Rate Of Stone Formation Research Articles

Stone growth patterns and risk for surgery among children presenting with hypercalciuria, hypocitraturia and cystinuria as underlying metabolic causes of urolithiasis

Hypercalciuria, hypocitraturia and cystinuria are the most common underlying metabolic stone abnormalities in children. The present study compared stone growth patterns, stone burden, and the risk of stone-related surgery among these underlying metabolic conditions. A retrospective cohort of 356 children with renal stones, followed from 2000 to 2015, was studied. Differences among metabolic groups were determined using Kruskal-Wallis test; the Scheffé-test was used for multiple comparisons to determine differences among single groups. Independent sample t-test was used when adequate, given the sample size, and Chi-squared test was used for categorical variables. Stone growth rates were calculated as differences in diameter divided by time elapsed between U/Ss (mm/year). Logistic regression was performed to assess the effect of initial stone size on the likelihood of surgery. Median stone size at presentation was significantly different among groups, with cystinuria being the group with the largest proportion of stones >10mm, while patients with stones <5mm were likely to have a normal metabolic workup (P<0.05). Stones with a higher growth rate were found in the operative group, while slower growing stones were mostly managed conservatively (3.4mm/year vs 0.8mm/year, respectively; P=0.014). However, stone growth rates were not significantly different among metabolic groups. On the other hand, the rate of new stone formation in cystinuric patients at their first follow-up was 30.4%, which was significantly higher than in patients with hypercalciuria (16.3%) or with a normal metabolic workup (17.2%; P<0.05). Compared with stones <5mm, stones measuring 5-10mm were more than four times more likely to result in surgery, whereas the likelihood of surgery for 10-20mm or >20mm stones was almost 16 or 34 times, respectively (P<0.001). It is believed that this is the first study to evaluate stone growth patterns, stone burden and surgical risk among children with hypercalciuria, hypocitraturia and cystinuria. Cystinuric patients presented with larger stones at the time of diagnosis, higher new stone formation rates, and were at higher risk of surgery. While no significant difference of growth rate was found among metabolic groups, stones with a higher growth rate were significantly more likely to result in surgical treatment than slower growing stones. Initial stone size, location of largest stone, previous urinary tract infection, and patient's metabolic type significantly influenced the likelihood of a surgical intervention. Better understanding of the natural history ultimately helps surgeons and clinicians defining prognosis, treatment, and prevention plans for pediatric urolithiasis.

Outcomes of seromuscular bladder augmentation versus standard ileocystoplasty: A single institution experience over 14 years

Ileocystoplasty is the standard technique used for bladder augmentation, and has been used widely for decades. However, it is known to be associated with complications such as stone formation, mucus production, metabolic acidosis, urinary tract infections, intestinal obstruction, and a long-term risk of bladder cancer. Seromuscular bladder augmentation (SMBA) is an alternative to the standard ileocystoplasty, and has been associated with a lower incidence of bladder stones. Few reports have been published on intermediate outcomes of SMBA. Herein, we report long-term outcomes of SMBA from a single institution compared with standard ileocystoplasty. After Institutional Review Board approval, a retrospective chart review of all patients who underwent bladder augmentation at our institution over a 14-year period was performed. The status of patients after SMBA (10 patients) was compared according to age, sex, and diagnosis with patients who underwent traditional ileocystoplasty (30 patients). Parameters such as demographic information, pre- and postoperative bladder capacity as assessed by urodynamic studies, urinary tract infections (UTIs), bladder calculi, incontinence, need for secondary surgical procedures, and spontaneous bladder perforation were compared in the two groups. All the patients were on a clean intermittent catheterization (CIC) regimen. Over the study period, 10 patients underwent SMBA and 30 patients (according to age, sex, and diagnosis) underwent standard ileocystoplasty; the average age at surgery was 10.3 and 10 years respectively, with a mean follow up of 6.7 years in the SMBA group and 6 years in the ileocystoplasty group. There were no statistically significant differences in the rate of UTIs, urinary incontinence, subsequent surgery, or spontaneous bladder perforation. The mean bladder capacity increased significantly for both groups as assessed by pre- and postoperative urodynamic studies, although the difference in the rate of bladder calculi between the two groups (0 [0%] vs. 8 [27%], p=0.06) did not reach statistical significance (Table). SMBA is safe and efficacious and may result in a lower rate of stone formation than standard ileocystoscopy. SMBA should be considered as a viable alternative to standard ileocystoplasty.

Cost-effectiveness of extracorporeal shock wave lithotripsy in a poor resource setting: The Okada, Nigeria experience.

