William H. Boyce

Organic matrix of human urinary concretions

Abstract Concentric laminations, radial striations, frond formation and spherules are morphologic characteristics of native human concretions occurring in any segment of the urinary conduits from nephron to external meatus. The organic matrix is invariably so structurally related to these gross physical characteristics as to justify the assumption that it has a definitive architectonic role in the morphology of all concretions. Intermolecular bonding between matrix molecules appears to be established by gross, histological and electron microscopic examination. Matrix composition is remarkably constant for calculi of any type of crystalline content. The molecular composition is predominantly of molecules of low molecular weight, high solubility in their native states, and relatively low concentration in the urine of patients who form calculi. Selectivity is clearly a factor in matrix formation from urinary macromolecules. Matrix deposition unquestionably precedes crystal formation in all forms of experimental intranephronic calculosis. The occurrence of “matrix calculi” and recrystallization of decrystallized cystine stone matrices suggest that matrix precedes crystal deposition in at least some human concretions. Calcium and phosphate are universally present in calculus matrix even after all microscopic or petrographically demonstrable crystals have been removed. Mineralization in terms of inorganic ion accretion by matrix is a distinct possibility. This may play a role in concrement formation by decreasing the solubility of matrix molecules. The molecular epitactic nucleation of hydroxyapatite may well be a characteristic of the majority if not of all calculus matrices.

The role of open stone surgery since extracorporeal shock wave lithotripsy

Of 893 stone procedures 37 (4.1 per cent) performed during the first 19 months after extracorporeal shock wave lithotripsy was instituted at our medical center were open operations. Procedures included ureterolithotomy in 23 patients (with simultaneous pyelolithotomy in 1), anatrophic nephrolithotomy in 8, pyelolithotomy in 3 (with concomitant pyeloplasty in 2), partial nephrectomy in 2 and nephrolithotomy with a bowel segment inlay in 1. The most common reasons for electing an open operation were unsuccessful endoscopic stone manipulation, presence of anatomical obstruction in the intrarenal collecting system or ureter, morbid obesity and underlying medical problems precluding lengthy repeated endourological procedures. Over-all surgical results were excellent. Our study indicates that patients who presently require an open stone operation have complex calculous disease associated with a variety of anatomical and physiological problems. Despite this finding good results may be attained.

Radical prostatectomy: palliation for stage C carcinoma of the prostate.

An objective comparison is made of patients with stage C carcinoma of the prostate treated with radical prostatectomy versus more conservative measures. Morbidity from local manifestations of the tumor left in situ was markedly increased, whereas those patients afforded an extirpative operation had a much improved quality of life.

Transrectal Ultrasonography in the Evaluation of Patients with Prostatic Carcinoma

There were 53 patients with biopsy-proved prostatic carcinoma evaluated by the usual modalities, in addition to ultrasonography. Of this group 23 patients underwent radical prostatectomy and ultrasonography was helpful in assessing tumor involvement around the seminal vesicles. Tumor response to hormonal therapy was detectable readily with ultrasonic imaging but tumor reactivation was not apparent consistently.

Selective Elevation of Urinary Enzyme Levels after Extracorporeal Shock Wave Lithotripsy

Urinary enzyme testing has been used by many investigators to diagnose and monitor various types of renal injury. Three urinary enzymes, N-acetyl-beta-glucosaminidase, beta-galactosidase and gamma-glutamyl transferase were monitored in 17 patients before and after a single, unilateral extracorporeal shock wave lithotripsy treatment. Stones were in the renal pelvis or calices except for 1 treated in situ in the proximal ureter. Urine specimens were collected before extracorporeal shock wave lithotripsy and at 1, 3, 5, 7, 10, 14, 21 and 28 days after treatment. N-acetyl-beta-glucosaminidase and beta-galactosidase levels increased significantly after treatment (p less than 0.05). Gamma-glutamyl transferase levels increased after treatment but this was not statistically significant. All enzyme levels were highest on days 1 and 3 after lithotripsy and returned to baseline by day 28. Factors associated with post-treatment enzyme elevation included female sex, a lower pre-treatment creatinine clearance and stone size greater than 1 cm. These findings indicate that there is a transient selective increase in urinary enzyme excretion after extracorporeal shock wave lithotripsy.

Present concepts concerning the origin of matrix and stones.

