Secondary Calculi Research Articles

Hem-o-Lok clip migration into renal pelvis and stone formation as a long-term complication following laparoscopic pyelolithotomy: a case report and literature review

BackgroundHem-o-Lok clips (HOLCs) are widely used in minimal access urological operations due to the advantage of vascular control and suture stabilization. In rare cases, however, they can develop problems themselves. Migration of HOLCs into the collecting system is a fairly rare complication after laparoscopic pyelolithotomy. To date, only two cases were reported in the literature.Case presentationThis article describes a case of 51-year-old man with a complaint of left flank pain. He had a medical history of ipsilateral retroperitoneal laparoscopic pyelolithotomy at another hospital 8 years ago. Non-contrast CT scan demonstrated a renal stone in the left ureteropelvic junction complicated by mild hydronephrosis. A straight foreign body was found near the renal pelvis, with part of it wedging into renal pelvic wall. A percutaneous nephrolithotomy (PNL) was performed for this patient. After some fragmentation, a HOLC was found in the kernel of the stone. With an alligator plier, the clip was totally removed out of the collecting system. The postoperative period and follow-up were uneventful.ConclusionsHOLC migration into renal pelvis is a rare complication following laparoscopic pyelolithotomy. It could act as nidus for stone formation under extended exposure to urine. Using HOLCs to stabilize the anastomotic suture near renal pelvis should be avoided to prevent this complication. Instead, knotting is a better choice under such condition. The secondary calculi and dislodged HOLCs can be removed through PNL by an alligator plier after laser lithotripsy.

Effect of percutaneous nephrolithotripsy under guidance of B-ultrasound for the treatment of complex renal calculi.

The purpose of this study was to investigate the effect of percutaneous nephrolithotripsy guided by B-ultrasound in the treatment of complex renal calculi. A total of 82 patients with complex renal calculi were selected, who underwent percutaneous nephrolithotripsy guided by B-ultrasound. The average operation time was 101.52±8.35 minutes, the average intraoperative bleeding volume was 132.86±7.22 ml, the average hospital stay was 10.47 ±1.68 days, the primary calculi clearance rate was 85.37% (70 cases), and the secondary calculi clearance rate was 95.12% (78 cases). Postoperative complications occurred in 18 (21.95%) cases, including fever in 13 (15.85%), residual stone in 4 (4.88%), and delayed bleeding in 1 (1.22%) case. The findings show that percutaneous nephrolithotripsy guided by B-ultrasound is safe and effective in the treatment of complex renal calculi and is suitable for popularisation and application in primary hospitals.

Urethral Calculi: Presentation, Evaluation and Management

Urethral calculi are common in developing countries. There are only a few studies that have been conducted so far on these subsets of patients with very limited literature from developing countries. Urethral calculi are divided into primary which forms in urethra and secondary, which migrates from upper urinary tract. Primary urethral calculi are usually small and multiple, and secondary migratory calculi are usually large. Small calculus is commonly found in the anterior urethra and larger calculi usually occur in the posterior urethra. Primary urethral stones are generally composed of magnesium ammonium phosphate (struvite) or uric acid.

Transperitoneal Laparoscopic Management of Pelvi–Ureteral Junction Obstruction with Associated Congenital Anomalies and Secondary Calculi: Our Technique and Experience

Abstract Introduction and Objectives: Open pyeloplasty has been the gold standard for ureteropelvic junction obstruction (UPJO) repair and achieves success rates exceeding 90%. Laparoscopic pyelopl...

PD40-02 TRANSPERITONEAL LAPAROSCOPIC MANAGEMENT OF PELVI-URETERIC JUNCTION OBSTRUCTION WITH ASSOCIATED CONGENITAL ANOMALIES AND SECONDARY CALCULI:OUR TECHNIQUE AND EXPERIENCE

