Presence Of Multiple Stones Research Articles

Bilateral duplex kidney and ureter with multiple stones: a case report

BackgroundBilateral duplicated kidney and ureter is a rare condition in urology, and it is even rarer for patients to have multiple stones simultaneously. We delineate the diagnostic and therapeutic trajectory of a patient presenting with bilateral duplex kidneys and ureters, characterized by the presence of multiple stones. Notably, the left kidney is a complete duplication, whereas the right kidney exhibits an incomplete duplication.Case presentationA 47-year-old male patient was diagnosed with bilateral duplex kidney and ureter combined with multiple stones. Ureteral flexible lithotripsy and percutaneous nephrolithotomy were performed successively in our hospital. On the postoperative five day, he was discharged from the hospital without apparent discomfort.The double J tube was pulled out one month later, and no stone recurrence was found after 3 months of follow-up.ConclusionsBilateral duplicated renal ureteral malformations combined with multiple stones are very rare. Stones can be removed by ureteroscopic lithotripsy or percutaneous nephrolithotripsy and sometimes multiple procedures are required, which should be chosen according to the patient’s relevant condition.

A Machine Learning Predictive Model for Ureteroscopy Lasertripsy Outcomes in a Pediatric Population-Results from a Large Endourology Tertiary Center.

Introduction: We aimed to develop machine learning (ML) algorithms for the automated prediction of postoperative ureteroscopy outcomes for pediatric kidney stones based on preoperative characteristics. Materials and Methods: Data from pediatric patients who underwent ureteroscopy for stone treatment by a single experienced surgeon, between 2010 and 2023 in Southampton General Hospital, were retrospectively collected. Fifteen ML classification algorithms were used to investigate correlations between preoperative characteristics and postoperative outcomes: primary stone-free status (SFS, defined as stone fragments <2 mm at the end of the procedure confirmed endoscopically and no evidence of stone fragments >2 mm at Xray kidney-ureters-bladder (XR KUB) or ultrasound kidney-ureters-bladder (US KUB) at 3 months follow-up) and complications. For the task of complication and stone status, an ensemble model was made out of Bagging classifier, Extra Trees classifier, and linear discriminant analysis. Also, a multitask neural network was constructed for the simultaneous prediction of all postoperative characteristics. Finally, explainable artificial intelligence techniques were used to explain the prediction made by the best models. Results: The ensemble model produced the highest accuracy (90%) in predicting SFS, finding correlation with overall stone size (-0.205), presence of multiple stones (-0.127), and preoperative stenting (-0.102). Complications were predicted by Synthetic Minority Oversampling Technique (SMOTE) oversampled dataset (93.3% accuracy) with relation to preoperative positive urine culture (-0.060) a1nd SFS (0.003). Training ML for the multitask model, accuracies of 83.3% and 80% were respectively reached. Conclusion: ML has a great potential of assisting health care research, with possibilities to investigate dataset at a higher level. With the aid of this intelligent tool, urologists can implement their practice and develop new strategies for outcome prediction and patient counseling and informed shared decision-making. Our model reached an excellent accuracy in predicting SFS and complications in the pediatric population, leading the way to the validation of patient-specific predictive tools.

The predictive ability of Mayo adhesive probability score for evaluating intraoperative bleeding in standard percutaneous nephrolithotomy in adult patients.

Mayo adhesive probability (MAP) score is one of the commonest tool to predict the adherence status of perirenal fat. The association between MAP score and intraoperative hemorrhage in patients undergoing micropercutaneous nephrolithotomy was comfirmed in a recent well designed study. We aimed to investigate if MAP score may predict the possibility for significant intraoperative bleeding in supine percutaneous nephrolithotomy (PCNL) performed with a 26 Fr rigid nephroscope. In this observational retrospective study, demographic, clinical, laboratory, radiological, perioperative (operation duration, hospitalization, intraoperative bleeding, success) and MAP score (perinephric fat stranding, posterior perinephric fat thickness and total MAP score) data of all patients who underwent supine PCNL between June 2021 and July 2023 were evaluated. The patients were divided into 2 groups according to their MAP scores (79 [54.1%] patients with MAP score < 3 [low MAP score] and 67 [54.1%] patients with MAP score ≥ 3 [high MAP score]). The rate of patients with intraoperative bleeding was 47.8% in the patient group with a high MAP score, while it was 22.8% in the patient group with a low MAP score (p = 0.002). In multivariate logistic regression analysis, anticoagulant drug use history (OR = 2.525; 95% CI = 1.025-6.224; p = 0.044), presence of multiple stones (OR = 3.015; 95% CI = 1.205-7.543; p = 0.018), calyx localization of the stone (OR = 2.871;95% CI = 1.166-7.068; p = 0.022), higher renal parenchymal thickness (OR = 1.119; 95% CI = 1.049-1.193; p = 0.001) and MAP score > 3 (OR = 3.486; 95% CI = 1.579-7.696; p = 0.002) were defined as independent risk factors for significant intraoperative bleeding. In clinical practice, the MAP score can be used to predict bleeding before PCNL.