Background:The first extracorporeal shock wave lithotripsy (ESWL) used in Nigeria was at Igbinedion Hospital and Medical Research Centre (IHMRC), Okada in 1992 and it functioned for 6 consecutive years. The objectives of this study were to analyze the cost-effectiveness of the procedure and highlight the associated factors that led to its failure.Methods:A retrospective study of medical records and publications associated with the use of ESWL at IHMRC, Okada, for the period of 1992 to 1998. The study was conducted between January 2003 and November 2008. Unclassified authentic information relating to the use of ESWL and treatment of upper urinary tract stones was obtained from the IHMRC Okada and some government hospitals on hospital bills. Relevant documents in public domains related to the national and international wages and emoluments of medical workers and socioeconomic development of Nigeria within the time the ESWL functioned were studied.Result:A total of 32 patients were treated with 51 treatment sessions which is an average of nine patients per year and an average of two treatment sessions per patient were involved. The reasons for the low patronage were the extremely low stone formation rate of Nigerians, poverty, and out-of-pocket payment system. In addition, each treatment session of ESWL at Okada cost an average of $681.8 compared to $227.3 for open nephrolithotomy in a nearby high profile teaching hospital. The IHMRC, Okada, paid an average annual salary of ₦180,000 ($8,181.8) for each medical consultant compared to ₦120,000 ($5,454.5) paid by federal teaching hospitals in Nigeria within the period. Expatriate consultant doctors from Europe and USA who initially manned the lithotriptor at IHMRC, Okada, were paid much higher salaries. Average annual income of $5,909 for each of the 6 years amounting to a total of $34,771.7 for the six years was realized which could not maintain staff salaries in the hospital leading to staff emigration, decline of the hospital services, and eventual closure of the ESWL procedure center in the hospital in 1998.Conclusion:ESWL at Okada was not cost-effective both to patients and the hospital management. Despite these, ESWL is desirable in poor-resource countries because of its noninvasiveness, low morbidity, and usability in patients who are unfit for open surgery. Purchasing high technological medical equipment as commodities by sub-Saharan Africans without considering the prevalence of diseases they are meant to cater for, their maintenance for steady function during useful lifespan, their cost-effectiveness and how to recoup the money spent on investments depletes the scarce foreign exchange reserve of the home countries and is eventually counterproductive as exemplified by this case.

The elementome of calcium-based urinary stones and its role in urolithiasis.

Urolithiasis affects around 10% of the US population with an increasing rate of prevalence, recurrence and penetrance. The causes for the formation of most urinary calculi remain poorly understood, but obtaining the chemical composition of these stones might help identify key aspects of this process and new targets for treatment. The majority of urinary stones are composed of calcium that is complexed in a crystalline matrix with organic and inorganic components. Surprisingly, mitigation of urolithiasis risk by altering calcium homeostasis has not been very effective. Thus, studies to identify other therapeutic stone-specific targets, using proteomics, metabolomics and microscopy techniques, have been conducted, revealing a high level of complexity. The data suggest that numerous metals other than calcium and many nonmetals are present within calculi at measurable levels and several have distinct distribution patterns. Manipulation of the levels of some of these elemental components of calcium-based stones has resulted in clinically beneficial changes in stone chemistry and rate of stone formation. The elementome--the full spectrum of elemental content--of calcium-based urinary calculi is emerging as a new concept in stone research that continues to provide important insights for improved understanding and prevention of urinary stone disease.

