Alternative management of complex renal stones.

INTRODUCTION: The gold standard for treatment of large and complex renal stones is percutaneous nephrolithotomy (PCNL). However, in patients with significant comorbididties, this option may be suboptimal. We reviewed our experiences with ureterorenoscopy and Holmium laser lithotripsy (UL) for the primary management of large and complex intrarenal calculi. MATERIALS AND METHODS: Forty-three patients with large (2 cm or greater in diameter) renal or staghorn calculi were treated with primary UL. Seven patients were morbidly obese, three had solitary kidneys, two had horseshoe kidneys, three had hepatitis C virus, and three were self-pay and refused admission to the hospital. We calculated the total amount of stone burden, location and composition of calculi, number or ureterorenoscopic procedures necessary, and operative time. RESULTS: In 42/44 renal units (95.5%), complete ureterorenoscopic fragmentation of the stone burden was accomplished. The mean number of procedures necessary to clear all stone burden was 2.07 (range 1-5). The mean stone size was 3.63 cm (range 2-9 cm). The mean operative time was 107.4 min per procedure (range 30-230 min). Two patients were treatment failures and required intervention following ureteroscopy. In both, SWL cleared the remaining stone burden. No patient required PCNL, and one patient was admitted for urosepsis. CONCLUSION: This series demonstrates that ureterorenoscopy and Holmium laser lithotripsy is an effective and safe primary treatment modality for the treatment of large complex kidney stones. It is an attractive alternative to PCNL, particularly in those with comorbid conditions.

A pilot study of intensity modulated radiation therapy with hypofractionated stereotactic body radiation therapy (SBRT) boost in the treatment of intermediate- to high-risk prostate cancer.

Clinical data suggest that large radiation fractions are biologically superior to smaller fraction sizes in prostate cancer radiotherapy. The CyberKnife is an appealing delivery system for hypofractionated radiosurgery due to its ability to deliver highly conformal radiation and to track and adjust for prostate motion in real-time. We report our early experience using the CyberKnife to deliver a hypofractionated stereotactic body radiation therapy (SBRT) boost to patients with intermediate- to high-risk prostate cancer. Twenty-four patients were treated with hypofractionated SBRT and supplemental external radiation therapy plus or minus androgen deprivation therapy (ADT). Patients were treated with SBRT to a dose of 19.5 Gy in 3 fractions followed by intensity modulated radiation therapy (IMRT) to a dose of 50.4 Gy in 28 fractions. Quality of life data were collected with American Urological Association (AUA) symptom score and Expanded Prostate Cancer Index Composite (EPIC) questionnaires before and after treatment. PSA responses were monitored; acute urinary and rectal toxicities were assessed using Common Toxicity Criteria (CTC) v3. All 24 patients completed the planned treatment with an average follow-up of 9.3 months. For patients who did not receive ADT, the median pre-treatment PSA was 10.6 ng/ml and decreased in all patients to a median of 1.5 ng/ml by 6 months post-treatment. Acute effects associated with treatment included Grade 2 urinary and gastrointestinal toxicity but no patient experienced acute Grade 3 or greater toxicity. AUA and EPIC scores returned to baseline by six months post-treatment. Hypofractionated SBRT combined with IMRT offers radiobiological benefits of a large fraction boost for dose escalation and is a well tolerated treatment option for men with intermediate- to high-risk prostate cancer. Early results are encouraging with biochemical response and acceptable toxicity. These data provide a basis for the design of a phase II clinical trial.

Urinalysis: a comprehensive review.

A complete urinalysis includes physical, chemical, and microscopic examinations. Midstream clean collection is acceptable in most situations, but the specimen should be examined within two hours of collection. Cloudy urine often is a result of precipitated phosphate crystals in alkaline urine, but pyuria also can be the cause. A strong odor may be the result of a concentrated specimen rather than a urinary tract infection. Dipstick urinalysis is convenient, but false-positive and false-negative results can occur. Specific gravity provides a reliable assessment of the patient's hydration status. Microhematuria has a range of causes, from benign to life threatening. Glomerular, renal, and urologic causes of microhematuria often can be differentiated by other elements of the urinalysis. Although transient proteinuria typically is a benign condition, persistent proteinuria requires further work-up. Uncomplicated urinary tract infections diagnosed by positive leukocyte esterase and nitrite tests can be treated without culture.