Procalcitonin determined at emergency department as an early indicator of progression to septic shock in patient with sepsis associated with ureteral calculi

ABSTRACT Introduction: To investigate the role of initial procalcitonin (PCT) level as an early predictor of septic shock for the patient with sepsis induced by acute pyelonephritis (APN) secondary to ureteral calculi. Materials and Methods: The data from 49 consecutive patients who met criteria of sepsis due to APN following ureteral stone were collected and divided into two groups: with (n=15) or without (n=34) septic shock. The clinical variables including PCT level for this outcome were retrospectively compared by univariate analysis, followed by multivariable logistic regression model. Results: All subjects had hydronephrosis, and were hospitalized with the mean of 11.8 days (3–42 days). The mean size of the ureteral stones was 7.5mm (3–30mm), and 57% were located in upper ureter. At univariate analysis, patients with septic shock were significantly older, a higher proportion had hypertension, lower platelet count and serum albumin level, higher CRP and PCT level, and higher positive blood culture rate. Multivariate models indicated that lower platelet count and higher PCT level are independent risk factors (p=0.043 and 0.046, respectively). In ROC curve, the AUC was significantly wider in PCT (0.929), compared with the platelet count (0.822, p=0.004). At the cut-off of 0.52ng/mL, the sensitivity and specificity were 86.7% and 85.3%. Conclusion: Our study demonstrated elevated initial PCT levels as an early independent predictor to progress into septic shock in patients with sepsis associated with ureteral calculi.

Value of color doppler ultrasound, kub and urinalysis in diagnosis of renal colic due to ureteral stones

Purpose Despite the routine use of helical CT in diagnosis of renal colic, there are recent concerns regarding the radiation exposure, overuse and costs. We attempted in this retrospective study to evaluate the accuracy of ultrasound (gray-scale and color Doppler with twinkling), KUB and urinalysis in diagnosis of renal colic due to ureteral calculi presented in Emergency Room. Materials and Methods A total of 939 consecutive cases of renal colic presented to ER have been managed and evaluated by ureteral ultrasound, KUB and urinalysis for the presence of ureteral stones. Non-confirmatory cases were subjected to Helical CT examination. Results Renal and ureteral ultrasound (gray-scale) alone detected ureteral calculi in 615 cases (65.4%) and after utilizing Color Doppler Ultrasound with twinkling the diagnosis was made with confidence in 935 cases (99.6%) but 4 (0.4%). KUB showed radiopaque stones in 503 (53.6%) patients and no stones were detected in 436 (46.4%). Microhematuria presented in 835 (88.9%) cases while absent in 102 (10.9%). There were 190 (20.3%), 77 (8.2%) and 671 (71.5%) patients with upper, middle and lower ureteral stones respectively. The simultaneous positive findings in US and KUB with microhematuria were found only in 453 (48.2%) cases. Conclusions The use of Color Doppler ultrasound with twinkling increased the detection rate of ureteral stones in acute renal colic patients presented to ER with less radiation exposure. Ultrasound examination as a single modality is superior to KUB and urinalysis in initial diagnosis of renal colic. .

Xanthogranulomatous Pyelonephritis (XGPN) in a Child with Multiple Ureteric Calculi.

Xanthogranulomatous pyelonephritis (XGPN) is an unusual suppurative granulomatous reaction to chronic renal infection, often in the presence of chronic obstruction, characterised histologically by granulomatous reaction with giant cells and foamy histiocytes1. XGPN is rare in children2. We report a case of XGPN, in a child with multiple lower ureteric calculi. An 11 year old male child presented to us, with features suggestive of acute pyelonephritis of two months duration.complete evaluation including contrast CT of the abdomen a diagnosis of XGPN was made. As the renal unit in question was non functional, he was treated successfully by subcapsular nephrectomy. This case is presented to emphasise the fact that, it is very important to diagnose XGPN early and differentiate it from chronic pyelonephritis. Prolonged antibiotic therapy and surgery is invariably required to relieve the obstruction and to eradicate the infection in patients with XGPN.