Comparative analysis of approaches to the Wharton's duct during surgery of the submandibular gland: A retrospective case-control study.

We investigated complications and recurrence rates after surgical techniques for sialolith removal with intact and resected Wharton's duct of the submandibular gland. The retrospective case-control analysis of a series analysed 271 surgical operations (2003-2022) for sialolithiasis performed at a hospital department of Otolaryngology-Head and Neck Surgery. The study compared two approaches: (1) pure endoscopic technique or pinpoint stone removal with Wharton's duct left intact and (2) transoral duct dissection or pinpoint stone removal technique, after which the duct was shortened. While choosing the surgical option, the size of the stone, the location of the stone, and the presence of multiple stones were taken into account. The rates of complications (lingual nerve paraesthesia, duct stenosis, drooling, and sialoadenitis), the incidence of foreign bodies, and the rate of recurrence during follow-up of ≥18 months were compared. 323 sialoliths were removed from 271 patients. Of these 323 calculi, 150 were removed by the first approach and 173 by the second approach. The calculi varied in diameter from 2 to 38 mm with an average diameter of 8.2 mm. For all 271 patients, the rate of recurrence was 4.8%, but 11 recurrent cases (8.7%) appeared after the first approach surgeries and 2 cases (1.4%) after the second approach surgeries (p = .03). Other variables did not show statistically significant differences. Surgical removal of the submandibular calculi, ending with shortening of Wharton's duct, reduces the recurrence rate for sialolithiasis but does not affect the rate of postsurgical complications.

A New Nomogram to Predict the Success of Shock Wave Lithotripsy in Ureteral Stones

Purpose. To design a new nomogram predicting the probability of stone‐free status of shock wave lithotripsy (SWL) in patients with ureteral stones. Materials and Methods. We retrospectively enrolled 2,144 patients with ureteral stones who underwent SWL between January 1993 and April 2020. The demographic and clinical parameters were assessed. The predictors of stone‐free status following SWL were identified. A logistic regression‐based nomogram was created by including the significant predictors in the multivariate analysis. Results. The mean age was 42.93 ± 13.85 in the stone‐free group (Group 1) and 46.51 ± 13.66 in the treatment‐failure group (Group 2) (p = 0.001). The cutoff value of the age was 45.5 years. The mean stone load was 0.71 ± 0.36 cm2 in Group 1 and 0.96 ± 0.51 cm2 in Group 2 (p = 0.001). Of the 2,144 patients, 1,708 (79.6%) were stone‐free within the first three SWL sessions. According to the multiple logistic regression analysis, older age, a stone load larger than 1 cm2, the presence of multiple stones, third‐generation lithotripter use, and pre‐SWL catheterization were statistically associated with low stone‐free rates. The C‐index was determined to be 0.75 in the bootstrapping method. Conclusion. A stone load larger than 1 cm2, age older than 45.5 years, the presence of multiple stones, new‐ (third‐) generation lithotripter use, and pre‐SWL catheterization had statistically significant effects on lower stone‐free rates in patients who underwent SWL due to ureteral stones. A nomogram was developed to predict the success of SWL. As a result of the internal validation of the nomogram, it was concluded to be suitable for clinical use.

The association between ureteral wall thickness and need for additional procedures after primary ureteroscopy in patients with ureteral stones above the iliac crest.

