Micro-elemental analysis and characterization of major heavy metals and trace elements in the urinary stones collected from patients living in diverse geographical regions.

In the process of urinary stone formation, several heavy metals and trace elements (HMTE) have been identified among the major constituents of the calculi. The micro-elements within the stones cannot be identified by ordinary laboratory analytical techniques, the latter can only detect the major crystalline component. The objective of the present study was to evaluate the different types of HMTE (no. 22) and their concentrations within the urinary stones. The stone samples were obtained from patients living in different geographical locations (10 countries: 5 Western and 5 non-Western). The number of retrieved stones after open or endoscopic procedures was 1177. The concentrations of the 22 HMTE in the stones were assessed by inductively coupled plasma optical emission spectrometry (ICP-OES). The statistical data were analyzed using Kruskal-Wallis, one-way ANOVA, and SPSS software (version 20). The biochemical stone analysis showed that calcium oxalate was present as a major component in 650 patients (55.2%), calcium phosphate in 317 (26.9%), and uric acid and cystine stones in 210 (17.8%). The analyzed stones showed the presence of HMTE in different concentrations. Significantly higher concentrations of 17 elements (Al, As, Ba, B, Ca, Cd, Co, Cr, Cu, Fe, Mn, Ni, Pb, S, Se, Sr, and Zn) were noted in all stones. Seven elements (Al, As, Se, Sr, Fe, Zn, and Ni) were present in higher concentrations in calcium-based stones. In comparison, eight elements (Mg, B, Ba, Cd, Se, Pb, Sr, and Zn) in higher concentrations were associated with phosphate-based stones. Both uric acid and cystine stones had a higher concentration of sulfur. The concentrations of HMTE in calcium phosphate stones were higher than in calcium oxalate and uric acid stones. Calculi obtained from patients living in western countries contained higher levels of 13 HMTE (B, Ba, Ca, Cd, Co, Cu, Fe, K, Mg, Mo, P, Pb, and Se) than those in non-western countries. The age of calculi-forming patients from non-western countries was younger than those living in western countries. These results may indicate the role of many significant heavy metals and trace elements in the pathogenesis of urinary stone formation. The types and contents of HMTE within urinary stones differ from one country to another. The conventional stone analysis techniques cannot either identify the stone micro-elements or the concentrations of HMTE, so a specific and additional instrument such as the ICP-OES is necessary. Further research work on the urinary stone micro-elemental structure could lead to a new strategy for the prevention of stone formation and recurrence.

Quantitative and qualitative evaluation of toxic metals and trace elements in the tissues of renal cell carcinoma compared with the adjacent non-cancerous and control kidney tissues.

Toxic metals and trace elements (TMTE) are linked to the development of several human cancers. Many reports have documented the association between some TMTE and renal cell carcinoma. In this work, we assessed the presence (qualitative) and evaluated the concentration (quantitative) of 22 TMTE in three groups of kidney tissue samples: renal cell carcinoma (RCC), adjacent non-cancerous, and control kidney tissues from cadavers. A total of 75 paired specimens of RCC and adjacent non-cancerous tissues were harvested immediately after radical nephrectomy and preserved in 10% diluted formalin solution. Twelve specimens, age- and sex-matched from the normal kidney tissue of the cadavers, who died from non-cancerous reasons, were collected and served as control. All tissue specimens were subjected to evaluation of TMTE concentration (22 elements in each specimen) by using the inductively coupled plasma optical emission spectrometry (ICP-OES) technique. The tumor, histopathology, stage, and grade were correlated with the concentration and types of TMTE. The results showed that the histological types of RCC were as follows: clear cell type in 35 (21.5%), chromophobe 22 (13.5%), papillary 7 (4.5%), oncocytoma 5 (3.1%), and unclassified 6 (3.7%). ICP-OES revealed that tumorous (RCC) tissues had a higher concentration of 9 TMTE (Ca, Cd, K, Mg, Mn, Na, Pb, S, and Sr) compared with both the adjacent non-cancerous and control tissue. The adjacent non-cancerous kidney tissues showed the highest concentration of Fe, K, and Na. The control of kidney tissues from cadavers had the highest level of Cu, Zn, Mo, and B compared with the cancerous and adjacent non-cancerous tissues. Female patients had higher concentrations of Zn and Cu in the non-cancerous tissues of their kidneys. Younger patients had a higher concentration of B in the adjacent non-cancerous, and higher Cu in the cancerous tissues. Cadmium concentration was highest in the chromophobe cell type of RCC compared with other subtypes. There was no correlation between the TMTE concentration and the pathological stage of RCC.

