in different locations in this age group.

Cytological diagnosis of squamous cell carcinoma of renal pelvis

Sir, Primary squamous cell carcinoma of the renal collecting system is rare. It is more frequently reported in the bladder and male urethra than in pelvis.[1] The incidence of squamous cell carcinoma among malignant renal tumors ranges widely from 0.5% to 0.8%.[2] It commonly occurs in patients with long standing renal calculi. Fine-needle aspiration cytology (FNAC) has become an important tool in diagnosing squamous cell carcinoma of the kidney. We would like to share our experience in diagnosing one such case on urine cytology and FNAC. A 50-year-old woman presented with left flank lump with pain and fever for two months. Physical examination was normal except for left-sided abdominal tenderness. Ultrasonography revealed hydronephrosis. Intravenous pyelography showed a functioning kidney with a slight left hydronephrosis and multiple calculi in the lower calyx. The patient was diagnosed to have hydronephrosis with calculi. We received four mL of straw colored urine, which was centrifuged, and smears were made from the sediment. On microscopic examination, urinary cytology was positive for malignant cells. Cytomorphological feature of squamous cell carcinoma was suggested [Figure 1]. Following this, ultrasound-guided FNAC of the lump was performed. Figure 1 Fine-needle aspiration cytology smear shows pleomorphic squamous cells in a hemorrhagic background (Giemsa stain, ×400) FNAC smears showed acute inflammatory cells, a few anucleate squames, necrotic cellular material, and a few isolated and occasional groups of epithelial tumor cells. The cells showed pleomorphism, central hyperchromatic nucleus with coarse irregular chromatin, and inconspicuous nucleoli; irregular nuclear outlines and mild to moderate amount of ground-glass–like basophilic cytoplasm were also observed. Occasional tadpole cells were also seen in a hemorrhagic background [Figure 2]. Considering the above features, a diagnosis of squamous cell carcinoma was made. Figure 2 Urine smear shows benign urothelial cells and pleomorphic squamous cells (Giemsa stain, ×400) Renal FNAC can produce an accurate diagnosis in most cases. FNAC when practiced in a multidisciplinary setting with direct involvement of pathologists, radiologists and clinicians is an extremely accurate, well-tolerated, relatively noninvasive, and low-risk test that obviates the needs for surgical intervention in most benign conditions and disseminated malignancy. Therefore, by taking an active role with onsite assessment of the FNAC material and discussion with radiologist colleagues, the cytopathologist can offer a FNAC service comparable to surgical pathology in sensitivity and very similar to frozen section in specificity.[3] Squamous cell carcinoma is estimated to represent 9%–20% of all tumors of the renal pelvis. Urinary calculi are accepted as main carcinogenic risk factors for squamous cell carcinoma. Chronic irritation and infection are believed to induce infective changes in the urothelium and lead to neoplasm via metaplasia and leucoplakia. Uretral obstruction is the main cause of the presenting symptom. Squamous cell carcinoma of upper urinary tract is generally considered as an aggressive tumor. Treatment of choice is nephrectomy with total ureterectomy, including bladder cuff around the ureteral orifice.[4] Chemotherapy conveys little benefit and value of radiotherapy is debatable. We have reported this case to highlight the fact that imaging techniques usually reveal only calculi and hydronephrosis, but FNAC can provide us with an accurate diagnosis of the underlying malignanacy.