Impacted Anterior Urethral Calculus Complicated by a Stone-containing Diverticulum in an Elderly Man: Outcome of Transurethral Lithotripsy without Resection of the Diverticulum

Introduction The prevalence of lower urinary tract symptoms (LUTS) is about 20% in men aged 40 or above. Other than benign prostatic hyperplasia (BPH), urethral diverticulum or calculus is not uncommon for LUTS in men. Surgical treatment is often recommended for urethral diverticulum or calculus, but treatment for an impacted urethral calculus complicated by a stone-containing diverticulum is challenging. Materials and Methods An 82-year-old man had the persistence of LUTS despite having undergone transurethral resection of prostate for BPH. Regardless of treatment with broad spectrum antibiotics and an α-blocker, LUTS and post-void residual urine volume (100 mL) did not improve although repeated urinalysis showed reduction of WBCs from 100 to 10 per high power field. Further radiology revealed multiple urethral calculi and the stone configuration suggested the existence of a diverticulum. He was successfully treated without resecting the urethral diverticulum; and a new generation of ultrasound lithotripsy (EMS, Nyon, Switzerland) through a 22F offset rigid Storz nephroscope (Karl Storz, Tuttingen, Germany) was used to fragment the stones. Results The operative time was 30 minutes and the stones were cleanly removed. The patient was discharged after 48 hours with no immediate complications and free of LUTS during a 2 years follow-up. Conclusions When the diverticulum is the result of a dilatation behind a calculus, removal of the calculus is all that is necessary. Compared with open surgery, ultrasound lithotripsy is less invasive with little harm to urethral mucosa; and more efficient as it absorbs stone fragments while crushing stones. .

Ureteroscopic Lithotripsy Using Swiss Lithoclast for Treatment of Ureteral Calculi: 12-Years Experience

Ureteroscopic lithotripsy using Swiss Lithoclast was performed in 411 cases from January 1996 to September 2007 in a single hospital. Medical records of 341 cases, in which Swiss Lithoclast was successfully applied, were available for this retrospective study. We used 9.5Fr and 10Fr Storz rigid ureteroscopes. A success was defined as being free of stone-related symptoms and residual stones larger than 2 mm. Sixty one stones were located in the upper ureter, 49 stones were in the mid ureter, and 231 stones were in the lower ureter. The overall success rate was 93.5%. The success rate of upper ureter stone (80.3%) was significantly lower compared with those of mid (93.8%) and lower (96.9%) ureter stones (P=0.001). The higher the calculi was located within the ureter, the more chance of upward migration there was (P<0.001). The success rate in male patients was lower than in female patients without a statistical significance (P=0.068). The success rate decreased as the size of the stone increased (P<0.001), and as the degree of hydronephrosis increased (P=0.03). Perforation rates were 4.9%, 4.1%, and 2.6% from upper to lower ureter stone group. Ureteroscopic lithotripsy using Swiss Lithoclast is a safe and useful treatment modality for ureteral calculi.

Evaluation of emergency extracorporeal shock wave lithotripsy for obstructing ureteral stones

PURPOSE: To assess the efficacy of extracorporeal shockwave lithotripsy (ESWL) for ureteral calculi during acute renal colic. MATERIALS AND METHODS: From January 2002 to March 2007, 108 patients were treated by ESWL for obstructing ureteral stones causing acute renal colic. ESWL was performed within 24 hours of the onset of renal colic. RESULTS: The mean age of the patients was 39.5 years (11-72 years). Male/female ratio was 85/23. Mean stone size was 8.45 mm (4-20 mm). They were located in the pelvic (n = 53), iliac (n = 28) or lumbar (n = 27) region. Fragmentation after a single session was complete in 56 patients (52 percent), incomplete in 28 (26 percent), and absent in 24 (22 percent). Patients presenting incomplete fragmentation underwent a second (n = 28) or even a third session (n = 11). Of the 24 patients in whom ESWL had no impact on the stone, 21 underwent ureteroscopy, and in one case open ureterolithotomy for a patient with a hard 17 mm stone, while spontaneous passage occurred in two patients with small stones. CONCLUSION: Emergency ESWL for obstructing ureteral stones has a satisfactory success rate and very low morbidity. The stone-free rate of retreating ureteral calculi with ESWL decreases significantly after failed initial treatment. Stone size may be the main predictive factor for retreatment. We suggest that no more than 3 treatments should be given for a particular stone due to minimal improvement in the subsequent cumulative treatment success rate.

