Artur Henrique Brito

Ureteroscopic pneumatic lithotripsy of impacted ureteral calculi

INTRODUCTION This work evaluates the results of ureteroscopic treatment of impacted ureteral stones with a pneumatic lithotripter. MATERIALS AND METHODS From March 1997 to May 2002, 42 patients with impacted ureteral stones were treated by retrograde ureteroscopic pneumatic lithotripsy. Twenty-eight patients were female and 14 were male. The stone size ranged from 5 to 20 mm. The ureteral sites of the stones were distal in 21, middle in 12 and proximal in 9. RESULTS Considering stones with distal location in the ureter, 1 patient had ureteral perforation and developed a stricture in the follow-up (4.7%). As for stones in the middle ureter, 2 perforations and 1 stricture were observed (8.3%) and regarding stones located in the proximal ureter, 5 perforations and 4 strictures occurred (44%). In the mid ureter, 1 ureteral avulsion was verified. In 34 patients without ureteral perforation, only 1 developed a stricture (2.9%). Of 8 patients who had perforation, 6 developed strictures. The overall incidence of stricture following treatment of impacted ureteral calculi was 14.2%. CONCLUSIONS Ureteroscopy for impacted ureteral calculi is associated with a higher incidence of ureteral perforation and stricture. Ureteroscopy of proximal ureteral calculi is associated with a high risk of perforation, when compared to mid or distal ureteral calculi. Ureteral perforation at the site of the stone seems to be the primary risk factor for stricture formation in these cases.

Adjuvant Tamsulosin or Nifedipine After Extracorporeal Shock Wave Lithotripsy for Renal Stones: A Double Blind, Randomized, Placebo-controlled Trial

OBJECTIVE To evaluate the effects of the adjuvant use of tamsulosin or nifedipine after extracorporeal shock wave lithotripsy for nonlower pole kidney stones 5-20 mm in size. METHODS We conducted a randomized double-blind trial involving 136 patients with radiopaque kidney stones. The patients received daily treatment with 0.4 mg tamsulosin, 20 mg nifedipine retard, or placebo for ≤30 days after 1 session of extracorporeal shock wave lithotripsy. Success was defined as plain film radiography showing the patient was completely stone free or with asymptomatic stone fragments ≤4 mm in size at any time during the weekly follow-up. RESULTS The success rate was 60.5% (23 of 38) in the tamsulosin group, 48.6% (17 of 35) in the nifedipine group, and 36.8% (14 of 38) in the placebo group (P = .118). In the subgroup analysis, stones 10-20 mm had significantly greater success rates in the tamsulosin (13 of 21, 61.9%) and nifedipine (15 of 25, 60%) groups compared with the placebo group (6 of 23, 26.1%; P = .024), but not for stones 5-9 mm (P = .128). The number needed to treat was 2.9 for tamsulosin and 3 for nifedipine. Adverse events were more frequent in the nifedipine than in the placebo group (28.5% vs 2.6%, respectively, P = .009), but without a significant difference between the nifedipine and tamsulosin (28.5% vs 15.8%, P = .15) or the tamsulosin and placebo (P = .54) groups. No difference was found among the groups with regard to pain intensity, interval to clearance, or steinstrasse. CONCLUSION The stone-free rates after extracorporeal shock wave lithotripsy with adjuvant tamsulosin or nifedipine were significantly increased only for nonlower pole renal stones 10-20 mm in size compared with placebo. Nifedipine was associated with more adverse effects than placebo.

Percutaneous Nephrolithotomy in Obese Patients: Comparison Between the Prone and Total Supine Position

BACKGROUND Percutaneous nephrolithotomy (PCNL) can be performed in the prone or in the supine position. Comparisons between the two techniques in obese patients are rare in the current literature. METHODS The records of obese patients (body mass index >30) who underwent PCNL in the prone or complete supine positions were reviewed. All patients had a noncontrast CT before and after the procedure. Stones were graded according to the Guy stone score and complications according to the Clavien grading. The stone-free rates, operative time, surgical complications, and hospital stay were analyzed. RESULTS A total of 56 PCNL were performed in 42 patients. Twenty-four PCNL were performed in the prone and 32 in the total supine position. Stone-free rate on the first postoperative day was 50% in the prone and 46.9% in the supine position (P=1.0). Final stone-free rates were 83.3% and 78.1%, respectively (P=0.74). Mean operative time was 164.6 minutes in the prone and 120.3 minutes in the supine position (P=0.0017), and hospital stay was 4.38 and 2.68 days (P=0.014), respectively. The transfusion rate was 20.8% in the prone and zero in the supine position patients (P=0.01). Excluding Guy IV stones, transfusion rate was 8.3% in the prone position (P=0.1). Significant surgical complications rate was 12.5% in the prone and 3.1% in the supine position (P=0.302). CONCLUSION PCNL performed in the prone or in the complete supine position in obese patients presents similar outcomes. The supine decubitus position has the advantages of a significantly shorter operative time and hospital stay.