To examine the parameters affecting the need for additional procedures in the primary ureteroscopy treatment in patients with ureteral stones above the iliac crest level. Seventy-one patients were included in the study who were ≥ 18 years old and had undergone ureteroscopy (URS) for ureteral stones above the iliac crest level between 2018-2020 and had a non-contrast-enhanced abdominal computed tomography before the procedures were included in the study. Patients and stone characteristics were prospectively collected. The results were evaluated six weeks after URS. The absence of any residual fragment was thought to indicate stone-free status. The patients with failure were referred for the additional procedures. The median patient age was 51 years [interquartile range (IQR): 18-66]. The median transverse stone diameter was 9.5 mm (IQR: 7.1-11.4), and the median ureteral wall thickness (UWT) was 5.8 mm (IQR: 4.3-6.5). In the univariate analysis, UWT (p < 0.001), presence of multiple stones (p = 0.008), and stone length (p = 0.022) affected stone-free status. The multivariate analysis revealed UWT as the only independent factor affecting the need for additional procedures after URS (p = 0.028). In the receiver operating characteristic curve analysis, the best threshold value for UWT according to the outcomes was identified as 5.8 mm. Ureteral wall thickness was the only independent parameter determining the need for additional procedures and affecting the treatment outcomes after the URS procedure.

Prediction models of low-power holmium laser effectiveness in renal stone lithotripsy during retrograde intrarenal surgery.

The objectives of this study are to develop prediction models for total laser energy (TLE) in order to infer surgical time and assist operative planning of intrarenal low-power Ho:YAG laser lithotripsy, and to predict the fragmented volume as well as the stone-free status (SFS). A retrospective review was performed, comprising all single surgeon standardized retrograde intrarenal surgery and low-power Ho:YAG laser lithotripsy at a tertiary care centre between October 2014 and September 2019. Automated measurement of stone volume and stone density (MSD), measured in Hounsfield units (HU), was employed in both pre- and post-operative non-contrast-enhanced computed tomography (NCCT), using a standardized technique on Osirix Lite® software. SFS was defined as complete absence of stone fragments, or fragments < 0.1cm on meticulous inspection at the end of the procedure, and residual stone burden < 0.0005 cm3 on postoperative NCCT at 3months. Statistical analysis was performed using the STATA® version 13.1 software for regression models. A p value < .05 was considered statistically significant. A total of 100 patients met the inclusion criteria, requiring a median of 22.3kJ/cm3 (13.4-36.0) and resulting in a SFS of 41% at 3months. In a multivariate analysis, according to stone composition, predicted TLE is equal: for uric acid (UA), 11.17 × volume(cm3) + 0.17 × MSD(HU) + 7.48kJ; for mixed stones, 11.17 × volume(cm3) + 0.17 × MSD(HU) + 6.26kJ; for calcium oxalate monohydrate (CaOM) stones, 11.17 × volume(cm3) + 0.17 × MSD(HU) + 1.14kJ; and for calcium phosphate (CaPh) stones 11.17 × volume(cm3) + 0.17 × MSD(HU) - 1.94kJ. Predicted fragmented volume is equal to 0.93 × volume(cm3) cm3. The significant predictors for SFS were UA stones, the presence of multiple stones, and lower TLE. In clinical practice, our models for intrarenal low-power Ho:YAG laser lithotripsy indicate that larger, denser, and UA stones are associated to higher TLE, and that single and UA stones are more commonly associated to SFS. Since higher TLE means longer operative time, when adjusting for laser parameters, our prediction models may help urologists plan surgeries more precisely based on stone characteristics, ultimately optimizing patients' treatment.

Ureteral wall thickness is an independent parameter affecting the success of extracorporeal shock wave lithotripsy treatment in ureteral stones above the iliac crest.

