Damien M. Bolton

Improved Renal Function Following Aggressive Treatment of Urolithiasis and Concurrent Mild to Moderate Renal Insufficiency

To our knowledge the prevalence of urinary stone disease and concurrent mild to moderate renal insufficiency has never been reported. A review of our last 2,000 urinary stone patients identified 33 (1.65%) with serum creatinine levels of 2.0 mg./dl. or greater at presentation. Chemical composition, location and complexity of the calculi, types of procedures required to render the patient stone-free and the effect of surgical intervention (independent of relief of obstruction) on renal function were evaluated. Mean serum creatinine level before surgical intervention and after placement of a ureteral stent or percutaneous nephrostomy tube in patients with evidence of obstruction was 3.2 mg./dl. (range 2.0 to 7.5). Complete or partial staghorn calculi were found in 21 of the 33 patients (64%), including 8 with bilateral staghorn calculi. Seven patients required 1 procedure, 1 required urinary alkalization alone and the other 25 required an average of 3.5 procedures each. Stone analysis revealed struvite, mixed calcium and uric acid to be the most common types. Followup creatinine values (the latest available within 1 year) and corresponding creatinine clearances showed remarkable improvement. The mean decrease in serum creatinine level was 1.2 mg./dl. (p < 0.001). There was no statistically significant difference in the rate of decrease between patients with pretreatment serum creatinine levels of 2.0 to 2.9 mg./dl. and those with initial values of 3.0 or more. Renal calculi and concurrent mild to moderate renal insufficiency warrant aggressive treatment. Patients demonstrate significant improvement in renal function independent of relief of obstruction.

Urologist Directed Percutaneous Nephrostomy Tube Placement

A retrospective analysis of 100 consecutive ultrasonically guided percutaneous nephrostomy tubes placed under the guidance of urologists was done. Complications related to tube insertion included sepsis in 3% of the cases, renal pelvic perforations in 2% and hemorrhage in 1%. There were no deaths and no need for open surgical intervention to manage these complications. An additional 21% of the tubes malfunctioned more than 24 hours after insertion, including dislodgement in 11%, occlusion in 6%, hemorrhage in 1%, peritubular leakage in 1%, puncture site infection in 1% and severe incrustation in 1%. These delayed complications were independent of tube type. Nephrostomy tubes may be placed safely by urologists. Urologists usually direct the need for percutaneous nephrostomy tube placement and use these ports for endourological manipulations and, therefore, they should have a greater role in catheter insertion.

Current indications for open stone surgery in an endourology center

OBJECTIVES To evaluate the current indications and outcome of open stone surgery in a tertiary endourology unit. METHODS A 3-year retrospective review (1990 to 1993) of all endoscopic and open stone surgery was undertaken. RESULTS Twenty-five open procedures were performed on 20 patients of a total of 799 stone treatment procedures (3.13%). The most common indications for open stone surgery included large stone burdens in association with abnormal anatomy limiting endoscopic access (31%), concurrent open surgical procedures (24%), or previous failed endourologic procedures (17%). Anatomic factors contributing to the need for open surgery included renal transplantation, morbid obesity, and severe limb contractures. CONCLUSIONS Open stone surgery has become more complex. Patients undergoing open surgery, who failed endourologic techniques, or for anatomic or medical reasons, currently are the cohorts who may still benefit from treatment for calculus disease using open surgical techniques.

Hypothermia associated withpercutaneous nephrolithotomy

Abstract Objectives. To characterize the perioperative fall in core body temperatureassociated with percutaneous nephrolithotomy, and to identify patients at greater risk of hypothermia. Methods. A retrospective review was undertaken of core body temperatures in 77 patientswho underwent 95 percutaneous-nephrolithotomy (PNL) procedures using room temperature irrigants over a 3 year period. Intraoperative temperature measurements were obtained via an esophageal thermistor probe. Results. Mean core body temperature fell from 36.7°C preoperatively to 35.8°C afterretrograde manipulations and subsequent patient positioning before commencing the renal puncture. The mean core temperature fell an additional mean 1.0°C during the percutaneous nephrolithotomy. This additional temperature drop was proportional to the length of the procedure. Female patients had a significantly greater decline in intraoperative core body temperature than male patients (p Conclusions. Hypothermia occurs in the majority of patients undergoing PNL. Nearly an equivalent fall in temperature is seen during presurgical preparation, induction of anesthesia, and patient positioning as is seen during the surgical procedure itself. Efforts to preserve core body temperature both before and during the percutaneous procedure may reduce the degree of hypothermia and its potential complications.

