Female urethral duplication: an unusual condition.

We present the case of a 34-year-old woman who presented with a stone fragment stuck near her distal urethra without obstruction of her urinary flow. During an attempt to explore and remove the fragment, she was discovered to have complete urethral duplication with the stone stuck in one of two distal urethral orifices. This represents an extremely rare variant of a very unusual congenital anomaly, even more so as it occurs usually in male patients. Embryology, etiology, and clinical appearance of this rare anomaly are discussed.

Repositioning and removal of an intra-renal migrated ureteric Memokath stent.

The increasing use of ureteric stents including permanent ones is not without their own set of problems. The authors describe the difficulties encountered and a novel technique to reposition a permanent ureteric stent migrated into the kidney with an illustrated case. The same technique can also be applied to a-traumatically remove the stent if required.

The unbreakable bladder stone--Munchhausen's tale.

A wide range of intra-vesical foreign bodies have been described in the literature. Causes include iatrogenic, migration from adjacent organs, penetrating injuries and self-insertion, either due to eroticism, inquisitiveness or as a result of a psychiatric illness. We present an unusual case of fictitious bladder stones that proved unbreakable using all standard endourological techniques.

Evaluation of the mechanisms of damage to flexible ureteroscopes and suggestions for ureteroscope preservation.

AIM: To investigate the causes and costs of flexible ureteroscope damage, and to develop recommendations to limit damage. METHODS: The authors analysed repair figures and possible causes of damage to 35 instruments sent for repair to a leading UK supplier over a 1-year period, and calculated cost figures for maintenance of the instruments as opposed to repair and replacement costs. RESULTS: All damages were handling-induced and therefore did not fall under the manufacturer's warranty: 28 % were damaged by misfiring of the laser inside the instrument; 72 %, mainly crushing and stripping of the ureteroscope shaft tube, were likely to have occurred during out-of-surgery handling, washing and disinfection. Seventeen (4 %) instruments were not repaired and consequently taken out of service due to the extensive costs involved. Eighteen (51 %) ureteroscopes were repaired at an average cost of 10 833 USD. CONCLUSION: Damages to flexible ureteroscopes bear considerable costs. Most damages occur during handling between surgical procedures. Thorough adherence to handling procedures, and courses for theater staff and surgeons on handling flexible instruments may help to reduce these damages and prove a cost-saving investment. The authors provide a list of recommended procedural measures that may help to prevent such damages.

The prevalence of silent kidney stones--an ultrasonographic screening study.

OBJECTIVE: Silent and not yet discovered stones of the upper urinary tract are potentially dangerous, since in due course they may cause infection, obstruction and renal damage. The aim of this study was to determine the prevalence of such silent kidney stones in a representative Pakistani population of Karachi. SUBJECTS AND METHODS: We studied 201 consecutive subjects at our hospital who underwent additional kidney screening whilst undergoing abdominal ultrasound. All these subjects did not have a history or symptoms of urolithiasis. RESULT: We found silent kidney stones in 3% of subjects. All stone bearers were males. Most stones were in the left kidney. Notably, multiple stones and stones of a considerable size went unnoticed. CONCLUSION: In addition to the usual figures of incidence and prevalence of stone disease drawn from patient data, there is a prevalence of 3% silent stones that may only be discovered incidentally or by screening. This is true for a "'stone country" like Pakistan. Figures for other regions have yet to be determined. Due to socioeconomic reasons, we believe that a general kidney screening for urolithiasis is, however, not indicated, at least in our country.

The radiolucent ureteric calculus at the end of a contrast-medium column: where to focus the shock waves.

OBJECTIVE: To compare the outcome of two different targeting strategies for treating radiolucent ureteric calculi by extracorporeal shock wave lithotripsy (ESWL), focusing the shock waves either at the end or 5 mm beyond the column of contrast medium visible in the ureter. PATIENTS AND METHODS: A total of 156 patients undergoing ESWL for a radiolucent ureteric stone were randomized into two groups. Group 1 comprised 74 patients in whom the shock waves were focused on the end of the contrast medium column, and group 2 comprised 82 patients in whom the shock waves were focused 5 mm beyond the end of the column. RESULTS: Both groups had comparable distributions of age, gender, treatment methods and stone characteristics. There were no adverse reactions to the contrast medium. The stone-free rate after 2 months was 17% greater in group 2 (91%) than in group 1 (74%; P < 0.05). CONCLUSIONS: The administration of intravenous contrast medium for ESWL of radiolucent ureteric calculi is effective and safe. We recommend that the shock waves are focused 5 mm beyond the end of the column of contrast medium, except where a stone becomes clearly visible within the column.