Laparoscopic Circumcaval Ureteral Repair with Concomitant Laparoscopic-Guided Nephroscopic Calculi Extraction

Introduction: The pre-ureteral vena cava anomaly, erroneously termed the retrocaval or circumcaval ureter, is a relative rare condition of extrinsic ureteral obstruction. Despite being more common on the right kidney, when present on the left side, it is usually associated with sites inverses. The laparoscopic approach, with all of its know advantages, has good results when used to treat this congenital anomaly. The present surgical video shows a ureteral transposition with ureteropyolostomy, associated with a nephroscopic calyceal calculi extraction. Case Report: A 54 years old man, with discomfort in the right flank and abdominal echography showing a pelvicalyceal dilatation of this side and a calculus of 1.5 cm in a lower calyx. An intravenous pyelogram and abdominal computed tomography showed an S-shaped (Atkinson classification) pre-ureteral vena cava, and a mid-ureteral extrinsic stricture associated with it. There were no patient pre-operative comorbities and a percutaneous nephrolithotripsy was done 4 years prior on the right kidney. In the present video, a transperitoneal laparoscopic approach was conducted, with 4 trocars. In a stepwise fashion, the ureter suband supracaval was gently dissected, sectioned near the renal pelvis, transposed, and spatulated .A ureteropyelostomy was done over a double J stent, which was placed in an antegrade manner. After the posterior wall anastomosis completed, we performed a nephroscopy through the left hand trocar and the calyceal stone was removed by percutaneous stone instrumentation. Result: The surgery lasted 240 minutes, with minimum blood loss. The diet was resumed on the first postoperative day and he was discharged home on the third postoperative day. After 8 months of follow up, the patient remains asymptomatic and his excretory urography shows good drainage of the right kidney as well a diuretic renography reveals good response following 20 minutes after furosemide intravenous administration. Furthemore, the pelvicalyceal dilatation improved and there are no subsequent calculi. Conclusion: The laparoscopic approach to circumcaval ureteral anomalies is a feasible option, with concomitant endourologic procedures possible with good results. Int Braz J Urol. 2009; 35 (Video #2): 753_4 Available at: www.brazjurol.com.br/videos/november_december_2009/Curcio_753_754video.htm Accepted: November 8, 2009 Correspondence address: Dr. Lessandro Curcio Goncalves Section of Urology Ipanema General Hospital Rio de Janeiro, RJ, Brazil E-mail: lessandrocg@ig.com.br doi: 10.1590/S1677-553820090006000031

Failure after shockwave lithotripsy: is outcome machine dependent?

To investigate the issue of shockwave lithotripsy failure by studying the effect of machine crossover to the Technomed Sonolith Vision (TSV) lithotriptor in patients with previously unsuccessfully treated renal stones with the Dornier Compact Delta (DCD). Records were examined for the period between 1998 and 2006. Parameters analysed were: size, multiple/single stones, location, treatments/stone. Seventy-six patients fulfilled the inclusion criteria. Following lithotripsy with the TSV, the stone-free rate (SFR) at 3 months was 56.7%, and the success rate (stone-free and fragments < or = 4 mm, SR) 86.7%. Twenty-two patients had multiple stones and the majority of the stones were located in the lower calyx (59.2%). Mean size was 8.9 mm prior to treatment with the TSV machine (10.2 mm for DCD). Further analysis followed in a subgroup of 42 patients of the same stone size (+/-2 mm) before and after DCD sessions. Mean stone size was 7 mm. The SFR was 61.9% (62.9% vs. 40.9% for single and multiple stones), and the SR was 88.1%. No difference in SFR was found for single or multiple stones in any of the two groups. The term 'extracorporeal shockwave lithotripsy (ESWL)-resistant stones' needs to be re-examined, as treatment with a different lithotriptor was successful in a group of stones where another machine had failed. Lithotripters with different shock wave characteristics may result in difference in the results of ESWL. Future research in ESWL should focus on stone characteristics and development of machines with the ability to adapt to specific stone features.