Solo extracorporeal shock wave lithotripsy for management of upper ureteral calculi with hydronephrosis

The aim of this study was to evaluate extracorporeal shock wave lithotripsy [SWL] outcomes as a solo therapy in patients with upper ureteral calculi and varying degrees of hydronephrosis. Eighty patients with upper ureteral calculi and a body mass index between 19.5 kg/m2 and 22.5 kg/m2 were included. They wre categorized into 4 groups according to the severity of hydornephrosis as seen on ultrasonography and intravenous urography: group 1, no dilatation; group 2, mild dilatation; group 3, moderate dilatation; and group 4, severe dilatation of the pyelocaliceal system. The size of calculi, time to calculus clearance, success rate of solo SWL, and the need for additional therapeutic methods were recorded and compared between the four groups of patients. The median size of the calculi was 13.5 mm, and the mean time to calulus clearance was 56.0 +/- 24.2 days. In 71.3% of the patients, solo SWL was successful in the treatment of the calculi. Twenty-three patients required other therapies including double-J stenting, ureteroscopy, and nephrolithotomy. The patients without hydronephrosis and those with severe hydronephrosis [groups 1 and 4] showed a significant difference in the days to clearance of the calculus [mean, 31.7 days versus 85.6 days; P<0.001]. Patients with upper ureteral calculi and mild hydronephorsis can be effectively treated with solo SWL therapy. In those with moderate hydronephrosis, clearance takes longer or requires secondary interventions. In patients with severe hydronephrosis, we recommend alternative/adjunctive procedures

Emergency ureteroscopic management of acute calcular anuria

To study the outcome and complications of emergency ureteroscopy in management of acute calcular anuria. 35 patients with calcular anuria were included in the study. The mean age was 45 +/- 18 years with 30 male and 5 females. The diagnosis was based upon anuria associated with high serum creatinine and hydronephrosis detected by ultrasonography. KUB was done to detect radio-opaque stones and its location and size. Emergency ureteroscopy was done to all cases. Bilateral ureteric calculi were detected in 31 patients and unilateral ureteric calculus in 4 patients in whom the other kidney was surgically removed. The stones were localized in the distal ureter in 50 units and in the proximal ureter in 16 units. 60 stones were radio-opaque and 6 stones were radiolucent. The mean stone size was 9 +/- 3mm. The mean serum creatinine was 7.3 +/- 2.5 mg/100 ml. The stone free rate in the proximal ureteric stones was 50% and for the distal ureteric stones was 90%. The overall stone free rate was 80%. No complications were discovered after ureteroscopy to any case. The urine output increased dramatically immediately after treatment in all cases. The serum creatinine dropped to the normal level in all cases [1.2 +/- 0.4 mg/100 ml] in 6.9 +/- 1.8 days after treatment. The mean hospital stay was 2.8 +/- 1.3 days. Emergency ureteroscopy is a safe and an appropriate therapeutic option in the management of acute calcular anuria. It can save patients from a second procedure

Avaliação da concordância interobservador na análise da tomografia computadorizada sem contraste no diagnóstico da urolitíase em pacientes com cólica renal aguda / Interobserver agreement on non-contrast computed tomography interpretation for diagnosis of urolithiasis in patients with acute flank pain

