A. Ceresoli

Long-term followup after extracorporeal shock wave lithotripsy treatment of kidney stones in solitary kidneys

A total of 64 treatments by the Dornier HM3 lithotriptor was performed on 52 solitary kidneys with stones. A slight increase but no significant variations in serum creatinine was noted in 15 patients without obstruction just after treatment (p greater than 0.05). No significant increases in serum creatinine were found even at the short-term, mid-term and long-term followup. After 12 to 56 months hypertension developed in only 1 previously normotensive patient. Of 37 patients at mid-term followup (12 to 24 months) 62% were stone-free, 24% had passable fragments, 8% had recurrent stones and 5% had regrowth of the residual fragments. At long-term followup (24 to 56 months) 50% of 26 patients were stone-free, 19% had dust or passable fragments, 19% had recurrences and 11% had regrowth of the residual fragments. The demonstrated effectiveness, small number of complications at the short-term followup, lack of sequelae at the long-term followup and relatively small number of recurrences confirm that extracorporeal lithotripsy is not only effective but also safe. It can be proposed as the treatment of first choice even when the stone is in a single remaining kidney.

Nephron Sparing Surgery with the Ultrasonic Scalpel: La Diagnosi Precoce ED IL Trattamento Conservativo Dei Tumori Del Rene

Surgical resection remains the cornerstone of treatment renal cell carcinoma. In the last 15 years a better understanding of tumor biology and the early diagnosis permitted an evolution of the surgical treatment towards a minimal invasive approach by nephron-sparing surgery. Together with absolute and relative indications, nephron-sparing surgery is performed also as an elective indication, in patients with small, localized, often incidental tumors and a normal controlateral kidney. The oncological outcome in these cases is identical with that of radical nephrectomy. In order to achieve a complete tumor resection with the maximal preservation of unaffected renal parenchyma, tumor enucleation is the best technique when feasible. With the use of the harmonic scalpel, clamping of the renal pedicle and renal ischemia can be avoided in most of the cases during enucleation of small tumors, while the thermal damage in the remaing renal parenchyma is minimal.

Urethro-vaginal fistulas: Our experience

— Urethro-vaginal fistulas are rare in western countries, but more frequent in under-developed countries. In the latter this pathology is usually due to obstetric causes, whereas in European countries it arises mainly from gynaecological operations (82%). Results differ according to the cause. Almost all authors report a recurrence rate between 3 and 28%. We have chosen transvaginal urethroplasty with overlapping flaps from among the other more complex repair procedures which involve completing the fistulorraphy with myo-lipomatoso-cutaneous flaps. Our case histories (1988–1991) include 19 simple and 6 complex fistulas with the following etiology: gynaecological operation (16), obstetric causes (4), traumas (4). “Simple” fistulas were first treated by urethroplasty with overlapping flaps. Of 24 patients at 8-months follow-up, 82% of those operated once only, and 100% of those operated several times, had fully recovered. There were 2 recurrences due to Infection in the suture and 2 from tissue fibrosis. For “complex” fistulas and re-operations, we modify the Falandry method. We have concluded that transvaginal urethroplasty with several overlapping flaps is a valid procedure for non-recurrent fistulas which are limited in size and with little loss of fluid from ischemic dystrophy, which would otherwise, in our opinion, require the interpositioning of a myo-lipomatoso-cutaneous flap.

Renal Complications Following Extracorporeal Shock-Wave Lithotripsy

Up to 90% of renal and ureteral stones are successfully treated by extracorporeal shock-wave lithotripsy (ESWL) at the present time, either alone or in combination with percutaneous nephrolithotomy. However, despite the wide use of ESWL treatment of kidney stones, few data have been recorded regarding the side effects of the shock waves on the renal parenchyma. Parenchymal, subcapsular, or peri-renal hematomas have been reported only in a few cases, but intra-renal edema and hemorrhage are more frequent. These lesions can be demonstrated by different imaging techniques (131I-hippuran clearance; CT-scan; NMR). The measurement of the N-acetyl-glucosaminidase (NAG) variation levels in urine is a much simpler method to demonstrate early renal damage (1, 2). Recently, second-generation lithotripters became available, differing from the Dornier HM-3 both in structure and wave generation. The second-generation lithotripters were built to achieve an anesthesia-free treatment and, consequently, to cut down the costs of each treatment. In order to obtain the same results, Dornier modified the ellipsoid of HM-3. In treating patients without anesthesia, the lithotripter should generate waves that have a low pressure and a wide skin area for body penetration; this means less pain, less renal damage but, also, less efficacy. Both prolonged treatments and multi-treatments are needed to break up the stones. The aim of the present study was to compare the effects on the kidney parenchyma of the original HM-3 with the modified Dornier HM-3 lithotripter.

Renal Stone Disease and Nutrient Intake in Italy

Dietary patterns have been implicated as major contributors to the high prevalence of upper urinary-tract stones in affluent countries (1, 2). Many studies have shown that a number of nutrients may influence the excretion of calcium (Ca), oxalate (Ox), citrate (Cit), and uric acid (UA) and predispose to Ca stone formation. Urinary Ca excretion is reported to increase from increased consumption of protein, refined carbohydrate (CHO), Ca, Na, and Mg, and decreased intake of phosphate and dietary fiber. A high intake of purine or ascorbic acid could produce an increment in urinary UA and urinary Ox levels. An increase of urinary Ox excretion has also been reported on a low Ca and/or high Ox diet, on a high animal or vegetable protein diet, after administration of vitamin D, and in pyridoxine deficiency. Changes in urinary Cit were reported in patients with high CHO or Na intakes. The relation between diet and renal stone disease has been the aim of this study.