Impact of a metabolic stone clinic on management of patients with cystinuria: 5 years follow-up.

PURPOSE: Cystinuric patients develop new stones and exhibit stone growth despite conservative measures and often require surgical intervention. There have been reports of better outcome both in surgical intervention rates and compliance when patients were referred to dedicated metabolic stone clinics. We wish to report our experience in the running of a metabolic stone disease clinic and to compare our intervention rates to the pre-metabolic stone clinic period in our department. PATIENTS AND METHODS: We reviewed retrospectively our cystinuria patients' database between the years of 1992 and 2008. Patients were divided into two groups. Group A patients (n=28) were treated before the introduction of a dedicated stone clinic (years 1992-2002) and group B patients (n=28) after the establishment of the metabolic stone clinic but every group B patient had a minimum follow up of 5 years. 21 patients were common between the two groups. Main therapy included hyperdiuresis and alkalization. Parameters recorded included the number of clinic visits, whether the patients were stone free or asymptomatic at the time of our review and the nature and frequency of surgical intervention. RESULTS: A total number of 145 procedures were carried out in group A including 89 ESWL, 27 PCNL, 24 ureteroscopy retrograde lithotripsies and 5 open procedures. In group B, a total of 54 procedures were carried out and included 6 ESWL, 5 PCNL and 43 ureteroscopy laser lithotripsies. The average number of surgical interventions per patient per year was 0.74 and 0.34 in group A and B respectively. The number of clinic attendances increased in group B to 279 from 188 in group A. Stone free rates were 46% for group A and 50% for group B patients but all group B patients were asymptomatic at the time of our review. CONCLUSIONS: The introduction of a dedicated cystinuria clinic halved the intervention rate in this complicated group of patients. The majority of surgical procedures shifted towards ureteroscopies (both as inpatients and as day case procedures). We believe that cystine stone patients should be managed in a devoted metabolic stone clinic. With this approach, compliance is better achieved and surgical intervention is less, resulting in better clinical outcome, and less burden both for the patient and the urological services.

Ureteral stents and their current use.

Stents in urology have been used for a long time in the management of nephro-ureterolithiasis. However, the indications for stent insertion have increased during the last few years and they are now used both diagnostically and therapeutically in a variety of cases. A brief history of the name is presented along with a review of the indications and the complications of stent usage.

Prevention of recurrent bacterial cystitis by intravesical administration of hyaluronic acid: a pilot study.

OBJECTIVES: To assess the effect of bladder instillations of hyaluronic acid (HA) on the rate of recurrence of urinary tract infection (UTI). PATIENTS AND METHODS: Forty women (mean age 35 years) with a history of recurrent UTI received intravesical instillations of HA (40 mg in 50 mL phosphate-buffered saline) once weekly for 4 weeks then once monthly for 4 months. The UTI status was assessed over a prospective follow-up of 12.4 months and compared with the rates of UTI before instillation, determined by a retrospective review of patient charts covering 15.8 months. RESULTS: After HA treatment no patients had a UTI during the 5-month treatment phase and 28 (70%) were recurrence-free at the end of the follow-up. The mean (sd) rate of UTI per patient-year was 4.3 (1.55) before treatment and 0.3 (0.55) afterward (P < 0.001). The median time to recurrence after HA treatment was 498 days, compared with 96 days beforehand (P < 0.001). The tolerability was excellent, as side-effects were limited to nine patients who reported mild bladder irritation; no patient interrupted the treatment. CONCLUSIONS: In this preliminary study, bladder instillations of HA had a significant effect on the rate of UTI in women with a history of recurrent UTIs. The bladder instillation of HA is an acceptable and promising therapeutic alternative in patients with recurrent UTI. Expanded placebo controlled clinical trials examining this application of HA are currently underway.

Successful partial transplant pancreatectomy with end-to-side duct-to-ureter anastomosis: salvage of a pancreatic allograft.

Segmental pancreatic transplantation has been abandoned because of the high incidence of technical complications. We report the first case in the literature of the salvage of a partially ischemic pancreatic allograft. The procedure consisted of resecting the head of the pancreas and draining the residual segment to the ureter with a duct-to-ureter end-to-side anastomosis. The postoperative course was uneventful, and 15 months after surgery graft function is satisfactory with a urinary amylase level of 5000 U/h. The duct-to-ureter drainage technique should be part of every transplant surgeon's repertoire, because in emergency situations like the one described, it can be used to save a pancreatic allograft.

Two cases of penile necrosis in diabetics with end-stage renal failure.

Distal penile necrosis associated with renal failure is a rare entity; only a few cases have been reported in the literature. Penile necrosis can frequently be a difficult management problem, the etiology of which is infectious, traumatic, or vascular. Physiological abnormalities are usually found in association with this condition, including diabetes, hyperparathyroidism, and peripheral vascular disease. Penile necrosis is a poor prognostic factor associated with high morbidity. We report two cases of this condition, presenting the clinical and pathophysiological background.

Reversal of steal syndrome following creation of arteriovenous fistula by banding with a Gore-Tex cuff: a new technique.

Steal syndrome, especially in elderly patients with peripheral vascular disease, is a serious complication following creation of an arteriovenous fistula (AVF) that, if neglected, can lead to amputation. The classic maneuver to deal with the steal syndrome is the ligation of the AVF and performance of another procedure to gain dialysis access. We describe a simple technique of effectively reversing the steal syndrome by banding the vein of the AVF with a ringed Gore-Tex cuff that salvages the AVF and allows its immediate use for dialysis.

Appendiceal mucocoele: a case report and review of the literature.

Mucocoele of the appendix denotes an obstructive dilatation of the appendiceal lumen due to abnormal accumulation of mucus, which may be related to a variety of pathological conditions. This may be the outcome of various processes. Most important for the surgeon, however, are the mucocoeles that are caused by mucinous cystadenomas and cystadenocarcinomas. In the latter case, a possible rupture of the mucocoele, either spontaneous or accidental, during surgery may result in the clinical condition of pseudomyxoma peritonei, a spread of malignant cells throughout the entire peritoneal cavity in the form of multiple mucinous deposits. It is therefore important both to identify the disease preoperatively and to plan a careful resection to remove the mass. We report one case and present the clinical and diagnostic aspects of this disease.