OBJETIVO: Avaliar a reprodutibilidade da tomografia computadorizada sem contraste na avaliação da litíase ureteral e os sinais secundários de obstrução do sistema coletor em pacientes com cólica renal aguda. MATERIAIS E MÉTODOS: Estudo prospectivo de 52 pacientes com diagnóstico clínico de cólica renal aguda submetidos a exame de tomografia computadorizada de abdome sem contraste. Os exames foram realizados com técnica helicoidal e posteriormente analisados por três observadores independentes, com a concordância interobservador avaliada pelo método estatístico kappa (kapa). Foram analisados os parâmetros: a) presença, localização e mensuração dos cálculos ureterais; b) dilatação do sistema coletor intra-renal; c) heterogeneidade da gordura perirrenal; d) dilatação ureteral; e) edema da parede ureteral (sinal do halo). RESULTADOS: Foram encontrados 40 cálculos ureterais na tomografia computadorizada (77 por cento). A concordância interobservador para a identificação do cálculo ureteral e da dilatação ureteral foi quase perfeita (kapa = 0,89 e kapa = 0,87, respectivamente), substancial para dilatação do sistema coletor intra-renal (kapa = 0,77) e moderada para heterogeneidade da gordura perirrenal e para edema da parede ureteral (kapa = 0,55 e kapa = 0,56, respectivamente). CONCLUSÃO: A tomografia computadorizada de abdome sem contraste apresenta elevada reprodutibilidade na avaliação da litíase ureteral e dos sinais secundários de obstrução do sistema coletor.

OBJECTIVE: To evaluate the interobserver agreement on non-contrast computed tomography interpretation by a group of experienced abdominal radiologists, for the study of urolithiasis in patients presenting acute flank pain. MATERIALS AND METHODS: Prospective study of 52 patients submitted to non-contrast enhanced helical computed tomography. The images were subsequently analyzed by three independent observers, with the interobserver agreement assessed by means of the kappa (kappa) statistical method. The following parameters were analyzed: a) presence, localization and measurement of ureteral calculi; b) intrarenal calyceal system dilatation; c) perirenal fat heterogeneity; d) ureteral dilatation; e) ureteral wall edema (halo sign). RESULTS: Ureteral calculi were found in 40 of 52 patients (77 percent). The interobserver agreement was almost perfect as regards identification of ureteral calculi (kappa = 0.89) and ureteral dilatation (kappa = 0.87), substantial for calyceal system dilatation (kappa = 0.77), and moderate for perirenal fat heterogeneity (kappa = 0.55) and ureteral wall edema (kappa = 0.56). CONCLUSION: Non-contrast-enhanced abdominal computed tomography presents high reproducibility in the evaluation of urolithiasis and secondary signs of the calyceal system obstruction.

[ comparison between colour doppler ultrasonography and intravenous urography in diagnosis of ureteral obstruction due to ureteral stone]

Urinary stone is one of the most common cause ofureteral obstruction. Degree of obstruction has an important role in choosing time and method of treatment. The aim of this cross-sectional study is comparison between Color Doppler Ultrasound and Intravenous Urogram in diagnosis ofureteral obstruction in patients with ureteral stone. 35 patients with unilateral renal colic were studied from October 2004 to June 2005. In all patients the presence of stone in the ureter was confirmed by Sonography. Mean age was 36.9 +/- 9.1 years. After analgesia and determination of serum creatinin level, color Doppler ultrasound [CDU] was done with semi-distended bladder. Number, velocity, and duration of ureteral jets were observed in five minutes, bilaterally. Immediately after CDU, the patients were transferred to the next room to perform standard IVU. All data was recorded and analyzed with statistical methods.%71.4 of patients were male and 28% were female. Mean serum creatinine was 0.9 +/- 0.18 mg/dl. In all patients with complete ureteral obstruction in IVU, ureteral jets were diminished [42.1%] or absent [57.9%] in CDU. In patients with partial obstruction in IVU, diminished jets in CDU were noted in 86.7%; and only in 2 patients [13.3%] normal jets were seen. Number of jets in one minute was 0.84 +/- 1.46 in patients with complete obstruction, and 5.18 +/- 3.4 in partial obstruction [P<0.001]. There was a significant difference in velocity and duration of jets between complete and partial obstruction [P<0.01 and P<0.001 respectively]. The number, velocity, and duration of the jets in the normal side was not significantly different between the two groups of patients [P=0.31, P=0.51, and P=0.27 respectively]. This study showed that CDU can determine ureteral obstruction in renal colic patients in most cases. It is a safe, fast, and noninvasive test. CDU of ureteral jets is recommended as a functional test in renal colic patients