Shock wave lithotripsy treatment of radiolucent ureteric calculi with the help of contrast medium.

OBJECTIVE: Extracorporeal shock wave lithotripsy (SWL) treatment of radiolucent ureteric calculi (UC) is hampered by the reduced visibility of the stone. Intravenous contrast medium (IV-CM) administration may overcome this problem by indirectly depicting the localisation of the stone. However, IV-CM administration bears known risks. The aim of this study was to compare the clinical outcome after SWL in two representative groups of patients with either radiolucent or radio-opaque UC. METHODS: Two groups of patients, 156 with a radiolucent UC and 203 with a radio-opaque UC, were assessed with regard to age, gender, treatment modalities, auxiliary measures, complications, stone properties and stone-free rate 3 months after treatment. RESULTS: Both groups were comparable with regard to epidemiology, treatment and clinical outcome. In both groups, stone-free rates were well within the percentages described by other investigators. There were no adverse reactions to CM. CONCLUSIONS: The clinical outcome of SWL treatment for radiolucent ureter stones does not differ from that for radio-opaque ureter stones. Being a non-invasive treatment, SWL with the help of IV-CM administration should be the first-line therapy for radiolucent ureter stones. Although awareness of possible adverse reactions to CM is mandatory, the risk remains small.

Double infundibular obliteration with abscess formation after percutaneous nephrolithotomy.

A case of an unusual complication after percutaneous nephrolithotomy. After removal of an infectious staghorn calculus followed by SWL, the patient developed a double infundibular stricture leaving the kidney divided into three separate compartments. In spite of the absence of clinical symptoms of infection, this was further complicated by abscess formation and finally, function loss of the upper part of the kidney. Combined retro- and anterograde endoscopic surgery failed to re-establish the complete continuity of the uretero-caliceal system and the patient had to undergo partial nephrectomy. Possible etiologies, contributing factors and means of prevention for this rare complication are discussed.

Genitourinary tuberculosis: a profile of 55 in-patients.

OBJECTIVE: To outline the pattern and trends in major cases of genito-urinary tuberculosis (GUTB) which require hospital treatment. METHOD: We retrospectively reviewed 55 patients with proven GUTB who were treated as in-patients in a major referral hospital in Pakistan. RESULTS: The male/female ratio was 3:1. Prevailing symptoms were lower urinary tract symptoms, flank pain, gross hematuria and fever. A urine culture was positive for tuberculosis (TB) in 57%, bladder biopsies in 54%. For renal TB, intravenous urogram (IVU) and ultrasound were suggestive in about 50% of cases. Ultrasound was very helpful in the diagnosis of testicular TB. Patients underwent surgery in 36% of cases. In contrast to the general trend reported worldwide, surgery was mainly ablative rather than re-constructive. Patient compliance in clinical follow-up and drug therapy was poor. CONCLUSION: Surgery for GUTB in Pakistan is still mainly ablative, probably due to a high number of complicated and progressed cases. To date, therapy of GUTB is mainly based on anti-tuberculosis chemotherapy (ATT). However, huge efforts will be required to improve patient compliance without which every therapeutic approach will remain futile.

Three-dimensional CT scan stone reconstruction for the planning of percutaneous surgery in a morbidly obese patient.

A three-dimensional spiral CT (3D CT) reconstruction of staghorn stones provides a precise picture of its extent and branching within the kidney. The author reports a case of a large renal staghorn stone in a morbidly obese woman, further complicated by malrotation and hypermobility of the kidney. Two-dimensional plain CT was unable to provide sufficient information for a safe percutaneous approach. This was achieved by means of 3D CT, which also was very helpful during the procedure. Although 3D CT should by no means be routinely employed, it is a valuable tool for pretreatment decision-making and intraoperative orientation in selected cases.

Ultrasonographic renal size in individuals without known renal disease.

