Maximum Stone Size Research Articles

Cumulative sum analysis of the learning curve for retrograde intrarenal stone surgery in newbie surgeons.

This study investigated the learning curve of retrograde intrarenal surgery (RIRS) in patients with medium-sized stones using cumulative sum analysis (CUSUM) to evaluate the competence and proficiency of three new surgeons during their first RIRS procedures. We conducted a retrospective review of 227 patients from 2019 to 2022 at a single institution. The patients were divided into four groups based on the operating surgeon: tutor surgeon (85 patients), newbie surgeon A (21 patients), newbie surgeon B (85 patients), and newbie surgeon C (36 patients). Patients had one or multiple stones with the largest stone diameter fell within the range of 10-30mm. Fragmentation efficacy was calculated as "removed stone volume (mm3) divided by operative time (minutes)." CUSUM analysis monitored changes in fragmentation efficacy and validated surgical outcomes. No statistically significant differences were observed in the total stone volume, maximum stone size, or total operation time between the three newbie surgeons and the tutor surgeon. The mean fragmentation efficacy value was comparable among the newbie surgeons, but significantly different from that of the tutor surgeon. The minimum acceptable fragmentation efficacy level was set at 25.12mL/min, based on the tutor's average value. The CUSUM curves for the three surgeons initially remained relatively flat until Cases 12-15, after which they increased and eventually plateaued. Stone-free rates and postoperative complications did not differ significantly among the surgeons. Learning curve analysis for the three newbie surgeons indicated that approximately 12-15 cases were required to reach a plateau.

Endoscopic stone surgery in patients having asymptomatic bacteriuria

Introduction. Endoscopic surgery for the treatment of urolithiasis is highly effective but is associated with the risk of infectious complications. Nevertheless, endoscopy is also associated with the risk of postoperative infectious complications, the primary risk factor being positive urine culture. Considering the possibility of detecting persistent asymptomatic bacteriuria (ASB) in this patients amid the shortfall of clear algorithms and schemes of ASB management before endoscopy, a comparative analysis of infectious complications in patients with sterile urine and persistent ASB undergoing endoscopic surgery for renal and ureteral stones is an urgent task.Оbjective. Analysis of the risk of infectious complications in patients undergoing endoscopic treatment of urinary stones, including those with preoperative evidence of asymptomatic bacteriuria.Materials & methods. We conducted a cohort, retrospective study of data from eligible patients who underwent endoscopic removal of renal and ureteral stones between January 2023 and July 2023. From the 449 patient records selected, 211 patients fulfilling the established inclusion and non-inclusion criteria were enrolled in further analyses. Antibacterial prophylaxis was administered a few hours before surgery for initial sterile urine culture, three days before surgery for clinically insignificant ASB, and seven days before surgery for clinically significant ASB, followed by repeat control urine culture and determination of antibacterial prophylaxis according to the proposed methodology.Results. A preoperative sterile urine culture was diagnosed in 152 patients (72.0%), while 59 patients 28% [22%; 34.5%] were found to have bacteriuria, of which 28 patients 13.3% [9%; 18.6%] had clinically significant bacteriuria at a titer of ≥ 105 CFU/mL. After antibiotic therapy, ASB persisted in six patients (22.0%). Accordingly, 37 patients 17.5% [12.79%; 23.4%] with clinically significant and insignificant ASB underwent endoscopic surgery. In the postoperative period, 54 patients (25.6%) had leukocytosis, 17 patients (8.1%) had hyperthermia, and 11 patients (5.2%) had fever accompanied by leukocytosis One patient (0.5%) had an elevated procalcitonin level, which may indicate a systemic inflammatory response. Logistic regression analysis revealed statistically significant associations between the probability of hyperthermia and bacteriuria. A positive urine culture increased the odds of hyperthermia 4.75-fold (OR = 4,75, 95% CI [1.222; 18.803], p = 0.023). Maximum stone size (p = 0.013), stone volume, and ureteral stent drainage (p = 0.006) were the factors influencing the development of leukocytosis. Moreover, the volume of the stone increases the odds of leukocytosis by 1.54 times (OR = 1.543, 95% CI [1.128; 2.158], p = 0.008) for a 1.0 cc enlargement.Conclusion. Our study shows that a positive urine culture is a significant risk factor for infectious complications after endoscopic surgery. Prolonged courses of antibiotic prophylaxis lasting seven and three days in patients having clinically significant and clinically insignificant ASB, respectively, seem adequate to minimize the risk of postoperative infectious complications.