Intravenous misplacement of the nephrostomy catheter following percutaneous nephrostolithotomy: two case reports

and it has remained an important approach for removing kidney stones since its inception. A nephrostomy tube is routinely positioned in the renal pelvis in order to tamponade bleeding and drain the collecting system. Although PCNL is an established procedure, major complication rates of up to 7% have been reported.

Laparoscopic pyeloplasty in secondary obstruction.

PURPOSE To evaluate the management of secondary ureteropelvic junction (UPJ) obstruction by laparoscopic pyeloplasty. MATERIALS AND METHODS Thirteen patients with symptomatic secondary UPJ obstruction undergoing laparoscopic pyeloplasty were included. Eight patients had obstruction on the right side and five patients on the left. The causes of obstruction were: failed Acucise retrograde endopyelotomy in seven patients, open pyelolithotomy in three, open pyeloplasty in one, retrograde endopyelotomy with laser in one, and laparoscopic pyeloplasty in one. Laparoscopic transperitoneal pyeloplasty was performed in all patients. A Double J stent was introduced antegrade and intraoperatively and removed 6 weeks later in all patients. RESULTS Laparoscopic transperitoneal pyeloplasty was successful in 12 patients (92.3%). Operative time ranged from 135 to 270 minutes, with a mean of 195 minutes. The mean hospital stay was 2.2 days (range 2 to 5 days). Follow-up ranged from 16 to 36 months with a mean of 22.4 months. Blood loss was insignificant in all surgeries, and no conversion or intraoperative complications occurred. CONCLUSIONS Laparoscopic pyeloplasty for secondary UPJ obstruction in our series was performed without conversion to open surgery. The initial results were similar to those of primary laparoscopy in our series or those of open pyeloplasty reported in the literature. These results led us to consider the laparoscopic correction as a good alternative in such cases.

Management of chronic unilateral hematuria by ureterorenoscopy.

BACKGROUND AND PURPOSE Chronic unilateral hematuria is characterized by intermittent or continuous gross hematuria that cannot be diagnosed using standard radiology and hematology methods. In the past, it was managed with partial or total nephrectomy. In the age of minimally invasive procedures, however, endoscopy has enabled more accurate diagnosis and management. We analyzed our experience with transurethral ureterorenoscopy using a flexible ureteroscope to determine the feasibility and success of endoscopic management of renal hematuria. PATIENTS AND METHODS We reviewed the records of 13 patients who presented with chronic unilateral hematuria, in whom radiologic and laboratory tests failed to reveal the source of bleeding. In the cases in which the lesion was identified, after complete inspection of the collecting systems, the bleeding site was treated ureteroscopically with a holmium: yttrium-aluminum-garnet (YAG) laser. RESULTS Follow-up ranged from 4 to 60 months (mean 26 mos). During the follow-up of the 13 patients, 11 remained symptom-free, with only one session of flexible ureterorenoscopy necessary. Relapse occurred in two patients after 4 months and 6 months, respectively; during a second session of flexible ureteroscopy, the bleeding site was successfully identified and cauterized with a holmium:YAG laser. No surgical complications occurred. CONCLUSIONS Conservative treatment of patients with chronic unilateral hematuria should always be considered. Laser ureteroscopic treatment is an excellent method and should be considered as the first option for the management of chronic unilateral hematuria.

Laparoscopic dismembered pyeloplasty in 47 cases

PURPOSE To evaluate the results of a sequence of 47 laparoscopic Anderson-Hynes pyeloplasties for the treatment of patients with ureteropelvic junction obstruction, independently of the etiology. MATERIALS AND METHODS Twenty male and 27 female patients diagnosed with ureteropelvic junction obstruction were treated by Anderson-Hynes transperitoneal laparoscopic dismembered pyeloplasty from April 2002 to January 2006. The age of the patients ranged from four to 75 years, with a mean age of 32.3 years. The follow-up ranged between six and 30 months, with a mean follow-up time of 24 months. The outcomes were evaluated through the assessment of symptoms and imaging studies. RESULTS In 44 (93.6%) of the 47 patients, resolution of the pain and a reduction in ureteropelvic dilation were observed. The mean operative time was 157 minutes (ranging from 90 to 270 minutes). Neither blood transfusion nor conversion to open surgery was required. The mean hospital stay was 2.2 days. The presence of crossing vessels over the ureteropelvic junction was verified in 26 patients (55%), and vessel transposition in relation to the urinary tract was performed in 25 of these cases. In one patient, the crossing vessel was mobilized out of the ureteropelvic junction with a perivascular suture to the renal capsule associated with the pyeloplasty. CONCLUSIONS The outcome of transperitoneal Anderson-Hynes laparoscopic pyeloplasty used for different causes of pyeloureteral obstruction presented a success rate similar to a previously-published open procedure, with the advantage of being less invasive. This procedure may be considered the first option for the treatment of ureteropelvic junction obstruction.