Endocervicosis of the Bladder

We report a case of endocervicosis of the bladder. The tumor was successfully resected transurethrally. Histopathology of this rare condition is discussed and the literature is reviewed. The natural course of this entity is poorly documented and close followup is mandatory. When endocervicosis is differentiated confidently from adenocarcinoma, local treatment may be satisfactory.

The Effect of Newer Generation Lithotripsy Upon Renal Function Assessed by Nuclear Scintigraphy

PURPOSE We studied the effect of second generation lithotripsy on renal function. MATERIALS AND METHODS We evaluated 42 patients with unilateral renal calculi by nuclear renography, serum creatinine levels, renal ultrasonography and plain radiographs. RESULTS There was no significant change in glomerular filtration rate at 1 or 3 months. Split function of the treated kidneys was lower at 1 month (mean 47.2%, p = 0.01) and 3 months (47.3%, p = 0.01) than before treatment (49.1%). A greater than 5% decrease in split function of the treated kidney occurred at 1 month in 6 patients (16.2%) and at 3 months in 3. Of the patients 23 (62.2%) were stone-free and 11 had residual fragments less than 4 mm., with a 19% retreatment rate for an overall success rate of 91.9%. CONCLUSIONS Newer generation lithotriptors may limit renal damage while permitting satisfactory treatment of renal calculi.

Pseudo-crossed renal ectopia secondary to ureteropelvic junction obstruction

To our knowledge we report the first case of pseudo-crossed renal ectopia without an apparent displacing retroperitoneal mass that was documented on sequential radiological studies. Ureteropelvic junction obstruction of the crossed kidney appeared to be the cause of pseudo-crossed renal ectopia. Our case is compared with previously described instances of pseudo-crossed renal ectopia and the pathophysiological basis of this condition is discussed.

Entrapped Malecot nephrostomy tube: etiology and management.

Nephrostomy tubes occasionally are resistant to extraction. During the last 7 years 3 such patients with entrapped Malecot nephrostomy tubes have been treated successfully at our university. The entrapped nephrostomy tubes were removed by endoscopically incising an anchoring tissue bridge that had grown over a flange. A small endoscope was easily advanced through the lumen of the entrapped catheter to allow for adequate visualization and electrocautery of the anchoring tissue bridge. With this method an entrapped Malecot nephrostomy tube may be removed intact without significant injury to the renal parenchyma. Malecot nephrostomy tubes should be used with caution for long-term drainage of small intrarenal pelves.

Voiding Dysfunction in Human Immunodeficiency Virus Infections

PURPOSE We prospectively evaluated the current spectrum of urodynamic pathology in patients infected with human immunodeficiency virus (HIV) who presented with voiding dysfunction. MATERIALS AND METHODS We obtained a directed genitourinary and neurological history, and performed a physical examination and urodynamic testing in 18 patients. A 4-channel membrane urethral catheter was used to record intravesical and intraurethral pressures simultaneously. RESULTS Detrusor hyperreflexia was present in 28% of our patients and detrusor-sphincter dyssynergia in 28%. Detrusor areflexia, previously described as the most frequent abnormality, was uncommon in our series (6% of patients). CONCLUSIONS This changing proportion of urodynamic diagnoses may reflect a changing pattern of neurological manifestations of HIV infection due to more aggressive management. Urodynamic evaluation remains critical for precise diagnosis and treatment in patients with HIV who present with urinary symptoms.