Prediction of differential creatinine clearance in chronically obstructed kidneys by non-contrast helical computerized tomography

PURPOSE: We investigate the use of non-contrast helical computerized tomography (NCHCT) in the measurement of differential renal parenchymal volume as a surrogate for differential creatinine clearance (CrCl) for unilateral chronically obstructed kidney. MATERIALS AND METHODS: Patients with unilateral chronically obstructed kidneys with normal contralateral kidneys were enrolled. Ultrasonography (USG) of the kidneys was first done with the cortical thickness of the site with the most renal substance in the upper pole, mid-kidney, and lower pole of both kidneys were measured, and the mean cortical thickness of each kidney was calculated. NCHCT was subsequently performed for each patient. The CT images were individually reviewed with the area of renal parenchyma measured for each kidney. Then the volume of the slices was summated to give the renal parenchymal volume of both the obstructed and normal kidneys. Finally, a percutaneous nephrostomy (PCN) was inserted to the obstructed kidney, and CrCl of both the obstructed kidney (PCN urine) and the normal side (voided urine) were measured two 2 after the relief of obstruction. RESULTS: From March 1999 to February 2001, thirty patients were enrolled into the study. Ninety percent of them had ureteral calculi. The differential CrCl of the obstructed kidney ( percentCrCl) was defined as the percentage of CrCl of the obstructed kidney as of the total CrCl, measured 2 weeks after relief of obstruction. The differential renal parenchymal volume of the obstructed kidney ( percentCTvol) was the percentage of renal parenchymal volume as of the total parenchymal volume. The differential USG cortical thickness of the obstructed kidney ( percentUSGcort) was the percentage of mean cortical thickness as of the total mean cortical thickness. The Pearson's correlation coefficient (r) between percentCTvol and percentCrCl and that between percentUSGcort and percentCrCl were 0.756 and 0.543 respectively. The regression line was percentCrCl = (1.00) x percentCTvol - 14.27. The percentCTvol overestimated the differential creatinine clearance by about 14 percent, but the correlation is good. CONCLUSION: The differential renal parenchymal volume measured by NCHCT provided a reasonable prediction of differential creatinine clearance in chronically obstructed kidneys.

Minimally Dilated Obstructive Nephropathy Initially Suspected as Pre-renal Azotemia in a Kidney Donor with Volume Depletion

Although ultrasonography is regarded as the gold standard in the diagnosis of obstructive nephropathy, dilatation is sometimes not observed by ultrasonography. We report upon a case of minimally dilated obstructive nephropathy due to an ureter stone in a kidney donor with volume depletion. A 54-year-old man was admitted due to anuria and abdominal pain of 2 days duration. Ten years previously, his right kidney was donated for transplantation, and one month before admission, he abstained from all food except water and salt, for 30 days for religious reasons. He had lost 8 kg of body weight. On admission, he had clinical signs of volume depletion, i.e., a dehydrated tongue and decreased skin turgor. Laboratory data confirmed severe renal failure, his blood urea nitrogen level was 107.3 mg/dL, and his serum creatinine 16.5 mg/dL. The plain X-ray was unremarkable and ultrasonography showed only minimal dilatation of the renal collecting system. On follow-up ultrasonography, performed on the 5th hospital day, the dilatation of the collecting system had slightly progressed and a small stone was found at ureter orifice by cystoscopy. Removal of stone initiated dramatic diuresis with a rapid return of renal function to normal by the third day.

