Giovanni Scala Marchini

Utility of the Guy's Stone Score Based on Computed Tomographic Scan Findings for Predicting Percutaneous Nephrolithotomy Outcomes

OBJECTIVEnTo evaluate the ability of the Guys stone score (GS) to predict the success rates and complications on the basis of the computed tomographic (CT) scan findings for renal stones treated with percutaneous nephrolithotomy (PCNL).nnnMETHODSnFrom 2008 to 2012, a total of 147 consecutive patients (155 renal units) who underwent PCNL in a completely supine position were prospectively evaluated. All patients underwent a CT scan preoperatively, and the stones were classified according to the GS. All PCNLs were analyzed to determine the association between the GS and treatment outcomes on the basis of CT findings and complications, according to the Clavien criteria.nnnRESULTSnOf the 155 PCNLs, 27% were classified as GS1, 28.4% as GS2, 27% as GS3, and 17.6% as GS4. Only the largest diameter of the stones differed among the groups (GS1=21.4, GS2=26.5, GS3=31.4, and GS4=50.5 mm; P<.001). After stratification according to the GS, the groups differed significantly regarding their operative times (GS1=63±28.5, GS2=101.4±40.8, GS3=127.6±47.6, and GS4=153.3±56 minutes; P<.001), tubeless rates (GS1=54.8%, GS2=45.4%, GS3=28.6%, and GS4=7.4%; P<.001), blood transfusion rates (GS1=0%, GS2=2.3%, GS3=4.8%, and GS4=22.2%; P=.01), complications (GS1=4.8%, GS2=9.1%, GS3=26.2%, and GS4=44.4%; P<.001), immediate success rates (GS1=95.2%, GS2=79.5%, GS3=59.5%, and GS4=40.7%; P<.001), and number of auxiliary procedures (GS1=0.05±0.32, GS2=0.28±0.6, GS3=0.35±0.66, and GS4=0.43±0.59; P=.031). The final success rates after the auxiliary procedures were similar among the groups (GS1=97.6%, GS2=86.4%, GS3=90.5%, and GS4=74.5%; P=.19).nnnCONCLUSIONnThe GS based on CT findings accurately predicted success rates and complications after PCNL for renal stones.

Extracorporeal shock wave lithotripsy in the treatment of renal and ureteral stones

The use of certain technical principles and the selection of favorable cases can optimize the results of extracorporeal shock wave lithotripsy (ESWL). The aim of this study is to review how ESWL works, its indications and contraindications, predictive factors for success, and its complications. A search was conducted on the Pubmed® database between January 1984 and October 2013 using shock wave lithotripsy and stone as key-words. Only articles with a high level of evidence, in English, and conducted in humans, such as clinical trials or review/meta-analysis, were included. To optimize the search for the ESWL results, several technical factors including type of lithotripsy device, energy and frequency of pulses, coupling of the patient to the lithotriptor, location of the calculus, and type of anesthesia should be taken into consideration. Other factors related to the patient, stone size and density, skin to stone distance, anatomy of the excretory path, and kidney anomalies are also important. Antibiotic prophylaxis is not necessary, and routine double J stent placement before the procedure is not routinely recommended. Alpha-blockers, particularly tamsulosin, are useful for stones >10mm. Minor complications may occur following ESWL, which generally respond well to clinical interventions. The relationship between ESWL and hypertension/diabetes is not well established.

Laparoscopy-assisted ileal pouch-anal anastomosis: surgical outcomes after 10 cases.

We analyzed outcomes of laparoscopy-assisted ileal pouch-anal anastomosis (LAIPA) from 10 patients (7 with ulcerative colitis and 3 with familial adenomatous polyposis) operated on between January 1998 and March 2004. Median operating time was 246 minutes. There were no intraoperative complications. There were no conversions. Postoperative complications occurred in 3 (30%) patients: 2 cases of wound infection and 1 case of a foreign body retrieved during pouch endoscopy. There was a 30% reoperation rate due to unsuspected duodenal perforation, a persistent postoperative pain, and 1 case of intestinal obstruction after ileostomy closure. There were no deaths. Median time to resumption of diet was 24 hours. Median hospital stay was 7 days. All ileostomies were closed 6 to 8 weeks after LAIPA. LAIPA is feasible and safe and should be selectively offered to nonobese patients.