INTRODUCTION AND OBJECTIVES: Open pyeloplasty has been thegoldstandard forureteropelvic junctionobstruction (UPJO) repair and achieves success rates exceeding 90%. Laparoscopic pyeloplasty (LP) provides a minimally invasive alternative to repair UPJO and has developedworldwide as the firstminimally option tomatch success rate of open pyeloplasty. We present our technique and clinical experience of transperitoneal laparoscopic pyeloplasty (LP) in ureteropelvic junction obstruction (UPJO) with associated congenital anomalies and secondary calculi METHODS: 150 consecutive patients underwent LP for UPJO performed by one surgeon from January 2102 to August 2015.81 patients had associated congenital anomalies and secondary calculi 11 Horseshoe kidney (5 also had secondary calculi),33 crossing vessels (2 patient having main renal artery and vein as crossing vessels),27 secondary calculi,10 lateral malrotation A four-port transperitoneal approach was used in all cases. Patient demographic and perioperative data were recorded prospectively. Outcome measures were demographic data, peri-operative data, complications and success rate at a mean follow-up of 12 months. RESULTS: The mean operative time was 175 minutes and average blood loss was 60 ml. There was no conversion to open surgery. Antegrade stenting was done in all the cases. There were 6(7.4%) complications namely hematuria in 3 patients and UTI in 3 patients. The mean drain removal was 2.1 days whereas the mean catheter removal and hospital stay was 3.1 days for both. The mean follow up was 15.1 months. The success rate in our cohort was 100% defined by resolution of symptoms and documentation of unobstructive drainage on intravenous pyelography and nuclear renogram at 3 months and 1 year. CONCLUSIONS: Transperitoneal LP is feasible with generally good results for managing UPJO even with associated congenital anomalies and secondary calculi with low morbidity, quick recovery and a durable success rate.

Flexible pyelocalicolitoextraction in gas medium (CO2 ) during the laparoscopic surgery for hydronephrosis

Hydronephrosis (HN) is a disease characterized by progressive distention and dilation of the pyelocaliceal system, which are caused by pelvoureteral segment stenosis and urine outflow problems. Increased hydrostatic pressure in the pyelocaliceal system gives rise to parenchymal atrophy and diminished renal function. Prior to the end of puberty, HN is more common in boys than in girls. In 20-to-40-year-old adults, HN occurs in 1 % of cases; being 1.5 times greater in women than in men. Modern urology has achieved a notable advance in treating patients with HN. Highly informative diagnostic techniques allow the detection of this disease at early stages and the choice of the most effective approach to managing the patients. The first laparoscopic pyeloplasty was performed by W. Schuessler in 1993. Up to date, it is the gold standard for HN surgery. Pelvoureteral segment stenosis and HN are often complicated by secondary lithogenesis. The quest of novel effective procedures for pyelocaliceal litholapaxy is due to technical complexities and a large number of residual calculi. This paper describes the use of flexible pyelocaliceal lithoextraction in a patient with secondary renal calculi during laparoscopic pyeloplasty.

Vesical calculi in children

Vesical calculi occur due to increased urinary concentration & are commonly seen in children belonging to low socio-economic status. They are usually formed of ammonium acid urate, calcium oxalate or calcium phosphate. Vesical calculi constitute about 70% to 85% of paediatric urolithiasis & boys are affected more than girls. Primary vesical calculi occur in sterile urine & are associated with nutritional deficiency whereas Secondary calculi occur due to infection, obstruction or inflammation. Endemic calculi are associated with oxalate-rich diet. They usually present with hematuria, dysuria, frequent urinary tract infection, urinary urgency & bedwetting. The diagnostic modalities of vesical calculi are Urinalysis, urine dipstick test, serum Creatinine level, plain x-ray abdomen &Intravenous Pyelography. Sonogram is effective in identifying both radiolucent & radiopaque stones. Spiral CT scanning is highly sensitive & specific whereas Pelvic MRI orTechnetium-99m MAG-3 renal scanning yields poor resolution & are not recommended in the evaluation of bladder calculi. Treatment for vesical calculi depends on the size, composition & symptoms. The only effective medical treatment is urinary alkalization. Indications for surgery are failure of medical management, recurrent infections, acute urinary retention, suprapubic pain & significant gross hematuria. Open cystolithotomy was done earlier which is being replaced by cystolitholapaxy. With ongoing advances in instrumentation procedures like Transurethral optical litholapaxy are now applicable to children. Minimally invasive surgeries like extracorporeal lithotripsy, percutaneous nephrolithotripsy & urethroscopy have reduced open surgery to only 1- 4% of cases. Early diagnosis & appropriate management are essential for managing vesical calculi in children.

English

INTRODUCTION: Until 20th century, bladder stones were one of the most prevalent disorders among the poor class and the incidence was especially high in childhood and adolescent.1 The decrease in incidence of bladder calculi is attributed mainly to dietary and nutritional progress especially in children.2 A solitary bladder calculus is usual, although multiple stones are found in 25% of cases.3 Bladder stones are rare, and they constitute about 5% of all urinary stones, 4, 5 it is classified as migrated from upper urinary tract, primary idiopathic, or secondary calculi.6 Bladder stones are managed by Extracorporeal Shockwave Lithotripsy (ESWL), endourology procedures, or open surgery. We report an unusual case of giant vesical calculus weighing 600grams in a 55 year old female with no evidence of hematuria, urinary retention, and dysuria.

