Management Of Upper Tract Calculi Research Articles

MP23-20 THIRTY-YEAR TRENDS IN THE MANAGEMENT OF UROLITHIASIS IN THE UNITED STATES

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making III (MP23)1 Sep 2021MP23-20 THIRTY-YEAR TRENDS IN THE MANAGEMENT OF UROLITHIASIS IN THE UNITED STATES Ridwan Alam, Jared Winoker, Ayman Alam, and Brian Matlaga Ridwan AlamRidwan Alam More articles by this author , Jared WinokerJared Winoker More articles by this author , Ayman AlamAyman Alam More articles by this author , and Brian MatlagaBrian Matlaga More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002014.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Over the past 30 years, the field of endourology has seen an explosion of technological advancements that has significantly changed the management of stone disease. We sought to determine if the constant refinement and increased familiarity with endoscopic procedures has led to a concomitant shift in treatment practices for both upper and lower urinary tract calculi. METHODS: In this population-based cohort study, we used data from TriNetX, a large health research network with real-time updates of electronic medical records (EMR) from 49 health care organizations in the United States. Due to the dependence on EMR, data from participating institutions prior to the implementation of an electronic record system are not included. Patients with upper tract stones who underwent shock wave lithotripsy (SWL), ureteroscopy (URS), percutaneous nephrolithotomy (PCNL), or open surgery were identified based on Current Procedural Terminology (CPT) codes. Similarly, patients with lower tract stones who underwent cystolitholapaxy or cystolithotomy were separately identified and analyzed. RESULTS: SWL was the primary mode of treatment for patients with upper tract stones until 2000, after which URS saw a dramatic increase that has persisted through 2020 (Figure 1). During this time, PCNL has remained relatively stable, representing about 10% of upper tract stone procedures. For patients with lower tract stones, cystolitholapaxy has always been favored over cystolithotomy, and the gap continues to increase over time (Figure 2). CONCLUSIONS: URS has gained considerable popularity at the expense of SWL for the management of upper tract calculi. However, the use of PCNL has been largely unaffected by this shift in practice patterns. The relative stability of PCNL may be a reflection of its surgical invasiveness when compared to SWL and URS, or may be due to less overlap in clinical indication with its less invasive counterparts, among other reasons. Minimally invasive approaches have always been and continue to be favored for the treatment of lower tract calculi. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e410-e410 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ridwan Alam More articles by this author Jared Winoker More articles by this author Ayman Alam More articles by this author Brian Matlaga More articles by this author Expand All Advertisement Loading ...

Predictors of success following extracorporeal shock-wave lithotripsy in a contemporary cohort.

Objectives:The objectives of this study are to determine the predictors of success following extracorporeal shock-wave lithotripsy (ESWL) in a contemporary cohort at a high-volume stone center.Methods:We conducted a retrospective review all patients who underwent an elective ESWL within our institution over a 24-month period (January 2014 to December 2015). Data on patient demographics, stone variables, and inpatient treatment outcomes were evaluated.The presence of residual stone fragments larger than 4 mm on follow-up imaging was considered to be treatment failure. Using this threshold, clinically relevant variables between the treatment success and failure groups were identified. Multivariable logistic regression analyses (MVA) of clinically relevant variables were used to determine the independent factors predicting ESWL success.Results:Of 446 study eligible patients, 421 patients had complete follow-up data and were included in the analysis. Treatment was successful in 72.2% of patients in this study. Stone size, number of shocks delivered, and maximum treatment intensity were statistically different in the two groups. In a MVA where stone size, location, density, presence of ureteric stent, skin-stone distance (SSD), number of shocks, and maximum shock intensity were included, only stone size of <10 mm (odds ratio [OR] 3.4 [95% confidence interval [CI]: 1.98–5.84]) and SSD <15 cm (OR: 0.133, [95% CI: 0.027–0.65]) were the independent predictor of ESWL success.Conclusion:We have demonstrated “real world” outcomes with high-volume use of ESWL. In our experience that with diligent patient selection, ESWL remains an effective tool for the management of upper tract calculi.