Quantitative Evaluation of Heavy Metals and Trace Elements in the Urinary Bladder: Comparison Between Cancerous, Adjacent Non-cancerous and Normal Cadaveric Tissue.

The role of heavy metals and trace elements (HMTE) in the development of some cancers has been previously reported. Bladder carcinoma is a frequent malignancy of the urinary tract. The most common risk factors for bladder cancer are exposure to industrial carcinogens, cigarette smoking, gender, and possibly diet. The aim of this study was to evaluate HTME concentrations in the cancerous and adjacent non-cancerous tissues and compare them with those of normal cadaveric bladder. This prospective study included 102 paired samples of full-thickness cancer and adjacent non-cancerous bladder tissues of radical cystectomy (RC) specimens that were histologically proven as invasive bladder cancer (MIBC). We used 17 matched controls of non-malignant bladder tissue samples from cadavers. All samples were processed and evaluated for the concentration of 22 HMTE by using Inductively Coupled Plasma Optical Emission Spectrometry (ICP-OES). Outcome analysis was made by the Mann-Whitney U, chi-square, Kruskal-Wallis, and Wilcoxon signed ranks tests. When compared with cadaveric control or cancerous, the adjacent non-cancerous tissue had higher levels of six elements (arsenic, lead, selenium, strontium, zinc, and aluminum), and when compared with the control alone, it had a higher concentration of calcium, cadmium, chromium, potassium, magnesium, and nickel. The cancerous tissue had a higher concentration of cadmium, lead, chromium, calcium, potassium, phosphorous, magnesium, nickel, selenium, strontium, and zinc than cadaveric control. Boron level was higher in cadaveric control than cancerous and adjacent non-cancerous tissue. Cadmium level was higher in cancerous tissue with node-positive than node-negative cases. The high concentrations of cadmium, lead, chromium, nickel, and zinc, in the cancerous together with arsenic in the adjacent non-cancerous tissues of RC specimens suggest a pathogenic role of these elements in BC. However, further work-up is needed to support this conclusion by the application of these HMTE on BC cell lines.

A Prospective Comparative Study of Color Doppler Ultrasound with Twinkling and Noncontrast Computerized Tomography for the Evaluation of Acute Renal Colic.

PURPOSE: We performed a prospective comparison of the use of twinkling color Doppler ultrasound and noncontrast computerized tomography in the diagnosis of renal colic in emergency room patients. MATERIALS AND METHODS: A total of 815 consecutive adult patients with suspected renal colic presented to the emergency room and were evaluated immediately with color Doppler ultrasound and noncontrast computerized tomography. The site, side and maximum transverse diameter of the stones were assessed. The patients were followed for 4 to 8 weeks. RESULTS: Of 815 patients 723 (88.72%) had ureteral stones, 60 (7.36%) had kidney stones and 32 (3.93%) had pain from extra-urinary causes. Mean patient age was 37.17±11 years. Of the 723 patients with ureteral stones 619 (85.6%) were male and 104 (14.4%) were female. The stones were located on the right side in 340 (47%) patients and on the left side in 383 (53%). Color Doppler ultrasound successfully identified the stones in 702 (97.1%) patients and failed in 21 (2.9%). Noncontrast computerized tomography confirmed stones in 720 (99.6%) patients and was negative in 3 (0.4%). The diagnosis was 166 (23%) upper ureter stones, 63 (8.7%) in the middle and 494 (68.3%) in the lower ureter. The color Doppler ultrasound results were significantly affected by the stone site and maximum transverse diameter (p = 0.03 and 0.007, respectively). CONCLUSIONS: The initial use of color Doppler ultrasound in the emergency room has led to the diagnosis and characterization of ureteral stones in the majority of patients. Color Doppler ultrasound results were comparable to those of the concomitant use of noncontrast computerized tomography. Therefore, color Doppler ultrasound can replace noncontrast computerized tomography in the emergency room.