Metanephric Adenoma: clinical, imaging, and Histological findings

Metanephric adenoma (MA), also designated nephronogenic nephroma or renal epithelial tumor resembling immature nephron, has just been recently recognized as a special type of benign renal epithelial tumor. Only few reports are found in the literature regarding this rare renal tumor. The purpose of this paper is to describe our clinical, imaging and histological / immunohistochemical observations of MA diagnosed in two patients and compare these data to previous information reported in medical databases.

Impact of Renal Anatomy on Shock Wave Lithotripsy Outcomes for Lower Pole Kidney Stones: Results of a Prospective Multifactorial Analysis Controlled by Computerized Tomography

PURPOSEnWe evaluated which variables impact fragmentation and clearance of lower pole calculi after shock wave lithotripsy.nnnMATERIALS AND METHODSnWe prospectively evaluated patients undergoing shock wave lithotripsy for a solitary 5 to 20 mm lower pole kidney stone between June 2012 and August 2014. Patient body mass index and abdominal waist circumference were recorded. One radiologist blinded to shock wave lithotripsy outcomes measured stone size, area and density, stone-to-skin distance, infundibular length, width and height, and infundibulopelvic angle based on baseline noncontrast computerized tomography. Fragmentation, success (defined as residual fragments less than 4 mm in asymptomatic patients) and the stone-free rate were evaluated by noncontrast computerized tomography 12 weeks postoperatively. Univariate and multivariate analysis was performed.nnnRESULTSnA total of 100 patients were enrolled in the study. Mean stone size was 9.1 mm. Overall fragmentation, success and stone-free rates were 76%, 54% and 37%, respectively. On logistic regression body mass index (OR 1.27, 95% CI 1.11-1.49, p = 0.004) and stone density (OR 1.0026, 95% CI 1.0008-1.0046, p = 0.005) significantly impacted fragmentation. Stone size (OR 1.24, 95% CI 1.07-1.48, p = 0.039) and stone density (OR 1.0021, 95% CI 1.0007-1.0037, p = 0.012) impacted the success rate while stone size (OR 1.24, 95% CI 1.04-1.50, p = 0.029), stone density (OR 1.0015, 95% CI 1.0001-1.0032, p = 0.046) and infundibular length (OR 1.1035, 95% CI 1.015-1.217, p = 0.015) impacted the stone-free rate. The best outcomes were found in patients with a body mass index of 30 kg/m(2) or less, stones 10 mm or less and 900 HU or less, and an infundibular length of 25 mm or less. The coexistence of significant unfavorable variables led to a stone-free rate of less than 20%.nnnCONCLUSIONSnObese patients with higher than 10 mm density stones (greater than 900 HU) in the lower pole of the kidney with an infundibular length of greater than 25 mm should be discouraged from undergoing shock wave lithotripsy.

Testicular adrenal rest tumor in infertile man with congenital adrenal hyperplasia: case report and literature review