MP33-15 MITOCHONDRIAL COLLAPSE DEPENDS ON CYCLOPHILIN D IN RENAL TUBULAR CELLS PROMOTES KIDNEY STONE FORMATION

INTRODUCTION AND OBJECTIVES: We recently reported that renal tubular cell injury induced by oxidative stress and subsequent mitochondrial collapse is the initial step in the process of kidney stone formation. Recently, it was shown that the mitochondrial permeability transition (MPT) is involved in mitochondrial collapse. Cyclophilin D (CypD) is a mitochondrial matrix protein involved in MPT. Thus, we hypothesized that CypD-dependent MPT causes mitochondrial collapse and is a trigger of kidney stone formation. In this study, we investigated whether mitochondrial collapse depends on CypD and determined its relationship to kidney stone formation using CypD-deficient mice. METHODS: We administered 80 mg$kg 1 glyoxylic acid, a precursor of oxalic acid, intraperitoneally for 6 consecutive days to 8week-old male CypD-deficient mice (CypD-/-, n 1⁄4 6) and wild-type mice (CypDþ/þ, n 1⁄4 6). We removed the kidneys of the mice in each group 6 days after glyoxylic acid administration. Stone formation and morphology were evaluated using a polarization microscope and Pizzolato staining, and the stone formation rate was estimated using image analysis software. The form of mitochondria was observed using a transmission electron microscope (TEM). Superoxide dismutase (SOD) and malondialdehyde (MDA), markers of oxidative stress, osteopontin (OPN), a stone matrix protein, and caspase 3, a marker of apoptosis, were evaluated by immunohistochemical staining and western blotting. RESULTS: The stone formation rate of CypD-/mice (0.05%) was significantly lower than that of CypDþ/þ mice (0.22%). Expression of MDA, OPN, and caspase 3 was lower in CypD-/mice than in CypDþ/þ mice. Expression of SOD was higher in CypD-/than in CypDþ/þ mice. Based on TEM observations, CypDþ/þ mice had a disorganized internal structure and rupture of the double membrane of the mitochondria suggesting mitochondrial collapse, but such morphological changes were rare in CypD-/mice. CONCLUSIONS: According to the results of this study, during kidney stone formation, CypD influences MPT by generating mitochondrial collapse via oxidative stress, leading to renal tubular cell injury and kidney stone formation. We elucidated the mechanism of CypDdependent MPT in promoting kidney stone formation.

Metabolic Disorders in Turkish Children With Urolithiasis

To review metabolic disorders in Turkish children with urinary tract stone disease. The medical records of 308 pediatric patients with the diagnosis of urolithiasis between 1996 and 2008, whose disease progression was followed in a single tertiary-care center, were reviewed retrospectively. Two hundred forty-eight patients whose metabolic analyses were performed were included in the study. Of the 248 patients participating in the study, 142 (57%) were men and 106 (43%) were women. The median age of the patients was 48months (minimum-maximum, 2-180 months). Seventy-six percent of the patients had metabolic disorders. Of all patients, 44% had 1, 23% had 2, and 7% had 3 metabolic disorders. Hypercalciuria, hypocitraturia, hyperoxaluria, hyperuricosuria, and cystinuria were detected in 41%, 39%, 22%, 9%, and 4% of the patients, respectively. The rate of multiple stone formation, infection, and recurrence was significantly higher in the 0-2 years age group (P= .030, P= .001, P= .019, respectively). The median age of patients was greater (P= .001) in patients with hyperoxaluria in comparison with other metabolic disorders. Compared with other metabolic disorders, multiple stones and recurrence were more frequent in patients with cystinuria (P= .022 and P= .008, respectively). The size of the stones was greater in patients with hyperuricosuria in comparison with other metabolic disorders (P= .009). The majority of children with urinary tract stone disease exhibited≥1 metabolic risk factors. Metabolic risk factors should be evaluated in all children with urinary stone disease to provide appropriate treatment.

Risk Assessment of Stone Formation in Stapled Orthotopic Ileal Neobladder

The increasing trend of performing radical cystectomy with a minimally invasive approach has made stapled neobladders an attractive alternative to hand-sewn pouches. To date, data on the incidence and clinical impact of stone formation in long surviving neobladder cases are scarce. We report a long-term, single-center experience of stapled orthotopic ileal neobladder and identify predictors of stone formation. From May 2001 to October 2012, 445 consecutive patients (388 male, 57 female) underwent radical cystectomy and stapled orthotopic ileal neobladder. Univariable and multivariable analyses were performed to identify independent predictors of an increased risk of stone formation. At a median followup of 41 months (IQR 16-58) neobladder stone formation occurred in 41 patients (9.2%). All of these patients successfully underwent endoscopic stone lithotripsy with 34 as outpatient procedures. On univariable Cox analysis only female gender (p = 0.001, HR 3.29, 95% CI 1.59-6.83) and intermittent self-catheterization (p <0.001, HR 15.2, 95% CI 5.87-39.5) were associated with an increased risk of stone formation. On multivariable analysis the only independent predictor of stone formation was intermittent self-catheterization (p = 0.001, HR 8.98, 95% CI 2.59-31.1). In our series of stapled orthotopic ileal neobladders the rate of stone formation was comparable to that reported in the literature for completely hand-sewn ileal reservoirs. The only variable independently predictive of stone formation was intermittent self-catheterization.

