[Diagnosis and management of suspected nephrolithiasis in a primary care setting]. / Die Nierenkolik in der allgemein-internistischen Praxis.

Based on the prevalence of asymptomatic kidney stones (5% in our general ward, in accordance with the literature) the value of abdominal ultrasonography in the clinical assessment of a suspected kidney-colic is discussed. The eminent importance of the stone-analysis is emphasized. In addition, the most common causes of kidney stone formation (low urine output, mechanical urinary obstruction in the renal pelvis, hypercalciuria, hyperoxaluria, insufficient urinary citric acid excretion, hyperuricosuria) are highlighted. The cardinal symptom of the urolithiasis is the presence of micro/macrohematuria (which is often absent - according to citations - in 20-80%!). Moreover, the differential diagnosis of acute flank pain, as neoplastic- or infectious diseases, reno-vascular and extrarenal causes (retro-peritoneal and mesenteric vascular processes and rupture of abdominal aneurysms), gynecological problems (e.g. rotation/rupture of ovarian cysts, ectopic pregnancy), appendicitis, diverticulitis, and splenic abscess/infarction, as well as hepato-pancreaticobiliary causes are discussed. Moreover, metabolic syndromes, e.g. the intermittant porphyria or infectious diseases (e.g, Fitz-Hugh-Curtis syndrome) and other rare pathologies (such as the «Mediterranean fever¼) may be at the origin of acute flank pains. A particular attention is given to possible diagnostic procedures in a primary care setting: in addition to medical history, clinical status and specific laboratory findings the value of diagnostic ultrasound, with special reference to the color-Doppler application, as the «twinkling artefact¼ from kidney stones and the «urinary-jet phenomenon¼ for the assessment of urinary outflow obstruction, is emphasized. In this context we point out that a lack of dilatation of the kidney pelvis never excludes a kidney-colic, on the other hand, a dilatation of the kidney pelvis does not necessarily mean congestion! The conservative treatment strategies (avoidance of excessive drinking - an obstructed kidney protects itself - NSAID in combination with Tamsulosin, especially in case of prevesical urolithiasis) are discussed. The critical stone size (≤5 mm) and the absence of «red flags¼ (especially obstructive and inflammatory signs) allow a non-specialist medical outpatient treatment of acute nephro-and ureterolithiasis. The possible complications of the urolithiasis, especially the urosepsis and the (iatrogenic) fornix rupture are highlighted, as well as the formation of a renal abscess or hydronephrosis. A short look is given to the metaphylaxis of the urolithiasis and its «recurrence rate¼.

Detection of fluid volume absorption by end-tidal alcohol monitoring in patients undergoing endoscopic renal pelvic surgery.

STUDY OBJECTIVE: To determine the risk of relevant fluid absorption (calculated volume above 500 ml) during endoscopic procedures of the renal pelvis. DESIGN: Prospective clinical investigation with implementation of statistical process control tools (SPC). SETTING: Nonuniversity teaching hospital. PATIENTS: 62 consecutive ASA physical status I and II patients scheduled for endoscopic renal pelvic surgery with general anesthesia. INTERVENTIONS: Intraoperative measurement of breath alcohol for detection of fluid absorption. Irrigation fluid (0.9% saline) with 1% alcohol for tracing the irrigation fluid. MEASUREMENTS AND MAIN RESULTS: Calculation of the amount of fluid absorbed using breath alcohol values. Process variability (numbers of patients with relevant fluid absorption) defined by SPC. The prevalence of fluid absorption in endoscopic renal pelvic surgery was 6%. Peak fluid absorption during a vascular route was detected by the monitoring. Monitoring was easily introduced into routine clinical practice. No relevant side effects due to the monitoring were seen in patients with relevant fluid absorption. There was no mortality, but two patients with detected severe fluid overload were admitted to the intensive care unit for treatment. CONCLUSION: Breath alcohol levels during general anesthesia for endoscopic renal pelvic surgery were technically simple to measure. Our results show the predictive value of alcohol monitoring, which has been previously demonstrated only for transurethral prostatectomy. The prevalence of relevant fluid absorption was 6% compared to 13% during transurethral resection of the prostate.

Adjuvant treatment with a vitamin A analogue (etretinate) after transurethral resection of superficial bladder tumors. Final analysis of a prospective, randomized multicenter trial in Switzerland.

Vitamin A and its derivatives, the retinoids, have antiproliferative effects and may induce cellular differentiation. Etretinate, a synthetic retinoid, has a more favorable therapeutic index experimentally than all-trans-retinoic acid or 13-cis-retinoic acid. Ninety patients with superficial papillary bladder tumors stages Ta and T1 entered a prospective randomized double-blind multicenter trial in Switzerland. Seventy-nine of the patients were eligible and received either 25 mg of etretinate or a placebo orally each day. The early withdrawal of a significantly greater number of patients in the placebo group for treatment failure during the first year of the study resulted in a secondary positive selection in this group. High-risk patients were removed and low-risk patients remained. In those patients who had tumor recurrences after randomization, the time to first recurrence was similar in both groups with 13.5 and 13.6 months in the placebo and etretinate groups, respectively. However, the mean interval to subsequent tumor recurrence was significantly longer in the etretinate group. The mean interval between recurrences in these subgroups was 12.7 months in the placebo arm and 20.3 months in the etretinate arm (p = 0.006). Consequently, the number of transurethral resections per patient-year was also reduced significantly in the etretinate group (p < 0.001). In patients with more than one transurethral resection of papillary tumors before randomization, the annual transurethral resection rate in the two treatment groups dropped from 1.7 to 1.3 in the 30 patients in the placebo group (NS, p = 0.1) and from 2.1 to 0.95 in the 25 patients in the etretinate group (p < 0.001). The side effects of etretinate (cheilitis, dryness of mucous membranes and skin) were acceptable to most patients. The relationship of the 3 myocardial infarcts observed in the etretinate group to the retinoid is not clear. Despite their significant effect on the recurrence rate of superficial papillary bladder tumors, retinoids should only be used in well-controlled prospective trials until more is known about their dosage-toxicity profiles.