To investigate the relationship between ureteral wall thickness (UWT) and other variables of patients who underwent extracorporeal shock wave lithotripsy (SWL) in the primary treatment of the ureteral stone above the iliac crest level. A total of 147 patients aged 18years and older, who underwent SWL in our clinic between December 2016 and December 2019 for the treatment of ureteral stones above the iliac crest level and had non-contrast enhanced abdominal computed tomography scans before the procedure were included in the clinical study. The results were evaluated at 3months after SWL. The absence of residual fragments was considered as stone-free status, and the existence of any size residual fragment was considered as treatment failure. In our study, the mean age of the patients was 42.4±12.8years, and the stone-free rate was 92.5%. The median transverse stone size was 7.5mm (min 2.8-max 15), and the median UWT was 4.2mm (1-8.7). In the multivariate analysis, UWT (P=.002) and multiple stone presence (P=.027) were found to be independent factors affecting stone-free status. In the receiver operating characteristic curve analysis, the optimal threshold value for UWT was determined as 5.25mm. We found that UWT was the most important independent variable associated with increased failure in SWL treatment. The presence of multiple stones was another independent factor that increased the failure rates. Using SWL technology through experience accumulated with the mechanical hardware of the machine, we can select patients who are more suitable for this treatment and improve treatment outcomes.

Percutaneous transhepatic Laser lithotripsy for intrahepatic cholelithiasis

PurposeTo report the technical success, complications and long-term outcomes of patients with intrahepatic cholelithiasis not amenable to endoscopic retrograde cholangiopancreatography (ERCP) who were treated with percutaneous transhepatic biliary Laser lithotripsy (PTBLL). Patients and methodsA retrospective review of 12 patients who underwent PTBLL for intrahepatic cholelithiasis was performed. There were 5 men and 7 women with a mean age of 46±18 (SD) years (range: 23–75 years). PTBLL was performed when stone clearance using ERCP had previously failed or was not appropriate due to unfavourable anatomy or the presence of multiple stones or a large stone. Percutaneous biliary access into intrahepatic ducts was obtained if not already present and lithotripsy was performed using a HolmiumYAG 2100nM Laser. Patients files were analyzed to determine the technical success, complications and long-term outcomes. ResultsEleven patients (11/12; 92%) had a history of previous hepatobiliary surgery and nine (9/12; 75%) had multiple stones confirmed on preprocedure imaging. A 100% success rate in fragmenting the target stone(s) was achieved and 11/12 patients (92%) had successful first pass extraction of target stone fragments. Two patients (2/12; 17%) required repeat lithotripsy. One patient (1/12; 8%) experienced a major complication in the form of cholangitis. Of patients with long-term follow-up, 4/10 (40%) had recurrence of intrahepatic calculi with a mean time interval of 31 months (range 3–84 months). ConclusionFor patients with intrahepatic biliary calculi not amenable to ERCP, PTBLL provides an effective and safe alternate treatment.

A new simple scoring system for prediction of success and complication rates in pediatric percutaneous nephrolithotomy: stone-kidney size score

Nomograms and scoring systems designed for predicting the success of percutaneous nephrolithotomy (PCNL) in adults are currently available. However, no scoring system currently exists primarily for predicting PCNL success in children. The objective of this study was to develop a scoring system to predict the stone-free and complication rates by using pre-operative parameters. A retrospective analysis was conducted on data from 434 renal units belonging to patients with kidney stones who underwent PCNL between 1997 and 2017. Renal stone index was calculated by dividing the length of the stone along its longest axis by the length of the kidney along its longest axis. Guy's Stone scores, S.T.O.N.E scores, and CROES scores for adults were calculated by filling in the variables for each patient. Factors that predicted success and complications were examined by univariate and multivariate analyses. Mean age was 8.3 (1-16) years, and male to female ratio was 236:165. When stone-free patients were compared with other patients, there was a statistically significant difference in the average stone/kidney index (SKI) value (stone size/kidney size on longitudinal axis) (0.266 vs 0.339, P<0.001). In multivariate analysis, factors that predicted success were the SKI and number of stones. A newly developed scoring scale, the stone-kidney score (SKS), combined scores for both the SKI and the number of stones into one value. A minimum total SKS score was 2, and a maximum total SKS score was 4. Success rates for SKS scores of 2, 3, and 4 were 86.4%, 73%, and 62.9% (P<0.001), respectively. Complication rates for SKS scores of 2, 3, and 4 were 13%, 22.1%, and 23.8%, respectively. The new scoring system has only two variables (number of stones and SKI) and three risk groups. An SKS score is easier to use and calculate. An SKI value can be simply calculated on any imaging modality by dividing the length of the stone along its longest axis by the length of the kidney along its longest axis. As in the new scoring system, the SKI value combined with the number of stones is useful in predicting stone-free rates after PCNL. When evaluated together, the SKI and presence of multiple stones may predict stone-free rates pre-operatively. The SKS is an individual-specific method that can be easily used in pediatric clinical practice. Further studies are required to develop and standardize this method.