CONTEXTnSynthesis of cortisol and aldosterone is impaired in patients with congenital adrenal hyperplasia (CAH) because of 21-hydroxylase deficiency. Men with CAH have low fertility rates compared with the normal population, and this is related to testicular adrenal rest tumors. Findings of azoospermia in combination with a testicular tumor on ultrasound are likely to have a mechanical cause, especially when in the testicular mediastinum. The preferred treatment method consists of intensive corticoid therapy. However, when the tumor is unresponsive to steroid therapy, surgical treatment should be considered.nnnCASE REPORTnWe present the case of a male patient with CAH due to 21-hydroxylase deficiency who presented a testicular tumor and azoospermia. Treatment with low daily corticoid doses had previously been started by an endocrinologist, but after 12 months, no significant change in sperm count was found. Although the adrenocorticotrophic hormone and 17-hydroxyprogesterone levels returned to normal values, the follicle-stimulating hormone (FSH), luteinizing hormone and testosterone levels remained unchanged. Ultrasound examination confirmed that the testicles were small and heterogenous bilaterally, and revealed a mosaic area at the projection of the testis network bilaterally. Magnetic resonance imaging confirmed the finding. Testicular biopsy revealed the presence of preserved spermatogenesis and spermiogenesis in 20% of the seminiferous tubules in the right testicle. The patient underwent testis-sparing tumor resection. After 12 months of follow-up, there was no tumor recurrence but the patient still presented azoospermia and joined an intracytoplasmic sperm injection program.

Semi-rigid ureteroscopic lithotripsy versus laparoscopic ureterolithotomy for large upper ureteral stones: a meta – analysis of randomized controlled trials

ABSTRACT Introduction: To provide a systematic review and meta-analysis of randomized controlled trials (RCT) comparing semi-rigid ureteroscopic lithotripsy (URS) with laparoscopic ureterolithotomy (LU) for the treatment of the large proximal ureteral stone. Materials and methods: A systematic literature review was performed in June 2015 using the PubMed, Scopus, and Web of Science databases to identify relevant studies. Article selection proceeded according to the search strategy based on Preferred Reporting Items for Systematic Reviews and Meta-analysis criteria. Results: Six RCT including 646 patients were analyzed, 325 URS cases (50.3%) and 321 LU cases (49.7%). URS provided a significantly shorter operative time (weighted mean difference [WMD] = −31.26 min; 95%CI −46.88 to −15.64; p<0.0001) and length of hospital stay (WMD = −1.48 days; 95%CI −2.78 to −0.18; p=0.03) than LU. There were no significant differences in terms of overall complications (OR = 0.78; 95%CI 0.21-2.92; p=0.71) and major complications – Clavien ≥3 – (OR = 1.79; 95%CI 0.59-5.42; p=0.30). LU led to a significantly higher initial stone-free rate (OR = 8.65; 95%CI 4.18-17.91; p<0.00001) and final stone-free rate (OR = 6.41; 95%CI 2.24-18.32; p=0.0005) than URS. There was a significantly higher need for auxiliary procedures in URS cases (OR = 6.58; 95%CI 3.42-12.68; p<0.00001). Conclusions: Outcomes with LU for larger proximal ureteral calculi are favorable compared to semi-rigid URS and should be considered as a first-line alternative if flexible ureteroscopy is not available. Utilization of flexible ureteroscopy in conjunction with semi-rigid ureteroscopy may impact these outcomes, and deserves further systematic evaluation.

Silent Ureteral Stones: Impact on Kidney Function—Can Treatment of Silent Ureteral Stones Preserve Kidney Function?

OBJECTIVEnTo report our experience with silent ureteral stones and expose their true influence on renal function.nnnMETHODSnWe analyzed 506 patients who had undergone ureterolithotripsy from January 2005 to May 2010. Silent ureteral stones were calculi found in the absence of any specific or subjective ureteral stone-related symptoms. Of the 506 patients, 27 (5.3%) met these criteria (global cohort). All patients were assessed postoperatively with dimercaptosuccinic acid scintigraphy (DMSA). A difference in relative kidney function of >10% was considered abnormal. Pre- and postoperative comparative DMSA analyses were electively obtained for 9 patients (kidney function cohort). A t test was used to assess the numeric variables, and the chi-square test or Fishers exact test was used for categorical variables. Two-tailed P<.05 was considered statistically significant.nnnRESULTSnStones were diagnosed by radiologic abdominal evaluation for nonurologic diseases in 40% and after previous nephrolithiasis treatment in 33%. The primary therapy was ureterolithotripsy in 88%. The mean follow-up time was 23 months. The overall ureteral stone-free rate after 1 and 2 procedures was 96% and 100%, respectively. In the global cohort, the mean pre- and postoperative serum creatinine levels were similar (P=.39), and the mean postoperative function on DMSA was 31%. In the kidney function cohort, no difference was found between the pre- and postoperative DMSA findings (22%±12.1% vs 20%±11.8%; P=.83) and serum creatinine (0.8±0.13 mg/dL vs 1.0±0.21 mg/dL; P=.45).nnnCONCLUSIONnSilent ureteral stones are associated with decreased kidney function present at the diagnosis. Hydronephrosis tends to diminish after stone removal, and kidney function remains unaltered.