MP15-10 MANUAL PRESSURE IRRIGATION AT FLEXIBLE URETERORENOSCOPY IS ASSOCIATED WITH INCREASED PAIN AND READMISSION

You have accessJournal of UrologyStone Disease: Surgical Therapy III (MP15)1 Apr 2020MP15-10 MANUAL PRESSURE IRRIGATION AT FLEXIBLE URETERORENOSCOPY IS ASSOCIATED WITH INCREASED PAIN AND READMISSION Matthew Farag*, Gregory Jack, Catriona Duncan, Nathan Lawrentchuck, and Damien Bolton Matthew Farag*Matthew Farag* More articles by this author , Gregory JackGregory Jack More articles by this author , Catriona DuncanCatriona Duncan More articles by this author , Nathan LawrentchuckNathan Lawrentchuck More articles by this author , and Damien BoltonDamien Bolton More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000840.010AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Pressured irrigation is routinely utilised in treatment of urinary calculi by uretero-renoscopic surgery. Although this can be in multiple forms, standardised pneumatic pressure upon the fluid irrigation bag is the routine. Another method is the use of similar fluid under pressure with routine intermittent manual pressure on a refillable chamber, which is suggested to provide improved vision during those periods when the hydrostatic pressure is increased. There is little data to suggest preferential outcomes from either format, and consequently the technique utilised tends to be at the discretion of the surgeon. We aimed to evaluate the outcomes of treatment for those patients from our institution who were treated using both of these forms of pressured irrigation. METHODS: Patients were allocated to the operating lists of a group of endourologists at a large teaching hospital by a bookings officer who had no knowledge of which surgeon would routinely use manually pressured irrigation intermittently throughout a period of standard pressured irrigation. There was no stratification of patients to different urologists based upon stone size, location, composition or patient demographics. Stone specific data was recorded in an established database, and outcomes of treatment were identified by an independent researcher who was not one of the treating urologists. RESULTS: 173 patients were treated by flexible ureterorenoscopic stone laser over a 2 year period. Mean patient age was 54 years and 111 patients (64%) were male. 149 (86%) of patients had renal stones and the remainder had proximal ureteric stones. 10 patients had staghorn renal calculi who were treated without percutaneous access. Median stone size was identical (10.0 mm) between the two groups who were treated with and without manually pressured irrigation. Retreatment rate was similar at 17% in each cohort. There was no difference in the inpatient length of stay (1.16 vs 1.14 days), although episodes of hypotension and tachycardia post surgery requiring medical review were more common in the group treated with manually pressured irrigation (29 patients vs 2 patients Chi2 p = 0.04). There was no difference in post operative rates of urinary tract infection. Time spent undertaking ureteroscopic stone laser and retrieval was significantly increased in the group who underwent treatment with additional manually pressured irrigation (98.4 vs 81.3 minutes). Representation rates of patients to the emergency department within 60 days were considerably increased in patients who had undergone treatment with routine use of intermittent manually pressured irrigation (44 patients vs 5 patients Chi2 p = 0.04), and the main cause of increased representation was flank pain (37 patients vs 1 Chi2 p = 0.003). CONCLUSIONS: Routine use of intermittent manually pressured irrigation in addition to background hydrostatic pressure irrigation does not appear to confer any objective benefit in regard to outcomes of stone treatment. Although there may be an anecdotal and temporary benefit in regard to vision during ureterorenoscopy this technique appears to be associated with a significantly greater readmission rate after surgery, and an increased risk of hypotension and tachycardia post surgery. It is hard to justify the routine use of this operative technique, which should be reserved for specific instances where routine techniques are proving inadequate for endoscopic management of upper tract calculi. Source of Funding: None © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e208-e208 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Farag* More articles by this author Gregory Jack More articles by this author Catriona Duncan More articles by this author Nathan Lawrentchuck More articles by this author Damien Bolton More articles by this author Expand All Advertisement PDF downloadLoading ...

Is retrograde intrarenal surgery the game changer in the management of upper tract calculi? A single-center single-surgeon experience of 131 cases.

