Patrick Krombach

Does Open Stone Surgery Still Play a Role in the Treatment of Urolithiasis? Data of a Primary Urolithiasis Center

OBJECTIVE The introduction and continuous development of percutaneous nephrolithotomy, the achievement of extracorporeal shock-wave lithotripsy, and the advancements in ureterorenoscopy have led to a revolution in the interventional management urolithiasis. The indications for open stone surgery have been narrowed significantly making it a second- or third-line treatment option. We report on patients undergoing open stone surgery for nephrolithiasis in our department during the last 10 years to examine our indications at a primary urolithiasis center and to determine the clinical situations in which open surgery is a reasonable alternative. PATIENTS AND METHODS We reviewed all patients undergoing open stone surgery for upper urinary tract stones from 1997 until 2007 at the Department of Urology, University Hospital Mannheim. A retrospective chart analysis was performed on these patients to identify factors and indications for open stone surgery. Indications for stone surgery, type of surgery performed, stone complexity, anatomical abnormities present, and the residual stone burden were reviewed. RESULTS During a 10-year period 26 open stone operations were performed in our high-volume center. Indications for open stone removal were complex stone mass with complete or partial staghorn stones, concomitant open surgery, nonfunctioning stone-bearing lower poles, the desire to facilitate future stone passages in cystine stone formers, multiple stones in peripheral calyces, and failed minimal invasive procedures. Procedures performed for stone removal included radial nephrotomies, extended pyelolithotomy, lower pole resection, partial nephrectomy, and ileum ureter replacement. Immediate stone-free rate after a single procedure was 69% (18/26 patients). CONCLUSIONS Although today most stone cases can be handled by minimally invasive treatment, open stone surgery maintains a mandatory role in very selected cases. The most common indication in our series though was complex stones with a high stone burden especially in combination with anatomical variations.

Prospective evaluation of acute endocrine pancreatic injury as collateral damage of shock-wave lithotripsy for upper urinary tract stones

There has been controversy over whether extracorporeal shock wave lithotripsy (ESWL) can cause damage to the endocrine cells of the pancreas, leading to the later development of diabetes mellitus. Authors from Germany prospectively evaluated acute endocrine pancreatic injury as collateral damage caused by the ESWL for treating upper urinary tract stones. In a careful study they showed that there was no effect on serum levels of variables indicating exocrine and endocrine pancreatic tissue damage, suggesting that the idea that ESWL might lead to future diabetes mellitus is unlikely to be correct.

Standardized Comparison of Prostate Morcellators Using a New Ex-Vivo Model

BACKGROUND AND PURPOSE Transurethral laser enucleation of the prostate is a common therapeutic option for the treatment of benign prostate enlargement. Evacuation of the enucleated tissue from the bladder is usually performed by electric morcellators. Until now, a standardized evaluation of the different morcellator settings does not exist. Therefore, we developed an ex-vivo model to find the best settings for four different morcellators. MATERIALS AND METHODS We morcellated pieces of a prostate adenoma after an open adenomectomy. The same speed settings were used to morcellate commercially available minced meat, fine pork sausage meat, and bovine heart, all of which had been cooked for 10 minutes using a Piranha Morcellator. We also morcellated raw pig perirenal fat tissue, raw pig liver, and raw bovine heart. The pieces were morcellated at different speed settings in an open water tank filled with saline. Because raw bovine heart showed to be the most equivalent tissue, we morcellated five pieces with four different settings of four different morcellators: The Piranha, the VersaCut, and two morcellator prototypes. RESULTS The median retrieval rate for the prostate adenoma was 14.02 (3.7-19.8) g/min. The retrieval rate for raw bovine heart was 13.75 (5.66-20) g/min. The maximum morcellation rates of the morcellators were: Piranha 20 (19.3-21.4) g/min, VersaCut 10.8 (8.2-13.1) g/min, Karl Storz prototype 9.8 (7.9-10.76) g/min, and Richard Wolf prototype 38.6 (35.3-42.9) g/min. CONCLUSION Raw bovine heart tissue is suitable for ex-vivo testing of prostate morcellators and can replace human prostate tissue in this standardized setting. In our ex-vivo study, the morcellation rates of the different morcellators increased with optimized oscillation speed and suction power settings. This needs to be confirmed in clinical studies.