The recommendations of the S2k guideline for the diagnosis, therapy and metaphylaxis of urolithiasis provide a safe course of action for ureterorenoscopic stone treatment - results of the BUSTER study

Given the high incidence, prevalence and rate of recurrence, urolithiasis stone treatment at a high stone-free rate should have a low complication rate. The German S2k guideline (GS2k-GL) for the diagnostic testing, therapy and metaphylaxis of urolithiasis provides recommendations for the first and second choice for stone treatment, depending on stone location and size. Ureterorenoscopy (URS) is the treatment of first choice for most stones. URS is only the second option for renal stones > 20 mm and proximal ureteric stones ≤ 10 mm. The objective was to examine the impact of using URS as the stone treatment of first or second choice on the endpoints stone-free rate and severity of complications. The multicentric prospective observational study "Evaluation of ureteroroscopic stone treatment- results with regard to complications, quality of life and the stone-free rate" (BUSTER) standardised recorded perioperative data from 307 patients who had undergone ureterorenoscopic stone treatment from January to April 2015 at 14 German urological clinics. Treatment decisions were not affected by the study protocol. In the univariate analysis, the stone-free rate for ureteric stones was significantly higher when URS was the treatment of first choice (OR 2.21, 95 % CI 1.11 - 4.40, p = 0.027). After adjustment for age, BMI, ASA score, preoperative ureteral stenting, stone location and size, presence of multiple stones, experience of the surgeon, acute or elective URS and operating time, the application of URS as treatment of first choice had no significant effect on the stone-free rate (OR 2.048, 95 % CI 0.890 - 4.710, p = 0.092). After adjustment for stone location and size as well as ureteral stenting following URS, the application of URS as treatment of first choice had no significant influence on the severity of complications (OR 1.019, 95 % CI 0.347 to 2.993; p = 0.973). On the basis of our data, URS proved to be a safe and effective stone treatment procedure regardless of the degree of guideline conformity. Although the stone-free rate was higher with URS as treatment of first choice, the results of URS as treatment of second choice were not significantly worse. The recommendations of the GS2k-GL offer a safe guide for ureterorenoscopic stone treatment. The tendency for higher stone-free rates in URS as a treatment of first choice should be examined in further studies.

Evaluation of postoperative hydronephrosis following semirigid ureteroscopy: Incidence and predictors.

Hydronephrosis developing following ureteroscopy (URS) is an important issue associated with the long-term postoperative renal functions. Studies investigating the role of postoperative imaging revealed conflicting results. In this study, we aimed to determine the incidence and predictors of hydronephrosis following semirigid URS. We evaluated the results of 455 patients who underwent U RS a nd postoperative imaging with non-contrast computed tomography (CT). Primary endpoints of the study were to determine the frequency of development of hydronephrosis and factors associated with the development of hydronephrosis. Logistic regression analysis was used to define factors effecting on the development of hydronephrosis. Postoperative non-contrast CT revealed hydronephrosis in 81 (17.8%) patients. Stone-free status was achieved in 415 (91.2%) patients. Univariate analysis revealed history of ipsilateral URS (p=0.001), duration of operation (p=0.022), presence of multiple stones (p=0.001), and occurrence of a renal colic episode postoperatively (p=0.013) as the parameters associated with increased risk of postoperative hydronephrosis. In the multivariate analysis, history of ipsilateral URS (OR: 2.724, p=0.017) and presence of multiple stones (OR: 2.116, p=0.032) were found to be the independent prognostic markers of developing postoperative hydronephrosis. Ipsilateral hydronephrosis following URS develops in a significant number of patients. In patients with history of ipsilateral hydronephrosis and multiple stones, risk of development of postoperative hydronephrosis is higher, therefore physicians should be keep these parameters in mind in the decision making process of selective imaging postoperatively.

A new approach in ureteral access sheath locating in retrograde intrarenal surgery (RIRS) by endovisional technique.

