Place of extracorporeal shock-wave lithotripsy (ESWL) in management of cystine calculi.

We treated 12 patients with sixteen renal and one ureteral cystine stones primarily with extracorporeal shock-wave lithotripsy (ESWL). Among the stones thirteen were greater than 25 mm. In four stones less than 25 mm, three stones completely disappeared and 1 was reduced to small fragments, following ESWL. In thirteen stones greater than 25 mm, twelve were treated by ESWL initially, and one by surgery. Of the 12 cases treated initially by ESWL, 4 became stone-free, 4 remained with small fragments, and 1 remained with large fragments. Two patients were operated on because of poor response to ESWL and 1 patient lost kidney function because of prolonged obstruction. Disintegration of cystine stones greater than 25 mm required an average of 8,522 shock-waves in 4.33 sessions. The problems associated with application of ESWL monotherapy to cystine stones are presented.

[Stone burden on extracorporeal shock wave lithotripsy].

Based on the 89 stones treated by ESWL therapy alone, the factors which influence the number of ESWL shots were analyzed. Stone volume was calculated by summing up the value "length x short axis" for each stone. The value correlated well with the number of shots needed to disintegrate the stone (p less than 0.01). The stones below the pelvis-ureteral junction needed twice shots compared with stones in the pelvis and calyces (80.3: 40.2, p less than 0.005). Stones formed by a single component of cystine or calcium oxalate were hard to be disintegrated (53.2: 31.6, compared with other complex stones). The radiological figure could not predict the fragility.

Bacteriology of upper urinary tract stones.

Extensive cultures of stones and urine were performed in 215 patients who underwent an operation for upper urinary tract calculi. Microorganisms could be cultured from the stone in 1 of every 3 patients. Despite the extended culture technique urease-producing microorganisms could be cultured from the stone in only 48% of the patients with calculi that contained magnesium ammonium phosphate. This finding suggests that an infection with urease-producing microorganisms is not obligatory for the formation of this type of stone. Of the patients with calcium oxalate phosphate stones 32% had positive stone cultures, which distinguished them from patients with pure calcium oxalate stones, only 8% of whom had a positive stone culture (p less than 0.001).

[Extracorporeal electromagnetic shock-wave lithotripsy. Initial results in the treatment of ureteral calculi in situ. A series of 50 consecutive cases]. / Lithotripsie extra-corporelle par ondes de choc électromagnétiques. Premiers résultats dans le traitement de la lithiase urétérale in situ. Série de cinquante cas consécutifs.

Electromagnetic shock waves are sufficiently powerful to break ureteral stones in situ under X-ray control. Fifty consecutive patients were treated for ureteral stones (20 lombar, 4 iliac, 26 pelvic); the average length was 7.5 mm; 48 times in one session, twice in two sessions. At 6 months, 98% of these patients were stone-free (with IVP control) and one patient was lost to follow-up.

Electrohydraulic lithotripsy of renal and ureteral calculi.

Electrohydraulic lithotripsy was used to manage 45 upper tract calculi (23 renal and 22 ureteral stones) in 40 patients. Electrohydraulic lithotripsy successfully fragmented 91% of the calculi. All ureteral fragments cleared; in 2 patients with renal calculi solitary 4 mm. stone fragments remained. There were no intraoperative or long-term complications directly related to the use of electrohydraulic lithotripsy in the upper urinary tract. We conclude that intrarenal and intraureteral electrohydraulic lithotripsy is a safe, effective, inexpensive means to perform intracorporeal lithotripsy.

[A case of 2,8-dihydroxyadenine stone with a partial deficiency of adenine phosphoribosyltransferase].

A 37-year old female was admitted with a complaint of gross hematuria. Intravenous pyelography and retrograde pyelography showed right non-functioning kidney with a radiolucent stone in the ureter. Computerized tomographic scan revealed right hydronephrosis and ureteral stone. Ureterolithotomy was performed. Infrared spectrometric analysis of the stone revealed a 2,8-dihydroxyadenine calculus. The adenine phosphoribosyltransferase activity in red blood cells was partially deficient. After the operation the patient has been given 100 mg/day of allopurinol and is on a low purine diet. There have been no signs of recurrence.

Abdominal radiograph and renal ultrasound versus excretory urography in the evaluation of asymptomatic patients after extracorporeal shock wave lithotripsy.

