Massimo D’Armiento

Early and Late Complications of Double Pigtail Ureteral Stent

Objectives: To analyze the early and late complications of indwelling ureteral stents in a series of 146 patients with nephroureteral lithiasis. Materials and Methods: 146 patients with obstructing nephrolitiasis were treated for urinary diversion with double pigtail ureteral stent before extracorporeal shock-wave lithotripsy (ESWL) and following ureterorenoscopic treatment of lithiasis. All patients were scheduled for stent removal or replacement at specific 3-month intervals until stone-free status was achieved. Results: Early complications during the first 4 weeks after stent insertion were stent discomfort (37.6%), irritative bladder symptoms (18.8%), hematuria (18.1%), bacteriuria (15.2%), fever >104F (12.3%) and flank pain (25.3%); late complications included hydronephrosis (5.7%), and stent migration (9.5%), encrustation (21.6%), fragmentation (1.9%) and breakage (1.3%). Conclusions: Ureteral stents have proven to be an invaluable tool for endourologists. Morbidity is minimal for up to three months but longer indwelling times are associated with an increasing frequency of incrustation, infections, secondary stone formation and obstruction of the stented tract.

The use of tamsulosin in the medical treatment of ureteral calculi: where do we stand?

It has recently been demonstrated that specific adrenoceptors subtypes (α1A/α1D) are prevalent in the distal part of the ureter, a finding supporting the interesting results obtained by different groups with the use of tamsulosin in the treatment of distal ureteral calculi. We performed a prospective randomized study to evaluate the effects of the addition of tamsulosin on our standard pharmacological therapy for the treatment of selected ureteral stones. A total of 64 patients referred to our department for the management of symptomatic ureteral calculi were considered. Patients were randomly divided into two treatment groups: group A (n=32) who received diclofenac (100xa0mg/daily) plus aescin (80xa0mg/daily) and group B (n=32) who received the same therapy plus tamsulosin (0.4xa0mg/daily) for a maximum of 2xa0weeks. No significant differences were found between the groups for age, gender distribution and mean stone size measured in the single largest dimension at presentation. The stone expulsion rate was 60% (19/32 patients) for group A and 88% for (28/32) for group B with a mean expulsion time of 7.4±2.2 (range 3.5–12) and 4.8±2.7xa0days (range 1.8–10.5), respectively. Group B showed a significant advantage in terms of both expulsion rate (P=0.01) and expulsion time (P=0.005). Different analgesics from those used in the standard treatment regimen were required in ten patients in group A (31%) but only three patients in group B (9%). This difference was significant (P=0.003). Hospitalization for recurrent colic was needed in 21% of patients in group A (7/32) and in 9% in group B (3/32) (P=0.01). Only two patients in each group (6%) experienced minor side effects associated with the expulsive therapy. Our data confirm the efficacy of tamsulosin in the treatment of distal ureteral stones up to 1xa0cm. This selective α-blocker should therefore be included in the pharmacological regimen of patients when a conservative approach is considered in the treatment of ureteral lithiasis.

Four-Year Outcome of a Prospective Randomised Trial Comparing Bipolar Plasmakinetic and Monopolar Transurethral Resection of the Prostate

