Extracorporeal shockwave lithotripsy in patients treated with antithrombotic agents.

PATIENTS AND METHODS: Between January 1996 and December 1999, 749 patients underwent electromagnetic SWL. Among them, 23 patients, 19 with renal and 4 with ureteral stones, were receiving antithrombotic drugs (aspirin, ticlopidine, dipyridamole). According to the cardiologist and hematologist, we divided these patients into two groups: Group 1 had a low thromboembolic risk (previous myocardial infarction), and Group 2 had a high thromboembolic risk (aortocoronary bypass, atrial fibrillation, cerebrovascular disease, peripheral occlusive arterial disease). Group 1 patients discontinued their antiplatelet therapy 8 days prior to SWL to permit a sufficient number of functioning platelets to remain. Group 2 patients suspended antiplatelet therapy, and unfractioned heparin 5000 IU tid (8 a.m., 4 p.m., and 12 p.m.) was administered for the 8 days prior to SWL. On the ninth day of withdrawal, SWL was performed in all patients. Close follow-up was performed during the postoperative period (hemoglobin, hematocrit, kidney ultrasonography, plain abdominal film). The antithrombotic therapy was restored in all patients within 10 to 14 days of withdrawal. RESULTS: Hematomas and thromboembolic events were not observed. At 3 months' follow-up, 14 patients (61%) were stone free, 3 (13%) had <4-mm fragments, and 6 (26%) had >4-mm residual fragments. CONCLUSION: Our schedules for the suspension or substitution of antithrombotic therapy, although tested in a small number of patients, allowed us to perform SWL without hemorrhagic or thromboembolic complications.

Ultrasound-fluoroscopy guided access to the intrarenal excretory system.

The access to the collecting system can be performed under fluoroscopy computerized tomography, ultrasonographic, mixed ultrasonographic and fluoroscopic guidance. In this paper the creation of a percutaneous transparenchymal ultrasound-fluoroscopy guided access to the intrarenal collecting system completely performed by urologist for different purposes is presented. In five years 297 patients underwent 330 percutaneous kidney accesses to perform derivative nephrostomies (217 pts), percutaneous nephrolithotomies (37 pts), antegrade ureteral manoeuvres (34 pts), antegrade endopyelotomies (7 pts), transitional cell carcinoma of the upper tract resection (2 pts). 11 patients out of these had a percutaneous kidney access in a transplanted kidney. The percutaneous access was successful in 98% of the attemps. A posterior calyx of the lower group (74%), of the medium group (25%) or of the upper group (1%) was accessed. In 73 accesses the mean target calyx diameter was 12.8 mm (range 5-45 mm), the mean operative time 5.4 minutes and the mean fluoroscopy time 5.1 seconds. In 84.5% of the patients the access was performed under local anesthesia when a dilation of the tract was not required. Gross haematuria was observed in 3.9% of the accesses and an arterial lesion treated by embolization in 0.9% of the accesses. Blood transfusion was required in 0.3% of the patients. The ultrasound-fluoroscopy guided access is at least as precise as the fluoroscopy guided one moreover it makes the procedure less invasive and it makes more precise the surgical planning.

Interventional radiology in the treatment of uretero-pelvic-junction.

Numerous authors have reported successful results with both antegrade or retrograde endopyelotomy. Both procedures have proved to be efficient in primary as in secondary obstructions. Some additional etiological factors, such as crossing vessels high-grade hidronephrosis and poorly functioning kidney, may decrease the success rate of these minimally invasive techniques. The development of a cutting balloon catheter used under fluoroscopic control simplified the retrograde technique. This technique proved to be easier to perform than antegrade or retrograde endoscopic incision and did not require specialized instrumentation. In our experience 6 patients from 30 to 65 years old (average age 52) with an ureteropelvic-junction obstruction secondary to open surgery underwent endopyelotomy with the cutting balloon device. At the three month followup 4 patients had renographic patent ureteropelvic junction and no modifications were seen at one year follow up The retrograde endopyelotomy under fluoroscopic control seems to offer a rapid and effective treatment of UPJO. It is indicated for all primary and secondary UPJO obstruction apart forpatients with a concomitant renal stone or with high-insertion ureteropelvic junction.

[Extracorporeal SWL in the treatment of reno-ureteral calculosis in day hospital]. / Trattamento extracorporeo SWL della calcolosi reno-ureterale (SWL) in Day Hospital.

Eighteen years after the first clinical shock wave lithotripsy (SWL), no doubt remains as to its therapeutic efficacy in ureterorenal lithiasis. The advent of lithotriptors with a large shock wave energy range and integration of both ultrasound and radiologic imaging equipment at the shock wave source has meant that outpatients treatment of urolithiasis is now feasible in a good proportion of cases. In our lithotripsy center, from January 1995 to August 1996, 208 out of 310 patients who underwent SWL treatment for renal and ureteral stones, were outpatients. Pretreatment manoeuvres were performed in 10.6% of the patients. No major complications occurred during the treatment. Only three patients (1.4%) were admitted to hospital because of fever, colics or perirenal haematoma in the first two days after SWL therapy. The stone free rate was 67 and 84% respectively one and three months after treatment. In our experience, the possibility of performing SWL treatments without anesthesia and even analgosedation, the absence of complications and the high success rate, make outpatient treatment of urolithiasis safe and suitable in a large number of patients.