OBESITY: A DELICATE ISSUE CHOOSING THE ESWL TREATMENT FOR PATIENTS WITH KIDNEY AND URETERAL STONES?

CONTEXT: Urolithiasis and obesity are now public health problems with an increased incidence worldwide. Management of urolithiasis in patients with morbid obesity is usually associated with higher morbidity and mortality compared to non-obese patients. ESWL is a nonsurgical procedure for the treatment of lithiasis. In obese patients the ESWL efficacy is influenced by the skin-to-stone distance or poorer detection of the calculus because of the fatty tissue. OBJECTIVE: To highlight the overweight or obese lithiasic patient profile that could be best treated by ESWL. SUBJECTS AND METHODS: We evaluated ESWL results in 1393 patients with kidney or ureteral stones between 5 and 20 mm. They were divided into 4 groups according to the BMI: Group A-overweight (BMI=25-30 kg/m2); Group B-grade I obesity (BMI=30-35 kg/m2); Group C-grade II obesity (BMI=35-40 kg/m2) and a control group of normal weight (BMI=18-25 kg/m2). RESULTS: Patients with a higher BMI required a greater number of ESWL sessions. A statistically significant greater number of patients with a waist circumference of >102 cm required more than 2 SWL sessions (p=0.007). Location of the stones in the pelvic ureter had the highest rate of success for obese patients (p=0.00001). The ESWL success rate in overweight and obese patients can be negatively influenced by BMI, abdominal circumference over 102 cm, and hardness of calculi reflected in the radiopacity on KUB. CONCLUSIONS: In patients with grade II obesity, pyelocaliceal calculus and increased hardness, other urological alternatives to lithiasis should be considered from the beginning.

Clinical Factors Influence the Trueness of Intra-oral Scanning.

AIMS: The aim of this in vitro study was to evaluate the influence of adjacent teeth in the trueness of digital impressions. MATERIALS AND METHODS: In this study the first premolar on a typodont mounted in a phantom head was prepared for an all ceramic crown. Three different operators scanned the tooth with an intraoral scanner, with three different clinical scenarios: with no adjacent teeth, with one adjacent tooth and with two adjacent teeth. Resulting scans from each operator were compared with a reference scan using metrology software. RESULTS: The results of this in vitro study showed differences of scanning trueness between each clinical simulated situation. CONCLUSIONS: The presence of adjacent teeth can decrease the view of interproximal surfaces and may generate a less precise scan in these regions. The results of this study showed that the trueness of an intraoral digital impression is conditioned by a good visibility of the abutment.

[Renal colic in pregnancy]. / Colica nefretica la gravide. Experienta clinicii urologice Iasi.

UNLABELLED: Renal colic in pregnant women is a serious condition, mainly when is associated with fever. MATERIAL AND METHOD: Our retro-prospective study analyzes 111 cases managed conservatively or with endourological procedures for renal colic--insertion of JJ stents and percutaneous nephrostomy. RESULTS: Clinical evolution determined the insertion of JJ stents in 60 cases and the failure of this procedure imposed percutaneous nephrostomy in 5 cases. In 56 cases urinary tract infection was associated and in 2 cases, despite all efforts, the patients deceased due to sever sepsis. CONCLUSIONS: The immediate drainage of the upper urinary tract for renal colic in pregnancy is the recommended treatment, especially when the pain is associated with fever. JJ stens were well tolerated, even when they were replaced after 3 months. Pregnant women with a history of UTI or stone disease should be carefully followed-up.

[Extracorporeal shock wave lithotripsy (ESWL) can be done for lithiasic patients with cardiac arrhythmias with a lithotriptor without ECG triggering system--the experience of Iasi Urological Department]. / Litotritia extracorporeala la pacientii cu tulburari de ritm. Experienta Clinicii Urologice Iasi.