Full-scale accelerated load testing of a new mechanised cement bound macadam (MCBM) pavement

The purpose of the research is to define and describe the performance behaviour during full-scale accelerated loading for a new heavy duty pavement type referred to as Mechanised Cement Bound Macadam (MCBM). MCBM is a cost-effective and reduced carbon footprint alternative to structural asphalt concrete and conventional concrete pavements. Four MCBM test sections were constructed with two key considerations in mind, the influence of layer thicknesses and maximum stone size within the gradation. In addition, defining the fundamental strength behaviour of the pavement, the failure mechanisms and their impact on perpetual pavement design were key objectives for the research. Dynamic and semi-static deflection measurements, strain measurements from strain gauges embedded in the pavement, crack mapping and transverse surface profile were collected at intervals throughout the accelerated loading. Performance testing showed that the stone interlocked structure is unique and undergoes multiple strength phases, enabling excellent shear and rut resistance by upholding vertical load bearing. The accelerated load testing also proved that significant structural strength remains post-bound phase. However, the MCBM design is based on a bound phase criterion and specifies a threshold fatigue stress value less than 30% of the flexural strength (breaking strength under four-point beam testing). Hence, the MCBM is perpetual by design and intended to function in the bound phase, requiring only intermittent resurfacing.

Factors Affecting Holmium Laser Efficiency: Comparison of Laryngeal Mask Airway and Endotracheal Intubation During Ureteroscopy for Renal Stones.

Introduction: Holmium laser lithotripsy is a standard energy source used for treatment of kidney stones during flexible ureteroscopy. Efficiency of laser surgery may be affected by patient and operator characteristics or perioperative management. Here, we sought to examine intraoperative data from patients undergoing high frequency dusting with high-powered holmium laser lithotripsy to evaluate surgical and demographic factors associated with lasing efficiency (LE). Methods: A total of 82 intraoperative reports were analyzed from an ongoing laser lithotripsy clinical trial evaluating the Lumenis Pulse™ 120H holmium laser with renal stones up to 20 mm in diameter with and without Moses 2.0 technology. For each case, the total pause time between lasing activations was corrected to remove lengthy pauses and divided by the total lasing time to calculate an efficiency percentage. This was then compared with patient demographics, anesthesia administration, stone burden, postoperative complications, and stone-free rates using both univariate and multivariate analyses. Results: Of the 82 included patients, 36 received endotracheal tube (ETT) intubation and 46 had a laryngeal mask airway (LMA). Patients with ETT had significantly higher LE (78.7%) compared to those with an LMA (73.3%) in our univariate analysis (p < 0.01) as well as in the multivariate model that adjusted for maximum stone size, number of stones, stone density, and patient body mass index (p < 0.05). There was also significantly higher mean LE in patients with no postoperative complications (76.3%) compared to those with any grade (I-V) Clavien-Dindo complication within 30 days after surgery (70.0%) (p < 0.05). Conclusions: Flexible ureteroscopy and laser lithotripsy cases with higher LE are associated with lower rates of postoperative complications. The data also support the use of ETT over LMA to improve overall LE; however, this remains one consideration among many for choosing anesthesia administration. Clinical Trial Registration number: NCT04505956.

Erector spinae plane block prior to extracorporeal shock wave lithotripsy decreases fluoroscopy time and promise a comfortable procedure for renal stones: A prospective randomized study