Introduction:Success of any modality for stone disease needs to be evaluated in terms of Stone Free Rates (SFR), auxiliary procedures needed; complications and follow up. SFR in RIRS is subject to parameters like stone burden, location, number, hardness, composition; calyceal and ureter anatomy; use of ureteric access sheath (UAS); surgeon experience etc.Methods:The aim of this study is to evaluate the efficacy and safety of RIRS for managing upper tract stones. The objectives include evaluating SFR in RIRS in relation to stone burden, location and number. Other objectives include evaluating SFR after re RIRS in relation to stone burden, necessity of pre DJ stenting, use of UAS and post operative complication rate. 131 patients operated by single surgeon for single/multiple renal and/or upper ureteric stones were evaluated. Stone size > 3 mm on follow up CT KUB was considered as residual. Re RIRS was required for residual stones.Results:The overall SFR was 76%. SFR were statistically lower with stone burden > 1.5 cm, lower calyceal stones and single stones with stone burden > 1.5 cm. SFR was 90% after 2nd RIRS and 98.5% after 3rd RIRS procedure. No significant difference in SFR was noted between single v/s multiple stones, single calyx v/s multiple calyx stones and renal v/s upper ureteric stones. No major complication was noted.Conclusion:Larger stone burden and lower calyceal location are important factors deciding SFR in RIRS. With auxiliary procedure, RIRS is safe and effective compared to PCNL.

Complications of Surgical Management of Upper Tract Calculi in Spina Bifida Patients: Analysis of Nationwide Data

The management of upper urinary tract stones in patients with spina bifida is challenging but poorly described in the literature. We compared urolithiasis interventions and related complications in patients with spina bifida to those in other stone formers using a national database. We retrospectively reviewed the NIS to identify hospital admissions for renal and ureteral stones from 1998 to 2011. We used ICD-9-CM codes to identify urological interventions, including shock wave lithotripsy, ureteroscopy, percutaneous nephrolithotomy and ureteral stent placement. NSQIP data were used to identify postoperative complications. We identified 4,287,529 weighted stone hospital admissions, including 12,315 (0.3%) of patients with spina bifida. Compared to those without spina bifida the patients with spina bifida who had urolithiasis were significantly younger (mean age 34 vs 53 years), more likely to have public insurance (72% vs 44%) and renal vs ureteral calculi (81% vs 58%), and undergo percutaneous nephrolithotomy (27% vs 8%). After adjusting for age, insurance, comorbidity, treatment year, surgery type, stone location and hospital factors patients with spina bifida were more likely to have urinary tract infections (OR 2.5), urinary complications (OR 3.1), acute renal failure (OR 1.9), respiratory complications (OR 2.0), pneumonia (OR 1.5), respiratory insufficiency (OR 3.2), prolonged mechanical ventilation (OR 3.2), sepsis (OR 2.7), pulmonary embolism (OR 3.0), cardiac complications (OR 2.4) and bleeding (OR 1.6). Compared to those without spina bifida the patients with spina bifida who were hospitalized for urolithiasis were younger, and more likely to have renal stones and undergo percutaneous nephrolithotomy. Urolithiasis procedures in patients with spina bifida were associated with a significantly higher risk of in-hospital postoperative complications.

Contemporary Surgical Trends in the Management of Upper Tract Calculi

Upper tract nephrolithiasis is a common surgical condition that is treated with multiple surgical techniques, including shock wave lithotripsy, ureteroscopy and percutaneous nephrolithotomy. We analyzed case logs submitted to the ABU by candidates for initial certification and recertification to help elucidate the trends in management of upper tract urinary calculi. Annualized case logs from 2003 to 2012 were analyzed. We used logistic regression models to assess how surgeon specific attributes affected the way that upper tract stones were treated. Cases were identified by the CPT code of the corresponding procedure. A total of 6,620 urologists in 3 certification groups recorded case logs, including 2,275 for initial certification, 2,381 for first recertification and 1,964 for second recertification. A total of 441,162 procedures were logged, of which 54.2% were ureteroscopy, 41.3% were shock wave lithotripsy and 4.5% were percutaneous nephrolithotomy. From 2003 to 2013 there was an increase in ureteroscopy from 40.9% to 59.6% and a corresponding decrease in shock wave lithotripsy from 54% to 36.3%. For new urologists ureteroscopy increased from 47.6% to 70.9% of all stones cases logged and for senior clinicians ureteroscopy increased from 40% to 55%. Endourologists performed a significantly higher proportion of percutaneous nephrolithotomies than nonendourologists (10.6% vs 3.69%, p <0.0001) and a significantly smaller proportion of shock wave lithotripsies (34.2% vs 42.2%, p = 0.001). Junior and senior clinicians showed a dramatic adoption of endoscopic techniques. Treatment of upper tract calculi is an evolving field and provider specific attributes affect how these stones are treated.

