Extracorporeal shock wave lithotripsy for lower pole nephrolithiasis: Efficacy and variables that influence treatment outcome

We evaluated the efficacy of Extracorporeal Shock Wave Lithotripsy [ESWL] for treatment of lower pole caliceal stones. The study attempts to identify the relationship between the radiographic anatomy of the lower pole and the outcome of ESWL treatment for a solitary lower pole caliceal stones to help in selecting patients that are likely to benefit from that treatment. A total of 100 patients with solitary lower pole calculi [less than 2 cm.] underwent ESWL monotherapy using the Dornier Lithotriptor S machine. Pretreatment intravenous urography [IVU] was done to determine the stone size and lower pole measurements which include; the lower pole infundibular length. The lower pole infundibular width and the lower pole infundibulopelvic angle. Clinical and radiographic follow-up was done every month for 6 months after ESWL treatment. Sixty-four patients [64%] were stone-free 6 months after starting ESWL treatment, eighteen patients [18%] showed improvement as decreased stone size and another eighteen patients [18%] failed ESWL treatment. Significant variables that influenced treatment outcome include, stone size and type: the number of ESWL sessions and the radiographic anatomy of the lower pole. A short and broad lower pole infundibulum were very important favorable factors that improved the stone clearance after ESWL. Also a wide infundibulopelvic angle significantly improves the stone free rate after ESWL.ESWL is the initial treatment of choice for lower pole calculi smaller than 2cm. The spatial anatomy of the lower pole as defined by the lower pole infundibulopelvic angle, infundibular length and infundibular width, has a significant role in stone free rates after ESWL

Direct versus nonrefluxing ureteroileal anastomosis in ileal neobladder

Does the theoretical benefit of reflux prevention in low-pressure bladder substitutions outweigh the potentially high rate of anastomotic stricture? Over 6 years, 120 renal units in 60 patients were reimplanted in orthotopic ileal neobladder following radical cystectomy. They were classified into 3 groups: 60 renal units were reimplanted by direct end to side technique, 30 units by extramural serous lined technique and 30units by Le Duc technique. Pre and postoperative bacteriologic study, blood chemistry, IVU, renal isotope scanning and postoperative micturating pouchogram were done in all cases after 3, 6months and then annually for 6-60months [mean, 36months].The following data were recorded in the 3 groups respectively: Rate of anastomotic stricture; 1.66%, 13.33% and 26.66%. Reflux; 15%, 3.33% and 6.66%.Upper tract dilation; 11.66%, 13.33% and 30%.Significant decrease in GFR; 11.66%, 13.33% and 30%.Azotemia; 3.33%, 6.66% and 13.33%. Asymptomatic bacteriurea; 26.66%, 20% and 20%.Pyelonephritis; 6.66%, 6.66% and 10%.Upper tract stone formation; 1.66%, zero and 3.33%. Nonrefluxing methods of ureteroileal anastomosis resulted in statistically significant higher rate of anastomotic stricture and upper tract dilation than direct end to side anastomosis. This is a high cost for any theoretical benefits of preventing pyelonephritis, azotemia or stone formation. In low-pressure bladder substitutions, direct ureteroileal anastomosis may be the technique of choice as it preserves kidney function and morphology, simple and time saving technique

Intrarenal doppler ultrasound versus diuretic renography and pressure flow study [Whitaker test] in obstructed kideny

Renal ultrasound examination and intrarenal arterial Doppler studies were performed on 30 patients with urographic evidence of renal obstruction. Renal Doppler ultrasound was compared with both drainage values [T [1/2]] and differential pressure obtained from diuretic renography and Whitaker test respectively, both pre- and post-operatively. Pre-operatively there was close correlation between resistive index [RI] and T [1/2] P<0.001 and also there was close correlation between RI and differential pressure P<0.05. Post-operatively out of the 30 kidneys, 8 still showing obstruction by RI and only one of them had shown obstruction by Whitaker test and 4 showed obstruction by diuretic renography giving us a sensitivity of 25%, specificity of 73.1% for the color Doppler as compared to Whitaker test and sensitivity and specificity of 45%, 81% respectively as compared to diuretic renography. Pre-operatively RI was 0.78 +/- 0.04 and post-operatively RI was 0.65 +/- 0.06 [P<0.001] which was significant Renal Doppler ultrasound correlates closely with both diuretic renography and Whitaker test pre-operatively, but not post-operatively after relief of obstruction, so it can not be used alone in evaluation of obstructive uropathy, but it can be used for follow up of dilated non obstructed system by diuretic renography i.e. non obstructed T [1/2] on a dilated system obviating the need for frequent isotope renography

Ureteroscopy: results and complications

In the period from July 1989 to December 1993, a total of 272 ureteroscopic procedures were performed in 258 patients. Indications of ureteroscopy included ureteric stones in 243 patients and ureteric strictures in 15. Successful stone removal or fragmentation was obtained in 216 patients [88.8% of stone group]. Failure occurred in 27 patients, failure to pass the ureteroscope via the ureteric orifice in 3 patients, stone migration in 7 patients, second session procedure in 14 and ureterovesical reimplantation in 3. Complications occurred in 37 patients, 8 major and 29 minor. Major complications included severe ureteric trauma requiring immediate surgery in 3 and delayed ureteric strictures in 5. Ureteric stricture was treated by transureteroscopic lateral or medial ureterotomy followed by balloon dilatation. The later procedure was successful in 7 patients [46.6% of the stricture group]. One patient had total anuria, 2 weeks postureterotomy. These results indicated that ureteroscopy is very valuable tool to urologists, particularly if complete set up of lithotriptors and ureteroscopes are available