Introduction and objectivesTo compare the efficacy of erector spinae plane block (ESPB) and intramuscular (i.m.) diclofenac sodium in regard to pain management and impact on stone-free status in patients undergoing SWL. Patients and materialsThe study included patients who underwent SWL for kidney stones in our institution. The patients were randomly assigned to the ESPB (Group 1: n = 31) and i.m. 75 mg diclofenac sodium (Group 2: n = 30) groups. The demographic data of the patients, fluoroscopy time during SWL, number of need of targeting, total shocks given, voltage, stone free rates (SFR), analgesy method, number of SWL sessions, VAS score, stone location, maximum stone size, stone volume and Hounsfield unit (HU) were also recorded. ResultsA total of 61 patients were included the study. There was no statistically significant difference between the two groups according to stone size, volume and density, SWL duration, total shocks given, voltage, BMI, stone-free status and stone location. Fluoroscopy time and number of need for stone targeting were significantly lower in group 1 than group 2 (p = 0.002, p = 0.021, respectively). The VAS score was significantly lower for group 1 compared to group 2 (p < 0.001). ConclusionsWe observed that the VAS score was lower in the ESPB group compared to i.m. diclofenac sodium group and although it was not statistically significant, we achieved a higher rate of stone-free status in the first session in ESPB group. Most importantly, the patients in the ESPB group were exposed to less fluoroscopy and radiation.

El bloqueo del plano del músculo erector espinal antes de la litotricia extracorpórea por ondas de choque reduce el tiempo de fluoroscopia y facilita el tratamiento de la litiasis renal: estudio prospectivo aleatorizado

Introduction and ObjectivesTo compare the efficacy of erector spinae plane block (ESPB) and intramuscular (i.m.) diclofenac sodium in regard to pain management and impact on stone-free status in patients undergoing SWL. Patients or MaterialsThe study included patients who underwent SWL for kidney stones in our institution. The patients were randomly assigned to the ESPB (Group 1: n = 31) and i.m. 75 mg diclofenac sodium (Group 2: n = 30) groups. The demographic data of the patients, fluoroscopy time during SWL, number of need of targeting, total shocks given, voltage, stone free rates (SFR), analgesy method, number of SWL sessions, VAS score, stone location, maximum stone size, stone volume and Hounsfield unit (HU) were also recorded. ResultsA total of 61 patients were included the study. There was no statistically significant difference between the two groups according to stone size, volume and density, SWL duration, total shocks given, voltage, BMI, stone-free status and stone location. Fluoroscopy time and number of need for stone targeting were significantly lower in group 1 than group 2 (p:0.002, p:0.021, respectively). The VAS score was significantly lower for group 1 compared to group 2 (p<0.001). ConclusionsWe observed that the VAS score was lower in the ESPB group compared to i.m. diclofenac sodium group and although it was not statistically significant, we achieved a higher rate of stone-free status in the first session in ESPB group. Most importantly, the patients in the ESPB group were exposed to less fluoroscopy and radiation.

The impact of endoscopic sphincterotomy incision size on common bile duct stone recurrence: A propensity score matching analysis.

The aim of this study is to clarify the relation between the incision size for endoscopic sphincterotomy (EST) and common bile duct stone (CBDS) recurrence. Patients who underwent elective endoscopic treatment for CBDS between January 2013 and December 2017 were enrolled, excluding those who met the exclusion criteria. The clinical characteristics were investigated using propensity score matching analysis. A total of 243 patients were investigated. Propensity scores were calculated using multinomial logistic regression with five relevant variables (age, gender, follow-up time, maximum stone size, and bile duct diameter), which led to extraction of 188 cases to compose cohorts of the small and medium EST incision groups. The CBDS recurrence rate was 17.0% in the small incision group and 6.4% in the medium incision group. Multivariate analysis identified the medium incision as an independent predictor of CBDS recurrence (hazard ratio 0.350, 95% confidence interval 0.133-0.922, P=.034). The CBDS non-recurrence rate of the medium incision group was significantly higher than that of the small incision group (log-rank test P=.019). Our findings suggest that the CBDS recurrence rate was lower in EST with medium incision size than with small incision size.

Optimization of shockwave lithotripsy use for single medium sized hard renal stone with stone density ≥ 1000 HU. A prospective study.