Urinary concretions have a relationship to a variety of metabolic, endocrinologic, cancerous, infectious, degenerative, toxic, and nutritional diseases. Calculi exhibit considerable variation in crystalline composition, in rate of growth, and in relative content of inorganic and organic material, not only from patient to patient but from center to surface in the same calculus. Occuring a priori within the urine, many physical chemical factors contribute to the growth of concretions. This does not exclude the existence of a primary mechanism essential to the initiation of calculus formation and common to the ninety-two per cent of calculi that are calcigerous, if not to all urinary concretions. Indeed, the failure of calculi to develop in a large proportion of patients with hyper-crystalluria, renal infections, hyperparathyroidism, and all other “predisposing” diseases strongly suggests the presence of an initiating mechanism more definitive than chance agglomeration of urinary solids. Technological and theoretical advances in the past two decades have permitted extensive investigation of urinary calculi and of related abnormalities of the urine and the urinary system. The identification, frequency distribution, and common admixture of crystalline components of calculi were estab1ished.l A mucoid matrix was demonstrated in all calculi? and the urine was found to contain increased quantities of mucosubstances during calculous formation in both man3 and animals.4 The calcium binding properties of urinary mucosubstances were studies.6. Interrelations of matrix and crystalline components suggested. that the former served an architectonic function in calculous growth.’0 A published symposiume and a reviewlo by Boshamer served to assemble the existing knowledge in this field and to stimulate interest in the basic mechanisms of calculus formation.

Recent Progress in Ultrasonography of the Bladder and Prostate

Gray scale transrectal ultrasonography has proved to be a valuable adjunct in the evaluation of patients with tumors of the prostate and bladder. Its application in patients with prostatic disease is in the detection of early asymptomatic tumors, in the accurate staging of local disease and in the following of patients after the institution of specific treatment. Although it is not being used for the detection of bladder tumors the procedure is a reliable means to evaluate the degree of tumor invasion so that proper therapy can be instituted.

A Comparison of Anatrophic Nephrolithotomy and Percutaneous Nephrolithotomy with and without Extracorporeal Shock Wave Lithotripsy for Management of Patients with Staghorn Calculi

A retrospective study was conducted comparing anatrophic nephrolithotomy (10 cases), percutaneous nephrolithotomy alone (4 cases) or percutaneous nephrolithotomy combined with extracorporeal shock wave lithotripsy (23 cases) for the treatment of large staghorn calculi. A comparison based on collecting system anatomy demonstrated that anatrophic nephrolithotomy resulted in a greater stone-free rate, shorter hospitalization and lower costs while complication rates were similar. Anatrophic nephrolithotomy should still be considered a viable treatment option, especially for patients with large branched calculi in complex collecting systems.

BIOCOLLOIDS OF URINE IN HEALTH AND IN CALCULOUS DISEASE. II. ELECTROPHORETIC AND BIOCHEMICAL STUDIES OF A MUCOPROTEIN INSOLUBLE IN MOLAR SODIUM CHLORIDE

A method for recovering the total biocolloids of urine by a combination of dialysis and ultrafiltration has been described (1). These biocolloids have been separated into two groups on the basis of their solubility in molar sodium chloride. The electrophoretic properties of those components which are soluble in molar sodium chloride have been reported, both for normal subjects and for patients with developing renal calculi (2). The urinary biocolloids which are insoluble in molar sodium chloride form the subject for the present study.

Intraoperative Renal Ultrasonography: A Useful Adjunct to Partial Nephrectomy

Several evolutionary changes in ultrasonographic instrumentation, including miniaturization of transducers and marked improvement in resolution, have made intraoperative renal ultrasonography a valuable adjunct for intrarenal surgery. We investigated its use in 6 patients undergoing partial nephrectomy for treatment of renal cell carcinoma. In addition, 14 kidneys with renal tumors were scanned immediately after radical nephrectomy and the specimens were subjected to simulated partial nephrectomy. Transverse and longitudinal real-time sonographic images were obtained with a 5 MHz. sector scanner or a 7.5 MHz. convex array transducer. With ultrasonography to define tumor extent and location, negative surgical margins were obtained in all 6 individuals undergoing partial nephrectomy. A negative surgical margin was obtained in 13 of the 14 radical nephrectomy specimens subjected to simulated partial nephrectomy. A small satellite lesion was not identified and not resected in 1 of the radical nephrectomy specimens. We found that intraoperative renal ultrasonography helps to identify the location and extent of deep intraparenchymal lesions. It also provides a guide for a more accurate nephrotomy, which facilitates the attainment of negative resection margins during partial nephrectomy.