MP55-16 SARCOPENIC OBESITY IN BLADDER CANCER: ADDITIVE RISKS OF CACHEXIA AND OBESITY IN PATIENTS UNDERGOING RADICAL CYSTECTOMY?

constructedhand-sewnpouches. Todate, fewpaperswithadequate follow up reported the incidence of stone formation into stapled neobladders. We assessed the risk of stone formation in a single centre cohort of open orthotopic ileal neobladder performed with stapler. METHODS: FromMay 2001 andOctober 2012, 445 consecutive patients, 388males and 57 females, were treatedwith radical cystectomy and orthotopic Padua ileal neobladder for bladder cancer. Follow-up included a complete physical examination, serum electrolyte and creatinine assessment, urine analyses and urine culture at each visit, abdominal ultrasonography or CT alternatively at 6 month intervals. In case of stone formation into the ileal reservoir, patients underwent cystoscopy and, when necessary, transurethral lithotripsy. Univariable analysis was performed including age, gender, day-time and nigh-time continence, urinary tract infections and urethral anastomosis strictures, to evaluate the risk of stone formation. RESULTS: At a median follow up was 37 (IQR 16-58) months, neobladder stones occurred in 41 patients (9.2%). Median time to stone formation was 31 (IQR 15-50) months. All these patients successfully underwent endoscopic stone lithotripsy, 34 of which as outpatient procedure. At univariable analysis only female gender was associated with an increased risk of stone formation (p1⁄40.007). CONCLUSIONS: In our series of “stapled” Padua ileal neobladder, the rate of stone formation was comparable with those reported in literature for completely hand sewn ileal reservoirs. Larger series are necessary to assess the independent role of stapler as determinant of neobladder stone formations.

MP55-15 SARCOPENIA IS ASSOCIATED WITH INCREASED CANCER-SPECIFIC AND ALL-CAUSE MORTALITY AMONG PATIENTS WITH BLADDER CANCER UNDERGOING RADICAL CYSTECTOMY

constructedhand-sewnpouches. Todate, fewpaperswithadequate follow up reported the incidence of stone formation into stapled neobladders. We assessed the risk of stone formation in a single centre cohort of open orthotopic ileal neobladder performed with stapler. METHODS: FromMay 2001 andOctober 2012, 445 consecutive patients, 388males and 57 females, were treatedwith radical cystectomy and orthotopic Padua ileal neobladder for bladder cancer. Follow-up included a complete physical examination, serum electrolyte and creatinine assessment, urine analyses and urine culture at each visit, abdominal ultrasonography or CT alternatively at 6 month intervals. In case of stone formation into the ileal reservoir, patients underwent cystoscopy and, when necessary, transurethral lithotripsy. Univariable analysis was performed including age, gender, day-time and nigh-time continence, urinary tract infections and urethral anastomosis strictures, to evaluate the risk of stone formation. RESULTS: At a median follow up was 37 (IQR 16-58) months, neobladder stones occurred in 41 patients (9.2%). Median time to stone formation was 31 (IQR 15-50) months. All these patients successfully underwent endoscopic stone lithotripsy, 34 of which as outpatient procedure. At univariable analysis only female gender was associated with an increased risk of stone formation (p1⁄40.007). CONCLUSIONS: In our series of “stapled” Padua ileal neobladder, the rate of stone formation was comparable with those reported in literature for completely hand sewn ileal reservoirs. Larger series are necessary to assess the independent role of stapler as determinant of neobladder stone formations.

Nephrolithiasis in patients exposed to deferasirox and desferioxamine: probably an age-linked event with different effects on some renal parameters

Dear Editor, We refer this letter to the manuscript by Efthimia et al. [1] in which they recently reported that in thalassemia major (TM) patients, the start of deferasirox (DFX) has been associated with increased risk of developing nephrolithiasis. However, in that series, several patients were also cotreated with calcium and vitamin D supplements, and the authors correctly hypothesized that it could have facilitated the renal calculi formation. Nevertheless, that clinical observation was not easy to evaluate by the fact that it was not a population-based case– control study and the definition of the population and the duration of patient exposure to DFX treatment were not reported; furthermore, the assessment of new cases was made only through the detection of renal colic. We reviewed the charts and radiological studies of our patients with TM to retrospectively evaluate the incidence of nephrolithiasis in those treated with DFX and in a matched control population treated with desferioxamine (DFO). The presence or the absence of nephrolithiasis had to be assessed by abdominal ultrasonography. To further analyze data, total therapy exposure and the incidence of nephrolithiasis adjusted to 100 years of patient exposure were calculated for each treatment. To make series comparable, data from patients under DFO treatment were collected since January 2010. The study was approved by the Ethics Committee of the Cardarelli Hospital, Napoli. Table 1 shows demographics and clinical characteristics of patients divided in those exposed to DFX and to DFO at baseline and at the end of drug exposure (October 2012). At baseline, both populations were comparable for previous chelation history, for the percentage of patients splenectomized and using calcium and vitaminD, for the mean creatinine level and GFR value, and for the prevalence of renal calculi [2], but patients treated with DFX tended to be younger and to have lower level of uric acid. Patients already affected by renal calculi were in average 40 years old and frequently splenectomized, but they did not use vitamin D and calcium supplementation more frequently than those without stones and were not always symptomatic; however, in those under DFO treatment, a decrease in GFR was observed following drug exposure. Comparing basal and final values in a population without stones, an increase in creatinine level and a decrease in GFR were observed in the DFX group. We observed eight (5.26/100 patients/year ) and five (4.76/100 patients/year) new cases of renal stones in patients treated with DFX and DFO, respectively, and the O.R. for developing nephrolithiasis under DFX was 1.17 , p=0.79 (data not shown). Interestingly, among stone formers following DFX treatment, a significant decrease in uric acid level without a decrease in renal function parameters was observed. Estimates of the incidence of renal stones in TM patients are lacking [3]. In spite of this, a sustained rate of renal stone formation under DFX treatment was confirmed; these data highlight the presence of an asymptomatic disease that may have contributed to its underestimation in the DFO group in Efthimia’s series [1]. In our series, renal stone formation appears to involve mainly patients older than 30 while the P. Ricchi :M. Ammirabile : S. Costantini :A. Spasiano : P. Cinque :M. Casale :A. Filosa : L. Prossomariti UOSD Centro delle Microcitemie “A. Mastrobuoni”, AORN A. Cardarelli, Naples, Italy