A prospective study was done to compare the relative efficacy of an abdominal radiograph and renal ultrasound to excretory urography for the evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy. We evaluated 101 renal units in 84 asymptomatic patients who had undergone extracorporeal shock wave lithotripsy 1 month previously with abdominal radiography, excretory urography and ultrasonography to evaluate the presence of retained stone fragments, dilatation of the collecting system and intrarenal or perirenal fluid collections or masses. The combination of abdominal radiography and ultrasonography identified retained fragments in 62 renal units, while excretory urography identified them in 54. Ultrasonography was less specific in identifying dilatation of part or all of the collecting system; proving falsely positive in 7 renal units and falsely negative in 14 compared to excretory urography. However, the case of obstruction was diagnosed correctly by both modalities. Finally, ultrasound appeared to be more specific and more sensitive in the evaluation of the presence of intrarenal or perirenal abnormalities. We conclude that a combination of abdominal radiography and ultrasonography is as good or better than excretory urography in identifying residual stone fragments and intrarenal or perirenal abnormalities. However, the finding of dilatation of all or part of the collecting system by ultrasonography is nonspecific and probably is better evaluated by excretory urography. We suggest that the routine radiological evaluation of asymptomatic patients 1 month after extracorporeal shock wave lithotripsy could be limited routinely to abdominal radiography and ultrasonography. However, when abnormalities of the collecting system are visualized on these studies excretory urography should be performed.

Thermogravimetric analysis of urinary stones.

Routine thermogravimetric (TG) analysis of 501 upper urinary calculi from the State of Jammu and Kashmir is described. The technique is simple, rapid and quantitative, and the equipment is easily maintained. The technique was found to be helpful in 95.4% of urinary stones and it is suggested that TG analysis may be employed as a technique of first choice in the routine quantitative analysis of all urinary calculi.

[Risk factors for the formation of urinary calcium-containing stones in diabetics].

Levels of 24-hour urinary calcium, magnesium, oxalate, citrate, uric acid, phosphorus and creatinine as well as urinary volume were determined in 85 patients and 81 normal subjects. Among the patients, 43 were diabetics without stone, 5 diabetics with stone and 37 with idiopathic calcium stone formation in the urinary tract. It is shown that the main risk factors involved in urinary calcium-containing stone formation are the levels of calcium, oxalate, uric acid and citrate and the volume of 24-hour urine. With the data obtained, the authors calculated the ion-activity products index of calcium oxalate and the relative probability of stone formation in the three groups of patients and the control group of normal subjects. The index in normal subjects, diabetics without stone, diabetics with stone and patients with idiopathic urinary calcium stone was 3.07 +/- 0.16, 2.90 +/- 0.25, 3.90 +/- 0.58 and 5.11 +/- 0.38 respectively. The upper limit of the relative probability in normal subjects was 0.54. Most of the patients with idiopathic urinary calcium stone (32/37) and all the 5 diabetics with stone had higher probability value than this, while most of the normal subjects (73/81) and of the diabetics without stone (39/43) had value lower than this. The results indicate that though the diabetics have higher level of urinary calcium and higher value of the product of calcium x oxalate x uric acid, they have also inhibitive factors for stone formation, such as increased level of urinary citrate. As a result, urinary stone formation will not be a frequent occurrence.

2,8-Dihydroxyadenine urolithiasis: report of a case in a woman in the United States.

Disorders of purine metabolism are well recognized clinical entities in modern medical practice. However, there are lesser known aberrations of purine and pyrimidine metabolism that can manifest as disease states. Deficiency of the enzyme adenine phosphoribosyltransferase is an autosomal recessive inherited disorder resulting in 2,8-dihydroxyadenuria, and possible urolithiasis and renal insufficiency. A woman with a pure 2,8-dihydroxyadenine ureteral calculus is reported, who represents the third reported case in the United States. Stones comprised of 2,8-dihydroxyadenine are difficult to distinguish from uric acid clinically, making sophisticated crystallographic analysis essential for accurate diagnosis. Treatment differs from that appropriate for uric acid lithiasis due to the limited solubility of 2,8-dihydroxyadenine at pH levels of less than 9. Prevention requires purine restriction and allopurinol.

The kidney-ureter stone sexual paradox: a possible explanation.

The greater frequency of renal stones seen on excretory urograms in women, compared with the greater frequency of ureteral stones in men has been termed a sexual paradox. We assessed stone composition and weight, and sex as possible explanatory factors. A total of 4,014 renal and ureteral calculi was analyzed. For the 3,119 calculi in which only calcium oxalate and/or phosphate was detected by infrared and wet chemical analysis, there was a strong relationship between the oxalate-to-phosphate weight ratio and sex (p less than 0.0001). The mean weight for phosphate stones was 330 mg. but for oxalate stones it was 107 mg. Male-to-female ratios were 2.7, 2.2 and 1.8 for stone weight groups of 20 or less, 21 to 100 and more than 100 mg. The male-to-female ratio was 0.87 for the 171 stones containing magnesium ammonium phosphate; the average weight was 508 mg. for men and 1,560 mg. for women. The tendency for phosphate stones to be heavier and relatively more common in women compared to predominantly oxalate stones may partly account for the sexual paradox.

[Local chemolysis of occluding uric acid calculi]. / Lokale Chemolyse okkludierender Harnsäuresteine.

