Richard J. Kahnoski

Extracorporeal Shock Wave Lithotripsy: The Methodist Hospital of Indiana Experience

A total of 982 patients underwent 1,416 treatments with extracorporeal shock wave lithotripsy for upper urinary tract calculi between February 23 and December 17, 1984. A single treatment was performed in 90 per cent of the patients. Morbidity was extremely low and hospital stay was short (3.0 days). Adjunctive procedures were required in 13 per cent of the patients. Of the kidneys 72 per cent were free of stones at the 3-month followup, while 23 per cent contained small (less than 5 mm.), asymptomatic fragments believed to be passable spontaneously. Only 1 per cent of the patients required surgical removal of the calculi. Morbidity was related directly to stone burden, while results were inversely related to stone burden. Extracorporeal shock wave lithotripsy is the preferred form of management for symptomatic upper ureteral and renal calculi less than 2 cm. in diameter.

Indiana continent urinary reservoir.

AbstractCecoileal reservoirs were created in 29 patients. Tunneled ureteral implantations along the tenia of the cecum provided the antireflux mechanism. Plication or tapering of the terminal ileal segment along with the ileocecal valve provided the continence mechanism.The tubular configuration of the cecum was disrupted with either an ileal or sigmoid patch, or it was re-configured in a Heineke-Mikulicz type of closure to avoid bolus (unit) contractions. Shortterm followup examination with excretory urography showed no upper tract obstruction. X-rays of the pouch showed no reflux and interviews revealed satisfactory continence in 93 per cent of the patients.

Combined Percutaneous and Extracorporeal Shock Wave Lithotripsy for Staghorn Calculi: An Alternative to Anatrophic Nephrolithotomy

Combinations of percutaneous and extracorporeal shock wave lithotripsy were performed on 46 patients with 52 staghorn calculi. Of the renal units 15 per cent had minute residual fragments but only 9.7 per cent with struvite had residual stones. The morbidity of this combined approach is less than that of anatrophic nephrolithotomy. We believe that the majority of staghorn calculi can be removed in this manner. Nephrostolithotomy should be the initial procedure in most instances. This less invasive approach is especially advantageous in patients at high risk for recurrence.

Ureteral Stone Management: Emerging Concepts

A total of 206 procedures was performed on 193 patients with ureteral calculi. The success rate was 62 per cent for stones proximal to the pelvic brim and 94 per cent for stones distal to the pelvic brim (87 per cent success over-all). Of the procedures 61 were done for fragments lodged in the ureter following extracorporeal shock wave lithotripsy. Ureteroscopy was done in 147 cases. Our current management concepts (including extracorporeal shock wave lithotripsy) for proximal and distal ureteral calculi are presented.

Hyperammonemia after transurethral resection of the prostate: a report of 2 cases.

We report on 2 patients who became deeply comatose after transurethral resection of the prostate. Both patients were severely hyponatremic and hyperammonemic but the course of the comas followed serum ammonia concentrations more closely than serum sodium concentrations. The genitourinary irrigant used in both procedures was a 1.5 per cent glycine solution. Serum amino acid analyses in 1 patient suggested that the postoperative hyperammonemia was due to catabolism of glycine absorbed during surgery. The inadequate activation of normal pathways of ammonia metabolism in this patient may have been caused by a partial deficiency of the urea cycle enzyme argininosuccinate synthetase. We believe that hyperammonemia should be considered as a cause of encephalopathy after transurethral resection of the prostate. The 1.5 per cent glycine genitourinary irrigating solution may not be as nontoxic as generally believed.

Treatment of Painful Caliceal Stones

Nonmobile caliceal stones cause pain more often than previously appreciated. The character and intensity of the pain differs from typical renal colic. Twenty-six patients with caliceal stones and pain underwent attempted treatment for pain control via stone removal or disintegration: 15 were treated with percutaneous stone extraction (PSE), 10 with extracorporeal shock-wave lithotripsy (ESWL), and 1 required open surgery after failing PSE. One patient had persistent pain after ESWL and subsequently underwent PSE; 25 of 26 patients had complete relief of pain. Morbidity was minimal. Patients with painful caliceal stones should be offered ESWL, followed by PSE if pain persists.