Metabolic evaluation and medical management of upper urinary tract stone disease. Guidelines from the Scandinavian Cooperative Group for Urinary Stones.

A set of simple guidelines for metabolic evaluation and medical/dietary management of patients with urolithiasis is presented. The evaluation scheme is based on the documented risk factors in the Nordic area and the results of controlled clinical trials, and takes its basis in the severity of the stone disease in the individual stone patient. The initial evaluation in all patients aims at diagnosing conditions with a definitive metabolic, infectious or anatomical/functional cause of stone formation (MIAF urolithiasis). Patients with MIAF urolithiasis are treated according to the nature of the underlying disease. Having excluded/diagnosed MIAF urolithiasis, patients with idiopathic calcium nephrolithiasis remain, and in this group, which comprises approximately 85% of the total stone population in the Scandinavian region, only those with a complicated stone disease are subjected to additional evaluation, which aims at identifying underlying pathophysiological derangements for which medical therapy has been proven to be effective in controlled clinical trials.

Assessment of possible nephrotoxicity from iohexol in patients with normal and impaired renal function.

PURPOSE: To evaluate the possible nephrotoxic effects of iohexol in patients with normal and impaired renal function. MATERIAL AND METHODS: A prospective urographic study using iohexol (50 ml, 300 mg I/ml) was performed in 100 patients, 63 with impaired renal function (IRF) and 37 with normal renal function (NRF). The group included 24 patients with diabetes mellitus, 17 of them with IRF. Renal function parameters and adverse events were recorded for one week after the urography. RESULTS: There were no significant changes in serum creatinine, creatinine clearance, or beta-2-microglobulin. The 24-h urine protein excretion showed a statistically significant increase in patients with NRF as well as in patients with IRF. Nine patients experienced adverse events but none of them required any treatment. CONCLUSION: Iohexol was tolerated well in patients with NRF and in patients with IRF without significant overall nephrotoxic effects. Some minor adverse events were recorded.

Radical nephrectomy is still preferable in the treatment of localized renal cell carcinoma. A long-term follow-up study.

OBJECTIVES: Due to the advances of radiological methods, an increased number of incidentally detected renal cell carcinomas is diagnosed. The reported excellent results of nephron-sparing surgery have promoted its application in patients with a normal contralateral kidney. However, the risk of local tumor recurrence and surgical complications after nephron-sparing surgery might be higher compared with radical nephrectomy. METHODS: In 89 patients with localized renal cell carcinoma treated with radical nephrectomy, long-term renal function, morbidity, and survival were evaluated. The renal function was followed up regularly with serum creatinine measurements. RESULTS: The cause-specific 5-year survival rate was 91.6%. There was neither local nor contralateral kidney tumor recurrence in any patient. Surgical complications were observed in 3% of the patients. Mean serum creatinine after the nephrectomy was 123 mumol/l without further increase during 10 years of follow-up. CONCLUSIONS: Radical nephrectomy of localized renal cell carcinoma has low morbidity, excellent local tumor control, and a high survival rate. For patients with a normally functioning contralateral kidney the long-term renal function remained adequate. Based on these data, there is no convincing evidence justifying nephron-sparing surgery to be used routinely for patients with a normally functioning contralateral kidney.

Perforation of the bowel during SWL in prone position.

Perforation of the small bowel during SWL is reported for the first time. The patient was treated in the prone position for a ureteral stone with 4500 shockwaves. There were no underlying or predisposing factors for the damage to the gut with the exception of the large number of shockwaves at a high energy setting. It is concluded that SWL in the prone position with shockwaves traversing the peritoneal cavity carries a risk of damage to the bowel. A reduction of the number of shockwaves and the energy level should be considered in this setting.

[Screening of persons referred to forensic psychiatry. Many of them were in contact with psychiatric services before the offence]. / Granskning av rättspsykiatriskt undersökta. Många i kontakt med psykiatrin före brottet.

Analysis of data for a sample comprising every second subject (266/533) who underwent forensic psychiatric examination in Sweden during a 12-month period (July 1995-June 1996) showed 50 per cent to have been in contact with psychiatric services during the 6-month period prior to the index offence. The study population was characterised by significantly higher than average proportions of women and of subjects suffering from psychotic disorder and/or serious psychiatric disorder as defined by the mental health act. In the subgroup who did not meet the criteria for special recommendations on medico-legal grounds (i.e., those without a serious psychiatric disorder according to forensic psychiatric examination) and in the youngest age group (< 20 years), the frequency of psychiatric contact prior to the index offence was lower than in the remainder, though the psychiatric consultation rate was nevertheless higher in both subgroups than in the general population. The findings suggest the need of increased alertness within the psychiatric sector, and of improved case management in the patient categories concerned. Further studies, particularly focused on violent and potentially violent offenders and their psychiatric contacts, are essential for the development of adequate programmes and guidelines for the treatment and care of such individuals.