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.

A correlation study between macro- and micro-analysis of pediatric urinary calculi.

OBJECTIVE: The aim was investigate the relationship between macro- and micro-compositions of pediatric urinary stones by using two combined analytical techniques: Fourier transform infrared spectroscopy (FT-IR) and inductively coupled plasma-optical emission spectrometry (ICP-OES). MATERIALS AND METHODS: A total of 74 consecutive urinary calculi were collected from children. Each stone was divided into two equal portions. One part was analyzed by FT-IR to determine mineralogical composition. The second part underwent analysis by ICP-OES to determine the heavy metals and trace elements contents. The association between mineralogical components and elemental contents was evaluated. RESULTS: The percentages of mineralogical components of the stones were 78.3% calcium oxalate monohydrate, 63.5% calcium oxalate dihydrate, 24.3% ammonium urate, 13.5% uric acid, 10.9% dahllite, 12.1% brushite, 8.1% ammonium calcium phosphate, 8.1% struvite, 4.5% cysteine, and 2.7% were xanthine. There were seven elements with significant different high concentrations; magnesium, sulfur, strontium, lead, chromium, calcium, and phosphorous. High calcium-containing stones had significant higher contents of magnesium, lead, strontium, and zinc (p<0.05) than low calcium-containing stones. Phosphate stones had significant contents of magnesium, strontium, zinc and chromium when compared to other stones (p<0.05). CONCLUSIONS: Pediatric urinary stones have variable biochemical structures. The stones contained many significant heavy metals and trace elements in different concentrations, and phosphate stones enclosed most of the heavy and trace elements.

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. .

Prognostic factors predicting successful response to sildenafil after radical cystoprostatectomy.

OBJECTIVES: To assess the efficacy and safety of sildenafil citrate in the management of erectile dysfunction (ED) following radical cystectomy (RC) and to define the different prognostic factors predicting the response to sildenafil in such a challenging group of patients. MATERIAL AND METHODS: One hundred patients with ED following RC participated in an open-label, non-randomized, prospective, dose-escalation study. The median age of the patients was 53 years and the mean period after RC was 80.7 +/- 54.8 months. The study duration was 12 weeks, comprising a 4-week run-in period followed by two active treatment periods of 4 weeks each with 50 and 100 mg of sildenafil. Patients were assessed by means of the International Index of Erectile Function (IIEF) questionnaire at baseline and after each treatment period. At the end of the study, the Global Efficacy Assessment Question was used to evaluate treatment satisfaction. Factors affecting the patient's response to sildenafil were assessed by means of uni- and multivariate analysis. RESULTS: The entire study group was suffering from severe ED at baseline, with a mean erectile function (EF) domain score of 6.5 +/- 0.93. EF scores improved to 12.2 +/- 7.76 and 18 +/- 10.3 with 50 and 100 mg of sildenafil, respectively. Sildenafil therapy significantly improved the ability of many patients to achieve and maintain an erection. The mean scores for question 3 of the IIEF were 1 +/- 0.14, 2.1 +/- 1.4 and 3 +/- 1.8 at baseline and with 50 and 100 mg of sildenafil, respectively, while the corresponding scores for question 4 were 1 +/- 0.10, 1.9 +/- 1.35 and 3 +/- 1.85. The satisfaction rate was 54%. The response was dose-dependent but the incidence of adverse effects increased from 6% with 50 mg of sildenafil to 34% with 100 mg. In univariate analysis, tumor histology and grade and postoperative partial tumescence were found to significantly impact the patient's response to sildenafil. In multivariate analysis, postoperative partial tumescence was the only independent predictive variable. CONCLUSIONS. Sildenafil was found to be a safe and satisfactory treatment for post-RC ED. The effect was dose-related. Patients with postoperative partial tumescence were the best responders.