Analyzing process uncertainty through virtual process simulation

Purpose – The purpose of this paper is to propose virtual process simulation as a technique for identifying and analyzing uncertainty in processes. Uncertainty is composed of both risks and opportunities.Design/methodology/approach – Virtual process simulation involves the creation of graphical models representing the process of interest and associated tasks. Graphical models representing the resources (e.g. people, facilities, tools, etc.) are also created. The members of the resources graphical models are assigned to process tasks in all possible combinations. Secondary calculi, representing uncertainty, are imposed upon these models to determine scores. From the scores, changes in process structure or resource allocation can be used to manage uncertainty.Findings – The example illustrates the benefits of utilizing virtual process simulation in process pre‐planning. Process pre‐planning can be used as part of strategic or operational uncertainty management.Practical implications – This paper presents an...

Technical note: Dynamic MRI in a complicated giant posterior urethral diverticulum

Congenital posterior urethral diverticulum is an uncommon anomaly, sometimes complicated by infection or calculi formation. A conventional voiding cystourethrogram (VCUG) is the most commonly used diagnostic modality. Dynamic magnetic resonance imaging (MRI) has not been frequently described in this entity. We describe a case of posterior urethral diverticulum complicated with secondary calculi, where the patient was evaluated using dynamic MRI and conventional VCUG.

Laparoscopic Pyeloplasty using the Postanastomotic Dismemberment Method: Technique and Results

Despite excellent results, widespread acceptance of the laparoscopic dismembered Anderson-Hynes pyeloplasty (AH) is hampered by its steep learning curve. Laparoscopic nondismembered pyeloplasty techniques, although simpler, have not matched the results of AH. We have been using a technical modification of AH to combine its excellent outcome with technical ease of nondismembered pyeloplasties. We describe the procedure and results of laparoscopic postanastomotic dismemberment (PAD) pyeloplasty for primary ureteropelvic junction (UPJ) obstruction. PAD technique involves an initial partial division of the dilated pelvis and ureteral spatulation without dismembering the UPJ. Both layers of ureteropelvic anastomosis are completed before dismemberment and pelvic reduction. Forty-one PAD procedures in 40 patients with UPJ obstruction and follow-up of at least 3 months were evaluated. Mean age was 37.2 years (range 2-82 years) with 22 patients younger than 15 years. The UPJ was dependent in 31 and had high insertion in 10 (24.4%). The stenotic segment was long (> or =1.5 cm) in 18 (43.9%). Crossing vessels and secondary calculi were observed in six (14.6%) and seven (17.1%) units. Mean (+/- SD) blood loss, hospital stay, convalescence, and analgesia requirement were 68.1 +/- 37.6 mL, 3.8 +/- 1.1 days, 11.4 +/- 3.9 days, and 204.8 +/- 60.5 mg diclofenac, respectively. The mean operative time was 97.6 +/- 22.1 minutes. There was one intraoperative complication in the form of injury to a renal vein tributary, with no transfusions or conversions. Postoperative complications included pain after stent removal, persistent drainage, and pyelonephritis in 1, 2, and 4 patients, respectively. Mean follow-up was 19.5 months (range 3-58 months), with a success rate of 95.1%. Failures were not attributable to UPJ configuration, length of stenosis, or age. The PAD technique has several practical advantages with a shorter operative time compared with other historical series of laparoscopic pyeloplasty (LP). It combines the ease of nondismembered LP with the excellent outcome of dismembered techniques.