A new system for descriptive classification of stones in the upper urinary tract.

A descriptive classification is proposed to stratify upper urinary tract stones by their number, size and location. The system considers the minimal but most important factors regarding the choice of surgical treatment and its success. Its principle is adaptable to more complex staging systems already existing. Practical use of the system has shown it to reflect clinical events, and its simplicity offers an opportunity for compliance in routine clinical study. It facilitates easy computerized stratification of stones in the upper urinary tract.

Significance of simple renal cysts and percutaneous cyst puncture on renal function.

Renal function was investigated in 17 patients with simple renal cysts. Single kidney glomerular filtration rate was estimated by gamma camera renography with 99mTc-DTPA before, 5 days and 6 months after percutaneous puncture and evacuation of the cysts. Prior to the puncture and evacuation, the only negative effects on renal function noted were signs of moderate obstruction of the renal outflow in 2 patients. Percutaneous puncture with evacuation of the cystic fluid did not change the renal function significantly. It was concluded that simple renal cysts do not have any functional consequences nor does percutaneous puncture and evacuation of the cysts.

Diagnostic aspects, functional significance and therapy of simple renal cysts. A clinical, radiologic and experimental study.

Simple renal cysts and renal cell carcinomas constitute the majority of the renal masses disclosed by radiologic methods. The reliability of radiologic diagnosis was studied in patients with different renal mass lesions. Based on the experiences from the study, ultrasonography is recommended when a renal mass is discovered at urography. Computerized tomography and rarely angiography and percutaneous puncture for cytologic examination are necessary when all criteria of a simple renal cyst have not been fulfilled. Forty-one patients with renal cell carcinoma and additional renal masses in the same or contralateral kidney were studied. In 3 patients the radiologic methods were insufficient to establish a definite diagnosis of the additional renal mass occurring in the kidney contra-lateral to the renal cell carcinoma. Only explorative surgery established the true diagnosis. A method for estimating single kidney glomerular filtration rate by gamma camera renography using 99mTc-DTPA was studied. The accuracy and reproducibility was satisfactory when compared to the 51Cr-EDTA clearance reference method. The functional consequences of simple renal cysts and percutaneous puncture were studied by gamma camera renography before as well as after puncture and evacuation of the cysts. Signs of obstruction of the renal outflow were rarely seen. No other effect on renal function was found and percutaneous puncture with evacuation of the cysts did not improve renal function significantly. The therapeutic efficacy of percutaneous puncture and instillation of bismuth-phosphate was compared to percutaneous puncture alone and to the natural course of simple renal cysts. After 24 months there were no significant difference in size between cysts that were only punctured and those that had no intervention. The cysts that were treated with bismuth-phosphate disappeared or diminished with few exceptions. The effects of bismuth-phosphate on the renal parenchyma and renal outflow tract were investigated by microangiography and histopathology in an experimental study. A zone of connective tissue around the deposited bismuth-phosphate was seen and no effects on glomeruli or renal vessels were disclosed. It is concluded that the radiologic diagnosis of simple renal cysts is definite when all diagnostic criteria are fulfilled by ultrasonography or computerized tomography. Simple renal cysts have no effect on renal function. Therapeutic interventions because of simple renal cysts are not indicated in patients without outflow obstruction.

Multiple renal masses in patients with renal cell carcinoma: diagnostic pitfalls and surgical implications.

Additional renal masses were found in the same or contralateral kidney in 41 of 131 patients with renal cell carcinoma. In 35 of the patients the additional renal masses were simple renal cysts situated in the kidney contralateral to the renal cell carcinoma in 16 patients, in the same kidney in 11 and bilaterally in 8 patients. Four patients had bilateral renal cell carcinomas. One patient had polycystic kidney disease as well as renal cell carcinoma and another patient had a benign tumour in the contralateral kidney. In 3 of the 30 patients with additional renal masses in the kidney contralateral to the renal cell carcinoma the radiologic examinations were insufficient to exclude malignancy. Only explorative surgery could establish a true diagnosis of these masses.

Renal cell carcinoma in a renal cyst: a case report and review of the literature.

We report a case of renal cell carcinoma within a simple renal cyst in the lower pole of the right kidney. Excretory urography showed a mass and ultrasonography revealed multiple renal cysts with a solid component arising from the wall in 1. This finding also was visualized by computerized tomography. Analysis of the cystic fluid showed a high cholesterol level but negative cytological results. At operation a 7 mm. tumor arose from the wall of the cyst. Histopathological examination showed grade 3 renal cell carcinoma with an aneuploid deoxyribonucleic acid content.