Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results.

PURPOSE: The efficacy of shock wave lithotripsy and percutaneous stone removal for the treatment of symptomatic lower pole renal calculi was determined. MATERIALS AND METHODS: A prospective randomized, multicenter clinical trial was performed comparing shock wave lithotripsy and percutaneous stone removal for symptomatic lower pole only renal calculi 30 mm. or less. RESULTS: Of 128 patients enrolled in the study 60 with a mean stone size of 14.43 mm. were randomized to percutaneous stone removal (58 treated, 2 awaiting treatment) and 68 with a mean stone size of 14.03 mm. were randomized to shock wave lithotripsy (64 treated, 4 awaiting treatment). Followup at 3 months was available for 88% of treated patients. The 3-month postoperative stone-free rates overall were 95% for percutaneous removal versus 37% lithotripsy (p <0.001). Shock wave lithotripsy results varied inversely with stone burden while percutaneous stone-free rates were independent of stone burden. Stone clearance from the lower pole following shock wave lithotripsy was particularly problematic for calculi greater than 10 mm. in diameter with only 7 of 33 (21%) patients becoming stone-free. Re-treatment was necessary in 10 (16%) lithotripsy and 5 (9%) percutaneous cases. There were 9 treatment failures in the lithotripsy group and none in the percutaneous group. Ancillary treatment was necessary in 13% of lithotripsy and 2% percutaneous cases. Morbidity was low overall and did not differ significantly between the groups (percutaneous stone removal 22%, shock wave lithotripsy 11%, p =0.087). In the shock wave lithotripsy group there was no difference in lower pole anatomical measurements between kidneys in which complete stone clearance did or did not occur. CONCLUSIONS: Stone clearance from the lower pole following shock wave lithotripsy is poor, especially for stones greater than 10 mm. in diameter. Calculi greater than 10 mm. in diameter are better managed initially with percutaneous removal due to its high degree of efficacy and acceptably low morbidity.

Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association.

PURPOSE: The American Urological Association convened the Ureteral Stones Clinical Guidelines Panel to analyze the literature regarding available methods for treating ureteral calculi and to make practice policy recommendations based on the treatment outcomes data. MATERIALS AND METHODS: The panel searched the MEDLINE data base for all articles related to ureteral calculi published from 1966 to January 1996. Outcomes data were extracted from articles accepted after panel review. The data were then meta-analyzed to produce outcome estimates for alternative treatments of ureteral calculi. RESULTS: The data indicate that up to 98% of stones less than 0.5 cm. in diameter, especially in the distal ureter, will pass spontaneously. Shock wave lithotripsy is recommended as first line treatment for most patients with stones 1 cm. or less in the proximal ureter. Shock wave lithotripsy and ureteroscopy are acceptable treatment choices for stones 1 cm. or less in the distal ureter. CONCLUSIONS: Most ureteral stones will pass spontaneously. Those that do not can be removed by either shock wave lithotripsy or ureteroscopy. Traditional blind basket extraction, without fluoroscopic control and guide wires, is not recommended. Open surgery is appropriate as a salvage procedure or in certain unusual circumstances.

Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel.

The American Urological Association Nephrolithiasis Clinical Guidelines Panel recommendations for managing struvite staghorn calculi are based on a comprehensive review of the treatment literature and meta-analysis of outcome data from the 110 pertinent articles containing viable, unduplicated data. The panel concluded that the 3 most significant outcome probabilities are those of being stone-free, undergoing secondary unplanned procedures and having associated complications. Panel guideline recommendations for most standard patients are that neither shock wave lithotripsy monotherapy nor open surgery should be a first-line treatment choice but that a combination of percutaneous stone removal and shock wave lithotripsy should be used.

Initial EDAP LT-01 lithotripsy group experience in the United States.

The initial United States cooperative experience with the EDAP LT-01 second generation piezoelectric extracorporeal shock wave lithotriptor using ultrasonic guidance is presented. Particular to the machine are lack of radiation exposure, no need for anesthesia, a purely outpatient procedure, no electrocardiographic problems, a high degree of safety and a paucity of complications. The equipment is described briefly. The same machine currently is being used to destroy renal and biliary stones. The results are encouraging and highly comparable to the initial experience with the earlier machines. Fragmentation rates are approximately 86%, with destruction rates of 63.4% over-all. Ultrasound localization and monitoring proved surprisingly easy to learn and were increasingly less of a problem as experience was gained. No serious complications were observed, and there were no renal losses and no deaths. Only 3 cases of steinstrasse were noted among 461 with 633 stones targeted during 595 treatments.