Our response to Letter

We thank the authors for valuable comments about our article. Today, extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and open surgery are the methods of choice in the treatment of most pediatric urinary stones [1]. Considering the small size of the kidneys, a high recurrence rate of stone formation increases the importance of minimally invasive urological treatment modalities in pediatric urinary stone disease. For this reason, it is reported in the literature that mini PCNL supersedes open stone surgery for pediatric stone diseases [2, 3]. There are limited experience about flexible ureteroscopy in pediatric patients. Resorlu et al. reported that retrograde intrarenal surgery (RIRS) was an effective alternative to mini-perc in children. They commented that operation time, hospital stay, radiation exposure and morbidities of PCNL could be significantly reduced with this technique [4]. But they also added mini-perc continued to be the best choice treatment modality for stones 2–3 cm in size because of its more effective nature. We think that advantages like ease inapplicability to pediatric patients from all ages and for stones of all sizes, the requirement of a minimal incision, a short hospital stay, and the rare requirement of a secondary process are moved to PCNL to first choice [5].

The Efficacy of Medical Prophylaxis in Children with Calcium Oxalate Urolithiasis After Percutaneous Nephrolithotomy

To evaluate whether medical prophylaxis decreases calcium oxalate stone recurrences in children after percutaneous nephrolithotomy (PNL) or not. To our knowledge this is the first study that evaluates this topic in children after PNL. We researched analysis of 42 children with calcium oxalate stone disease. They were divided into two groups. Twenty-two children who had a follow-up with medical prophylaxis after PNL were included in group I; 20 children who did not have medical prophylaxis were included in group II. They were all stone free and they were evaluated with 24-hour urine analysis and blood samples, abdominal X-ray, and ultrasonography. The average follow-up was 25.9 (12-42) months for group I and 24.6 (14-40) months for group II. Age, gender, follow-up time, and 24-hour urine samples were similar between groups (p>0.05). New stone formation was detected in two (9.1%) and seven (35%) patients in group I and II, respectively. New stone formation seemed to be higher in group II, but because of the less number of patients, this difference was not statistically significant (p=0.062). The number of patients with recurrence was statistically higher in group II (p=0.032). Stone formation rate (SFR) was calculated as 0.034 and 0.2 per patient per year for group I and II, respectively. This difference of SFR between groups was statistically significant (p=0.028). Medical prophylaxis of children after PNL can reduce new stone formation and SFR. Although it was not statistically significant because of low patient numbers, higher recurrence rate was detected in patients who did not have medical prophylaxis.

Residual fragments after percutaneous nephrolithotomy.

Clinically insignificant residual fragments (CIRFs) are described as asymptomatic, noninfectious and nonobstructive stone fragments (≤4 mm) remaining in the urinary system after the last session of any intervention (ESWL, URS or PCNL) for urinary stones. Their insignificance is questionable since CIRFs could eventually become significant, as their presence may result in recurrent stone growth and they may cause pain and infection due to urinary obstruction. They may become the source of persistent infections and a significant portion of the patients will have a stone-related event, requiring auxilliary interventions. CT seems to be the ultimate choice of assessment. Although there is no concensus about the timing, recent data suggests that it may be performed one month after the procedure. However, imaging can be done in the immediate postoperative period, if there are no tubes blurring the assessment. There is some evidence indicating that selective medical therapy may have an impact on decreasing stone formation rates. Retrograde intrarenal surgery, with its minimally invasive nature, seems to be the best way to deal with residual fragments.