To identify shock wave lithotripsy (SWL) success predictors in hard renal stones (average stone density ≥ 1000 HU). We prospectively evaluated patients who underwent SWL for hard renal stones between April 2018 and December 2020. Radiological parameters were identified, e.g., stone site, size, the average density in addition to stone core and shell mean density, and renal cortical thickness (RKT). SWL sessions were performed using Doli-S lithotripter till a maximum of 3-4 sessions with 2-4weeks interval. Initial response to SWL included stone fragmentation and decreased stone size after the first SWL. Treatment success was considered if complete clearance of renal stones occurred or in case of clinically insignificant residual fragments ≤ 4mm after 12weeks follow up by NCCT. Out of 1878 patients who underwent SWL, the study included 157 patients with hard renal stones. Treatment overall success was found in 92 patients (58.6%) where 69 patients (43.9%) had complete stone clearance. On multivariate analysis, stone shell density < 901 HU, maximum stone size < 1cm, RKT > 1.95cm and initial treatment response were associated with increased the success rate after SWL for hard renal stones (P = 0.0001, 0.009, < 0.0001 and < 0.0001, respectively). In hard renal stones, treatment overall success was found in 58.6% where complete stone clearance was found in 43.9%. Stone outer shell fragility, lower stone size, increased RKT and initial response to SWL were associated with a higher success rate at 12-week follow-up.

The Comprehensive Complication Index (CCI) for improved reporting of complications in endourological stone treatment.

The Clavien-Dindo Classification (CDC) lacks a combined score of multiple complications in one patient. The comprehensive complication index (CCI) circumvents this problem making it a valuable instrument to optimize quality control. We aimed to introduce and validate CCI in the treatment of urolithiasis. 60day postoperative complications of 327 consecutive patients undergoing percutaneous nephrolitholapaxy (PNL) and ureterorenoscopy (URS) between 2017 and 2019 were retrospectively assessed and graded according to CDC. CCI was calculated for each patient. Overall morbidity scores of CCI and CDC were compared. Correlation analyses between the two scores and length of hospital stay (LOS) were performed. A multivariate analysis was performed to identify predictive factors for complications. Sample size calculation for an imaginary clinical trial was compared between CCI and CDC. A significant difference in overall morbidity between CCI and CDC was revealed for PNL (p < 0.001) and URS (p = 0.001). There was no statistically significant difference in comparing correlations between cumulative CCI and LOS versus non-cumulative CDC and LOS for both cohorts. Operating time > 90min, maximum stone size, positive preoperative urine culture and PNL type (p < 0.001) were predictive factors for postoperative complications in PNL, while urine culture (p = 0.02) was for URS. Sample size calculation based on CCI resulted in a significant reduction of required patients for PNL (- 48%) and URS (- 84%) compared to CDC. CCI could successfully be validated in endourological stone treatment with the advantage of assessing complications in their entirety compared to CDC. CCI can significantly reduce the required sample size in future clinical trials.

Comparison of Laparoscopic Common Bile Duct Exploration Combine with Cholecystectomy and Laparoscopic Cholecystectomy with Preoperative Endoscopic Sphincterotomy: In Terms of Surgical Outcomes and Recurrences

Introduction: It is controversial whether Laparoscopic common bile duct exploration (LCBDE) combine with laparoscopic cholecystectomy(LC) is better than LC with preoperative endoscopic sphincterotomy (pre-EST) for management of choledocholithiasis. Methods: 157 patients who underwent LCBDE+LC and 278 patients who underwent pre-EST+LC from January 2010 to December 2018 in single institution were retrospectively reviewed the preoperative characteristics, surgical outcomes, and recurrence of choledocholithiasis. Results: The maximum CBD diameter (13.2 vs 9.5mm, p< 0.001) and the maximum stone size (11.4 vs 6.3mm, p< 0.001) was significantly larger in patients who underwent LCBDE+LC than pre-EST+LC. Multiple stones were also frequently found in LCBDE group (54.8 vs 43.0%, p=0.017). The operative time (111.4 vs 55.6 minutes, p< 0.001) was significantly longer in LCBDE group, while duration of hospital stays after first procedure (6.2 vs 9.8days, p< 0.001) was significantly shorter in LCBDE group. There is no statistical significance in conversion to open surgery (1.9 vs 0.4%, p=0.104), retained stones rate (3.2 vs 1.4%, p=0.219), and recurrence rate of choledocholithiasis (8.3 vs 9.4%, p=0.707) between the two groups. In multivariate analysis, old age (over 70years) and CBD dilatation (over 8mm) were risk factor for recurrence of choledocholithiasis. Conclusion: In our experience, LCBDE+LC can be a safe and feasible management for choledocholithiasis, if appropriate experience and when expertise is available. High risk group of recurrence of CBD stone with old age and dilated CBD should carefully follow-up.