Pediatric Extracorporeal Shockwave Lithotripsy: Its Efficiency at Various Locations in the Upper Tract

Several reports demonstrated the effectiveness of extracorporeal shockwave lithotripsy (SWL) in the management of pediatric upper tract urolithiasis. The majority of these studies used the stone-free rate as the main indicator for treatment success. Efficacy Quotient (EQ) is an important outcome measure because it not only takes into consideration the stone-free rate, but also includes other undesirable outcomes that increase patient morbidity and utilizes hospital resources. Nevertheless, very few studies reported on the EQ of pediatric SWL at various locations in the upper tract. We retrospectively reviewed the records of 84 children (103 urinary calculi) who were treated with SWL in our institution between 1995 and 2005. There were 84 renal (pelvis, n = 27; upper calyx, n = 13; middle calyx, n = 8; lower calyx, n = 36) and 19 ureteric (upper third, n = 10; middle third, n = 5; lower third n = 4) stones. EQ for renal pelvic stones was 67% compared to 48% for caliceal stones (upper calyx: 52%, middle calyx: 46% and lower calyx: 47%). Overall, the EQ for renal stone was 54% and it was 59% for ureteric stones. This efficiency in the ureter was achieved at the expense of a higher number of shock waves delivered (3606 vs. 2592, P < 0.01). Overall, the stone-free rate was 82% (renal, 81%; ureteric calculi 84%). The only factor that affected the stone-free rate was the size of the stone (33% in stones >2 cm and 87% in stones <2 cm (P < 0.01). The overall retreatment rate was 41% (renal, 40% and ureteric 42%). However, the number of total treatments ranged from 1 to 5 sessions in renal stones and 1 to 2 sessions in ureteric stones. Auxiliary procedures were performed in 9 patients (stenting, n = 3; ureteroscopy, n = 4 and percutaneous nephrolithotomy, n = 2). Pediatric SWL appears to be more efficient in the renal pelvic stones compared to caliceal stones. The efficiency of SWL in the ureter is achieved with a higher number of shock waves delivered. A discussion on the possible future modifications of the definition of EQ, especially in children, is also provided.

Lower Calyceal Occlusion by Autologous Blood Clot to Prevent Stone Fragment Reaccumulation after Retrograde Intra-Renal Surgery for Lower Calyceal Stones: First Experience of a New Technique

We tested the hypothesis that lower calyceal (LC) autologous blood clot (ABC) occlusion, after retrograde intra-renal surgery (RIRS) may prevent LC fragment reaccumulation where all fragments cannot be directly removed. Over two years, patients with LC stones >6 mm <2 cm, that had presented de-novo or failed primary SWL or PNL elsewhere, were treated with RIRS. After intra-renal relocation into a favorable lie, stones were fragmented with Holmium laser energy to <3 mm, suitable for spontaneous passage. The LC was filled with 5-10 cc venous autologous blood with the patient in reverse Trendelenberg, leaving the blood to clot. After confirmatory pyelogram a DJ stent was placed. Ultrasound and KUB at 3 months assessed stone free rate. This technique was tested in 35 patients with LC calculi (16 as primary treatment, and 19 as salvage for residual fragments post SWL or PNL). Nine salvage patients had indwelling DJ stents (three significantly encrusted at RIRS). Nine unstented patients had upper ureteral tortuosities or narrowing limiting multiple instrument passes for stone removal. Median maximum stone dimension was 1.2 cm. All were successfully relocated & fragmented. A Nitinol basket was required for stone relocation in 60%. All but one occlusion procedures succeeded at the first attempt. None required re-admission for clot colic. Only 8.6% required more than overnight hospital stay. Three and six month stone free rates were 94% and 97% respectively. The simple LC autologous blood clot occlusion technique after RIRS, for difficult LC stones, validates our hypothesis and results in excellent stone free rates, while minimizing ureteral trauma from multiple instrument passages needed for active fragment removal. This study supports the need for multi-center experience of this technique to validate our results.