Can we predict which patients will evolve to chronic kidney disease after nephrectomy for cortical renal tumors

INTRODUCTIONnWhile some studies show that patients submitted to radical nephrectomy have a higher risk of developing chronic kidney disease (CKD), some studies report that carefully selected living kidney donors do not present a higher risk for CKD. Here, we aim to study predictive factors of CKD after radical nephrectomy.nnnMATERIALS AND METHODSnBetween January 2006 to January 2010, 107 patients submitted to radical nephrectomy for cortical renal tumors at our institution were enrolled in this study. Demographic data were recorded, modified Charlson-Romano Index was calculated, and creatinine clearance was estimated using abbreviated Modification of Diet in Renal Disease (MDRD) study equation. Pathological characteristics, surgical access and surgical complications were also reviewed. The end-point of the current study was new onset estimated glomerular filtration rate (eGFR) less than 60 and less than 45 mL/minute/1.73 m(2).nnnRESULTSnAge, preoperative eGFR, Charlson-Romano Index and hypertension were predictive factors of renal function loss, when the end-point considered was eGFR lower than 60 mL/minute/1.73 m(2). Age and preoperative eGFR were predictive factors of renal function loss, when the end-point considered was eGFR lower than 45 mL/minute/ 1.73 m(2). Moreover, each year older increased 1.1 times the risk of eGFR lower than 60 and 45 mL/minute/1.73 m(2). After multivariate logistic regression, only age remained as an independent predictive factor of eGFR loss.nnnCONCLUSIONnAge is an independent predictive factor of GFR loss for patients submitted to radical nephrectomy for cortical renal tumors.

Percutaneous nephrolithotomy in patients with solitary kidney: a critical outcome analysis

ABSTRACT Purpose: To describe our experience with percutaneous nephrolithotomy (PCNL) in patients with solitary kidneys and analyze factors that can impact on intra-operative bleeding and postoperative complications. Materials and Methods: We reviewed our stone database searching for patients with solitary kidney who underwent PCNL from Jan-05 through Oct-13. Demographic data, stone characteristics, and intra- and postoperative outcomes were recorded. Spearman correlation was performed to assess which variables could impact on bleeding and surgical complications. Linear and logistic regressions were also performed. Results: Twenty-seven patients were enrolled in this study. The mean age and BMI were 45.6 years and 28.8Kg/m2, respectively; 45% of cases were classified as Guys 3 (partial staghorn or multiple stones) or 4 (complete staghorn) – complex cases. Stone-free rate was 67%. Eight (29.6%) patients had postoperative complications (five of them were Clavien 2 and three were Clavien 3). On univariate analysis only number of tracts was associated with increased bleeding (p=0.033) and only operative time was associated with a higher complication rate (p=0.044). Linear regression confirmed number of access tracts as significantly related to bleeding (6.3, 95%CI 2.2-10.4; p=0.005), whereas logistic regression showed no correlation between variables in study and complications. Conclusions: PCNL in solitary kidneys provides a good stone-free rate with a low rate of significant complications. Multiple access tracts are associated with increased bleeding.