Determination of the chemical composition of urinary calculi by noncontrast spiral computerized tomography.

Various techniques for noncontrast spiral computerized tomography (NCCT) were utilized for the determination of the Hounsefield unit (HU) values of various types of urinary calculi with the aim of determining the best technique for distinguishing various stones compositions. A total of 130 urinary stones, obtained from patients who underwent open surgery, were scanned with a multidetector row scanner using 1.25 mm collimation at two energy levels of 100 and 120 kV at 240 mA. Two post-scanning protocols were used for the HU value assignment, tissue and bone windows, for both kV values. In both protocols, three transverse planes were defined in each stone, one near the top, one in the middle, and one near the bottom. Three regions of interest (ROI) were obtained in each plane. The absolute HU value was determined by three methods: the mean of the nine ROI, the mean of the central three ROI, and the central ROI in the middle plane. Determination of the stones' composition was performed using the absolute HU value measured at 120 kV, the dual CT values (HU values at 100 kV-HU values at 120 kV), and HU values/stone volume ratio (HU density). All stones were analyzed by x-ray diffraction to determine their chemical composition. After the exclusion of groups with few calculi, 47 pure stones [25 uric acid (UA), 15 calcium oxalate monohydrate (COM), seven struvite], and 60 mixed stones [15 COM 60-90%+hydroxyl apatite (HA), 14 COM 40-90%+UA, 21 UA+COM <40%, ten mixed struvite+COM+hydroxyl apatite] were included in the statistical analysis. From the least to the most dense, the pure stone types were UA, struvite, COM. Mixed UA+COM<40% calculi were less dense but insignificantly different from pure UA, while when the COM ratio was > or =40% their density became higher than and significantly different from pure UA, and less than but not significantly differentiated from pure COM. Mixed COM+HA were the most dense stones. Using the absolute HU values at 120 kV and HU density, we could distinguish, with statistical significance, all pure types from each other, pure UA from all mixed calculi except UA+COM <40%, pure COM from mixed UA+COM <40%, and pure struvite from all mixed stones except mixed struvite stones. Dual CT values were not as good as absolute HU values and HU density in the determination of stone composition. These results demonstrate that absolute HU values and HU density derived from CT scanning using a small collimation size could uncover statistically significant differences among all pure and most of the mixed urinary stones. This permits more accuracy in the prediction of stone composition. Moreover, this technique permits diagnostic conclusions on the basis of single CT evaluation.

Prognostic factors for extracorporeal shock-wave lithotripsy of ureteric stones--a multivariate analysis study.

OBJECTIVE: To define factors that have a significant impact on the stone-free rate after extracorporeal shock-wave lithotripsy (ESWL) of ureteric stones using multivariate analysis. MATERIAL AND METHODS: Between February 1992 and February 2002, a total of 938 patients with ureteric stones were treated with in situ ESWL using the Dornier MFL 5000 lithotripter. The outcome of treatment was evaluated after 3 months and failure was defined as the presence of any residual stones. The stone-free rate was correlated with patient characteristics (age, sex and radiological renal picture) and stone features (site, side, length, width, nature, opacity and the presence of ureteral stents). Factors with a significant impact on the stone-free rate using the chi (2) test were further analyzed using multivariate analysis. RESULTS: Overall, the stone-free rate was 88.7%. Repeat treatment was required in 50.4% of cases. Post-ESWL complications were observed in 32 cases (3.4%), including static steinstrasse in 19 (2%). Auxiliary procedures were needed in 28 cases (3%). Using the chi (2) test, only three factors had a significant impact on the stone-free rate, namely stone site, the transverse diameter of the stone and the presence of a ureteral stent. The stone-free rate was highest for stones located in the lumbar ureter (436/470; 92.8%) and lowest for those located in the pelvic ureter (268/324; 82.7%) (p = 0.0017). Stones with a transverse diameter of < or =1 cm were associated with a stone-free rate of 89.7% (715/797), compared to 83% (114/141) for those with a transverse diameter of >1 cm (p = 0.017). Non-stented patients had a stone-free rate of 89.8% (732/815), compared to 81.3% (100/123) for stented patients (p = 0.006). On multivariate analysis, these three factors maintained their statistical significance. A logistic regression model was designed to estimate the probability of stone-free status after ESWL. CONCLUSION: The site and transverse diameter of the stone and the presence of a ureteral stent are the only significant predictors of success of ESWL therapy for ureteric stones.