Laparoscopic Ureterocalicostomy: Initial Experience

Ureterocalicostomy is a reconstructive option in the rare patient with surgically failed or difficult ureteropelvic junction (UPJ) obstruction with fibrosis and significant hydronephrosis. We introduce the technique of laparoscopic ureterocalicostomy. Laparoscopic ureterocalicostomy was performed in 2 patients, of whom 1 had UPJ obstruction and multiple secondary calculi in a dilated, dependent lower pole calix, and 1 had surgically failed UPJ obstruction with a scarred pelvis and significant hydronephrosis. Using a transperitoneal technique the UPJ was dismembered and suture ligated, the cut end of the ureter was spatulated, the attenuated lower pole renal parenchyma was amputated and mucosa-to-mucosa ureterocaliceal anastomosis was performed with running 4-zero absorbable suture over a stent. In the first case 32 renal calculi were also removed using a combination of laparoscopic nephroscopy and intraoperative ultrasonography. In cases 1 and 2 operative time was 5.2 and 2.5 hours, estimated blood loss was 200 and 75 cc, and hospital stay was 2 days, respectively. There were no intraoperative complications. The stent was removed at 8 and 5 weeks, respectively. Postoperative retrograde pyelogram and diuretic renal scan confirmed anastomotic patency and improved drainage in each patient. At 9 months patient 1 remains without flank symptoms and a second renal scan at 6 months showed further improvement in drainage. Patient 2, who continued to be symptomatic with flank discomfort despite objective improvement in drainage parameters, elected secondary nephrectomy at 6 months. Laparoscopic ureterocalicostomy is feasible and it effectively duplicates established open surgical principles. To our knowledge the initial experience in the literature is presented.

Management of complex biliary tract calculi with a holmium laser.

The difficulty in managing complex biliary tract calculi is exemplified in patients with primary intrahepatic calculi. Standard surgical and endoscopic approaches often fail to clear calculi in these patients who have recurrent episodes of cholangitis. The success of the holmium laser for urologic calculi led us to adapt treatment strategies for primary and secondary biliary tract calculi where standard treatments had been unsuccessful. Our goals were to remove all calculi, prevent recurrent sepsis, and preserve hepatic parenchyma. Thirty-six patients with complex biliary calculi were treated. After sepsis was controlled and the extent of calculi was evaluated, appropriate access to and drainage of the biliary tract was achieved. Holmium laser lithotripsy was performed under video guidance using flexible choledochoscopes and a 200 micro laser fiber generating 0.6 to 1.0 joules at frequencies of 6 to 10 Hz. Lithotripsy procedures were repeated until cholangiography and cholangioscopy confirmed the clearance of calculi. Twenty-two patients of Asian descent with primary intrahepatic calculi and 14 patients with secondary intrahepatic calculi were treated. Access to the biliary tract could be accomplished through percutaneous catheter tracts, T-tube tracts, or the cystic duct during laparoscopic cholecystectomy. Biliary drainage was by biliary enteric anastomosis or endoscopic sphincterotomy. Complete stone clearance required an average of 3.9 procedures (range 1 to 15) for patients with primary intrahepatic calculi and 2.6 procedures (range 1 to 10) for patients with secondary intrahepatic calculi regardless of stone composition. No patient required hepatic resection and no complications or deaths were attributed to the holmium laser. Clearance of calculi can reliably and safely be achieved with a holmium laser regardless of stone composition or location while preserving hepatic parenchyma and preventing recurrent sepsis.

VAGINAL CALCULI SECONDARY TO PARTIAL VAGINAL OUTLET OBSTRUCTION IN PEDIATRIC PATIENTS

Vaginal calculi are classified as primary or secondary and they are rare, especially in children. Primary vaginal calculi are believed to originate from the stasis of urine in the vagina without an obvious nidus, whereas secondary vaginal calculi are the result of crystallization of urinary constituents around a foreign body in the vagina. The 2 previously described children with vaginal calculi had primary stones. Eton noted a large struvite stone associated with an ectopic ureter draining into the vagina of a 7-year-old child. Bissada and Hanash removed a struvite calculus from a 12-year-old patient with urinary incontinence secondary to spina bifida. We recently treated 2 children with primary vaginal stones associated with partial vaginal outlet obstruction.

Vesicoureteric reflux in patients with bladder tumours.

In the course of treatment of 224 patients with bladder neoplasms over an 18-year period, 44 patients were noted to have associated vesicoureteric reflux, bilateral in 12 and unilateral in 32. Reflux was suspected in 8 patients because of associated ureterotrigonal abnormalities such as paraureteric diverticulum, complete duplication of the ureter and gaping ureteric orifice, and it was diagnosed by micturating cystography obtained before the bladder tumour was treated. In the remaining 36 patients reflux developed after treatment of the bladder tumours. In most patients with reflux the clinical course was benign, but it caused recurrent pyelonephritis in 9 cases and secondary struvite calculi in 2. Five patients had antirefluxing ureteric reimplantation to control episodes of recurrent pyelonephritis. The pathogenesis and implications of vesicoureteric reflux in association with bladder tumours are discussed.