Preliminary Outcome Comparison of Flexible Uretero-Renoscopic Lasertripsy Versus PCNL in the Treatment of Staghorn Calculi

Percutaneous nephrolithotomy (PCNL) is a well-established treatment for staghorn stones. Given the im-provement in technology and techniques of flexible ureterorenoscopic lasertripsy (FURS), we retrospectively compared its treatment outcome against PCNL for staghorn stones at our institution. Materials and Methods All patients with partial and complete staghorn stones treated by FURS or PCNL between December 2014 and December 2017 were included. Outcome measures included the duration of the procedure, length of stay, retreatment rate, auxiliary rate, complications, and clinical success rates (stone or dust-free status). Results Out of 22 staghorns, 10 (1 complete, 9 partial) had FURS and 12 (2 complete and 10 partial) had PCNL. Comparatively, the FURS group were older (mean 70.1 vs. 57.1 years, U-test p&lt;0.001) with higher mean ASA scores (mean 2.3 vs. 1.5, U-test, p=0.04), with a similar body-mass index (mean 29.1 vs. 27.3), maximum stone size (29.7 vs. 34.6mm) and Hounsfield unit (836 vs. 891HU). FURS was quicker to clinical success (102.4min vs. 159.5min, U-test p&lt;0.001) and had shorter hospital stay (1.1d vs. 3.5d, U-test p&lt;0.001). Higher primary procedure success [80% vs. 36%, 95% CI = (-3.0%, 74.5%)], higher overall success [90% vs. 73%, 95% CI = (-22%, 51%)], similar retreatment rate (10%), and higher auxiliary treatment rate (100% vs. 18%) were observed. 1 patient from FURS had a small intrapa-renchymal aspect of staghorn inaccessible to a laser. There were no complications in the FURS group. In the PCNL group, one developed a pseudoaneurysm requiring embolization, and 1 had failed PCNL access (excluded from the statistical calculation). Conclusion Our preliminary data suggest that FURS is efficacious and safe for staghorn stones treatment, and comparable to PCNL. In this context, we highlight FURS potential role as first-line management of staghorn stones.

Frequency and risk factors for antegrade ureteral stone migration after percutaneous nephrolithotomy.

IntroductionPercutaneous nephrolithotomy (PCNL) is the minimally invasive procedure of choice for the treatment of large and/or complex nephrolithiasis. Migration of residual fragments (RFs) into the ureter after PCNL is presumed to be uncommon. However, should associated stone-related events (SREs) occur, ancillary procedures may be required. The objective of this study was to describe the frequency and to analyze predictors of antegrade migration of RFs after PCNL.Material and methodsA case-control study of patients who underwent PCNL for nephrolithiasis and had a postoperative computed tomography available within 48 hours was performed. Descriptive statistics and logistic regression analysis were carried out.ResultsThe final sample included 169 interventions. Mean age was 49 ±13 years, median maximum stone size was 26 (7 to 87) mm and mean stone density was 835 (70 to 2022) Hounsfield Units (HUs). 7.1% of the patients experienced migration of RFs into the ureter after PCNL, of whom 41.6% suffered SREs. Lithotripsy was performed using ultrasonic (67.5%), laser (23.7%), and pneumatic (14.8%) technologies. Univariate analysis found female gender (OR 4.1, p = 0.02) height ≥1.68 m (OR 5.52, p = 0.009), middle (OR 6.71, p = 0.01) and upper (OR 3.59, p = 0.04) caliceal location, staghorn calculi (OR 4.72, p = 0.02), stone area (OR 1.001, p = 0.03), lasertripsy (OR 3.61, p = 0.03) and operative time (OR 1.007, p = 0.02) statistically significant for migration of SFs into the ureter after PCNL. Of these, only height ≥1.68 m (OR 7.17, p = 0.01) and staghorn nephrolithiasis (OR 13.27, p = 0.02) remained independent predictors in the multivariate analysis with an area under the curve of 0.69.Conclusions71.% of patients undergoing PCNL had a SF migrating to the ureter. Of these 41% suffered a SRE that required ancilliary interventions. Staghorn nephrolithiasis and ≥1.68 mts of height were found to predict this event.