Prospective randomized comparative study of the effectiveness and safety of electrohydraulic and electromagnetic extracorporeal shock wave lithotriptors.

PURPOSE: We compared the efficacy of 2 shock wave energy sources, electrohydraulic (Dornier MFL 5000, Dornier MedTech, Wessling, Germany) and electromagnetic (DLS, Dornier Lithotriptor S, Dornier MedTech), for the treatment of urinary calculi. MATERIALS AND METHODS: A prospective randomized study of 694 patients with urinary stones was conducted during 12 months to compare the efficacy of the 2 machines. Entrance criteria were radiopaque single or multiple stones at any location within the kidney or the ureter, 25 mm or smaller that had not previously been treated by any means. Patients with congenital anomalies were excluded from this study with all other contraindications for extracorporeal shock wave lithotripsy. Following lithotripsy a plain abdominal film and tomograms were done 1 week after each session to determine if there were residual stones and assess the need for re-treatment. Patients were evaluated 4 weeks after lithotripsy by plane abdominal x-ray and spiral computerized tomography. Success was defined as no residual stones. Univariate and multivariate statistical analyses were performed for different variables that may have an impact on the success rate, including the type of lithotriptor. Comparisons of treatment parameters, complications and success rate for both lithotriptors were done. RESULTS: Of 9 variables examined with univariate analysis 6 had a significant impact on the success rate. Of these 4 maintained their statistical impact on multivariate analysis. These were side, site of the stones, renal morphology and type of lithotriptor. Treatment time was significantly shortened for DLS (54 +/- 32.9 minutes compared to 65.7 +/- 44.7 for MFL, p <0.001). The re-treatment rate was lower for DLS at 34% versus 51.6% for the MFL (p <0.001). The overall success rate was 85.4%. It was 88.5% for DLS compared to 82.4% for MFL (p = 0.03). No statistically significant difference between the lithotriptors was noted for ureteral calculi (p >0.05). The success rate was higher in the DLS group for renal stones especially lower caliceal and pyelic stones (p <0.05). The success rate was higher in DLS group for stones 10 mm or smaller, 92.8% versus 85.3% for MFL (p = 0.03). The success rate was comparable in both groups for stones larger than 10 mm (81.8% for DLS versus 77.9% for MFL, p >0.05). No statistically significant difference was found in the complication rate for the groups. Steinstrasse were noted in 4% of patients treated with MFL and 3% of those treated with DLS. Subcapsular hematomas were noted in 2 patients in each group. No procedures after extracorporeal shock wave lithotripsy were needed in either group. CONCLUSIONS: The electromagnetic lithotriptor (Dornier lithotriptor S) has significant clinical advantages over the electrohydraulic lithotriptor (Dornier MFL 5000) in terms of treatment time, re-treatment rate and success rate, although there is no difference in the complication rate.

Extracorporeal shock wave lithotripsy in anomalous kidneys: 11-year experience with two second-generation lithotripters.