OBJECTIVE: In order to establish some preliminary data of our population, we determined the ultrasonographic kidney dimensions in individuals without known renal disease. We assessed whether age, sex, side, body mass index (BMI) and presence or absence of diabetes mellitus and hypertension affect the renal size. METHODS: Ultrasonographic kidney measurements were performed on 194 adult patients without known kidney lesions. Measurements included length, width, cortical thickness and estimation of renal size which was obtained by multiplying the first three variables. The effect of age, gender, side, height, weight, BMI, hypertension and diabetes mellitus was statistically analyzed. RESULTS: The mean kidney length was 10.4 +/- 0.8 cm, mean with 4.5 +/- 0.6 cm and mean cortical thickness 1.6 +/- 0.2 cm. The estimated mean renal size was 76 +/- 22 cm3. Kidney length did not significantly differ between right and left, however, kidney width, cortical thickness and size did (p < 0.05). Right kidneys were smaller than the left ones. In univariate analysis, the mean renal size correlated with age, sex, side, BMI and absence or presence of hypertension and diabetes mellitus. In a multivariate analysis, however, the only significant factors affecting renal size were sex and BMI. CONCLUSION: We conclude that renal size is related to age, side, sex and the individual's height and weight. Population-based studies are needed to establish the normal values for the Pakistani population.

Reduction of radiation exposure to patients in the follow-up of shockwave lithotripsy.

OBJECTIVES: To assess, in patients undergoing extracorporeal shock wave lithotripsy (ESWL), if a policy of using unilateral X-rays of the kidney, ureter and bladder (hemi-KUB) whenever possible and appropriate during diagnosis and follow-up, was successful in reducing the radiation exposure associated with ESWL. PATIENTS AND METHODS: Two groups of patients of statistically comparable size and demography were assessed retrospectively before and after the implementation of the policy. All had undergone ESWL for radio-opaque upper urinary tract stones and all were finally rendered stone-free. The number and type of all radiological procedures from initial diagnosis of the stone to documented stone-free status were recorded and the dose calculated. RESULTS: The appropriate use of hemi-KUB X-rays resulted in a significant mean reduction of radiation exposure after treatment of 2.28 mSv per patient (P<0.05). Furthermore, as expected, the radiation dose was clearly but not closely correlated with stone size (r = 0.419). CONCLUSIONS: The appropriate use of hemi-KUB X-rays during the follow-up after ESWL is a simple and effective way of significantly reducing the radiation exposure of such patients.

Water as an irrigant in transurethral resection of the prostate: a cost-effective alternative.

The safety of water as an irrigant solution in transurethral resection of the prostate (TURP) has been a controversial issue. Although it has been mostly abandoned in more affluent countries, it is still widely used in developing countries simply because of financial reasons. With this study, we attempted to show in a representative number of cases that this method can be applied without major fluid absorption, as would be indicated by changes in sodium (Na), creatinine (Crea), blood urea nitrogen (BUN), and free haemoglobin (fHb) levels in serum. Prospectively, we assessed the occurrence of clinical symptoms of TUR-syndrome, as well as changes in serum parameters in 60 patients irrigated during TURP with sterile water. Values of patients with some degree of resorption, as indicated by a drop in serum sodium, were compared to patients without any resorption. There was no TUR-syndrome in our patients, and serum levels of all parameters did not change significantly after TURP with water. Patients with a drop in sodium post-TURP did not have significant changes in Crea, BUN or fHb. The average saving was 162.60 USD per treatment. In our study population, water was a safe irrigation solution. Even with some degree of resorption, there were no significant haemolysis or metabolic imbalances. Saving for the patient are considerable and render the treatment affordable.

The effect of warfarin therapy on the charge properties of urinary prothrombin fragment 1 and crystallization of calcium oxalate in undiluted human urine.