1805 COMPUTERIZED TOMOGRAPHIC RADIATION EXPOSURE AND UPPER TRACT ENDOSCOPIC CALCULUS REMOVAL: APPROACHING THE SAFETY LIMIT

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopic or Percutaneous Stone Removal III1 Apr 20101805 COMPUTERIZED TOMOGRAPHIC RADIATION EXPOSURE AND UPPER TRACT ENDOSCOPIC CALCULUS REMOVAL: APPROACHING THE SAFETY LIMIT Joseph Jamal, R. Ernest Sosa, Madhan Srinivasan, Michael Brodherson, and John A. Fracchia Joseph JamalJoseph Jamal More articles by this author , R. Ernest SosaR. Ernest Sosa More articles by this author , Madhan SrinivasanMadhan Srinivasan More articles by this author , Michael BrodhersonMichael Brodherson More articles by this author , and John A. FracchiaJohn A. Fracchia More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1730AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The utility of Computed tomography (CT) scans in detailing upper urinary tract calculi has been well established. The mean mSv per CT of the abdomen and pelvis without contrast is 20 mSv and double that if contrast is utilized. The accepted annual recommended limit of radiation exposure/adult is ≤50 millisieverts (mSv). We sought to appreciate the CT radiation exposure in our patients undergoing therapeutic endoscopic management of upper tract calculi during the peri-procedure period. METHODS We identified all patients undergoing upper tract endoscopic stone removal between 2005 and 2009. To calculate the radiation exposure we included all CTs performed during the peri-procedure time period which we defined as three months before and three months following the procedure. Radiation exposure for a non-contrast CT abdomen/pelvis was calculated at 20 mSv. RESULTS A total of 233 patients were identified; 127 underwent ureteroscopy (URS) and 106 underwent percutaneous nephrolithotripsy (PCNL). No significant differences were observed in age or gender between these 2 groups. The mean number of CT scans performed was 1.58 for all patients (Table 1). Of concern, 90 patients (38.6%) underwent 2 or more CT scans in the peri-procedure period, with an average number of 2.49 CT/patient in this group, translating to 49.8mSv. Patients undergoing URS were significantly more likely to have multiple CT scans (Pearson Chi-Square Test p = 0.003) than those undergoing PCNL. In a multivariate logistic regression analysis, both age (OR: 1.03, 95% CI 1.01 – 1.05, p = 0.006) and procedure type (OR: 2.6, 95% CI 1.47 – 4.57, p = 0.001) were significant predictors of having multiple CTs. All URS PCNL Procedure (n) 233 127 106 Age (years) 57.9 56.1 60.0 Males 138(59.2%) 85(66.9%) 53(50.0%) Females 95(40.8%) 42(33.1%) 53(50.0%) 1 CT Scan 143(61.4%) 67(52.8%) 76(71.7%) ≥ 2CT Scans 90(38.6%) 60(47.2%) 30(28.3%) Mean # CTs (all Patients) 1.58 1.77 1.34 Radiation Exposure for All Patients (mSv) 31.6mSv 35.4mSv 26.8mSv Mean # CTs (Patients ≥2 CTs) 2.49 2.63 2.20 Radiation Exposure for Patients ≥2CTs (mSv) 49.8mSv 52.6mSv 44.0mSv CONCLUSIONS CT radiation exposure in the peri-operative period for patients undergoing therapeutic endoscopic upper tract stone removal is considerable. In our study, 38.7% of patients underwent at least 2 CT scans. Patients undergoing URS had an average of 2.63 CTs, translating to 52.6mSv. Urologic surgeons should be cognizant of the potential risks of CT radiation exposure, and where appropriate should consider other imaging modalities. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e700 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joseph Jamal More articles by this author R. Ernest Sosa More articles by this author Madhan Srinivasan More articles by this author Michael Brodherson More articles by this author John A. Fracchia More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Strategies for managing upper tract calculi in young children.