Comment to “Laparoscopic radical cystectomy with extracorporeal creation of a ‘y’ shaped orthotopic ileal neobladder using non-reabsorbable mechanical suture (Fontana)”

Increasing evidence in published reports has suggested that titanium staples may be well tolerated inside the urinary tract. Recently, the Italian Group from Piedmont described an “easy, fast, and reliable” technique of a Y-shaped ileal neobladder that was created during open surgery with nonabsorbable mechanical staples. They observed an acceptable 6% rate of stone formation at a median follow-up of 20 months (range 8 to 47). We describe our initial experience with laparoscopic Y-shaped orthotopic ileal neobladder constructed entirely intracorporeally using titanium staples exclusively in an attempt to mitigate the time-consuming and skill-intensive task of freehand suturing required during laparoscopic creation of continent reservoirs.

Pharmacotherapy of urolithiasis: evidence from clinical trials

Urolithiasis is a worldwide problem with significant health and economic burdens. Medical therapy that alters the course of stone disease has enormous medical and financial impact. Urolithiasis is a final manifestation of a broad range of etiologies and pathogenesis. The modest progress in understanding the pathophysiology has hampered successful development of targeted therapy. Current regimens are based mostly on rational alteration of urinary biochemistry and physical chemistry to lower the risk of precipitation. In terms of pharmacotherapy, there are drugs to successfully improve hypercalciuria, hypocitraturia, aciduria, hyperuricosuria, and hypercystinuria. These agents have been proven to be effective in randomized controlled trials in improving urinary biochemical and physicochemical risk factors, as well as clinical outcomes. Although our current regimens have clearly improved the management and lives of stone formers, there are still clearly identifiable immense voids in the knowledge of pathophysiology of stone disease that can be filled with combined basic science and clinical studies.

Complications after bladder augmentation or substitution in children: a prospective study of 86 patients

• To evaluate complications after urinary bladder augmentation or substitution in a prospective study in children. • Data of 86 patients who underwent urinary bladder augmentation (80 patients) or substitution (6 patients) between 1988 and 2008 at the authors' institute were analysed. • Ileocystoplasty occurred in 32, colocystoplasty in 30 and gastrocystoplasty in 18. Urinary bladder substitution using the large bowel was performed in six patients. • All patients empty their bladder by intermittent clean catheterization (ICC), 30 patients via their native urethra and 56 patients through continent abdominal stoma. Mean follow-up was 8.6 years. • Rate of complications and frequency of surgical interventions were statistically analysed (two samples t-test for proportions) according to the type of gastrointestinal part used. • In all, 30 patients had no complications. In 56 patients, there were a total of 105 complications (39 bladder stones, 16 stoma complications, 11 bowel obstructions, 5 reservoir perforations, 7 VUR recurrences, 1 ureteral obstruction, 4 vesico-urethral fistulae, 4 orchido-epididymitis, 4 haematuria-dysuria syndrome, 3 decreased bladder capacity/compliance, 3 pre-malignant histological changes, 1 small bowel bacterial overgrowth and 7 miscellaneous). • In 25 patients, more than one complication occurred and required 91 subsequent surgical interventions. Patients with colocystoplasty had significantly more complications (P < 0.05), especially more stone formation rate (P < 0.001) and required more post- operative interventions (P < 0.05) than patients with gastrocystoplasty and ileocystoplasty. • Urinary bladder augmentation or substitution is associated with a large number of complications, particularly after colocystoplasty. • Careful patient selection, adequate preoperative information and life-long follow-up are essential for reduction, early detection and management of surgical and metabolic complications in patients with bladder augmentation or substitution.

Combining gastric and ileal segments, does it overcome segment-related complications? An experimental study on rats

Bladder augmentation has revolutionized the care of children with neurogenic bladder but it is associated with certain short- and long-term complications. Using the combination of gastric and ileal segments to balance effects of these segments might be a solution for complications. A total of 39 female Spraque-Dawley rats randomly divided into four groups: ileocystoplasty (11), gastrocystoplasty (9), ileogastrocystoplasty (11) and control (8). Serum/urine electrolytes and pH values, and serum creatinine levels and urine mucus concentration were measured. Kruskal-Wallis non-parametric variance analysis was performed to compare the groups and p < 0.05 was accepted as significant. Metabolic alkalosis with significantly lower urine pH was observed in gastrocystoplasty group. Gastroileal group showed similar results with the ileal group in all parameters. No stone formation was detected in the sham and gastric cystoplasty groups. Metaplastic and hyperplastic changes were observed in all segments surrounding urothelium. In conclusion, combination of gastric and ileal segments does not significantly reduce the rate of metabolic impairments, stone and mucus formation. Besides it is not associated with significant improvement in histological outcome since urine is still in contact with the gastrointestinal mucosa.