Between 1984 and 1986 nineteen patients (20 renal units) were admitted with obstructing uric acid calculi. Seventy-eight percent of all patients with urolithiasis were treated endourologically: 8 kidneys were infected, 8 kidneys were non-functioning and 3 kidneys caused a status colicus. Sodium bicarbonate was used for percutaneous irrigation and all 20 kidneys were cleared within 4 to 18 days. The technique is a valuable adjunct to the ESWL.

[Recurrence of upper urinary tract calculi].

Treatment of upper urinary tract stones has changed greatly. The recurrence of calculi after the discharge was studied in the 634 patients with urolithiasis admitted to our department during the 9 years up to the end of 1984. The recurrence rate in the 325 cases followed for more than 3 months after the disappearance of the original stones, was 15.6% after 2 years, 27.6% after 5 year and 51.4% after 8 years. In recurrent stone formers, the rate of recurrence thereafter was greater than that of primary stone formers. The growth of calculi was rapid in the renal stone former concomitant with urinary tract infection together with a past history of renal surgery. In relation to the composition of the stone, uric acid calculi tended to recur more often than calculi composed of other substances. In view of recurrence, pyelolithotomy is preferred to renal parenchymal incision.

Electrohydraulic lithotripsy in the ureter.

Intravesical lithotripsy using electrohydraulic probe appears to be a rapid and safe technique to treat ureteral stones that are too large for intact extraction and inaccessible to ESWL. Strict adherence to the guidelines that have been discussed must be maintained to assure its safety.

Composition and structure of renal and ureteral calculi in patients under covalitin therapy.

We examined the composition and texture of 53 urinary calculi from patients receiving Covalitin therapy. The texture of the infection stones and of concrements containing mainly apatite showed no changes as compared to concrements from control groups receiving no such therapy. Calcium oxalate stones more often showed a whewellite texture (Type 2) and a less frequent occurrence of weddellite (Type 4) as compared to the control groups. Surface or marginal changes indicating a possible litholysis could not be shown.

Extracción de cálculos renales por nefrolitotomía percutánea y de ureterales por ureteroscopía en 108 pacientes / Renal stone extraction by percutaneous nephrolithotomy and ureteral axtraction by ureteroscopy in 108 patient

Se presenta un grupo de 108 pacientes que fueron sometidos, entre Diciembre de 1986 y Octubre de 1987 a la remoción de litiasis urinaria con técnicas endoeurológicas. En 50 de ellas se utilizó cirugía percutánea renal, con un 94% de éxito, en 53 pacientes su litiasis fue resuelta con el uso del ureterorrenoscopio, teniendo éxito en 94,3% y en 5 pacientes portadores de cálculos vesicales se utilizó ultrasonido para su solución. La técnica demostró eficacia para el tratamiento de estas patologías

[Chemolysis of cystine calculi incarcerated in the ureter by the alkaline organic amine, tromethamine-E].

We dissolved the cystine calculi incarcerated in the ureter by irrigation with tromethamine-E via percutaneous nephrostomy. Case 1: A 25-year-old man with a past history of cystinuria and staghorn calculi in the right kidney, suffered from obstructive renal failure caused by the incarceration of a stone (18 x 15 mm) in the left middle ureter. After recovering promptly from renal failure by left percutaneous nephrostomy, he received continuous irrigation with tromethamine-E through an angiographic catheter percutaneously placed in the ureter. The ureteral calculus was reduced by 70% in size after the irrigation for 35 days, and then extracted percutaneously. Case 2: A 3-year-old child had multiple cystine calculi in the right renal pelvis and ureter. Although a calculus in the renal pelvis was extracted by the percutaneous ultrasound lithotripsy, two calculi incarcerated in the middle ureter were impossible to remove by a percutaneous approach. The irrigation with tromethamine-E was initiated through the catheter placed percutaneously in the right ureter. Both calculi completely dissolved 47 days later. The chemolysis by irrigation with tromethamine-E was greatly valuable in the treatment of cystine calculi. This dissolution could be an alternative to surgery especially in the treatment of ureteral cystine calculi, which might be difficult to be extracted by the percutaneous or transurethral approach.

[Clinical experience of percutaneous nephrolithotomy].

Between July, 1984 and January, 1986, 20 cases of renal and ureteral stones were treated by percutaneous nephrolithotomy (PNL). Stone removal was successful in 17 cases (85%). In 14 cases, stones were removed completely and in 3 cases there were small residual fragments. There were 4 major and 9 minor complications. The major complications consisted of loss of tract in 2 cases, bleeding from the tract after removal of nephrostomy catheter in 1 case and pneumothorax in 1 case. The minor complications consisted of small perforation during PNL in 6 cases, gross hematuria impossible to continue PNL in 2 cases and ureteral injury due to ureteral occlusion catheter in 1 case. No patients required blood transfusion. In near future all urologists will be required to master the technique of PNL.