Pediatric urolithiasis is relatively uncommon and there is little information on the application of modern surgical procedures in young children. We present a single center experience with the surgical management of upper tract calculi in this age group. We reviewed presentation, co-morbidity, treatment, outcome and complications in all prepubertal patients who required surgical treatment for ureteral or renal calculi during a 4-year period. The series consists of 24 girls and 17 boys 17 months to 14 years old (mean age 7.5 years). A total of 26 children were anatomically normal, and 4 had myelomeningocele, 4 had ureteropelvic junction obstruction (in a pelvic kidney in 1), 2 had cloacal anomalies, 2 had vesicoureteral reflux, and 1 each had nonrefluxing megaureter, orthotopic ureterocele and a functioning renal transplant. Extracorporeal shock wave lithotripsy was performed in 24 patients. Stents or nephrostomy tubes were only used in the 4 patients who presented with pyonephrosis. Of the 41 cases 17 were rendered stone-free, 3 had a decreased stone burden and 4 were failures. Ureteroscopic extraction of distal ureteral calculi was successful in 11 of 12 children, of whom the youngest was 2.5 years old. No child had postoperative infection or evidence of ureteral obstruction. Stent placement facilitated stone passage or dissolution in 2 patients, a renal calculus was percutaneously extracted in 2 and 7 required open surgery, mostly for correcting simultaneous anatomical abnormalities or after minimally invasive surgery failed. Some metabolic abnormality was detected in 80% of the children tested. The surgical management of upper urinary tract calculi in young children parallels that in adults. Minimally invasive surgical methods may be safely used even in young infants. Most children do not need elective stenting before lithotripsy. Open procedures are still required in 17% of cases. The majority of children have definable metabolic abnormalities.

STRATEGIES FOR MANAGING UPPER TRACT CALCULI IN YOUNG CHILDREN

Purpose Pediatric urolithiasis is relatively uncommon and there is little information on the application of modern surgical procedures in young children. We present a single center experience with the surgical management of upper tract calculi in this age group. Materials and Methods We reviewed presentation, co-morbidity, treatment, outcome and complications in all prepubertal patients who required surgical treatment for ureteral or renal calculi during a 4-year period. The series consists of 24 girls and 17 boys 17 months to 14 years old (mean age 7.5 years). A total of 26 children were anatomically normal, and 4 had myelomeningocele, 4 had ureteropelvic junction obstruction (in a pelvic kidney in 1), 2 had cloacal anomalies, 2 had vesicoureteral reflux, and 1 each had nonrefluxing megaureter, orthotopic ureterocele and a functioning renal transplant. Results Extracorporeal shock wave lithotripsy was performed in 24 patients. Stents or nephrostomy tubes were only used in the 4 patients who presented with pyonephrosis. Of the 41 cases 17 were rendered stone-free, 3 had a decreased stone burden and 4 were failures. Ureteroscopic extraction of distal ureteral calculi was successful in 11 of 12 children, of whom the youngest was 2.5 years old. No child had postoperative infection or evidence of ureteral obstruction. Stent placement facilitated stone passage or dissolution in 2 patients, a renal calculus was percutaneously extracted in 2 and 7 required open surgery, mostly for correcting simultaneous anatomical abnormalities or after minimally invasive surgery failed. Some metabolic abnormality was detected in 80% of the children tested. Conclusions The surgical management of upper urinary tract calculi in young children parallels that in adults. Minimally invasive surgical methods may be safely used even in young infants. Most children do not need elective stenting before lithotripsy. Open procedures are still required in 17% of cases. The majority of children have definable metabolic abnormalities.

Long-Term Incidence and Risks for Recurrent Stones Following Contemporary Management of Upper Tract Calculi in Patients with a Urinary Diversion

Purpose The long-term rate of stone recurrence following contemporary minimally invasive management of calculi was determined in patients with urinary diversion and to identify specific risk factors for these recurrences. Materials and Methods We followed for a minimum of 12 months 25 patients (29 renal units) with upper tract calculi associated with urinary diversion, and treated with extracorporeal shock wave lithotripsy and/or percutaneous nephrostolithotomy. The risk of recurrent stones at 5 years was determined by a Kaplan-Meier estimate, while potential risk factors for recurrence were analyzed using a log-rank comparison. Results Stones recurred in 8 patients (32 percent) 18 to 61 months (mean 27.0) after treatment. The risk of new stone formation after 5 years was estimated to be 63.3 percent and was significantly greater in patients with recurrent bacteriuria after treatment. Neither stone history, type of procedure used, stone composition nor radiographic status of completion of treatment significantly influenced this risk. Conclusions Contemporary management of upper tract calculi in patients with a urinary diversion is associated with a high recurrence rate, especially among those with recurrent bacteriuria, regardless of whether the patient is initially rendered stone-free. Continued close surveillance and antibiotic prophylaxis seem to be essential in this high risk patient population.