To compare the results of patients who underwent retrograde intrarenal surgery (RIRS) using endovisional technique for ureteral sheat locating with control group in which endovisional technique was not applied. Of the 41 patients who underwent RIRS treatment for kidney stone, between March 2014- August 2015, 19 patients treated with endovisional technique formed the study group and remaining 22 patients formed the control group. Patients were evaluated for age and gender, baseline and post procedural creatinine level, duration of operation, fluoroscopy and hospitalization time, size and localization of the stone, presence of multiple stones, previous shock wave lithotripsy (SWL) procedure, double J catheter requirement, complication rate, residual stone rate and absence of stone ratio. There was no statistically significant difference between age, gender, location of the stone, previous SWL procedure, presence of multiple stones, baseline and postprocedural creatinine level, absence of stone ratio, double J catheter requirement and hospitalization duration between the groups. The duration of operation and fluoroscopy of the patients were significantly shorter than the control group (p = 0.036 and p &lt; 0.001, respectively). The complication rates of the endovisional technique group was significantly lower than that of the control group (p = 0.032). Endovisional technique is considered to be an appropriate and useful technique in order to locate the sheath safely in patients who has difficulty in ureteral access sheath locating and to decrease the duration of operation and fluoroscopy.

Risk factors for developing a perirenal hematoma after flexible ureteroscopic lithotripsy

ObjectiveTo investigate the risk factors of perirenal hematoma (PRH) after flexible ureteroscopic lithotripsy (FURSL). Materials and methodsWe retrospectively reviewed the medical records of 45 patients who underwent FURSL with a holmium:yttrium–aluminum–garnet laser. We divided all patients in two groups: the PRH group and the non-PRH group. The patient demographic and baseline characteristics, surgical outcomes, and complications were compared and risk factors were identified and analyzed. ResultsOf the 45 consecutive patients treated with FURSL, four (8.9%) developed PRH. Compared with patients without PRH, patients with PRH had a lower body mass index (BMI; 20.2 ± 3.2 kg/m2 vs 26.9 ± 5.5 kg/m2, p = 0.015), thinner kidney cortex thickness (0.88 ± 0.41 cm vs 1.39 ± 0.41 cm, p = 0.024), and a history of chronic kidney disease (CKD; 75% vs 14.6%, odds ratio = 17.5, confidence interval = 1.55–197.46, p = 0.021). However, patient age, diabetes mellitus, hypertension, liver disease, coronary artery disease, history of urolithiasis, presence of multiple stones, and stone size and location were comparable in both groups. Three patients with PRH were successfully managed with conservative treatment. One patient with PRH underwent an emergency nephrectomy within 1 day but died 2 weeks later despite vigorous resuscitation. ConclusionAmong our patients, those with lower BMI, CKD, and a thinner renal cortex had a higher risk of developing PRH after FURSL. Endourologists should have a heightened awareness for potential PRH when treating patients who present with low BMI, CKD, and a thin renal cortex.

PTH-035 Dilated common bile duct, stone size and multiple stones are predictors of endoscopic papillary large volume balloon dilatation in the management of complex common bile duct stones