Prise en charge des calculs du rein (hors coralliforme et calice inférieur)

The management of renal stones needs a recent and good quality imaging. Contrast medium injection is optional. Extracorporeal shockwave lithotripsy (ESWL) is the most common treatment of renal stones. ESWL is indicated as first line treatment for less than 1.5cm stones. The stone-free (SF) rate at 3 months of ESWL is 70-80%. Results of ESWL for stones with more than 1000UH density or located in the lower calyx are poor. Flexible ureteroscopy (URS) is indicated in case of ESWL failure or for hyperdense, 1-2cm stones. The SF rate of flexible is 80%. Percutaneous nephrolithotomy is indicated for complex or more than 2cm stones. Asymptomatic and non infected stones, especially if located in the lower calyx, do not need urological treatment but must be followed up. In all cases, renal stones needs a metabolic evaluation and treatment, and annual follow-up.

Retrograde intrarenal surgery for lower pole renal calculi smaller than one centimeter

Objectives:Recently there has been an increasing interest in the application of retrograde intrarenal surgery (RIRS) for managing renal calculi. In this review we discuss its application for the management of lower calyceal (LC) stones less than 10 mm in maximum dimension.Materials and Methods:Literature was reviewed to summarize the technical development in flexible ureterorenoscopy and its accessories. Further, the indications, outcome and limitations of RIRS for LC calculi < 1 cm were reviewed.Results:Use of access sheath and displacement of LC stone to a more favorable location is increasingly employed during RIRS. Patients who are anticoagulated or obese; those with adverse stone composition and those with concomitant ureteral calculi are ideally suited for RIRS. It is used as a salvage therapy for shock wave lithotripsy (SWL) refractory calculi but with a lower success rate (46-62%). It is also increasingly being used as a primary modality for treating LC calculi, with a stone-free rate ranging from 50-90.9%. However, the criteria for defining stone-free status are not uniform in the literature. The impact of intrarenal anatomy on stone-free rates after RIRS is unclear; however, unfavorable lower calyceal anatomy may hamper the efficacy of the procedure. The durability of flexible ureteroscopes remains an important issue.Conclusions:RIRS continues to undergo significant advancements and is emerging as a first-line procedure for challenging stone cases. The treatment of choice for LC calculi < 1 cm depends on patient's preference and the individual surgeon's preference and level of expertise.

Tubeless percutaneous neprolithotomy: the new gold standard

We present our experience with tubeless percutaneous nephrolithotomy (PCNL). Between July 2004 and December 2006, 121 patients (82 males and 39 females) with 18-70 mm (mean 31.19 mm) renal stones underwent tubeless PCNL leaving only a 6 Fr externalized ureteric catheter. Their ages ranged between 4 and 80 years (mean 37.27). Two patients had bilateral disease, so a total of 123 renal units are included. The procedure was performed under general anesthesia in the prone (110 units) or supine position (13 units). A total of 133 punctures were performed. The punctures were single (114 units), double (8 units), or triple (1 unit). The approach was subcostal through the lower calyx (n=110) or middle calyx (n=10), or supracostal through the middle calyx (n=8) or upper calyx (n=5). Mean operative time was 46.30 min (range 15-100). Mean reduction in hemoglobin level was 1.57 g (range 0.3-4) with blood transfusion rate 4.13%. Complication rate was 9.9% in the form of perirenal collection (five patients), urinary leakage (two patients), fever (four patients), and hydrothorax (one patient). The ureteric catheter was left for 7-72 h (mean 45.67). Postoperative analgesia was required in 22 patients (18.2%) with mean 22.9 mg diclofenac sodium per patient. Mean hospital stay was 50.69 h (range 12-96) with 106 units (86.18%) rendered stone free, 13 (10.57%) with insignificant residuals, and four units (3.25%) were left with significant residual stones. Tubeless PCNL is a good option in non-complicated PCNL with the advantages of reduced hospital stay, low postoperative pain, and little need for postoperative analgesia.

