Fernando Marchant

Comparación entre cirugía retrógrada intrarrenal y litotricia extracorpórea para el tratamiento de la litiasis de polo inferior renal de hasta 15 mm. Estudio prospectivo aleatorizado

INTRODUCTION Extracorporeal Shock Wave Lithotripsy (ESWL) is currently the recommended treatment for intra-renal calculi smaller than 2 cm. However the low Stone Free Rate (SFR) in lower pole calculi gives rise to new techniques, such us retrograde intrarenal surgery (RIRS), for improve the surgery outcomes. OBJECTIVE To compare the efficacy of a treatment with ESWL with RIRS, in terms of SFR after surgery, in patients with kidney stones up to 15 mm in the lower pole. MATERIAL AND METHODS A prospective study was carried out in order to assess the results of ESWL and RIRS in patients with lower pole stones less than 15 mm. Among a total of 55 patients, 31 were underwent to ESWL (Group 1) and the remaining 24 to RIRS (Group 2). Clinical data recorded, including general characteristics of each patient, were: calculi size, side, operative time, complications according to Clavien scale, SFR and the presence of residual fragments at 2 months post-treatment assessed by a CT scan. STATA 11 was used to perform the statistical analysis. RESULTS There were no differences for general descriptors among groups with the exception of a significantly longer operative time for RIRS. The rates of SFR and residual fragments lesser than 3 mm. were lower in the RIRS group than in ESWL ones. RIRS also showed a lower rate of clinically significant fragments (0% vs 42.3%. P < .05). In the subgroup of patients with stones between 10/15 mm RIRS showed higher SFR (75% vs. 41.2%) and a lower rate of stones>3 mm (0% vs. 58.8%), being statistically significant (P < .05). Clavien III or higher complications were not reported in any of the groups. CONCLUSIONS In the treatment of lower pole stone RIRS has the same results than ESWL in terms of SFR. Regarding absence of a clinically significant residual fragment, RIRS was superior to ESWL. A bigger sample size is required in order to confirm this results.

Estudio prospectivo que compara la litotricia extracorpórea y la ureteroscopia en el tratamiento de la litiasis de uréter distal

Resumen Objetivos Comparar los resultados en el manejo de la litiasis de ureter distal entre la litotricia extracorporea (LEC) y ureteroscopia (URS) y asi evaluar la mejor alternativa de tratamiento en esta afeccion. Material y metodos Un total de 104 pacientes con diagnostico de litiasis de ureter distal, que requerian tratamiento quirurgico. Se realizo un enrolamiento y seguimiento prospectivo. Se utilizo en LEC un litotriptor Modulix SLX Storz, en la URS se utilizo un ureteroscopio semirrigido Storz 33 cm, diametro de 7,5 a 9,5 Fr, optica 6°. Del total de pacientes, 54 fueron a LEC y 50 a URS, y 62 eran varones y 42, mujeres, con una edad promedio de 49,72 anos para LEC y de 52,16 anos para URS. En la LEC el promedio de tamano fue 8,29 mm y en la URS, de 8,96 mm. Se establecio una significacion estadistica p Resultados El tiempo del procedimiento para la LEC, separado por sexo, fue de 55 min en el caso de los varones y de 45 min en las mujeres. Para la URS fue de 80 min para los varones y de 55 min para las mujeres. El tiempo de hospitalizacion promedio para la LEC fue de 4,8 h (todos los procedimientos ambulatorios). En el caso de la URS, fue de 22 h. Las complicaciones en el caso de la LEC fueron del 7% y para la URS, del 7,9%. De los pacientes tratados por LEC, el 74,3% presento stone free a los 30 dias, a diferencia de la URS, que presento un porcentaje de stone free del 92,3% (p Conclusiones Basados en los resultados de este estudio, la URS es el metodo mas adecuado para el manejo de la litiasis de ureter distal, tanto en resultados de stone free como en la falta de significacion en la comparacion de complicaciones.

Concordance of renal stone culture: PMUC, RPUC, RSC and post-PCNL sepsis—a non-randomized prospective observation cohort study

IntroductionBetween 5 and 10% of patients undergoing percutaneous nephrolithotomy (PCNL) develop postoperative sepsis 1, 2. Strategies to prevent infectious complications are based on information provided by preoperative midstream urine cultures (PMUC). The aim of this study is to evaluate the concordance of the microbiologic findings of PMUC, cultures of the renal stone (RSC) and urine obtained directly from the renal pelvis (RPUC) in patients undergoing PCNL.Materials and methodsThis is a multicenter prospective study. The study included all patients who underwent PCNL from May 2013 to July 2015 in three academic hospitals. All patients underwent a PMUC. Samples for RPUC were obtained by renal puncture for PCNL. Stone fragments extracted during the procedure were sent for culture (RSC). Clinical variables, stone configuration, burden and microbiology reports of cultures were recorded. We analyzed concordance between cultures and association with infectious complications.ResultsOne hundred and twenty-two patients underwent PCNL. Twenty-four percent had positive culture, 3.2% (4/122) PMUC, 14.7% (18/122) RPUC and 13.9% (17/122) RSC. Positive PMUC demonstrated multidrug-susceptible Escherichia coli and Staphylococcus aureus, while RPUC showed multidrug-resistant pathogens and/or fungus. Seven patients (5.7%) developed postoperative infectious complications prior to discharge. There was a weak correlation between PMUC and intraoperative urine cultures (RPUC and RSC). Concordance rate between RPUC and RSC was 83.3%. The most common isolated pathogens were multidrug-resistant bacteria or fungus.ConclusionsPMUC did not reflect the microbiological environment found in stones and urine directly obtained from the renal pelvis. Patients with postoperative infectious complications had negative PMUC with positive RPUC or RSC. RPUC and RSC can help guide prompt and appropriate antibiotic treatment for patients who develop postoperative infectious complications after PCNL.

The lithotripsy table height: a novel predictor of outcome in shockwave lithotripsy

BACKGROUND Outcome of Extracorporeal Shockwave Lithotripsy (SWL) is determined by physical factors that affect stone fragmentation and clearance. PURPOSE To evaluate the predictive value of the Lithotripsy Table Height (LTH) in SWL outcome. Lithotripsy Table Height (LTH) is a variable that represents skin to therapy head distance, and it is proportional to the energy that reaches the stone. MATERIALS AND METHODS A prospective study enrolled patients undergoing SWL for radiopaque urinary stones. All procedures were performed using a Modulith SLX (Karl Storz, Germany) Lithotripter. Patient weight, height and age; stone location and size; number of shock waves delivered, and LTH were recorded. One month post-procedure a KUB was obtained. Logistic regression analysis was used to evaluate the effects of these variables on stone-free outcome. A ROC curve was plotted. RESULTS Fifty-six patients were enrolled. After one month follow-up, overall success rate (Stone Free) was 83.9% (n = 47). LTH was the only independent predictor of outcome in both univariate and multivariate analysis (p = 0.029). Stone size (p = 0.45) and BMI (p = 0.32) were not significant. In the ROC curve, LTH showed an Area under the Curve = 0.791. Patients with LTH < 218 (n = 8) had relative risk of residual stones = 7.5, odds Ratio: 6.6 (Stone free rate 37.5% vs. 91.5%). CONCLUSION LTH appears to be an independent predictor of SWL outcome. High success rates can be expected if LTH > 218. Patients with lower LTH had a less effective therapy, therefore, worse stone fragmentation and clearance. These findings may help improve patient selection for SWL therapy.