Long-Term Incidence and Risks for Recurrent Stones Following Contemporary Management of Upper Tract Calculi in Patients with a Urinary Diversion

Long-Term Incidence and Risks for Recurrent Stones Following Contemporary Management of Upper Tract Calculi in Patients with a Urinary Diversion

Childhood urolithiasis: urological management of upper tract calculi in the era of extracorporeal shock-wave lithotripsy.

To evaluate the management of urolithiasis in children since the development of extracorporeal shock-wave lithotripsy (ESWL). Between 1988 and 1994, 37 children, aged from 2 to 15 years (mean 10), with upper tract urolithiasis were evaluated and treated. Lithogenic metabolic disorders or anomalies of the urinary tract were present in 11 children (30%) Urolithiasis was multiple in 9 cases and bilateral in 2 cases. A total of 47 renal (30) or ureteral (17) stones were managed, of which 5 were partial or complete staghorn calculi. Initial treatment was surgery in 4 cases (1 nephrectomy, partial nephrectomy and 2 pyelolithotomies) and piezoelectric ESWL in 43 cases. The overall ESWL success rate was 82.2%, with auxillary endoscopic procedures in 3 cases. ESWL failures required surgical stone removal in 5 cases, endoscopic ureterolithotripsy in 1 case and electrohydraulic ESWL in 1 case. Residual fragments after pyelolithotomies were also treated by ESWL. ESWL is the mainstay of treatment of childhood upper tract urolithiasis, but other therapeutic methods retain specific indications. Its application requires great vigilance and its long-term effects are uncertain. It is therefore important to rule out any underlying pathology and where possible to prevent further stone formation.

Effect of Urinary Intestinal Diversion on Urinary Risk Factors for Urolithiasis

We investigated the effect of urinary intestinal diversion on risk factors for calcium urolithiasis, such as calcium, phosphate, magnesium, uric acid, oxalate and citrate, in 3 groups of patients (Kock pouch, Indiana pouch and ileal conduit). Mean urinary volume was not significantly different among the 3 groups. Mean serum creatinine and 24-hour creatinine clearance in the continent reservoir group were better than in the ileal conduit group. Mean urinary excretion of calcium, phosphate and magnesium was significantly greater in the continent reservoir group than in the ileal conduit group. Although calcium excretion had a positive correlation with 24-hour creatinine clearance, calcium excretion per ml. per minute creatinine clearance still showed a significant difference. Increased calcium excretion is considered to reflect metabolic disturbances resulting from reabsorption of urinary solutes through the intestinal segments. Overall, there was no significant difference in the urinary parameters between the Kock and Indiana pouch groups. While mean urinary oxalate and citrate were within the normal range in all 3 groups, more than a third of the patients in each group were hypocitraturic (less than 100 mg. per day). In none of the 3 groups did the levels of urinary calcium, phosphate and magnesium, as well as other urinary risk parameters show any correlation with the duration of diversion. In summary, our study indicated that the continent urinary reservoir causes a long-term increase in urinary excretion of calcium, phosphate and magnesium. These urinary metabolic alterations might promote the formation of calcium urolithiasis as well as infectious stones. The degree of metabolic alterations may be greater with a continent reservoir than with an ileal conduit.

Management of Upper Tract Calculi in Patients with Tubularized Urinary Diversions

In a retrospective review of patients with urinary diversion who presented to our stone center during a 3.5-year period 9 underwent 20 procedures for suspected stone episodes. Eventual outcome was excellent in all but 1 patient. In particular, all attempts at retrograde trans-stomal manipulation were successful. We present our cases, and note the technical considerations and management principles. Frequently, these patients are best served by a combination of percutaneous antegrade, trans-stomal retrograde and/or extracorporeal shock wave lithotripsy.