A new transportable shock‐wave lithotripsy machine for managing urinary stones: a single‐centre experience with a dual‐focus lithotripter

To assess the efficacy and safety of a transportable extracorporeal shock wave lithotripsy (ESWL) machine, the Modulith SLX-F2(TM) (Storz Medical Italia, Rome, Italy), in the management of solitary urinary calculi. The study included 233 patients (mean age 51 years; 172 male, 61 female) with symptomatic solitary renal (group A, 170, mean diameter 15.5 mm) or ureteric stones (group B, 63, mean diameter 9.5 mm) treated in a tertiary care institution. Exclusion criteria for the analysis were: pelvi-ureteric junction obstruction, multiple stones, stone diameter >2 cm, stones in a lower calyx with unfavourable anatomy, active infection, or impacted ureteric stones. Selected patients had ureteric stenting before treatment, and all patients were treated with no anaesthesia. Hospitalization, complications and subsequent auxiliary procedures were evaluated. Patients were assessed after a single ESWL session and after 3 months by a plain abdominal film and renal ultrasonography. Stone-free status was defined as no evidence of calculi, and clinical success as the presence of stone fragments of <4 mm. An efficiency quotient (EQ) was calculated for the ESWL treatment. Pain was assessed using a visual analogue scale. The mean number of shocks used was 3779 and the mean (range) treatment time was 35 (5-55) min. The overall clinical success rate after one ESWL session was 83.7% and 82.5% for renal and ureteric stones, respectively, and the overall 3-month stone-free rate was 77% and 74.6%, respectively; the overall EQ was 0.64. When risk factors for persistent calculi were analysed simultaneously in a logistic regression model, only stones of >1 cm were statistically significant (P < 0.05). Most patients reported that pain during ESWL was mild to moderate and easily tolerated. Only minor complications occurred, with an overall complication rate of 3.8%. This transportable lithotripter is a safe and effective device for managing solitary stones throughout the urinary tract. Its main advantage is represented by the dual-focus system. Moreover, it shares with other contemporary machines several important features such as outpatient setting, no need for anaesthesia, easy patient positioning, and the capability of ancillary procedures.

Management of calyceal diverticular stones with extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy: long‐term outcome

To review patients with an extended follow-up after extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones (CDS), over a 15-year period, assessing the long-term outcome. In all, 56 patients were treated for symptomatic CDS disease by ESWL (38) or PCNL (18). The stone-bearing diverticula were in the upper calyces in 26, middle calyces in 24 and lower calyces in six patients, and in the right kidney in 22 and in the left in 34. The most frequent symptom was ipsilateral flank pain (84%) and 32% of patients presented with associated chronic urinary tract infections. In a retrospective analysis, we assessed stone size, diverticulum location, stone-free rate, symptom-free rate, complications and extended follow-up. In the short-term in the ESWL group, 21% of patients were stone-free and 61% were asymptomatic; 8% developed symptoms and 8% developed recurrence or stone-growth in the long term. There were six minor complications. In the PCNL group, 15 patients (83%) were stone-free in the short term; two had a recurrence (11%) and two had stone growth (11) in the long term. There were three complications after PCNL. This series shows that PCNL is an effective and durable means of treating CDS, regardless of stone size or location of the diverticulum. Despite low stone-free rates with ESWL, most patients were rendered symptom-free with minimal complications. The long-term recurrence rates, 8% for ESWL and 11% for PCNL, were comparable.

Minimally invasive percutaneous nephrolithotomy for upper urinary tract calculi in transplanted kidneys

To report our experience with minimally invasive percutaneous nephrolithotomy (mPCNL) for upper urinary tract (UUT) calculi in transplanted kidneys. Between August 2002 and June 2006, seven patients (mean age 40.7 years) with UUT stones in transplanted kidneys (including one staghorn, two pelvic and four ureteric stones) were treated by mPCNL. A 16 F peel-away sheath was placed as the percutaneous access port and a 8.5/11.5 F nephroscope or a 8/9.8 F ureteroscope was used for manipulation. Every 2-3 months during the follow-up, patients had their serum urea, creatinine and uric acid measured, with urine culture and ultrasonography. All patients were rendered stone-free at one mPCNL procedure, with no complications during or after surgery. The mean (range) operative duration was 53 (20-100) min and the mean haemoglobin decrease was 0.55 (0.2-1.2) g/dL. At a mean (range) follow-up of 23 (3-48) months renal allograft function was stable in all patients and no recurrence of stone was detected. mPCNL is safe and effective for managing calculi in transplanted kidneys, and it can be the initial therapy for most cases of UUT stones in transplanted kidneys, except for simple and small stones in the middle or lower calyx.