Introduction Endoscopic papillary large volume balloon dilatation (EPLVBD) has been used safely and effectively for stone removal in patients with complex common bile duct stones (CBDS). There remains a significant variation in practice particularly concerning the timing and preference to perform EPLVBD for removal of CBDS. Method A single large volume tertiary referral centre study looking at factors predictive of EPLVBD for biliary stone removal and safety outcomes using a prospectively collected procedural database together with an electronic hospital clinical record. All ERCP records were interrogated over a period of five years from Oct 2009 to Sep 2014. Results EPLVBD was performed in 202 patients (78 males and 124 females) with median age of 77 years (range 24–94). The main indication for performing ERCP was suspected biliary stone disease. 94(47%) patients had prior ERCP for stone disease and 108(54%) patients were undergoing their first ERCP. ERCP was performed predominantly under conscious sedation containing midazolam and fentanyl with median doses of 1.5mg (range 1.5–7) and 92.5 mcg (range 10–200) respectively. General anaesthesia was used in 34 patients. Median stone size was 10.09 mm (range 4–24) while median stone number was 2 (range 1–13). Distal, middle and proximal median common bile duct diameter were 10.68 mm (range 4–20), 13.37mm (range 9–28) and 12.66 mm (range 12–30) respectively. Median papillary balloon dilatation size was 15 mm (range 10–20). In 131 (65%) patients duct clearance was achieved with EPLVBD at first ERCP. In addition to EPLVBD, per-oral cholangioscopy (POC) and electrohydraulic lithotripsy (EHL) was performed in 14 and mechanical lithotripsy in 20 patients. 71(35%) patients did not achieve duct clearance at first ERCP. This was despite using mechanical lithotripsy in 30/71. Duct clearance was achieved at subsequent ERCP with POC and EHL in 30; mechanical lithotripsy in 7; repeat sphincteroplasty in 4 and extraction balloon in 34 patients. 40 patients (20%) had ampullary and peri-ampullary diverticulum. 23/40 (57%) had endoscopic sphincterotomy (ES) followed by EPLVBD at first ERCP without any complications. There were 2 cases of bleeding and pancreatitis (1%) each without any other procedural, sedation or anaesthesia related complications. Conclusion EPLVBD is a safe and effective technique used to extract bile duct stones. There is no difference in outcomes whether it is performed at the time of sphincterotomy or at a later procedure or whether there is a full or limited sphincterotomy. Dilated CBD, stone size and presence of multiple stones are strong predictors of EPLVBD for biliary stone extraction. Disclosure of interest None Declared.

Outcomes of Living Donors With Asymptomatic Nephrolithiasis.

Background: Improved sensitivity of CT imaging has increased the prevalence of incidentally detected nephrolithiasis in potential living kidney donors(LKD). We compare the clinical outcomes in potential LKDs who were found to have incidental nephrolithiasis vs. LKDs without nephrolithiasis. Methods: 24 LKD candidates with incidental nephrolithiasis(study group) were identified; 20 donated(all laparoscopically). A control group of 26 LKDs without nephrolithiasis was identified. A questionnaire was administered to identify the frequency of: 1) symptoms/signs related to nephrolithiasis and 2)procedures needed for management of nephrolithiasis after either CT imaging(if no donation) or living donation Results: % of males, mean age, mean BMI, and mean follow-up time in the study and control groups were 20.8% and 34.6%, 48 and 40 years, 24.3 and 27.4, and 895 and 1106 days, respectively. Mean stone size of the largest stone in each patient of the study group was 3mm (range:0.25-9mm).Table: No Caption available.Conclusions: The risk of stone-related complications in individuals with asymptomatic nephrolithiasis identified by CT imaging during the donor evaluation process is not increased compared to individuals without nephrolithiasis. The presence of multiple stones or bilateral stones is not associated with an increased risk of stone-related complications. The presence of a stone >2mm to <9mm or a solitary kidney with nephrolithiasis may be associated with a lower post-donation GFR. A larger sample size, with longer follow-up, needs to be evaluated to confirm these preliminary findings.

Subcapsular renal haematoma after holmium:yttrium‐aluminum‐garnet laser ureterolithotripsy

To report the incidence, risk factors, and outcomes of subcapsular renal haematoma (SRH) after ureteroscopic lithotripsy (URSL) using holmium:yttrium-aluminum-garnet (Ho:YAG) laser to treat ureteric stones. Prospective data from 2848 URSLs performed between January 2003 and September 2010 were retrospectively analysed. In all 11 patients were identified as having a SRH after URSL if they had persistent severe ipsilateral flank pain or a palpable mass within a day of surgery, or presented with radiographic evidence of a SRH. Risk factors for the development and course of the SRH were reported. Of the 2848 consecutive patients treated with URSL using Ho:YAG laser, 11 (0.4%) developed a SRH after surgery. Patients who developed a SRH had larger stones (1.4 vs 0.9 cm, P < 0.001), more severe ipsilateral hydronephrosis (P < 0.001), longer operation duration (41 vs 33 min, P < 0.001), and higher perfusion pressure of hydraulic irrigation (176.8 vs 170.2 mmHg, P < 0.001) than patients who did not develop a SRH. Patient age, sex, body mass index, presence of diabetes mellitus, history of urolithiasis and hypertension, presence of multiple stones, stone location and flow rate of hydraulic irrigation were not statistically different in patients who did or did not develop a SRH. Most patients were managed conservatively, with no further intervention or with a flank drain, until the SRH resolved. Overall, in three patients the SRH resolved with no further intervention, six patients were treated with a drain only, and two patients had open surgery within a day of presenting with SRH. The rate of development of SRH after URSL is very low. Most patients who present with a SRH after URSL, can be treated conservatively with no intervention or with a drain only.

