Kim Davenport

A comparative in vitro study to determine the beneficial effect of calcium‐channel and α1‐adrenoceptor antagonism on human ureteric activity

To compare the in vitro human ureteric muscle response to calcium‐channel and α‐adrenoceptor antagonists, to determine the promoting factor for stone passage. Clinical trials suggest that stone passage in renal colic can be promoted by ureteric relaxation using these agents, however nonsteroidal anti‐inflammatory drugs appear to reduce ureteric activity in vitro but do not promote stone passage when used in clinical trials.

Conventional and alternative methods for providing analgesia in renal colic.

Opioid analgesics and NSAIDs remain the mainstay of treatment for acute renal colic. Opioid analgesics, e.g. morphine and pethidine, are highly effective during the acute episode. Various preparations are available but the intravenous form has the most rapid onset of action and the advantage that the dose may be titrated to effect. However, prolonged use may cause dependence and tolerance. Side-effects are common, including nausea, vomiting, constipation and drowsiness, and larger doses can cause respiratory depression and hypotension. The data are conflicting for the effect of opiates on ureteric tone; results generally indicate an increase or no effect [4]. Ideally, an alternative to opiates would be preferred, as increased ureteric tone is thought to be counterproductive in acute renal colic and the side-effects of opiates can be problematic.

New Ureteral Stent Design Does Not Improve Patient Quality of Life: A Randomized, Controlled Trial

PURPOSE Ureteral stents result in significant morbidity in many patients. Manufacturers have altered stent design and composition to minimize symptoms. The Polaris™ stent is made of a Percuflex® combination, providing a firm proximal aspect with a softer distal aspect to minimize symptoms. In this prospective, randomized study we compared symptoms and quality of life after stent insertion to determine whether this stent is better tolerated than the InLay® stent. MATERIALS AND METHODS Between September 2002 and September 2006 we randomized 159 patients requiring stent insertion for stone disease to receive the InLay or the Polaris ureteral stent. Patients were asked to complete the validated Ureteral Stent Symptom Questionnaire 2 weeks after stent insertion and 1 week after removal. RESULTS A total of 98 patients completed and returned each questionnaire, including 45 with the InLay and 53 with the Polaris. There were no significant differences between the groups on any health domain assessed. In the InLay and Polaris groups 91% and 94% of patients experienced pain with the stent in situ, which decreased to 40% and 43%, respectively, after stent removal. The urinary symptom score with the stent in situ was equal in the 2 groups (32, maximum 55). Of the InLay and Polaris groups 60% and 66% of patients, respectively, would be against receiving a further stent due to symptoms (p = 0.79). CONCLUSIONS The Polaris stent, designed with the specific aim of improving urinary symptoms and pain associated with ureteral stents, continues to have a significant detrimental effect on patient quality of life.

Antegrade versus retrograde stenting in laparoscopic pyeloplasty.

PURPOSE To compare operative times between retrograde and antegrade ureteral stenting as part of laparoscopic pyeloplasty. PATIENTS AND METHODS Laparoscopic pyeloplasty procedures from January 2002 to January 2007 were identified through a prospective database. Procedures on 126 patients were performed using the same transperitoneal technique apart from the method of stent placement, which was performed in either a retrograde manner before laparoscopy or an antegrade manner during the laparoscopic portion of the procedure. RESULTS A total of 45 patients underwent antegrade stenting, 53 had retrograde stenting, 20 patients already had a stent in place, and 8 patients had retrograde pyelography followed by antegrade stenting. Operative time in patients with antegrade stent placement was significantly faster than in those with retrograde stent placement (median 185 v 245 min, P < 0.0001 [two-way analysis of variance]), even when the variability of the operative surgeon was taken into account. There was no difference in the complication rates. CONCLUSION Antegrade stent placement results in a significantly faster overall operative time when compared with retrograde stent placement.

