Jorge Gutierrez-Aceves

LOWER POLE I: A PROSPECTIVE RANDOMIZED TRIAL OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY AND PERCUTANEOUS NEPHROSTOLITHOTOMY FOR LOWER POLE NEPHROLITHIASIS—INITIAL RESULTS

PURPOSE The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.

Management of Infectious Complications in Percutaneous Nephrolithotomy

Infectious complications are one of the most frequent and feared adverse medical events in percutaneous nephrolithotomy. They represent a dangerous and life-threatening condition, especially when postoperative septicemia or severe sepsis develops. In order to limit morbidity and mortality it is crucial to recognize preoperative and intraoperative risk factors that could be clear contributors to an adverse infectious event; those factors are mainly immunosuppression caused by some comorbidities, presence of urinary infection or colonization, stone characteristics, obstruction, long-lasting operation, and high intrapelvic pressure during nephrolithotomy. Close observation during the immediate and early postoperative period must be established and a high index of suspicion must be maintained to identify a major complication. The early recognition and prompt multidisciplinary management of sepsis is mandatory to optimize the final outcome. Appropriate therapy is a continuum of management of infection, ranging from adequate drainage and broad-spectrum antibiotics to aggressive fluid resuscitation and invasive monitoring with medical management in the intensive care setting until the causative agent is found and eradicated.

Percutaneous Renal Access: The Learning Curve of a Simplified Approach

BACKGROUND AND PURPOSE Fluoroscopically guided techniques to access the kidney percutaneously with low exposure to radiation have been used successfully for many years in our training center. The purpose of this study was to analyze the learning process and to establish the number of procedures necessary for a nonexperienced urologist to achieve competence at performing percutaneous renal access. MATERIALS AND METHODS Eighty-two percutaneous renal accesses in patients with renal stones or ureteropelvic junction obstruction were evaluated. The time needed to perform a correct puncture and the fluoroscopic screening time were recorded for each renal access. Descriptive analysis, analysis of variance, and a Markov chain were used to analyze the results. RESULTS The rate of success increased from 82.5% to 97.6% after the first 40 punctures. Puncture time and fluoroscopy time decreased as the number of procedures increased. Incidence of complications was 30% for the first 20 cases, decreasing to 10% in the next 20 cases and 3.7% in the last 33 cases. CONCLUSIONS The fluoroscopy-guided approach used in this study is an effective and reproducible technique. Our analysis revealed that at least 50 procedures are needed to acquire reliable competence in obtaining access to the kidney.

Infected Urinary Stones, Endotoxins and Urosepsis

Joel Gustavo Gomez-Nunez1, Ulises M. Alvarez2, Francisco Fernandez3, Jorge Gutierrez-Aceves1, Luz Maria Lopez-Marin3 and Achim M. Loske3 1Nuevo Hospital Civil de Guadalajara, Universidad de Guadalajara, Guadalajara Jal. and Instituto de Endourologia, Hospital Puerta de Hierro, Zapopan Jal., 2Posgrado en Ciencias Quimicas, Facultad de Quimica, Universidad Nacional Autonoma de Mexico 3Centro de Fisica Aplicada y Tecnologia Avanzada, Universidad Nacional Autonoma de Mexico, Mexico

Intracorporeal Nonlaser Lithotripsy

Introduced in the 1980s, shock wave lithotripsy (SWL) is still considered a primary treatment option. Actually,minimally invasive endourological procedures may have a similar or even major role as therapeutic options. Most of the stones requiere fragmentation and the urologist has several options of intracorporeal lithotripsy technologies. The ideal lithotripter should be usable in a variety of settings, multifunctional, with adjustable energy output, effective for all stone compositions, reusable, safe, and inexpensive. To decide which is the best alternative of the nonlaser options, it appears that the election needs to be individualized to the patient population, clinical scenario and to the physician practice.