The effect of short-term preoperative ureteral stenting on the outcomes of retrograde intrarenal surgery for renal stones.

To evaluate the effect of preoperative ureteral stenting duration on the outcomes of retrograde intrarenal surgery (RIRS). We reviewed our database of patients who underwent RIRS between May 2011 and April 2017 at our institution. The patients were divided into three groups according to preoperative ureteral stenting duration: group 1: no stenting, group 2: short preoperative stenting (< 7days) and group 3: long preoperative stenting (≥ 7days). We compared the rate of ureteral injury, other perioperative complications, ureteral dilation and readmission, stone-free rate (SFR) and operative time among the groups. A total of 560 patients (215 in group 1, 177 in group 2 and 168 in group 3) were included in this study. The mean of maximum stone size was 13.1 (± 6.2) mm, the mean number of stones was 2.3 (± 1.9) and preoperative ureteral stenting duration was 7.2 (± 3.7) days. There were no significant differences in operative time (75.6, 78.5 and 82.4min, p = 0.280), SFR (79.1, 84.2 and 81.0%, p = 0.433), ureteral injury rate (7.0, 5.1 and 2.4%, p = 0.123) and other perioperative complication rates (12.1, 6.8 and 6.0%, p = 0.061). The only one case of grade IV ureteral injury occurred in group 1 and the rate of ureteral dilation was significantly higher than in group 2 and 3 (14.9, 5.7 and 6.0%, p < 0.001). Although preoperative ureteral stenting duration has no significant effect on operative outcomes, it is an effective procedure for reducing the rate of intraoperative ureteral balloon dilation and preventing high-grade ureteral injuries.

Evaluation of stone volume distribution in renal collecting system as a predictor of stone-free rate after percutaneous nephrolithotomy: a retrospective single-center study.

We analyzed our stone-free rates of PNL with regard to stone burden and its ratio to the renal collecting system volume. Data of 164 patients who underwent PNL were analyzed retrospectively. Volume segmentation of renal collecting system and stones were done using 3D segmentation software with the images obtained from CT data. Analyzed stone volume (ASV) and renal collecting system volume (RCSV) were measured and the ASV-to-RCSV ratio was calculated after the creation of a 3D surface volume rendering of renal stones and the collecting system. Univariate and multivariate statistical analyses were performed to determine factors affecting stone-free rates; also we assessed the predictive accuracy of the ASV-to-RCSV ratio using the receiving operating curve (ROC) and AUC. The stone-free rate of PNL monotherapy was 53% (164 procedures).The ASV-to-RCSV ratio and calyx number with stones were the most influential predictors of stone-free status (OR 4.15, 95% CI 2.24-7.24, <0.001, OR 2.62, 95% CI 1.38-4.97, p<0.001, respectively). Other factors associated with the stone-free rate were maximum stone size (p<0.029), stone surface area (p<0.010), and stone burden volume (p<0.001). Predictive accuracy of the ASV-to-RCSV ratio was AUC 0.76. Stone burden volume distribution in the renal collecting system, which is calculated using the 3D volume segmentation method, is a significant determinant of the stone-free rate before PCNL surgery. It could be used as a single guide variable by the clinician before renal stone surgery to predict extra requirements for stone clearance.

Ductal stones recurrence after extracorporeal shock wave lithotripsy for difficult common bile duct stones: Predictive factors

Background & purposeExtra-corporeal shock wave lithotripsy (ESWL) can be considered in difficult common bile duct stones (DCBDS), with a success rate greater than 90% but data on stone recurrence after ESWL are limited. We performed a retrospective analysis to evaluate long-term outcomes in patients who underwent ESWL for DCBDS. MethodsFrom May 1992 to October 2012, patients who underwent ESWL treatment for DCBDS, not amenable to endoscopic extraction, were included. Data on long-term outcome were collected through phone interviews and medical records. ResultsA total of 201 patients with a successful clearance of DCBDS after ESWL were included. During a median follow-up period of 4.64 years, 40 patients (20%) developed a recurrence of bile duct stones. Logistic regression analysis showed that the common bile duct diameter, gallstones presence and the maximum stone size were significantly associated with recurrence. ConclusionsWe observed a recurrence rate of 20% over a median follow-up of 4 years. Gallbladder stones, stone size and a dilated common bile duct diameter are risk factors for recurrent stone formation, while ursodeoxycholic acid treatment did not influence recurrence in our population.

