International Alliance of Urolithiasis Guideline on Shockwave Lithotripsy.

Different international associations have proposed their own guidelines on urolithiasis. However, the focus is primarily on an overview of the principles of urolithiasis management rather than step-by-step technical details for the procedure. The International Alliance of Urolithiasis (IAU) is releasing a series of guidelines on the management of urolithiasis. The current guideline on shockwave lithotripsy (SWL) is the third in the IAU guidelines series and provides a clinical framework for urologists and technicians performing SWL. A total of 49 recommendations are summarized and graded, covering the following aspects: indications and contraindications; preoperative patient evaluation; preoperative medication; prestenting; intraoperative analgesia or anesthesia; intraoperative position; stone localization and monitoring; machine and energy settings; intraoperative lithotripsy strategies; auxiliary therapy following SWL; evaluation of stone clearance; complications; and quality of life. The recommendations, tips, and tricks regarding SWL procedures summarized here provide important and necessary guidance for urologists along with technicians performing SWL. PATIENT SUMMARY: For kidney and urinary stones of less than 20 mm in size, shockwave lithotripsy (SWL) is an approach in which the stone is treated with shockwaves applied to the skin, without the need for surgery. Our recommendations on technical aspects of the procedure provide guidance for urologists and technicians performing SWL.

Reperfusion and Compartment Syndrome After Flexible Ureteroscopy in a Patient with an Iliac Vascular Graft.

Background: Flexible ureteroscopy (fURS) is one of the main treatment options for urolithiasis less than 2 cm. Although fURS has no relative contraindication, some anatomical factors may need to be considered, as not all patients are suitable for the regular lithotomy position (LP). We report the case of a patient with a right iliac vascular graft that after an fURS without intraoperative incidences developed a reperfusion syndrome of the right lower limb. Case Presentation: A 46-year-old male patient was referred for treatment and follow-up in the cystinuric clinic after being found to have a 3 cm pelvic stone with a Double-J catheter in place after two failed sessions of shockwave lithotripsy. The patient was placed in the LP and a standard ureteroscopy was done with no intraoperative complications. During the first hour in the recovery room, the patient developed severe pain in the right calf muscle stiffness, edema, and increased volume. A postreperfusion and compartment syndrome diagnosis was made with emergency fasciotomy. Conclusion: To perform fURS, each case must be assessed individually. If a patient with an iliac vascular graft has to undergo fURS, the patient positioning must be modified by keeping the ipsilateral (or both) legs straight to avoid graft complications.

[Renal cell carcinoma: pathological prognostic factors, staging and histopathological classification of 355 cases]. / Carcinoma de células renales: factores patológicos pronósticos, estadificación y clasificación histopatológica.

BACKGROUND: New morphologic entities for Renal Cell Carcinoma (RCC) that influence the prognosis have been described. Clinical staging has also undergone several modifications, the last one published in 2010 7th edition of the American Joint Committee on Cancer. The aim of this article is to determine the prevalence of histological subtypes, Fuhrman grading and clinical staging of renal cell carcinomas. METHODS: This is a retrospective, descriptive and comparative study, from January 2008 to June 2013. 355 cases of RCC were reclassified according to nuclear grading and new histopathological diagnostics and staging according to the TNM. A Kappa index was used for the diagnostic concordance and nuclear grading. RESULTS: Conventional renal cell carcinoma corresponded to 84.51 %, followed by chromophobe carcinoma and papillary. Less common subtypes were: multilocular cystic carcinoma, papillary clear cell carcinoma and others. Nuclear grading was directly related to the tumoral size and clinical staging (p < 0.001). The predominant stage was pT1b N0 M0, followed by pT3a N0 M0. CONCLUSIONS: The most frequent tumor was clear cell RCC, followed by chromophobe carcinoma and papillary carcinoma. Nuclear grading, necrosis, eosinophilic cells areas with areas of sarcomatoid and rhabdoid differentiation are prognostic factors associated with an increased aggression and risk of metastases.

Introducción: recientemente se han descrito nuevas entidades morfológicas de carcinomas de células renales (CCR) que influyen en el pronóstico. La estadificación clínica también ha sufrido modificaciones. El objetivo de este trabajo es conocer la prevalencia de los subtipos histológicos, el grado nuclear de Fuhrman y el estadio clínico del CCR. Métodos: estudio retrospectivo, descriptivo y comparativo de enero de 2008 a junio de 2013. Se analizaron 355 casos de CCR, fueron reclasificados de acuerdo con el grado nuclear y nuevos diagnósticos histopatológicos (clasificación de Vancouver) y estadificados de acuerdo con el TNM. Se realizó índice de Kappa para la concordancia diagnóstica y gradación nuclear, la asociación de variables cualitativas fue comparada con chi cuadrada. Resultados: el CCR claras convencional fue del 84.5 %, seguido del cromófobo y papilar. Otros subtipos menos frecuentes fueron: el carcinoma quístico multilocular, el CCR papilar de células claras y otros. El grado nuclear estuvo directamente relacionado con el tamaño tumoral y con el estadio clínico (p < 0.001). El estadio que predomino fue el pT1b N0 M0, seguido del pT3a N0 M0. Conclusiones: el tumor más frecuente fue el CCR claras, seguido del cromófobo y papilar. El grado nuclear, necrosis, áreas eosinófilas, sarcomatoides y rabdoides son factores pronósticos asociados a mayor agresividad y riesgo de metástasis.