Drain placement can safely be omitted for open partial nephrectomy: Results from a prospective randomized trial

To examine the benefit of drain placement during open partial nephrectomy.

Cystinuria and Cystine Stones

Cystinuria is responsible for up to 2% of all renal stones, and up to 10% of childhood stone disease. Patients affected by this inherited disease suffer from recurrent stone formation, leading to repeated surgical/endoscopic interventions, consecutive renal impairment, and, consequently, a significant impairment of life quality. The responsible genes causing cystinuria were first described in 1994. Unfortunately, the rarity of the disease accounts for the absence of large clinical series. The establishment of the International Cystinuria Consortium attempts to combine small single-center series, which already has led to a better genetic understanding and a recently revised classification.

1277 IN VITRO EFFICACY OF HOLMIUM:YAG LASER LITHOTRIPSY IN NON FLOATING STONES. - EFFECT OF PULSE FREQUENCY, ENERGY AND LENGTH -

INTRODUCTION AND OBJECTIVES: Holmium:YAG (Ho:Yag) laser lithotripsy is the gold standard in endoscopic stone treatment. Aim of this study was to evaluate the influence of pulse frequency, power and length on the effectiveness of Ho:Yag laser lithotripsy using two different artificial stone compositions in-vitro. METHODS: Three different Ho:Yag laser devices (Sphinx, RevolixDuo (both LisaLaser, Germany) and Odyssey 30 (Cook, Ireland) were tested. The devices were used at different pulse energy rates (1 and 2 Joule) and frequency settings (5 and 10 Hz) all resulting in an output power of 10W, respectively. Where possible (Sphinx and Odyssey 30), pulse length was modified (350 vs. 700 msec). The light was transmitted via flexible 365 m fibers. Experiments were performed in a water bath using cone shaped artificial stone (20ml volume) consisting of a soft stone composition (plaster of paris; Quick-mix, Germany) and a hard stone composition (Fujirock type 4 dental stone; GC Europe, Belgium). Lithotripsy was performed for 60 sec in contact mode on fixed stones applying 600 W in total per setting. Stones were dried for 72 h; fine granulated sand was used to measure the volume of the craters. Sample size was n 10 for all settings using hard stones, and n 6 when using soft stones. Unpaired t-test was used for statistical analysis. RESULTS: In all of the 5 tested groups per stone type, a slower pulse rate but increased pulse energy (5 Hz/ 2 J vs. 10 Hz/1 J) resulted in a higher stone disintegration. At 5 Hz/ 2 J Ho:Yag laser lithotripsy was more effective applied on hard stones ( 27.46% (10-55.4%); all p 0.05) and on soft stones ( 33.62% (8-54.3%); 3 of 5 tested groups p 0.05) compared to the 10 Hz/ 1 J setting. Furthermore, reduction of the pulse length from 700 to 350 msec resulted in a significantly higher stone disintegration ( 71.58% (57-120.6%); all p 0.05) in soft stone composition in 4 tested groups. In hard stone composition, reducing the pulse length was associated with a significant higher stone disintegration ( 27.25% (23.8-30.7%); all p 0.05) in combination with higher pulse energy (2 J/ 5 Hz). At lower pulse energy (1 J/ 10 Hz), the increased stone disintegration rate was not significant ( 6,5% (6.4-6.5%), p 0.05, respectively). CONCLUSIONS: Our results indicate that higher pulse energy and shorter pulse length increase disintegration rates of Holmium:YAG laser lithotripsy when retropulsion is excluded in vitro. This may help to improve efficacy of Holmium:YAG laser lithotripsy in non floating stones in vivo.