Outpatient endourologic procedures.

Many endourologic procedures can be performed routinely on an outpatient basis, including flexible cystoscopy, ureterorenoscopy, and percutaneous nephroscopy through a mature tract. Others, such as percutaneous nephrostomy, nephrostolithotomy, and antegrade ureteral stent placement, can sometimes be done on an outpatient basis. This article describes the indications, techniques, postoperative care, and results of these procedures.

Endourological treatment of ureteral calculi.

Endourological treatment of ureteral calculi can be highly successful and result in low morbidity rates. Several techniques are described that have a primary role and that serve as backup, including retrograde flushing, flexible nephroscopy, antegrade fluoroscopic basket, ultrasonic lithotripsy, ureteroscopy, chemolysis, and a combined antegrade and retrograde method. With these methods 114 of 120 consecutive patients with ureteral stones (95 per cent) underwent successful removal. The associated number of complications was low, with most patients being treated conservatively.

Major traumatic and septic genital injuries.

Major injuries to the testicles, penis, and genital skin from trauma and infection were seen in 62 patients over a 6-year period (1977 to 1983). Urethral injuries were excluded. In the past blunt testicle injuries were infrequently diagnosed and surgically ignored because of large surrounding hematomas. With the use of real-time ultrasound, 17 of 18 cases of testicle rupture were correctly diagnosed preoperatively. Surgical repair resulted in testicle salvage in 16 patients. Penetrating testicle injuries resulted in a high orchiectomy rate secondary to the infrequently described but recognized entity of self-emasculation in transsexuals. Penile rupture from blunt injuries (8) was successfully repaired and complete function was recovered. Penetrating penile injuries (4) were extensive and involved the urethra in two cases; full function returned after reconstruction. Major skin loss of the penis and/or scrotum (19) occurred from necrotizing fasciitis, burns, avulsion and penetrating injuries. Early debridement, bowel and urinary diversion followed by penile skin grafting, thigh pouches to protect testicles, and scrotal reconstruction resulted in acceptable cosmetic and functional results in all cases of major skin loss.

Percutaneous renal and ureteral stone removal.

Percutaneous removal of upper urinary tract calculi has become an accepted alternative to surgical removal. Calculi may be removed through large nephrostomy tracts under fluoroscopic or endoscopic control. Close cooperation between the radiologist and urologist should increase the success rate of the procedure.

Pyelonephritis from severe incrustations on silicone ureteral stents: management.

We report an unusual case of pyelonephritis secondary to large incrustations on silicone double J ureteral stents left indwelling for 12 months. After the pyelonephritis was treated with antibiotics, hemiacidrin irrigation via percutaneous nephrostomy tubes and a ureteral stent was used to dissolve the incrustations and allow removal of the stents.

Percutaneous renal stone manipulation--a nonoperative alternative.

Nephrostomy tube tracts, established operatively or percutaneously, can provide access to stones in the upper urinary tract. A variety of rigid or flexible urologic instruments can be used to percutaneously disintegrate or extract calculi, thus sparing a patient an operative procedure. This is most important in the case of high-risk patients, those previously operated upon or those who have active nephrolithiasis, in whom recurrent stones are prone to form. Our early experience in percutaneous renal stone disintegration and stone manipulation enabled us to remove most (in four patients) or all (again in four patients) calculi in nine patients. The procedure offers lower morbidity, shorter hospital stay and earlier return to employment than conventional operative stone procedures.

Granulomatous disease of the testis.

Granulomatous disease of the testis may have a specific cause or it may be idiopathic. We found 3 specific agents as the cause of the disease in a retrospective review of 17 cases of granulomatous disease of the testis. Mycobacterium tuberculosis was the most common cause of subsequent granulomatous orchitis. The clinical presentations of the patients varied but several clues often were present that led to the diagnosis of granulomatous reaction. The patients were treated with orchiectomy. The acid-fast lipid of the tubercle bacillus and spermatozoa is suggested as a possible common denominator in the pathogenesis of the granulomatous reaction.