51 DOWNSTREAM CONSEQUENCES OF URINARY DIVERSION

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes II1 Apr 201051 DOWNSTREAM CONSEQUENCES OF URINARY DIVERSION John L. Gore, Scott M. Gilbert, Julie Lai, and Christopher S. Saigal John L. GoreJohn L. Gore Seattle, WA More articles by this author , Scott M. GilbertScott M. Gilbert Gainesville, FL More articles by this author , Julie LaiJulie Lai Santa Monica, CA More articles by this author , and Christopher S. SaigalChristopher S. Saigal Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.097AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Surveillance following urinary diversion should capture complications downstream from the initial reconstruction. Most analyses of the morbidity of urinary diversion are restricted to the index admission or the immediate postoperative period. We sought to characterize the long-term complications and burden of healthcare utilization following urinary diversion. METHODS Using the 5% Medicare sample from 1997–2007, we identified individuals undergoing cutaneous and orthotopic neobladder, ileal conduit urinary diversion, and other diversion including enterocystoplasty from physician claims for the index admission. We restricted our sample to subjects with claims 1 year prior to surgery and at least 2 years after the diversion. We included benign and malignant primary diagnoses, and evaluated the incidence of complications 2 and 5 years after surgery. We stratified complications by diversion type, and compared healthcare utilization after surgery with control groups of non-diverted bladder cancer patients (BC, n = 20,479) and patients undergoing colectomy (n = 37,042). RESULTS Of 1,565 subjects identified, 80% underwent ileal conduit urinary diversion, 7% underwent cutaneous or orthotopic neobladder, and 13% underwent other types of reconstruction. Table 1 lists 2 and 5-year complication rates by diversion type. Neobladder subjects had higher rates of other wound complications and urinary stone formation 2 and 5 years after diversion. Fistula formation 5 years after surgery was likewise significantly higher in the neobladder group. Compared with the BC and colectomy cohorts, diversion subjects had more hospital readmissions (56% vs 41% and 53%, respectively, p<0.001, in year 1, 38% vs 31% for both, p<0.001 in year 2) and ER visits (2.1 ± 3.2 vs 1.5 ± 2.5 and 1.7 ± 2.7, respectively, p<0.001) in the 24 months after surgery. Table1. Complication rates 2 and 5 years after urinary diversion. Diversion type p-value Ileal conduit Neobladder Other 2-year complication rates, no. (%) Total 1,248(80) 105(7) 212(13) Infection 14(1) 1(1) 4(2) 0.62 Stomal 50(4) 4(4) 6(3) 0.72 Hernia 77(6) 5(5) 8(4) 0.34 Other wound 134(11) 13(12) 11(5) 0.03 Urinary obstruction 149(12) 6(6) 29(14) 0.11 Urinary stones 22(2) 6(6) 4(2) 0.02 Fistula formation 36(3) 3(3) 11(5) 0.21 5-year complication rates, no. (%) Total 544(78) 56(8) 94(14) Infection 11(2) 2(4) 2(2) 0.75 Stomal 35(6) 5(9) 7(7) 0.75 Hernia 58(11) 8(14) 9(10) 0.65 Other wound 104(19) 19(34) 17(18) 0.03 Urinary obstruction 95(17) 7(13) 15(16) 0.62 Urinary stones 21(4) 7(13) 4(4) 0.01 Fistula formation 20(4) 6(11) 7(7) 0.03 CONCLUSIONS Complications are common after urinary diversion and continue to occur through 5 years postoperatively. Neobladder patients are at higher risk for urolithiasis and delayed wound complications than those undergoing other urinary diversions. Regardless of diversion type, healthcare utilization after urinary diversion is high. Further investigation is warranted to understand patient and provider factors associated with late complications and increased healthcare utilization after urinary diversion. © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e21-e22 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information John L. Gore Seattle, WA More articles by this author Scott M. Gilbert Gainesville, FL More articles by this author Julie Lai Santa Monica, CA More articles by this author Christopher S. Saigal Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