Urolithiasis in the lower urinary tract

I N COMPARISON to the upper urinary tract, lower tract calculi are infrequent. The majority are found in the urinary bladder. A ureteral calculus that spontaneously passes into the bladder may, on rare occasion, reside there for a considerable time. This is referred to as a migrant calculus. Otherwise, vesical calculi fall into three etiologic categories: primary, stasis, and foreign body nidus calculi. Primary or endemic calculi form in the urinary tract of patients, usually children, in whom obstruction, infection, or other known calculogenie factors are absent. They are especially prevalent in young boys of low socioeconomic class in the Middle and Far East, and are possibly related to deficiencies of milk or certain proteins in their diets. They are usually composed of ammonium hydrogen urate which may be admixed with calcium oxalate or, less frequently, calcium phosphate, and are nonopaque or poorly opaque.’ Radiologic discovery of calculi in the bladder or urethra occurs when evaluating such children for symptoms of lower tract irritation or intermittent involuntary interruption of the urinary stream (Fig. 1). The majority of secondary calculi occur in adults and are related to urinary stasis. The stasis is usually associated with bladder outflow obstruction in men with residual urine, vesical diverticula, or lower urinary tract infection. Women with a large cystocele and patients of either sex with neuropathic bladder dysfunction and residual urine, especially if infected, are also at risk for developing bladder calculi. These calculi may be of almost any composition, including uric acid, struvite, calcium phosphate, or

Urolithiasis in children

Urinary tract calculi in children are rare in the United States, with an incidence of 1 to 4 per 1,000 pediatric admissions. Primary and secondary calculi are different in causation, chemical composition, and prognosis, and must be considered separately. Review of the literature in the United States and England suggests that in 60 per cent of children, as in adults, no causation will be found. Our experience with twenty-five primary and twenty-five secondary calculi in a nonendemic area, however, shows only six truly idiopathic stones. Thorough urologic and metabolic evaluation has been rewarded with an appreciable yield of metabolic or structural abnormalities. Treatment consists of standard urologic management of stones, as well as specific therapy directed at the underlying causes.

Magnesium ammonium phosphate monohydrate--a hitherto undetected constituent of urinary calculi.

Magnesium ammonium phosphate monohydrate, MgNH4PO4·H2O, has been detected as a constituent of urinary calculi. The substance was identified by X-ray powder diffraction analysis, and the analysis was confirmed by comparison with synthetic material. Magnesium ammonium phosphate monohydrate may occur in secondary calculi which are formed in a strongly inflamed urinary tract. A possible mechanism of formation is discussed.

膀胱結石構造の偏光顯微鏡的觀察

Polarizing microscope studies on 98 cases of the lower urinary calculi including 82 cases of vesical calculi were made preparing 122 sheets of thin slices to observe the components and constructions of the calculi. Especially, the considerations were made on the nuclei of the vesical calculi.(1) Chemically, uric acid was the most readily recognized component and calcium oxalate, MgNH4PO4·6H2O, amorphous-like substance (mainly apatite) were followed by polarizing microscope examination. As the components of nuclei, calcium oxalate which might fall in the bladder from the upper urinary tract were most commonly observed.(2) Although the nucleic substances of the vesical calculi were mainly calcium oxalate and amorphous-like substance, many other substances were also observed as nuclei, so that all of the vesical calculi would not seem to be secondary calculi.(3) The stages of growth of vesical calculi were mostly identical. They grow gradationally and we have been observed, between each stages of growth, the dissolved space, suggesting naturally dissolved in many cases.(4) Observations on calculi may be conveniently divided into two places: the nucleus and perimeter. When uric acid and MgNH4PO4·6H2O were observed as nuclei, the same substances were crystalized off at the stages of growth in bladder, while calcium oxalate was found as nuclei, the different substances were produced.(5) Four cases of foreign bodies stone (clayon, paraffin mass, grass shaft and needle) were observed. In the needle, the main component were CaC2O4·H2O, MgNH4PO4·6H2O and amorphous-like substance, while the rest of them were MgNH4PO4·6H2O and amorphous-like substance.(6) Nine cases of urethral calculi and 7 cases of prostatic calculi were observed. Two cases of 7 of prostatic calculi were seemed to be consisted of pure apatite crystal.

Hydronephrosis with Secondary Calculi: Specimen

Hydronephrosis with Secondary Calculi: Specimen