The recommendations for spark gap lithotripters include that the shock waves must be delivered according to the ECG, avoiding the discharge during the refractory part of the heart activity. The lithotripters we have in our department does not have from the factory an ECG correlated triggering system. Observing that ESWL for patients without heart problems did not induced arrhythmias, we decide to perform this procedure under strict cardiologic supervision to the patients having arrhythmias (chronic fibrillation, chronic atrial fibrillation, supraventricular arrhythmias, supraventricular premature beats, ventricular premature beats, ventricular tachycardia). All the ESWIL sessions did not have any major incidents and all the patients return home safe, without any changes of the cardiac medication. Even we did not notice any aggravation of the cardiac arrhythmias during ESWL we consider that the careful monitoring of the patients by the cardiologist is necessary during the procedure, most of all when the spark gap lithotripter has not an ECG triggering system.

[Can selective alpha-blockers help the spontaneous passage of the stones located in the uretero-bladder junction?]. / Pot ajuta alfa-blocantele selective eliminarea calculilor ureterali aflati la jonctiunea uretero-vezicala?

The majority of ureteral stones at presentation in hospital are located within the distal ureter. Knowing that only half of the stones 4 to 5.9 mm will pass spontaneously, we tried to see: if we can facilitate this elimination for the stones smaller than 8 mm by selectve alpha-blockers (alfuzosin and tamsulosin) which induce relaxation of the smooth muscle of uretrotrigonal area and if there is any difference between these two drugs, concerning efficiency and tolerance. The inclusion criteria for each group were: stone size between 4 and 8 mm--even patients with steinstrasse--and previous, at least 2 weeks of expulsion treatment with nonsteroidal antiinflammatory and antispasmodic agents and Rowatinex. The results were encouraging: almost all the patients eliminated the stones without any pain in the first 5-10 days of treatment (only two patients from alfuzosin group did not tolerate this drug). We believe that both alfuzosin and tamsulosin have a crucial impact in spontaneous painless elimination of the stones smaller than 8 mm located in the uretero-bladder junction.

[Ureterolithotomy versus retrograde ureteroscopy for lumbar ureteral stone. A cost analysis]. / Ureterolitotomia versus ureteroscopia retrograda pentru calcul ureteral lombar o analiza a costurilor.

Ureterolithotomy is considered to be the last option for treating a lumbar ureteric stone. The authors reviewed two cases with lumbar ureteric stones treated in january 2003, one by ureterolithotomy and one by retrograde ureteroscopy regarding the costs for hospitalisation, investigations and medication. Among the certain clinical advantages for the patients, including a smaller rate of complications, ureteroscopy is considerably cheaper than open surgery. We consider that these costs criteria should be taken into consideration when the necessary equipment for-urological departments are set.

[Ureteral stenting after retrograde ureteroscopy. Experience of Iasi urological department]. / Protezarea ureterului dupa ureteroscopia retrograda. Experienta clinicii urologice Iasi.

Ureteroscopy is a well-established procedure, which has proven the efficiency for diagnostic purposes, but mostly for ureteric stone removal. The authors describe their strategy after ureteroscopic lithotripsy with Wolf 8 Ch semirigid ureteroscope. Insertion of a double J stent for 2-4 weeks was the rule when there was an important bleeding during the procedure, the fragments were big and could not be extracted, some fragments migrated in upper third of the ureter or renal pelvis, a perforation occurred or it was found a ureteral stenosis. If the stone can be extracted without any problems (in one piece) and the ureter is normal there is no need for ureteral stenting. Having in mind that many patients describe problems with the double J stent (pains, polakiuria, etc) we recommend to insert a stent at the end of ureteroscopy only for selected cases.

[Caliceal stones:What did we learned after 10 years of ESWL (extracorporeal shock wave lithotripsy)]. / Litiaza caliceala. Ce am învatat în 10 ani de litotritie extracorporeala?

