Anthony Verstandig

Complete Staghorn Calculi: Random Prospective Comparison Between Extracorporeal Shock Wave Lithotripsy Monotherapy and Combined With Percutaneous Nephrostolithotomy

PURPOSEnWe determined the preferred treatment of staghorn calculi.nnnMATERIALS AND METHODSnBetween January 1992 and December 1994 we performed a prospective, randomized, single center study involving 50 kidneys with complete staghorn calculi: 27 renal units were treated with extracorporeal shock wave lithotripsy (ESWL) monotherapy (group 1) and 23 were treated with combined (initial) percutaneous nephrostolithotomy with ESWL (group 2). The 2 treatment groups were compared regarding stone size, grade of collecting system dilatation and urine culture at presentation. The number of treatment sessions, narcotic doses, renal colic episodes, septic complications, unplanned ancillary procedures, length of hospitalization, total treatment duration and stone-free rate at 6 months were recorded and compared.nnnRESULTSnAt the conclusion of therapy the stone-free rate was significantly greater in group 2 than in group 1 (74 versus 22%, respectively, p = 0.0005). The complication rate was significantly greater in group 1, with 15 septic complications (fever greater than 38.5C for longer than 3 days) in 10 patients compared to only 2 episodes in group 2 (p = 0.007). The unplanned ancillary procedure rate was significantly greater in group 1 (8 procedures in 7 patients versus 1 procedure in group 2, p = 0.03). The overall treatment length was significantly shorter in group 2 (1 versus 6 months, p = 0.0006). There was no significant difference in the number of procedures performed with anesthesia or in the number of hospitalization days between the 2 treatment groups.nnnCONCLUSIONSnCombined percutaneous nephrostolithotomy and ESWL should be recommended as the first line treatment choice for most patients with staghorn stones.

Treatment of complete staghorn calculi by extracorporeal shock wave lithotripsy monotherapy with special reference to internal stenting

Extracorporeal shock wave lithotripsy monotherapy was used to treat 41 patients with complete staghorn calculi. In 20 patients polyethylene angiographic pigtail catheters were inserted prophylactically as ureteral stents and the other 21 patients did not receive stents. Prophylactic stenting reduced the incidence of complications and the need for percutaneous nephrostomy tubes to relieve subsequent ureteral obstruction. Internal stenting maintained the sterility of the urinary tract and reduced the average hospital stay by a third. Residual stone fragments representing less than 5 per cent of the original stone mass remained in 56 per cent of the patients, particularly in those with hydronephrotic kidneys. We suggest that extracorporeal shock wave lithotripsy monotherapy with prophylactic stenting is the preferred treatment for noninfected complete staghorn calculi.

Hypertrophic osteoarthropathy and primary intestinal lymphoma

Hypertrophic osteoarthropathy (HOA) in association with primary bowel disease is rare, but is usually seen in patients with chronic diarrheal states, such as Crohns disease and ulcerative colitis. We record the first case of HOA associated with primary intestinal lymphoma in a patient who presented with chronic diarrhea.

Bilateral obstructing ureteral uric acid stones in an infant with hereditary renal hypouricemia

We report on a 15-month-old boy with renal hypouricemia who presented with acute renal failure, anuria and sepsis due to bilateral obstructing ureteral uric acid stones. He was treated successfully with extracorporeal shock wave lithotripsy. Metabolic survey of 10 relatives revealed a rare hereditary disorder in 4 siblings: isolated renal hypouricemia and hyperuricosuria. To our knowledge this is the youngest reported case of hereditary renal hypouricemia and 1 of the youngest patients to be treated with extracorporeal shock wave lithotripsy.

Repeated Subselective Renal Embolization Following Pyelolithotomy: Angiographic Salvage of a Kidney

A bleeding intrarenal aneurysm secondary to pyelolithotomy was treated successfully by super-selective catheterization of the feeding arteries and embolization using stainless steel Gianturco coils. Three therapeutic procedures were performed because of recurrent hemorrhage. The advantages of this mode of treatment are that it is well tolerated, relatively safe and allows maximal preservation of functioning renal tissue.

Use of internal polyethylene ureteral stents in extracorporeal shock-wave lithotripsy of staghorn calculi.

Ureteral stenting during extracorporeal shock-wave lithotripsy (ESWL) of complete staghorn calculi, using an internal polyethylene pigtail catheter, was found to be an efficient prophylactic measure against the high rate of complications in these cases. In the presence of a ureteral stent the stone fragments passed more easily into the bladder, accumulation of obstructing stone streets was prevented, and internal drainage of the urine was guaranteed. The need for auxiliary measures such as percutaneous nephrostomy, ureteroscopy or ureteral meatotomy was prevented in most cases. This prophylactic measure may turn ESWL to become the primary treatment of large staghorn calculi.

Salvage of an obstructed single kidney by combined percutaneous nephrostomy, percutaneous stone extraction and alkalinisation.

A 72-year-old woman with a single kidney and renal calculi was admitted as an emergency with sepsis and anuria. Renal drainage was established by percutaneous nephrostomy (PTN) as an emergency procedure. A nephrostogram showed multiple lucent stones and a single opaque calculus in the renal pelvis. The definitive treatment of the mixed calculi was carried out through the PTN. The lucent stones were dissolved by alkaline irrigation and the opaque stone removed by a biliary basket via the dilated tract. The safety and simplicity of PTN as an emergency procedure and its use for definitive treatment with the avoidance of surgery are stressed.

The tooth-root sign: a characteristic appearance of distal ureteric calculi

Diagnostic accuracy in identifying calculi in patients with ureteric colic is poor. Lower ureteric calculi may be confused with other pelvic calcific opacities. A characteristic appearance of some larger lower ureteric calculi is described and likened to the root of a tooth. It is hoped that the tooth-root sign will be of assistance in the diagnosis of distal ureteric stones.

Simultaneous Sonographic Demonstration of Tumor Thrombus in the Inferior Vena Cava and Patent Main Renal Vein in Renal Carcinoma

With the introduction of new imaging modalities the optimal protocol for the evaluation of renal tumors is under close review. Angiographers frequently are faced with the question of whether to proceed to inferior venacavography following a selective renal angiogram that demonstrates a patent renal vein. We report a case of renal cell carcinoma in which the main renal vein was shown by ultrasound to be unequivocally patent but at the same time there was considerable tumor extension into the inferior vena cava. The necessity of full examination of the inferior vena cava, either by venacavography or ultrasound, in all cases of renal cell carcinoma is stressed.

The psoas sign in normal subjects without bowel preparation: The influence of scoliosis on visualisation

The lumbar spine films of 1494 subjects who were examined for low back pain or prior to job placement were studied to assess psoas muscle visualisation. The study group were almost all aged 18-39 years. None of the subjects had prior bowel preparation for a contrast examination. In the subjects without scoliosis only 36% had well seen psoas shadows on both sides. Taking the psoas shadows separately, 72% of left psoas shadows were well seen, while only 40% were seen on the right side. In the scoliotic group, the psoas shadow was seen bilaterally in 30% of subjects while in another 50% the muscle was seen only on the convex side of the curve. In no case was it seen only on the concave side. The direction of the curve to left or right did not influence visualisation. Thus in 80% of subjects with scoliosis of 5 degrees or more, the psoas was seen on the convex side, while in only 30% was it seen on the concave side.