BACKGROUNDnNo data have been published on the midterm efficacy of bipolar transurethral resection of the prostate (TURP).nnnOBJECTIVEnTo evaluate 4-yr results from a prospective randomised trial comparing bipolar TURP with standard monopolar TURP.nnnDESIGN, SETTING, AND PARTICIPANTSnSeventy patients with symptomatic benign prostatic hyperplasia were enrolled in this prospective randomised controlled trial in a tertiary-care institution. Inclusion criteria were age > 50 yr, good performance status, urinary retention, International Prostate Symptom Score (IPSS) > or = 18, and maximal flow rate (Q(max)) < or = 15 ml/s. Exclusion criteria were prostate volume < 30 cm(3), documented or suspected prostate cancer, neurogenic bladder, bladder stone or diverticula, urethral stricture, and maximal bladder capacity > 500 ml.nnnINTERVENTIONnPatients underwent standard or bipolar plasmakinetic TURP performed by the same surgeon using the same surgical technique.nnnMEASUREMENTSnTreatment efficacy was evaluated at 1, 2, 3, and 4 yr by comparing urinary flow rates, IPSS, and estimated postvoid residual (PVR) urine volume. Midterm complications were also recorded.nnnRESULTS AND LIMITATIONSnThe number of dropouts was not statistically significantly different in the two groups (p=0.2). The significant improvements in both groups were maintained at 4 yr for the IPSS, quality of life score, Q(max), and PVR versus baseline values. The main outcome variables at 4 yr for bipolar and monopolar TURP were mean IPSS 6.9 and 6.4 (p=0.58); mean Q(max) 19.8 ml/s and 21.2 ml/s (p=0.44), and mean PVR volume 42 ml and 45 ml (p=0.3). Overall, 2 of 32 (6.2%) and 3 of 31 (9.6%) patients required reoperation because of late complications (p=0.15). The major study limitation was the small sample size.nnnCONCLUSIONSnThis study represents the secondary, midterm analysis of a previously published trial. Our 4-yr data confirm our initial positive findings for the efficacy and safety of bipolar plasmakinetic TURP. Larger well-designed studies are needed to corroborate these findings.

Quality of life in women with multiple sclerosis and overactive bladder syndrome

The aim of this study was to evaluate the impact of symptoms of overactive bladder syndrome (OAB) on the quality of life (QoL) in female patients with or without multiple sclerosis (MS) and their correlation with findings from urodynamics (UDS). We enrolled 107 female patients with clinically definite MS and urinary symptoms of OAB. One-hundred female patients with similar OAB symptoms were used as a control group. Data on OAB symptoms, onset and progression, and results of any previous investigation were obtained, and any urinary complications were documented. A complete UDS investigation was performed. Health status assessment was obtained using the Kings Health Questionnaire. Results showed that urinary symptoms had a greater impact on the QoL in patients with MS. Nevertheless, the perception of the severity of these symptoms was minor in the MS group compared to the control group. No significant correlations were found between the dysfunctions as detected by UDS and the OAB symptoms in both groups. Recurrent urinary tract infections represented the main complication in the study population. In conclusion, OAB symptoms have a major impact on the QoL in patients with MS, even if their perception of QoL impairment remains limited. Optimal management in these subjects should include a complete UDS assessment.

A new transportable shock-wave lithotripsy machine for managing urinary stones: a single-centre experience with a dual-focus lithotripter

To assess the efficacy and safety of a transportable extracorporeal shock wave lithotripsy (ESWL) machine, the Modulith SLX‐F2TM (Storz Medical Italia, Rome, Italy), in the management of solitary urinary calculi.

BIPOLAR PLASMAKINETIC TECHNOLOGY FOR THE TREATMENT OF SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA: EVIDENCE BEYOND MARKETING HYPE?

Recently, bipolar electrosurgical technology has gained worldwide attention [1] with various companies introducing devices, e.g. the Gyrus PlasmaKinetic Tissue Management System (Gyrus ACMI, MN, USA), aimed at minimizing the morbidity of standard monopolar transurethral resection of the prostate (TURP) while maintaining efficacy and durability. Bipolar electrocautery systems might offer a promising alternative to conventional monopolar resectoscopes and there is increasing published data to support this marketing hype.

Adrenalectomy: Defining Its Role in the Surgical Treatment of Renal Cell Carcinoma

Objectives: With the recent widespread use of modern imaging techniques, the frequency of small low-stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We evaluated the characteristics of adrenal involvement and the accuracy of computerized tomography (CT) in the diagnosis of RCC, defining the real need for adrenalectomy during surgical treatment. Methods: The medical records of 201 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2002, were analyzed, retrospectively. We considered 76 with stage T1–2 disease and 125 with T3–4N0–1M0–1 disease. In all cases a blinded review of the preoperative abdominal CT was performed. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC. Results: The overall incidence of adrenal metastasis was 4.4%. The mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with a probability of adrenal spread (p < 0.05), with T1–2 tumors accounting for 1.3% of cases only. The adrenal gland was diagnosed as abnormal on preoperative CT in 21 patients (10.4%). CT scan demonstrated 88.8% sensitivity, 92.1% specificity, 99.4% negative predictive value and 34.7% positive predictive value for adrenal involvement by RCC. Conclusions: Adrenal involvement is not likely in patients with localized early stage RCC and adrenalectomy can be omitted in such cases, particularly when CT is negative. However, in selected patients with large high-risk tumors, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed.