OBJECTIVES: To present our experience with extracorporeal shock wave lithotripsy (ESWL) in patients with anomalous kidneys and to determine the factors that may influence the stone-free rate in such patients. METHODS: From February 1989 to February 2000, 198 patients were treated for urolithiasis in anomalous kidneys using ESWL. The mean patient age (SD) was 40.48 (11.53) years. The kidneys were horseshoe in 49 (24.7%), malrotated in 120 (60.6%), and duplex in 29 (14.7%). All patients were treated on an outpatient basis using two second-generation lithotripters (Dornier MFL 5000 and Toshiba Echolith). Pretreatment auxiliary measures were required in 6 patients (3%). Follow-up data were recorded at 3 months. The statistical analysis was performed using the chi-square and Mann-Whitney U tests, with differences considered statistically significant if P <0.05. RESULTS: The mean stone length (SD) was 13.54 (5.49) mm. The stones were single in 148 (74.7%), of new onset in 155 (78.3%), and on the right side in 82 (41.4%). All stones, but 5 (2.5%), were radiopaque. The overall stone-free rate was 72.2%. Neither the type of renal anomaly nor the type of lithotripter had any impact on the stone-free rate (P >0.05). Stone burden (length and number) had a significant influence on the stone-free rate (P <0.05). No extraordinary complications were recorded. Steinstrasse developed in 7 patients (3.5%). No deterioration of renal function or configuration was detected. CONCLUSIONS: ESWL is safe and reliable for treatment of urolithiasis in anomalous kidneys. It should be the primary therapy when the stones are less than 20 mm. The ESWL outcome is comparable for normal and anomalous kidneys when the calculus size is considered.

Prognostic value of angiogenesis in schistosoma-associated squamous cell carcinoma of the urinary bladder.

OBJECTIVES: To evaluate angiogenesis as a prognostic marker in squamous cell carcinoma of the urinary bladder in 154 patients who underwent radical cystectomy. METHODS: The tumors from 98 men and 56 women (mean age 46.3 +/- 8.4 years) were examined. Vessels were stained using an antibody to the platelet endothelial cell adhesion molecule CD31. Microvessels were counted in active areas of angiogenesis within the tumors. Microvessel density (MVD) was quantified using the mean of three counts. Age, sex, tumor grade and stage, DNA ploidy, and MVD were evaluated in relation to outcome. Univariate and multivariate analyses of survival were performed. RESULTS: The median follow-up period was 63 months. The overall 5-year survival rate was 56 +/- 4.1. Tumor grade, tumor stage, DNA ploidy, and MVD had a significant impact on the survival of patients in univariate analysis. The 5-year survival rate in patients with a low MVD (11 or less) was 68.1% compared with 50.4% for those with a high MVD (greater than 11; P <0.01). Men had more vascular tumors than did women. Also, high-grade tumors had significantly higher vascular counts. In a Cox proportional hazard model, tumor angiogenesis sustained its significant impact on survival of the patients in addition to tumor stage and DNA ploidy. CONCLUSIONS: These findings suggest that angiogenesis and DNA ploidy are independent additional prognostic factors in patients with squamous cell carcinoma of the urinary bladder.

Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model.

PURPOSE: We studied the various stone, renal and therapy factors that could affect steinstrasse formation after extracorporeal shock wave lithotripsy (ESWL), Dornier Medical Systems Inc., Marietta, Georgia to define the predictive factors for its formation. Thus, steinstrasse could be anticipated and prophylactically avoided. MATERIALS AND METHODS: Between February 1989 and May 1999, 4,634 patients were treated with a Dornier MFL 5000 lithotriptor (Dornier Med Tech, GmbH, Germany). Renal stones were encountered in 3,403 patients and ureteral stones in 1,231. Steinstrasse were recorded in 184 patients, of whom 74 required intervention and formed the "complicated group." All patient data, stone and renal characteristics, and data of ESWL were reviewed. Univariate and multivariate statistical analyses of patients, stones and therapy characteristics in correlation with the incidence of steinstrasse formation were performed to assign the factors that had a significant impact on steinstrasse formation. RESULTS: The overall incidence of steinstrasse was 3.97%. The steinstrasse was in the pelvic ureter in 74% of the cases, lumbar ureter in 21.7% and iliac ureter in 4.3%. Steinstrasse incidence significantly correlated with stone size and site, the power level (kV.) used during therapy and radiological renal features. Steinstrasse was more common with renal stones more than 2 cm. in diameter in a dilated system, especially with the use of high power (greater than 22 kV.) for disintegration. A statistical model was constructed to estimate the risk of steinstrasse formation accurately. CONCLUSIONS: Stone size and site, renal morphology and shock wave energy are the significant predictive factors controlling steinstrasse formation. If a patient has a high probability of steinstrasse formation, close followup with early intervention or prophylactic pre-ESWL ureteral stenting is indicated.