Unusually large sialolith of submandibular gland

Introduction: Pathologically sialolithiasis is a disease which results in the obstruction of a salivary gland by a sialolith. sialolith is generally seen in small size and their sizes range from 1 mm to 1 cm. Large salivary gland calculi are infrequent and defined as the size of 1.5 cm or larger. Only a few cases of large sialolith of the submandibular glands have been reported in literature. Imaging methods have an important role in making a diagnosis and in planning further management, operative or otherwise. case report: A 52-year-old male patient with multiple stones in the submandibular gland admitted to our hospital with swelling at submandibular region. Plain films show large stones at the region of submandibular gland. the maximum stone size was 1.8x0.8 mm. submandibular gland size increased due to the sialoadenitis caused by stones. After surgery, the patient had a nearly normal function of the glands for three months. conclusion: the swelling which is seen in the submandibular region most commonly originates from sialolithiasis of submandibular gland, so it should be carefully evaluated by clinicians. Diagnostic imaging methods may complement each other in examining glands with sialolithiasis and may offer a promising

Design Standard of Control Structures Against Debris Flow in Japan

Countermeasures to prevent or mitigate sedimentrelated hazards, debris flow in this paper are classified as structural measures or nonstructural measures. The structural measures are Sabo dams, leading dikes, and channels for debris flow control. The nonstructural measures are the designation of areas prone to debris flow, proper land use in the areas, the reinforcement of houses, the creation of warning systems and the evacuation of the inhabitants in case of emergency. A technical standard on debris flow control structures of Japan was revised in 2007. Major revision is that check dams called Sabo dams constructed near houses are changed from closed type Sabo dams to open type Sabo dams because the occurrence frequency is low as once for longer than one hundred years, natural torrent environment should be conserved in ordinary days and sediment trap capacity should be kept until debris flow occurs. Points changed are explained such as the opening of open type dams is as equal as the maximum stone size.

LARGE BALLOON PAPILLARY DILATION FOR REMOVAL OF BILE DUCT STONES IN PATIENTS WHO HAVE UNDERGONE A BILLROTH II GASTRECTOMY

Extraction of large bile duct stones in patients who have undergone a Billroth II (B-II) gastrectomy can be challenging. Recently, a large balloon dilation performed after endoscopic sphincterotomy (ESLBD) was useful for the removal of large bile duct stones. The aim of our study was to evaluate the feasibility and safety of ESLBD for removal of bile duct stones in patients who have undergone a B-II gastrectomy. ESLBD for removal of bile duct stones were performed in 11 patients with a B-II gastrectomy at Tokyo Medical University Hospital. Immediately after EST, a large balloon catheter (maximum diameter 15 mm, 18 mm, or 20 mm) was passed over the guide-wire and positioned across the main duodenal papilla. Maximum stone size (short diameter) ranged from 7 to 30 mm with a median of 13.5 mm. The number of stones was 1-26 with a median of 4.8. The common bile duct diameter was 10 mm to 30 mm with a median of 18.1 mm. A mechanical lithotripter for crushing stones was used in two patients (18%). Papillary balloon dilation using variously sized balloons was performed in addition to endoscopic sphincterotomy. Complete clearance of bile duct stones was achieved in all cases at one session. There were no procedure-related adverse events such as acute pancreatitis or retroperitoneal perforation. ESLBD appears to be an effective and safe treatment for removal of difficult bile duct stones in patients who have undergone a B-II gastrectomy.