A Case of Transoral Approach of Multiple Sialolithiasis in Parotid Duct

Sialolithiasis is a condition characterized by the obstruction of a salivary gland or its duct due to the formation of calcareous material or sialoliths resulting in salivary ectasia and even provok- ing the subsequent dilation of the salivary gland or salivary duct. The most difficult cases involve sialoliths in the posterior part of the Stensen's duct, the presence of multiple stones with stenosis of the distal part of the duct. We report on a case of Stensen's duct abscess with multiple sialo- lithiasis in a 46-year-old man. The patient's cheek was swollen, and showed no evidence of any other lesions. The patient was treated with surgical removal of stones by the intraoral approach, sialodochoplasty and antibiotics therapy. There has been no recurrence nor duct problem during the 12 months period of follow up. Korean J Otorhinolaryngol-Head Neck Surg 2010;53:501-4 Key WordsZZSalivary gland calculi·Salivary duct calculi·Parotid gland.

Development of a Mathematical Model to Predict Extracorporeal Shockwave Lithotripsy Outcome

To determine statistically significant parameters that influence shockwave lithotripsy (SWL) outcome and to develop a mathematical equation to predict the possibility of a successful outcome. Radiopaque ureteral and renal stones (1997) underwent SWL in a single center using the Siemens Lithostar Plus lithotripter. Investigated variables were stone size and location; presence of multiple stones; patient sex, age, body mass index (BMI), and ureteropelvic junction (UPJ) diameter; and Double-J catheter presence. The investigation included intravenous urography or ultrasonography and plain radiography of the kidneys, ureters, and bladder (KUB). Ten percent of the patients also underwent unenhanced CT to determine stone volume and density. Patients were evaluated 3 months postoperatively by plain radiography of the KUB. Student t test, chi-square test, and multiple logistic regression analysis were used to determine statistically significant variables and to create predictive mathematical equations. Kidney, ureter, total stone-free rate, and re-treatment rate were 71%, 80.9%, 74.9% and 18%, respectively. Complications included two perirenal hematomas, one significant cardiac arrhythmia, and 3.7% stein-strasse. Statistically significant variables were patient age, sex, BMI, stone size, volume, density, multiple lithiasis, and UPJ diameter. By using statistical analysis, coefficients were calculated for each significant variable. The mathematical model calculating the probability (P) of success with a mean predictive value of about 80% is: P = 1/1 + e(-z) where e is the base of the natural logarithm and z = ct + the total of products of each coefficient multiplied by each variable value. Using the described method, similar predictive equations can be created for different lithotripters and used by computer software to aid both patient counseling and doctor decision and ensure an optimal combination of maximum efficacy and safety and minimum cost.

A Patient with a Left Accessory Hepatic Duct with Gallstones

Abstract: Accessory hepatic ducts, especially the left ducts, are relatively rare anomalies of the biliary tract. We present here a patient with this anomaly complicated by the presence of multiple stones. Endoscopic retrograde cholangiography (ERC) and ultrasound (US) were very useful in establishing the diagnosis preoperatively and in determining our surgical strategy. ERC demonstrated the left accessory hepatic duct with multiple radiolucent stones at the level of the cystic duct on the opposite side of the gallbladder. US demonstrated a hyperechoic mass measuring 15×10 mm with an acoustic shadow at the hepatic hilus. It also showed the internal “honey‐comb” structure of the mass which contained numerous stones measuring 5–6 mm in diameter and a fine tubular structure between the accessory hepatic duct and the caudate lobe. Intraoperatively the sac‐like, dilated (35×10 mm), left accessory hepatic duct was filled with numerous bilirubin stones originating at the cystic duct from its contralateral side. A few fine bile ducts communicated with the accessory hepatic duct and the caudate lobe.