758 STAPLED CREATION OF ILEAL NEOBLADDERS REVISITED

You have accessJournal of UrologyUrinary Diversion: Bladder Reconstruction, Augmentation, Substitution, Diversion I1 Apr 2010758 STAPLED CREATION OF ILEAL NEOBLADDERS REVISITED Matthew Ercolani, Christopher Wright, Murali Ankem, and Robert Weiss Matthew ErcolaniMatthew Ercolani More articles by this author , Christopher WrightChristopher Wright More articles by this author , Murali AnkemMurali Ankem More articles by this author , and Robert WeissRobert Weiss More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.1310AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since the introduction of the Camay reservoir in 1959, urologists have tried to improve construction and reduce complications for ileal neobladders in patients with muscle-invasive bladder cancer. Linear anastomotic staplers, particularly ones with polyglycolic acid absorbable staples, were briefly evaluated in the 1990s as a tool for faster pouch creation, but fell out of favor due to reports in the urologic literature of increased rates of stone formation, decreased mean pouch capacity, and increased day and nighttime incontinence. Newer reports in recent years have supported the use of stapled neobladders as a safe and functional method for continent urinary diversion. The use of stapled pouches is also supported in the colorectal literature. Our aim was to review the experience with stapled pouches and evaluate their functional outcomes and complications. METHODS A MEDLINE search was performed from 1990 to present with keywords ileal neobladder, stapled, U-shaped, W-shaped, and Y-shaped. 9 peer-reviewed articles were identified of which 5 had adequate data for review. The following data points were compared: number of patients, neobladder type, median construction time, use of absorbable staples, median follow-up time, mean pouch capacity, mean end-filling pressure, presence of pouch stones, presence of daytime incontinence, presence of ureteroneobladder anastomotic stricture (UNAS) and presence of any neobladder-associated anastomotic leak (NAAL). RESULTS The analysis is shown in Table 1 below. Median pouch creation time was 23 minutes and average pouch capacity was 427.2 mL. Median follow up time was 16.4 months. Mean end-filling pressures were within limits for protection of the upper urinary tracts. Complication rates were as follows: pouch stones 3/116 (2.6%), daytime incontinence 20/116 (17.2%), UNAS 4/116 (3.4%), and NAAL was 2/116 (1.7%). Table 1. Montie (1996) Cecchi (1997) Ugyur (2000) Fontana (2004) Abreu (2006) Totals # of Patients 19 14 30 50 3 116 Pouch Type W W U Y U Absorbable? Yes Yes Yes No No Median Creation Time (minutes) 20 20 15 20 40 23 Median Follow-Up (months) 15 18 26 20 3 16.4 Mean Pouch Capacity (mL)⁎ 526 377 521 390 322 427.2 Mean End-Filling Pressure (cm H2O) 23⁎⁎⁎ 23.8 30⁎⁎ 18 Not Done 20.9 Pouch Stones 0/19 0/14 0/30 3/50 0/3 3/116 Daytime Incontinence 8/19 1/14 1/30 10/50 0/3 20/116 Ureteroneobladder Anastomotic Stricture 0/19 1/14 1/30 2/50 0/3 4/116 Neobladder Anastomotic Leak 0/19 0/14 1/30 0/50 1/3 2/116 ⁎ As determined by measurement at last follow-up by urodynamic evaluation ⁎⁎ Individual pressures not listed in study but all pressures reported as less than 30 cm H2O ⁎⁎⁎ 7/19 patients had pressures above 40 cm H20 prior to end filling; Average listed is for the remaining 12 patients CONCLUSIONS Ileal neobladders can be constructed using both absorbable and non-absorbable staple types with a short creation time, an adequate pouch volume capacity, and few postoperative complications. A larger prospective, randomized study is warranted to assess complications and functional outcomes, particularly with long-term urodynamic evaluation. New Brunswick, NJ© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e296-e297 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Matthew Ercolani More articles by this author Christopher Wright More articles by this author Murali Ankem More articles by this author Robert Weiss More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

New horizons in the management of patients with cystinuria

Although the formation of cystine stones is seen in only a small fraction of all patients with urolithiasis, this disease is associated with a pronounced morbidity. The difficult clinical management of these patients, with the aim of arresting or decreasing the rate of recurrent stone formation, is well recognized. This review summarizes some recent knowledge. An early and correct diagnosis of cystinuria is fundamental for a successful course of the disease in these patients. Formation starts early in life, and attention to this diagnosis is necessary for the paediatric stone formers. New radiological and biochemical improvements seem useful in this respect. A combination of medical tools is usually necessary to influence the very often, troublesome stone-forming activity. Urine dilution, alkalization and chelating therapy have remained the cornerstones of the therapeutic approach. The importance of a high urine pH has been further emphasized, and the possibility to use acetazolamide is a promising improvement of the medical treatment. In order to increase the compliance and reduce the need of active stone removal, special stone clinics seem to be of particular value. The understanding of the genetic background might open future treatment alternatives. Patients afflicted by cystine stone disease need an aggressive medical treatment, gentle stone-removing surgery and careful follow-up.