Evaluation of outcome following lithotripsy.

PURPOSE OF REVIEW: Shockwave lithotripsy (SWL) is considered as an initial option for a significant proportion of urinary tract stones. Despite efforts for standardized terminology and methodology, published studies on lithotripsy outcome are very different. This review will focus on a brief description of evidence-based medicine and recent literature results on SWL outcome. RECENT FINDINGS: The introduction of hierarchy in scientific evidence is becoming more widespread. Various grading systems have attempted to rank recommendations according to type and amount of evidence. Different levels of evidence have been created for therapy, diagnosis and prognosis. Various authors have developed scoring systems and identified radiographic parameters to predict SWL outcome. The long-term safety of lithotripsy on renal function has been demonstrated. Randomized controlled trials and meta-analysis have shown that medical expulsive therapy and a slower shockwave rate will improve SWL outcome. SUMMARY: Evidence-based medicine is rapidly becoming an indispensable part of everyday medical practice. Common terminology is necessary for proper evaluation of SWL. Different types of studies are required to investigate efficacy, compare SWL to other options, complications and so on. Randomized clinical trials are of the highest value; matched-pair analyses and well designed controlled studies can offer significant help.

Ureteric stents compromise stone clearance after shockwave lithotripsy for ureteric stones: results of a matched-pair analysis.

OBJECTIVE: To identify the effect of the presence of a ureteric stent on the outcome of extracorporeal shockwave lithotripsy (ESWL), by comparing patients with ureteric stones with matched-pair analysis. PATIENTS AND METHODS: Patients undergoing ESWL with the Sonolith Vision lithotripter (Technomed Medical Systems, Vaulx-en-Velin, France) were identified from our prospectively maintained database. Only adult patients with a solitary, radio-opaque, previously untreated ureteric stone were considered for further analysis. A follow-up of >or=3 months with a plain abdominal film was used to identify residual fragments. Patients were exactly matched for gender, side, location in the ureter and size (in two dimensions, within +/-2 mm). If both diameters could not be matched exactly, the size was extended to +/-1 mm and then to +/-2 mm of both diameters. An effort was finally made to match patients by age. The treatment outcome in terms of stone-free rates was assessed and compared using McNemar's test. RESULTS: In all, 45 patients with a ureteric stent in place during ESWL were identified. The only patient who could not be adequately matched was a 40-year-old man with an 8 x 3 mm stone in the upper ureter. The best/closest match for age was selected. Most stones were in the upper ureter (77%); the mean stone size was 8.5 and 8.6 mm, respectively, with no statistical differences between the groups for age and size of stones (P = 0.41 and 0.86, Student's t-test). In 12 pairs, only patients with no stent were stone-free, compared to two pairs where the patient with a stent was stone-free. Using McNemar's test, the odds ratio was 6.0 (95% confidence interval 1.3-55.2) and the difference between the groups was statistically significant (P = 0.016). CONCLUSION: These results show that the presence of a stent is associated with a worse outcome after ESWL for ureteric stones. Ureteric stents should still be used in cases of obstruction, when there is a risk of sepsis, and in patients with intolerable pain or deteriorating renal function. However, their use in patients offered ESWL for ureteric stones should be considered with caution.

Blood splash injury: an underestimated risk in endourology.