1571 WHICH OF RENAL STONE CHARACTERISTICS IN NONCONTRAST COMPUTED TOMOGRAPHY CAN PREDICT SUCCESSFUL TREATMENT BY SHOCK WAVE LITHOTRIPSY? UNIVARIATE AND MULTIVARIATE ANALYSIS

You have accessJournal of UrologyStone Disease: SWL, Ureteroscopic or Percutaneous Stone Removal II1 Apr 20101571 WHICH OF RENAL STONE CHARACTERISTICS IN NONCONTRAST COMPUTED TOMOGRAPHY CAN PREDICT SUCCESSFUL TREATMENT BY SHOCK WAVE LITHOTRIPSY? UNIVARIATE AND MULTIVARIATE ANALYSIS Adel Elbakry, Mokhtar Metaewea, Mohamed El Koshy, and Ahmed El Nashar Adel ElbakryAdel Elbakry More articles by this author , Mokhtar MetaeweaMokhtar Metaewea More articles by this author , Mohamed El KoshyMohamed El Koshy More articles by this author , and Ahmed El NasharAhmed El Nashar More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1337AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES To determine which of the stone characteristics in noncontrast computed tomography (NCCT) has a significant and reliable value in predicting the outcome of the treatment of renal stones by extracorporeal shock wave lithotripsy (ESWL). METHODS Forty patients with renal stones were subjected to stone disintegration by ESWL. Patients were 27 males and 13 females aged 32-69 years (mean SD 48.9±7.9). Four patients had bilateral renal stones, thus total stone number was 44. All stones were radio opaque and their NCCT characteristics were determined before ESWL. All patients'data and stones characteristics were analyzed via univariate and multivariate statistical analysis in correlation to the success and failure of ESWL. RESULTS The outcome of ESWL therapy was classified as successful (34 stones) and failed ESWL treatment (10 stones). The range (mean SD) of stone size,stone burden,stone density, skin to stone distance and body mass index (BMI)were 5.8 – 21.8 mm(13.6±3.7), 145 – 3000 mm 3 (1155.44±646.4), 401 – 1325 hounsfield units(HU)(675.8±264.9), 63.07 – 131.7mm(100.01±18.3) and 22.9–33.6(27.9 ± 2.4)respectively. Univariate analysis revealed that the most important factors predicting successful ESWL therapy were Stone density (P=0.001), skin to stone distance (P=0.001), body mass index(P=0.001), stone size (P=0.01), stone burden (P=0,02)and stone location(P=0.04) in descending sort. Receiver operating curve revealed that cut-off value above which failure of ESWL may be expected were stone size ≥14.49mm, stone density ≥993 HU, skin to stone distance>110.5mm and stone burden ≥ 1600 mm 3. Multivariate analysis showed that the most fitting predicting factors are maximum stone density (P= 0.01), maximum stone size (P=0.01), skin to stone distance (P=0.01) and stone burden (P= 0 0.01). CONCLUSIONS Renal stone characteristics in NNCT can predict success or failure of ESWL particularly stone attenuation (density), skin to stone distance, stone size and stone burden. Other parameters have no valuable effect on the result of ESWL. Thus, determination of NCCT characteristics of a renal stone effectively help in decision making and the patient can be informed about the most probable outcome of ESWL before the treatment. Ismailia, Egypt© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e607 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Adel Elbakry More articles by this author Mokhtar Metaewea More articles by this author Mohamed El Koshy More articles by this author Ahmed El Nashar More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

ESWL for difficult bile duct stones: A 15-year single centre experience

To evaluate the efficacy of extracorporeal shock wave lithotripsy (ESWL) for the management of refractory bile duct cholelithiasis in a third level referral centre. The clinical records of all patients treated with a second generation electromagnetic lithotripter (Lithostar Plus, SIEMENS) from October 1990 to April 2005 were evaluated. All patients were monitored during the procedure and antibiotics were administered in case of cholangitis. The chi(2) test and logistic regression analysis were performed as appropriate. Two hundred and fourteen patients (102 males, 112 females; mean age 74.8 +/- 0.84 years--single stone 97, multiple stones 117) underwent ESWL. The mean number of sessions and shock waves were 3.5 +/- 0.13 and 3477.06 +/- 66.17, respectively. The maximum stone size was 5 cm. Complete stone clearance was achieved in 192 (89.7%) patients. Of the remaining patients 15 required surgery, 2 a palliative stent and in 5 patients stone fragmentation led to effective bile drainage with clinical resolution despite incomplete clearance. Age, sex and stone characteristics were not related to treatment outcome. Major complications occurred in two patients (haemobilia and rectal bleeding) and minor complications in 25 (3 vomiting, 22 arrhythmias). No procedure-related deaths occurred. ESWL is a safe and effective technique for clearance of refractory bile duct stones.