Comparison of the Cost and Effectiveness of Different Medical Options for Treating Lower Calyceal Stones Less than 2cm: Extracorporeal Shock Wave Lithotripsy versus Percutaneous Nephrolithotomy

Purpose: We wanted to evaluate the cost and effectiveness of different medical options for treating lower calyceal stones that measure less than 2cm, and specifically percutaneous nephrolithotomy (PNL) versus extracorporeal shock wave lithotripsy (ESWL). Materials and Methods: A total of 61 patients with lower calyceal stones that measured less than 2cm were divided into two groups according to the first-line of treatment modality: the PNL (group 1) group and the ESWL (group 2) group. Each group was divided into two sub-groups; subgroup A, which included stones less than 1cm (group 1A and 2A) and subgroup B, which included stones that measured 1-2cm (group 1B and 2B). The stone-free rate and many other factors were analyzed. Results: The success rates of treatment for group 1A and 2A were 100% (8/8) and 76.4% (13/17), respectively (p=0.269). However, in groups 1B and 2B, the success rates of treatment were 100% (14/14) and 63.6% (14/22), respectively (p=0.013), with group 1B showing a higher success rate. The total cost of treatment and the average of a patient's expenditure per group were as follows: group 1 with 2,622,501 won and 1,093,508 won, respectively; group 2 with 938,225 won and 447,935 won, respectively (p< 0.001). Conclusions: The results of this study indicate that ESWL can serve as an effective first-line treatment modality for lower calyceal stones that measured less than 2cm. However, when considering other factors, such as the expensive burden of additional treatment and our national health insurance system, PNL may be an acceptable first-line treatment modality for lower calyceal stones that measure 1-2cm. (Korean J Urol 2006;47:703707) ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ

“Angular Percutaneous Renal Access”. Multiple Tracts Through A Single Incision for Staghorn Calculous Treatment in A Single Session

Purpose: We herein describe the technique of a single subcostal skin incision with multiple angular punctures to approach the superior, middle and lower pole of the kidney for the management of staghorn calculi. Materials and method: One hundred patients with staghorn calculi were managed between January 1997 and June 2000. The superior calyx was approached by a subcostal triangulation technique and the middle and lower calyces were approached by angular punctures. Correct advancement of the needle was monitored by biplane fluoroscopy. Maximum effort was made for complete stone clearance in a single session. Results: 87% patients were rendered stone free in a single session. The average number of tract dilation per renal unit was 2.4 with an average anesthesia time of 110 minutes and the average blood loss of 450 ml. The average hospital stay duration was 4.6 days. The secondary procedures required were 0.11 per patient and the complication rate totalled 7% with one case of excessive hemorrhage requiring embolization. Conclusions: We therefore propose the triangulation technique as a safe and appealing method for the percutaneous management of staghorn calculi.

Perkutane Nephrolithotomie

The introduction of percutaneous nephrolithotomy (PNL) marked a turning point in the interventional treatment of nephrolithiasis. For the first time, the minimally invasive removal of larger kidney stones, which had previously required open surgery, became possible. With the increasing use of extracorporeal shock wave lithotripsy (SWL) during the 1980s, PNL lost clinical importance. However, since SWL has revealed its limitations, and both the patients' wishes and economic demand require a fast stone removal, the importance of PNL has risen again. Given the correct indications and performance, PNL is an efficient treatment modality reaching stone free rates of up to 100%. When PNL is performed by an experienced urologist, complications are low and can be managed conservatively in most cases. The most important step in the performance of a PNL is the anatomically correct puncture of the kidney gaining optimal access to the stone. To reach this, a lower calyx is punctured whenever possible, under combined sonographic and fluoroscopic guidance.