Ureteroscopia: 15 años de experiencia / Ureteroscopy: 15 years experience

Se presenta la experiencia recogida en 15 años de realización de ureteroscopia rígida aplicada fundamentalmente al tratamiento de la litiasis uretral y en menor proporción a otras indicaciones. Con el objeto de homogenieizar la muestra en estudio se ha considerado únicamente la estadística extrahospitalaria. Se realizaron en total 335 ureteroscopias en 320 pacientes, de los cuales 312 (93,1 por ciento) correspondieron a litiasis, 3 (0,89 por ciento) a investiogación de hematurias unilaterales criptogénicas, 2 (0,59por ciento) a biopsias de tumores de urotelio, 2 (0,59 por ciento) a extracción de catéteres perdidos y 1 (0,29 por ciento) a tratamiento retrógrado de estenosis ureteropiélica. Se trata de un procedimiento de baja hospitalización (promedio 1,25 días) y de alta efectividad en el tratamiento de la litiasis uretral (90,77 por ciento de éxito). Las complicaciones intraoperatorias más frecuentes fueron: la imposibilidad de hallar (0,59 por ciento) o de dilatar (1,79 por ciento) al meato uretral, ascenso indeseado del cálculo al riñón (2,56 por ciento), y perforación extraperitoneal del uréter (1,60 por ciento). En el postoperatorio inmediato se produjeron ocasionalmente dolor, fiebre o hematuria, que remitieron en pocas horas con tratamiento adecuado. En los casos que tuvieron un correcto seguimiento no se pudieron objetivar las complicaciones alejadas citadas en la literatura, como lo son estrechez del meato o la existencia de reflujo vesicoureteral. Se convirtieron a cirugía abierta el 3,52 por ciento de la litiasis tratadas y se utilizó como rescate de las ondas de choque en un 9,29 por ciento de los casos. Su utilización prudente se acompaña de baja morbilidad por lo que se ha constituido en un recurso definitivamente incorporado al armamentorio urológico

Rotura espontânea bilateral das vias coletoras, por cálculo de ureter / Spontaneous bilateral urinary tract rupture due to ureteral calculi

A rare case of bilateral ureteral lithiasis associated with bilateral rupture of the urinary tract in a 34-year-old male is presented. The patient was admitted with renal failure and bilateral retroperitoneal urinoma. An endoscopic approach with bilateral ureteral catheterization with a double-J stent was used. After stabilization of renal failure and complete reabsorption of the urinoma, extracorporeal shock wave lithtripsy with was performed the stents in place. After 2 months, both stents were removed and the stones have been completely eliminated. Urinary lithiasis and ureteral tumors are the most common causes of urinary rupture. Emergency drainage of the urinary tract may be necessary. Urinoma often has a spontaneous absorption. It is unwise to attempt extraction of stones in patients with bilateral obstruction and acute renal failure as this can lead to serious complications. The renal failure must be resolved first and the stones managed afterwards

Ureterolitotripsia endoscópica en paciente embarazada. Presentación de un caso y revisión de la literatura / Endoscopic ureterolithotripsy in a pregnant women: report of a case and literature review

Se presenta un caso de ureterolitotripsia endoscópica delñ tercio inferior en una paciente embarazada con 12 semanas de gestación, de 30 años de edad. El cálculo medía 12 x 6 mm, y se utilizó ureteroscopia semirrígido de calibare 6.9 francés. La fragmentación del cálculo tuvo muy buenos resultados. Se dejó colocado un catéter "doble J", el cual se retiró tres semanas después. Expulsó múltiples arenillas, y cursó sin complicaciones hasta esa fecha