Audit of safety, efficacy, and cost-effectiveness of local anaesthetic cystodiathermy

INTRODUCTION The aim of this study was to audit our experience of cystodiathermy under local anaesthetic (LA) at the time of flexible cystoscopy for recurrent superficial bladder transitional cell carcinoma (TCC). PATIENTS AND METHODS A total of 264 flexible cystoscopies were performed on patients with a past history of TCC. The number and site of recurrences were recorded and selected patients were offered cystodiathermy. Patient tolerability was noted. At follow-up, any recurrence was recorded. RESULTS Eighty patients (30%) had 91 procedures showing one or more recurrences. Fifty-one of the 80 patients (64%) were treated with cystodiathermy under LA. All completed treatment. Forty-five (88%) tolerated the procedure well. Forty-seven (92%) treatments were completed within 5 min. At a median follow-up of 15 weeks, 30 (59%) treated patients had no recurrence and three (6%) had recurrence at the site of treatment. CONCLUSIONS LA cystodiathermy is an effective and well-tolerated alternative to general anaesthetic cystodiathermy that enables treatment at the time of detection and may, thereby, reduce patient anxiety.

A Comparative Study of Quality of Life Issues Relating to Open Versus Laparoscopic Nephrectomy: A Prospective Pragmatic Study

PURPOSE We determined whether laparoscopic nephrectomy confers improved health related quality of life in the early postoperative period compared with open nephrectomy. MATERIALS AND METHODS Patients undergoing open or laparoscopic nephrectomy were prospectively recruited. Patients completed the Comorbidity Symptom Scale preoperatively as well as the SF-36(R) quality of life health survey and pain visual analog scale preoperatively, and 2 days and 1 month postoperatively. RESULTS A total of 100 patients were recruited, of whom 71 completed all questionnaires, including 38 in the laparoscopic group and 33 in the open group. In the 2 groups mean patient age was the same (56.8 years) and there was a similar sex distribution. The laparoscopic group had improved quality of life scores with significantly higher physical component scores 1 month postoperatively vs the open group (-5.7% vs -22.2%, p = 0.009). The laparoscopic group also had significantly higher mental component scores 2 days postoperatively vs the open group compared to baseline (6.0% vs -6.6%, p = 0.009). The laparoscopic group had significantly lower pain visual analog scale scores 1 month postoperatively compared to baseline. Patients with higher Comorbidity Symptom Scale scores were more likely to undergo a laparoscopic approach (p = 0.036). Despite this they had a significantly shorter hospital stay (4 vs 6 days, p <0.001). CONCLUSIONS Quality of life benefits of laparoscopic over open nephrectomy were found in the early postoperative period despite more comorbidities in the laparoscopic group. This provides further evidence of the benefits of the laparoscopic approach over open surgery.

The Role of Ureteral Relaxation in the Promotion of Stone Passage

In order to promote stone passage in renal colic, we must first understand normal ureteral activity and how this is affected by the presence of a stone. Measuring normal ureteral activity in humans is difficult without the use of invasive methods or techniques which in themselves may affect peristalsis. Monitoring the activity during confirmed renal colic is even more difficult and virtually impossible. Both animal and human studies have therefore been used in an attempt to understand the physiology of the ureter and how this is affected by the presence of a stone. Using this knowledge, drugs can be used to alter the behavior of the ureter in an attempt to promote stone passage. Peristalsis has always been thought to be essential to allow stone passage and therefore it has been necessary to determine whether stone passage occurs by promotion of ureteral activity or by smooth muscle relaxation. Research indicates that drugs which allow continued peristalsis whilst preventing the increased uncoordinated activity seen in renal colic would be the most advantageous. The alpha-lA-adrenoceptor antagonists are the most effective drugs to date.

Medical Expulsive Therapy

Although large randomized controlled trials using medical therapy to promote stone passage in renal colic are lacking, the evidence to date would support the use of calcium channel antagonists or alpha-adrenoceptor antagonists during the initial period of conservative therapy for uncomplicated distal ureteral stones. Further studies are required to investigate their role in the treatment of proximal ureteral stones.