Sami A. Moussa

ONE WEEK OF CIPROFLOXACIN BEFORE PERCUTANEOUS NEPHROLITHOTOMY SIGNIFICANTLY REDUCES UPPER TRACT INFECTION AND UROSEPSIS: A PROSPECTIVE CONTROLLED STUDY

Urosepsis after percutaneous nephrolithotomy (PCNL) is a severe complication, and its avoidance can sometimes be difficult despite antibiotic prophylaxis. Authors from the UK with a considerable experience in this procedure describe a prospective controlled study using ciprofloxacin for 1 week before PCNL, and found that it significantly reduces the risk of urosepsis.

Clearance of Lower-Pole Stones following Shock Wave Lithotripsy: Effect of the Infundibulopelvic Angle

Objective: To assess the effect of anatomic factors, especially the angle of the lower-pole infundibulum, on stone clearance following shock wave lithotripsy (SWL) in order to determine selection criteria for percutaneous nephrolithotomy. Methods: We retrospectively analyzed 116 patients with single lower-pole stones measuring 11–20 mm treated with SWL. Intravenous urograms were reviewed to measure the infundibulopelvic angle, the angle of the infundibulum to the vertical, and the anatomy of lower-pole calyces. Results: The overall stone-free rate was 52%. Factors most closely associated with a stone-free status were obtuse infundibulopelvic angle, lack of calyceal distortion, and a large infundibular diameter. The infundibulopelvic angle was the only factor to attain significance in predicting stone-free status (p = 0.012). The size of the stone did not predict eventual stone-free status (p = 0.911), but larger stones were more likely to require intervention after SWL. Conclusion: For solitary lower-pole stones 11–20 mm in size, the angle of the lower-pole infundibulum as it relates to the pelvis plays a role in eventual stone clearance and should be taken into account before choosing a mode of treatment.

Management of calyceal diverticular stones with extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy: long-term outcome

In this section this month, we have two papers. The first is from authors from Scotland. They present a review of patients with an extended follow‐up who have undergone extracorporeal shock wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PCNL) for calyceal diverticular stones over a 15‐year period to assess long‐term outcome, irrespective of treatment. They concluded that PCNL is an effective and durable means of treating calyceal diverticular stones, regardless of stone size or location of the diverticulum. Despite low stone‐free rates with ESWL, most patients are rendered symptom‐free with minimal complications. The second paper is from the USA; the authors discuss the new generation of flexible ureteroscopes, which provide exaggerated active deflection to facilitate intrarenal manipulation. They compared the relative ease of manipulation around a calyceal model. The authors concluded that the Wolf Viper proved superior for manipulation in the hands of experienced endoscopists.

Sixteen Years of Experience with Stone Management in Horseshoe Kidneys

Introduction: Horseshoe kidney is the commonest congenital renal fusion anomaly, and is often complicated by urolithiasis. We focus on our 16 years of experience with stone management in horseshoe kidneys. Materials and Methods: We reviewed the progress of 44 patients treated between 1987 and 2002. Shock wave lithotripsy (SWL) was used in 25 patients; the average stone surface area was 91 (range 10–1,600) mm2 and average follow-up was 36.5 (range 1–91) months. 19 patients underwent percutaneous nephrolithotomy (PCNL); the average stone surface area was 197 (range 6–2,400) mm2. Follow-up data are available for 8 patients and the average follow-up was 42.3 (range 3–144) months. Results: In the SWL group the 3-month stone-free rate (SFR) was only 31%. In the PCNL group the SFR was 75% on the postoperative day-1 KUB. Complications occurred in 9 patients. Conclusions: Stone management in horseshoe kidneys is challenging: PCNL produces a higher SFR with minimal major complications and failed access. PCNL thus appears to be the preferred management option in patients with urolithiasis in horseshoe kidneys.