Metabolic assessment of elderly men with urolithiasis

OBJECTIVE: To assess the presence of metabolic disorders in elderly men with urolithiasis. METHODS: We performed a case-control study. The inclusion criteria were as follows: (1) men older than 60 years of age and either (2) antecedent renal colic or an incidental diagnosis of urinary lithiasis after age 60 (case arm) or (3) no antecedent renal colic or incidental diagnosis of urolithiasis (control arm). Each individual underwent an interview, and those who were selected underwent all clinical protocol examinations: serum levels of total and ionized calcium, uric acid, phosphorus, glucose, urea, creatinine and parathyroid hormone, urine culture, and analysis of 24-hour urine samples (levels of calcium, citrate, creatinine, uric acid and sodium, pH and urine volume). Each case arm patient underwent two complete metabolic urinary investigations, whereas each control arm individual underwent one examination. ClinicalTrials.gov: NCT01246531. RESULTS: A total of 51 subjects completed the clinical investigation: 25 in the case arm and 26 in the control arm. In total, 56% of the case arm patients had hypocitraturia (vs. 15.4% in the control arm; p = 0.002). Hypernatriuria was detected in 64% of the case arm patients and in 30.8% of the controls (p = 0.017). CONCLUSION: Hypocitraturia and hypernatriuria are the main metabolic disorders in elderly men with urolithiasis.

Irreversible Renal Function Impairment Due to Silent Ureteral Stones

OBJECTIVE To evaluate if renal function loss and hydronephrosis due to a silent ureteral stone might be reversed. MATERIALS AND METHODS We prospectively selected patients with silent ureteral stones between January 2006 and January 2014. A silent case was considered if there were no specific or subjective symptoms related to the ureteral stone. Patient, stone, and kidney characteristics were evaluated preoperatively, 3 and 12 months postoperatively. Renal function was accessed in the same intervals with serum creatinine (SCr), glomerular filtration rate (GFR), and (99m)Tc-dimercaptosuccinic acid. Patients without complete pre- and postoperative evaluation were excluded. Primary end point was midterm progress of global and ipsilateral renal function. Secondary end points included the evaluation of renal and collecting system anatomy from diagnosis to 12 months after treatment. Analysis of variance with repeated measures and marginal homogeneity test were used to evaluate renal function and hydronephrosis progression. RESULTS Twenty-six patients met our inclusion criteria. Mean preoperative SCr and GFR were 1.24 mg/dL and 72.5 mL/min, respectively. At initial scintigraphy, mean renal function was 33.4%. Laser ureterolithotripsy was performed in 84.6% of cases and all patients were rendered stone free. Two patients (8%) developed ureteral stenosis. There was no difference regarding SCr (P = .89), GFR (P = .48), and renal function at scintigraphy (P = .19) during follow-up. Hydronephrosis significantly improved from preoperatively to 3 months postoperatively (P < .0001), but not from 3 to 12 months (P = .065). CONCLUSION Patients with silent ureteral stones present with significant impairment of ipsilateral renal function and hydronephrosis at diagnosis. On midterm follow-up evaluation, renal function of the affected unit remains stable whereas hydronephrosis improves after treatment.

Laparoscopic ureteropyeloanastomosis in the treatment of duplex system

PURPOSE Duplex system is one of the most common anomalies of upper urinary tract. Anatomical and clinical presentation determine its treatment. Usually, the upper moiety has a poor function and requires resection, but when it is not significantly impaired, preservation is recommended. Laparoscopic reconstruction with upper pole preservation is presented as an alternative treatment. MATERIALS AND METHODS Four female patients with duplex system, one presenting with recurrent urinary tract infection and the others with urinary incontinence associated to infrasphincteric ectopic ureter, were treated. Surgical procedure envolved a laparoscopic ureteropyeloanastomosis of the upper pole ureter to the pelvis of the lower moiety, with prior insertion of a double J stent. RESULTS Surgical time varied from 120 to 150 minutes, with minimal blood loss in all cases. Follow-up varied from 15 to 30 months, with resolution of the clinical symptoms and preservation of the upper moiety function. CONCLUSION Laparoscopic ureteropyeloanatomosis is a feasible and safe minimally invasive option in the treatment of duplex system.