1046 Occlusion of the lower calyx by autologous blood prevents accumulation of stone fragments at this site after retrograde intra-renal surgery

1046 Occlusion of the lower calyx by autologous blood prevents accumulation of stone fragments at this site after retrograde intra-renal surgery

5-year-follow-up of Patients with Clinically Insignificant Residual Fragments after Extracorporeal Shockwave Lithotripsy

Objectives: After SWL treatment, many patients have residual fragments in the kidney or ureter. Fragments ≤4 mm have high probability to pass spontaneously and are normally not further treated. The term clinically insignificant residual fragment (CIRF) has been established for these stones. However, this term is still controversial, as persisting fragments might be important risk factors for stone growth and recurrence. Aim of this study was to evaluate the impact of CIRF on stone recurrence. Methods: We evaluated 173 patients (age 3–89 years) who have been treated by SWL and released with CIRF. Mean follow up was 4.9 years (4.5–5.3). 78% of the patients were recurrent stone formers with >2 stones episodes. These patients and their referring urologist received follow-up questionnaires which contained questions about stone clearance, late complications, auxillary measures and dietary or drug metaphylaxis. Results: Most residual stone fragments were located within the lower calyx (17%) and the renal pyelon (14%). Stone analysis was available in 142 patients with CIRF and revealed calciumoxalate calculi in 93.6% of the cases. In 78.6%, CIRF cleared spontaneously within few weeks and did not recur within 5 years. However, residual stones led to stone recurrence and need of re-treatment in 21.4%. Renal pyelon (23%) and calices showed comparable growth of former CIRF (lower calices 26.5%, middle calices 27%, upper calices 26%). Only 48% of the patients with recurrent stone formation followed dietary metaphylaxis. However, a significant correlation between a general or specific metaphylaxis and stone growth of CIRF could not be demonstrated. Conclusions: Most of the CIRF after SWL pass spontaneously without any complications. But considering that one fifth of the patients developed new stones at the side of residual fragments, it is obvious that close follow-up is required. Although we could not demonstrate a relation between metaphylaxis and stone re-growth, it is conceivable that adequate metaphylaxis can reduce stone recurrences.

Lumbar Ureteral Lithiasy: Therapeutical Options

Patients with lumbar ureteral stones larger than 5 mm should be addressed towards ESWL. It is an effective nonintrusive modality with limited adverse effects. In our study we matched treatment effectiveness and patients compliance in standard ESWL versus ureteroscopy with lithotripsy. Material and Methods. Since January 2001 to March 2003 72 patients with middle ureteral calculi underwent ESWL treatment, and 48 patients with the same stone location were submitted to ureteroscopy with lithotripsy. It was the first choice modality in strongly symptomatic patients. A 1–5 score system was employed to assess the compliance degree. Patients with the highest compliance were referred as 1 and patients with the lowest one were regarded as 5. Results. A 96% stone free rate (46/48) was achieved in the ureteroscopy arm. The stone was pushed back in the lower calyx of the kidney only in 2 (4%) patients. 37 (52%) out of 72 patients in ESWL arm were stone free at the 1st ESWL treatment. 14 (19%) patients were stone free at the 2nd one, and 8 patients (12%) were stone free at the 3rd one. 13 patients (18%) were never stone free and underwent ureteroscopy. The means of compliance degree were 1.6 in the ureteroscopy with lithoripsy, and 3.8 in the ESWL treatment. Conclusions. Ureteroscopy with lithotripsy may effectively replace ESWL in the lumbar ureteral lithiasy treatment, because of high stone free rate and low morbility. Expenditure is almost the same in both modalities.