BACKGROUND AND PURPOSE: Mucocutaneous and transconjunctival exposure are important portals for the transmission of blood-borne infections to surgeons and health-care workers. Despite this knowledge, few surgeons or their assistants wear protective equipment for procedures perceived to be affiliated with less risk. This study investigates the potential risk of mucocutaneous and transconjunctival blood splash injury during common laparoscopic and endourologic procedures undertaken using standard video endoscopy equipment. MATERIAL AND METHODS: Masks combined with eye shields were consecutively collected from the surgeon, surgical assistant, and theater nurse after a variety of endourologic procedures over a 4-month period. These were analyzed macroscopically for visible blood droplets. Modern forensic techniques were then instituted to assess for nonvisible blood exposure. RESULTS: Eye shields from 118 procedures performed by five surgeons were collected. Two hundred and thirty-six masks were examined for visible and visually enhanced evidence of blood contamination. In total, 48.5% of surgeons' masks, 29.5% of assisting surgeons' masks, and 31.8% of scrub nurse masks were positive for either visible or visually enhanced blood contamination. In terms of evidence of blood splash, 84.2% of laparoscopic nephrectomies, 66.7% of pyeloplasties, and 58.3% of flexible ureteroscopies tested positive. CONCLUSION: Splash injuries remain commonplace, even with the use of video endoscopy equipment. Therefore, all health-care workers should be encouraged to wear eye and face protection when undertaking both endoscopic and laparoscopic urologic procedures. These observations may have broader implications relevant to all minimally invasive surgical procedures, because they demonstrate a much greater potential risk of blood-borne disease transmission during surgery than has been previously appreciated.

Case report: endourologic treatment for a ureteral stone in a patient with osteogenesis imperfecta.

A 53-year-old man with osteogenesis imperfecta presented with a 9-mm stone in the left middle ureter. The patient was treated endourologically by ureteroscopy and laser lithotripsy. The lack of similar cases, the rare nature of the disease, and the difficulties in treatment suggest that the entire endourologic armamentarium and a specialized center are necessary to achieve a successful outcome.

Optimizing shock wave lithotripsy in the 21st century.

OBJECTIVE: Shock wave lithotripsy (SWL) has radically changed treatment of stone disease and appears to be the first option for the majority of patients. This review of current literature focused on suggestions for optimising technique, patient selection, results, and lithotriptor comparison for SWL. METHODS: Literature search for SWL was performed for recently published papers in English language. Topics of interest were treatment protocols; patient evaluation; pre-SWL prediction of outcome; lithotriptor technology; efficacy; and methods to assess the effects, decrease complications, and compare lithotriptors. Earlier classic papers on SWL and guidelines for stone disease were also reviewed. RESULTS: Recent literature contained important recommendations about SWL concerning (1) methods to predict stone fragmentation; (2) identification of factors contributing to treatment failure for lower pole and ureteric calculi; (3) guidelines from urological associations; (4) manoeuvres and changes in SWL delivery (slower rate, twin-pulse technique) to increase efficacy and decrease complications; (5) clarification of the role of medical treatment (antibiotics, alpha-blockers); (6) role of SWL in calyceal stones, CIRF, and abnormal kidneys; (7) obesity and SWL; and (8) methods to evaluate and compare lithotriptors. CONCLUSIONS: SWL delivered in an outpatient setting as an anaesthesia-free treatment is still considered the first option for the majority of stones with a minimal number of complications. Better understanding of the physics of shockwave delivery is required, together with treatment optimisation by limiting renal damage and better selection of patients because this approach will offer maximum benefit to patients and physicians, as well as more cost-effective treatment.

Time of administration of a single dose of oral levofloxacin and its effect in infectious complications from transrectal prostate biopsy.

OBJECTIVE: To evaluate the efficacy of two prophylactic schemes for prostate biopsy using a single dose of oral levofloxacin given either before, or immediately after transrectal ultrasound-guided prostate biopsy. MATERIALS AND METHODS: A total of 300 men formed two groups of 150 patients each: the first group received one dose of 500 mg of levofloxacin 30 min to an hour before, and the second group the same antibiotic immediately after prostate biopsy. No pre-biopsy enema was used. Side effects after prostate biopsy were recorded, and the two groups were compared. RESULTS: Only one patient from the first group developed a urinary tract infection after biopsy. A mean number of more than 10 cores per patient were taken. Haematuria was the most common complaint, followed by haemospermia. Haematuria and rectal bleeding were more common in patients where more than 8 cores were taken from the prostate (P = 0.005 and P = 0.017, respectively). Prostate cancer was detected in 34.3% of patients in total. CONCLUSION: The use of a single dose of 500 mg levofloxacin given immediately after prostate biopsy proved to be quite effective for the prevention of infectious complications, even in the setting of an extensive biopsy protocol.