Since its first clinical application in 1980, the indication of ESWL has rapidly extended from renal pelvis stones to almost all urinary stones. The authors discuss about their experience accumulated in the past ten years, when 476 patients with caliceal stones were treated by ESWL. The global stone free rate was 60.05%, but almost a third of the patients (where fragmentation was radiological documented after ESWL) did not returned back for control. ESWL is a good solution for superior and middle calix stones less than 1.5 cm, not very opaque, with a sufficient large caliceal width. For the stones in the lower calix, the most important criteria for success are: the stone size, the opacity and, for sure, the angle between infundibulopelvic and ureteropelvic axis.

[Role of computerized tomography in the diagnosis of transitional cell carcinoma of the upper urinary tract]. / Rolul tomografiei computerizate în diagnosticul carcinomului tranzitional de uroteliu superior.

PURPOSE: To evaluate the computed tomography (CT) semiological criteria used in the diagnosis of transitional cell carcinoma of the upper urinary tract. MATERIALS AND METHODS: 26 patients with transitional cell carcinoma of the upper urinary tract underwent preoperative CT. In all cases nephroureterectomy was performed and CT and histopathologic findings were compared. RESULTS: 16 tumors were infiltrative and 10 tumors were sessile. The smallest tumour had 7 mm diameter and the largest one 13 cm. Associated focal hydronephrosis appeared in 11 cases and diffuse hydronephrosis in 7 cases. The vast majority of these tumors (69.23%) had a 21 to 50 Hounsfield Units enhancement. CONCLUSIONS: CT is a powerful tool to diagnose transitional cell carcinoma of the upper urinary tract when data acquired in intravenous urography and echography are equivocal.

[Transitional cell carcinoma of the upper urinary tract- staging by computed tomography]. / Stadializarea prin tomografie computerizata a carcinomului tranzitional de uroteliu superior.

PURPOSE: To determine the accuracy of computed tomography (CT) in staging transitional cell carcinoma of the renal pelvis and calyces and to identify whether hydronephrosis proximal to the tumor used as a criterion for minimal invasion may improve the overall accuracy of the method. MATERIALS AND METHODS: 24 patients with transitional cell carcinoma of the upper urinary tract underwent preoperative CT. In all cases nephroureterectomy was performed and CT and pathologic staging were compared. RESULTS: Pathologic staging revealed two stage I tumors, eight stage II tumors, five stage III tumors, and 9 stage IV tumors. The initial overall CT staging accuracy was 66.66% (16 of 24 patients). Reevaluation of the CT studies by using proximal hydronephrosis as a criterion for minimal invasion improved the overall CT staging accuracy (83.33%). CONCLUSIONS: When CT demonstrates direct tumor extension through the pelvic wall, it is a sensitive indicator of high-stage tumor. Hydronephrosis proximal to the tumor may cause overstaging of stage 0-II disease.

[The role of intravenous urography in the diagnosis of urinary tract lithiasis in the era of new therapeutical methods]. / Rolul urografiei intravenoase în diagnosticul litiazei reno-ureterale în epoca noilor metode terapeutice.

Urinary stones continue to be an interesting and major problem for both urologists and radiologists. The authors try to present the imaging diagnosis possibilities for this pathology according to the expectations of the urologists who have to deal with urinary tract lithiasis with the new methods (extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy, and ureteroscopy). Helical CT has certain advantages and in different centers in Europe appear to be less expensive than intravenous urography (IVU), but unfortunately, is not available in our medical center. So, for us, IVU remains the basic investigation for urinary stones. Echography helps a lot for correct strategy, but together with KUB cannot replace IVU if we want to avoid mistakes.

[Is partial cystectomy a justified intervention in the treatment of bladder tumors?]. / Este cistectomia partiala o interventie justificata în tratamentul tumorilor vezicale?

The authors present their experience of 122 partial cystectomy cases made on a number of 288 vesical tumors in our clinic, during 5 years (1986-1991) from which 23 are superficial tumors and 99 are infiltrative ones. The treatment of vesical tumors can be done in many ways; this partial cystectomy must be completed with an other therapeutic method: irradiation on chemotherapy in conformity with the anatomo-pathological form, the steady and tumoral grading.