Choosing the nephrostomy size after percutaneous nephrolithotomy

PurposeTo evaluate the effect of nephrostomy tube size on perioperative outcomes of percutaneous nephrolithtotmy (PCNL).MethodsForty-five well-matched patients with normal renal function were prospectively divided in two nonrandomized groups after uneventful PCNL (to receive either a 22-Fr, group 1 (nxa0=xa024 pts), or a 12-Fr nephrostomy tube, group 2 (nxa0=xa021 pts)). In all a balloon nephrostomy catheter with detachable funnel (Rüsch Teleflex, Germany) was used. A Visual Analogue Scale (VAS) for measuring the pain was administered 8 and 24xa0h after the procedure. Postoperative analgesics use (Ketoralac Tromethamine 30xa0mg), pre- and postoperative Hb, renal function and urinary leaks were registered.ResultsGroups were comparable as demographics and stone characteristics. VAS pain score was significantly higher in group 1 (4.25 vs. 3.2, Pxa0<xa00.001) only 8xa0h postoperatively. No significant difference was found in the VAS pain score 24xa0h p.o. Similarly, analgesics use (1.6 vs. 1.1, Pxa0=xa00.05), sHb (1.42 vs. 1.21, Pxa0=xa00.055) and hospital stay (3.8 vs. 3.6, Pxa0=xa00.63) were not significant between the two groups of patients.ConclusionsA small bore nephrostomy catheter may reduce pain in the immediate postoperative time. It does not affect blood loss and hospital stay so it can safely be used instead of a large size nephrostomy tube, after uneventful percutaneous procedures.

Expanding Applications of the Access Sheath to Ureterolithotripsy of Distal Ureteral Stones

Objective: Distal ureteral stones are routinely managed with semirigid ureteroscopy without the need for ureteral dilatation, but some conditions, e.g. large stone burden or difficult catheterization of the ureteral meatus, are time-consuming and would require a tool to facilitate multiple insertions of the ureteroscope and to avoid ureteral injury. An access sheath is now available and it facilitates ureteroscopy of the upper ureter. To answer the question whether its application could be expanded to the distal ureter is the aim of our paper. Patients and Methods: 12 distal ureteral stone patients, 8 with stone size >1 cm and 4 with a large prostate, underwent ballistic ureterolithotripsy with the aid of the Access Sheath. The results of the procedure were compared to a second group of 16 patients from our archives. Results: There was no significant difference in operating time and stone-free rate. Although no complications were related to the ureteroscopy, in 42% (5 patients) of the access group the procedure could be completed only after removing the sheath. Conclusion: The Access Sheath does not improve the results of the semirigid ureteroscopy of difficult stones in the distal ureter.

Comparing two different ballistic intracorporeal lithotripters in the management of ureteral stones.

Introduction: During the 1990s, two different in situ ‘ballistic’ lithotripters were introduced into clinical practice. The Swiss Lithoclast (SLC) was the first to be clinically tested. After a few years, a very similar device, the electrokinetic lithotripter (EKL), was described and has recently become available to us. In this paper we compare the clinical efficacy and features of these two ballistic lithotripters in the ureteroscopic treatment of ureteral stones. Materials and Methods: Thirty-eight patients with ureteral stones were randomized into two equal groups to undergo fragmentation using the SLC or the EKL via semirigid ureteroscope. In both groups the stones were in the mid- or lower ureter. The following parameters were evaluated: total procedure duration, complete fragmentation rate, time to complete fragmentation, proximal migration rate, complications and need for further procedures. Results: Although not statistically significant, a trend towards a higher fragmentation rate, a shorter time to fragmentation and a slightly higher proximal migration rate emerged in the SLC group. No difference was found in the stone-free rate in the two groups (94.7 vs. 89.4%). Only 2 cases of minor ureteric injury were observed in each group. Conclusions: As previously described by others, the SLC and EKL are both attractive cost-effective options in the treatment of ureteral stones. Ten years after its introduction, the SLC still remains probably the best choice for most urologists.