A PROSPECTIVE STUDY OF ENDOLUMINAL ULTRASOUND VERSUS COMPUTERIZED TOMOGRAPHY ANGIOGRAPHY FOR DETECTING CROSSING VESSELS AT THE URETEROPELVIC JUNCTION

PURPOSE Crossing vessels at the ureteropelvic junction are associated with bleeding complications and a higher risk of failure after endopyelotomy. We compared computerized tomography (CT) angiography and endoluminal ultrasound for detecting crossing vessels before planned endopyelotomy. MATERIALS AND METHODS Preoperatively patients underwent CT angiography. Intraoperative evaluation included retrograde ureteropyelography, endoluminal ultrasound and ureteroscopy. Intraoperative findings were used to direct treatment. RESULTS Endoluminal ultrasound detected 19 crossing vessels in 14 of 20 patients (70%), while CT detected 9 crossing vessels in 7 (35%). Endoluminal ultrasound identified a septum between the ureter and renal pelvis in 7 patients (35%) but CT demonstrated none. On the basis of imaging findings we selected 5 patients for pyeloplasty, and endoluminal ultrasound accurately predicted the absence or presence of crossing vessels in all 5. CT angiography was accurate in 3 patients. However, in 2 patients a total of 4 vessels were missed by CT. A total of 15 patients underwent endopyelotomy with no bleeding complications. The presence or absence of a septum on endoluminal ultrasound was confirmed in all patients. Imaging findings altered the treatment chosen in 4 patients and changed the direction of the incision at the ureteropelvic junction in another 4. Clinical and radiographic success was achieved in all 13 patients (100%) with adequate followup. CONCLUSIONS Endoluminal ultrasound was more sensitive than CT angiography for identifying crossing vessels and septa. Treatment based on endoluminal ultrasound findings may decrease complications and improve the results of minimally invasive treatment for ureteropelvic junction obstruction.

Matched pair analysis of ureteroscopy vs. shock wave lithotripsy for the treatment of upper ureteric calculi

There is controversy over whether shock wave lithotripsy (SWL) or ureteroscopy (URS) is the best management of ureteric calculi, especially for stones located in the upper ureter. This study compares URS and SWL management of upper ureteric stones directly for the first time using a different analysis tool, the matched pair analysis study design. This method enables meaningful comparisons to be made on a small number of matched patients, using precise like‐for‐like matching.

Safety and Outcome of Percutaneous Nephrolithotomy in the Elderly: Retrospective Comparison to a Younger Patient Group

AIM To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (>70 years) patients might influence the decision for the procedure in the elderly. MATERIALS AND METHODS A large database was created from our patients (n = 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n = 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operation-related adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments <4 mm). Further analysis was performed for the same endpoints after stratification of the patients by (1) previous stone procedures and (2) special clinical features. RESULTS In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P = 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P = 0.01). CONCLUSION In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population.

Upper-pole puncture in percutaneous nephrolithotomy: a retrospective review of treatment safety and efficacy.

To review the safety and efficacy of supracostal puncture during percutaneous nephrolithotomy (PCNL) for renal calculi.

Patient selection before endopyelotomy : can it improve the outcome?

Objective To compare endopyelotomy and primary reconstructive procedures in patients with pelvi‐ureteric junction (PUJ) obstruction and with risk factors for endopyelotomy failure.

Treatment of lower ureteral stones using the Dornier Compact Delta lithotripter.

BACKGROUND AND PURPOSE Lithotripsy using new-generation machines requires minimal anesthesia and so can easily be given in an outpatient setting. We report our experience with the Dornier Compact Delta lithotripter in the primary management of lower ureteral stones. PATIENTS AND METHODS We identified 128 patients treated with SWL for lower-ureteral stones between April 1999 and August 2001. Complete follow-up was available for 112 patients. Their ages ranged from 19 to 78 years, with women accounting for 23%. Only three patients had a ureteral stent in situ. All patients were routinely followed up at 2 weeks with a plain film. The timing of further follow-up depended on the initial response to treatment. RESULTS Fragmentation occurred in 83 of 112 stones (74%): 93% of the successful cases and 43% of the unsuccessful ones. A total of 59 patients (53%) were stone free after one treatment. This figure increased to 73 (65%) after a second treatment. The mean size of the successfully treated stones was less than that of the failed stones (7.6 v 8.7 mm), although the difference did not reach statistical significance. Stone-free rates decreased as stone size increased, being 71% for the 28 stones < or =5 mm in diameter, 65% for the 52 stones 6 to 9 mm, 64% for the 25 stones 10 to 14 mm, and 42% for the 7 stones > or =15 mm. CONCLUSIONS When SWL can be delivered promptly in an outpatient setting, it remains a useful first-line treatment for lower ureteral stones. Although it is not as effective as ureteroscopy, its use can avert the need for more invasive treatment in half to two thirds of patients. It should be limited to stones <15 mm.