Urinary prothrombin fragment 1 (UPTF1) is the principal protein in calcium oxalate (CaOx) crystals precipitated from human urine and is a potent inhibitor of CaOx crystallization, a property that should depend, at least in part, upon the extent of gamma-carboxylation of the 10 glutamic residues in its N-terminal region. Warfarin therapy limits full gamma-carboxylation of vitamin K-dependent proteins, including UPTF1. The aims of this study were to determine the effect of warfarin therapy on UPTF1, its occlusion into CaOx urinary crystals, and its influence on the crystallization of CaOx in undiluted human urine. In the first part of the study, urines were collected from six men prior to cardiac surgery and after stabilization on long-term warfarin treatment. Proteins in the urines and in the matrix of CaOx crystals precipitated from them were analyzed by two-dimensional SDS-PAGE and Western blotting. In urine, at least two charge variants of UPTF1 with low isoelectric point (pI) values were detected before and during warfarin therapy, but additional higher pI forms of the protein were also seen during anticoagulation. Nonetheless, the majority of UPTF1 was present in the more fully gamma-carboxylated state. CaOx crystals precipitated from the same urine samples contained only low pI forms of UPTF1. The effect of warfarin treatment on CaOx crystallization in urine was tested by collecting two consecutive 24-h urine samples from 16 men prior to cardiac surgery and during subsequent warfarin treatment. CaOx crystallization was induced in each sample by the addition of sodium oxalate. The size and volume of the particles deposited were determined using a Coulter counter, and the crystals were examined by scanning electron microscopy (SEM). There were no significant differences between the urinary metastable limits before or during warfarin treatment or in the total volume of crystals precipitated. A slight increase in the mean diameter of the crystalline particles precipitated from the urines during anticoagulant therapy was not significant. SEM showed little evidence of changes in overall particle size, although individual crystals of CaOx tended to be larger during warfarin treatment. It was concluded from these studies that the binding of UPTF1 to CaOx crystal surfaces is related to the degree of gamma-carboxylation of its Gla domain, which would also influence the protein's inhibitory effects on CaOx crystallization. However, during warfarin therapy the majority of UPTF1 exists in a highly charged state, indicating that it is completely, or almost completely, gamma-carboxylated, which would explain the lack of any difference between CaOx crystallization parameters in the urine of subjects before and during warfarin administration. We conclude that physiologically significant reductions in the inhibitory potency of UPTF1 would be likely to occur only as a result of proscription of gamma-carboxylation more extensive than that induced by warfarin.

The role of ureteral stent placement in the prevention of Steinstrasse.

BACKGROUND AND OBJECTIVE: Steinstrasse constitutes a potentially serious complication of extracorporeal shock-wave lithotripsy (SWL). Ureteral stent placement has been used to prevent Steinstrasse after fragmentation of larger stones. However, particularly more recently, its preventive efficacy has been questioned. The aim of this study therefore was to analyze the role of ureteral stent placement in the prevention of Steinstrasse. METHODS: We analyzed data of 1087 patients who had been treated with a Wolf Piezolith 2300 in the General Infirmary in Leeds/UK for stones ranging from 10 to 95 mm in diameter. RESULTS: The incidence of Steinstrasse was 6.3%. The likelihood was significantly correlated with the stone size and was significantly less in patients with stones >20 mm if a stent had been inserted prior to SWL. Moreover, in these patients, the risk of acute clinical symptoms in the event of Steinstrasse was greatly reduced, and the treatment could be continued safely in the majority of cases (86%). Treatments of the Steinstrasse itself with SWL resulted in its clearance in most of the cases (78%). It was always possible to clear even extended persistent Steinstrasse by laser lithotripsy. CONCLUSION: These results provide a clear indication for the pre-SWL insertion of a ureteral stent in patients with stones >20 mm in diameter. In the event of Steinstrasse, SWL of the collection should be tried before more invasive endourologic procedures are considered.

Carcinoma in a bladder diverticulum: the place of diverticulectomy.

A carcinoma within a vesical diverticulum represents a therapeutic challenge because it has generally a poor prognosis, and unambiguous guidelines for its therapy are not at hand. The authors report their experience with two low-grade single and confined tumours which were treated by simple diverticulectomy. Both patients remained tumour-free after 2 and 4 years of follow-up, respectively. The literature has been reviewed to assess the state of the art approach for such tumours. Whereas simple diverticulectomy may be indicated in selected, confined cases, an aggressive approach combining surgery and radio- and/or chemotherapy is recommended in the majority of vesical diverticulum tumours.

Urolithiasis in pregnancy--a clinical challenge.

Symptomatic urolithiasis in pregnancy is a rare event. We present a series of 13 cases. Although controversial, we think that X-rays should be avoided if possible. Ultrasound may not be the perfect diagnostic tool in every case of stone disease, however in pregnancy it is the imaging of choice and led to an accurate diagnosis in all our cases. Thirty-eight percent of the patients were managed conservatively throughout their pregnancy, and another thirty-eight percent of our patients needed more extended treatment but could be managed by simple insertion of a double J ureteric stent (DJ). Therefore, in our series invasive treatment was not necessary in the majority of patients. Each one patient required a percutaneous nephrostomy (PCN) and a nephrectomy for a non-functional pyonephrotic kidney. Urolithiasis in pregnant women constitutes a challenge for the treating urologists since they are deprived of some of their essential tools, such as X-rays and extracorporeal shock wave lithotripsy (ESWL), and since normally tolerable complications of less invasive treatments can have disastrous consequences in pregnant patients. Therefore, decisions on any kind of treatment have to be made very prudently and critically. We present an algorithm for the management of stones in pregnancy which may be helpful in decision making.