Percutaneous resection of renal transitional carcinoma: venous injury and its conservative management.

An interesting observation encountered at percutaneous resection of a renal transitional cell carcinoma and its conservative management is described. During resection of the tumour sudden heavy haematuria was encountered. Nephroscopic inspection revealed the blood to be coming from behind a loop-generated flap, the raising of which allowed entry of the endoscope into a sizeable vein and thence upwards into the renal vein and inferior vena cava (IVC). On table nephrostogram confirmed contrast outlining the renal vein and IVC. Placement and clamping of a nephrostomy tube was followed by stabilization of the patient and the bleeding stopped. The urine became clear within 24 h. Later on repeat nephrostogram showed an intact pelvicalyceal system with an acceptable tumour clearance. This case highlights the importance of a trial of conservative management in the treatment of bleeding complications during nephroscopy.

Management of staghorn calculus: analysis of combination therapy and open surgery.

OBJECTIVE: To assess the role of primary open surgery versus the recommended combination approach (percutaneous and lithotripsy) to treat staghorn calculi in a developing country. PATIENTS AND METHODS: Available records (n = 91) of patients with staghorn managed during the last 4 years were retrieved. Patients were placed in two groups, open surgery and combination group, according to the primary procedure chosen by the patient. Demographic data in two groups was comparable in most of the respects except that renal failure patients were more in the combination group. Stone clearance, major residue, auxiliary procedures, morbidity, hospital stay and the cost were studied in the two groups for comparison. RESULTS: Complete clearance could be obtained in 66 and 59% with open and combination method respectively. Major residue (> 16 mm2) was present in 21% of open and 38% of the combination group. In patients with primary stone burden < 900 mm2, the total clearance rates were 66 and 60% in open and combination group, respectively. Total clearance was not affected by caliceal dilatation, total stone burden, pelvic and caliceal bulk separately or their ratio, as arrived by logistic regression analysis. The incidence of haematuria in the combination group was marginally higher, probably due to more renal failure patients in this group. Hospital stay in the two groups was comparable (13.0 days in combination vs. 12.1 days for open). The cost of treatment with combination group was significantly higher. CONCLUSION: Open surgery for staghorn is still an economically viable option for difficult stone disease, specially in a developing country, with comparable efficacy, favourable morbidity and hospital stay.

Comparison of freezing and lyophilizing for preservation of colostrum as a source of immunoglobulins for calves.

Lyophilizing was compared to freezing as a method of colostrum storage. Eight lots of colostrum from the first milking were divided into two equal parts; one was frozen, and the other was lyophilized. Twenty-two newborn calves were divided into two groups and fed either 2 L of frozen and thawed colostrum or 2 L of reconstituted lyophilized colostrum. The calves were bled at 12, 18, 24, and 72 h after feeding, and levels of the immunoglobulins IgG1, IgG2, IgM, and IgA were determined with a radial immunodiffusion assay, in colostrum and sera. The mean concentration of individual immunoglobulin isotypes in the sera of calves fed either frozen or lyophilized colostrum did not differ significantly. Calves fed from the same lots of colostrum had similar immunoglobulin concentrations in their sera, irrespective of the method of storage. All immunoglobulin isotypes were absorbed with equal efficiency from frozen and lyophilized colostrum as determined by calculation of the absorption coefficient.

Chronic renal failure and nephrolithiasis in a solitary kidney: role of intervention.

PURPOSE: We determined the role of intervention and its outcome in patients with a solitary kidney, nephrolithiasis and chronic renal insufficiency, as well as the role of clearance in these patients compared to those with a solitary kidney, nephrolithiasis and normal renal function. MATERIALS AND METHODS: A total of 36 records was evaluable, including 16 from patients with normal (group 1) and 20 from those with abnormal (group 2) renal function. Group 2 was further subdivided into those with mild to moderate (group 2A) and advanced (group 2B) renal failure. Patients with acute renal failure were excluded from the study. Glomerular filtration rate was calculated by the Cockcroft and Gault formula. The reciprocal of serum creatinine was used to determine outcome. RESULTS: Groups 1 and 2 were comparable demographically except for serum creatinine, stone bulk and hospital stay. Of 36 patients 8 with normal renal function and 15 with chronic renal failure underwent percutaneous nephrolitholapaxy, 6 underwent extracorporeal shock wave lithotripsy and 7 underwent open surgery. Total clearance was achieved in 25 of 36 patients (72%). Glomerular filtration rate improved in 24 patients, remained stable in 8 and deteriorated in 4. However, 3 patients had less than 20% deterioration and 1 had significant deterioration in function after intervention. Improvement in glomerular filtration rate after intervention was significantly greater in cases of advanced renal failure. Patients with residual stones did worse than those without residual calculi. Mean hospital stay, deterioration in glomerular filtration rate and major morbidity rate were significantly greater in patients with residual calculi than in those with total clearance. CONCLUSIONS: Intervention should be contemplated in patients with a solitary kidney, stone disease and renal failure as in any other patient with stone disease, with the aim being total clearance. Stone eradication delays deterioration, and decreases the requirement for dialysis and renal replacement.

Endoscopic management of traumatic posterior urethral stricture: early results and followup.

PURPOSE: We assessed the outcome of core through internal urethrotomy for traumatic posterior urethral stricture, and reviewed the followup results of these patients. MATERIALS AND METHODS: During the last 4 years 13 patients with a stricture up to 2 cm. long underwent core through internal urethrotomy with C-arm fluoroscopy guidance and an orientation in 2 planes. Retrograde urethrotomy was performed and an 18F Foley catheter was left indwelling for 4 weeks, after which urethrotomy was repeated. All patients were advised to perform clean intermittent self-catheterization for urethral calibration and dilation. Outcome was defined as class 1-3 patients who required 2 or fewer urethrotomies with clean intermittent self-catheterization discontinued after the primary procedure, class 2-5 who required 2 or fewer urethrotomies with clean intermittent self-catheterization and class 3-5 who required 3 or more urethrotomies. RESULTS: Of the 13 patients 8 (61%) did well after a mean followup of 17.7 months. The 3 patients with a class 1 outcome did well, while 2 of 5 with a class 2 outcome required repeat urethrotomy during followup. Of the 5 patients (39%) with a class 3 outcome in whom core through internal urethrotomy failed 3 required open surgery and 2 were lost to followup. Recurrence rate was 69% at 3 months and 25% at 12 months after the initial procedure. No patient was incontinent at last followup. Two patients had significant hematuria postoperatively, which resolved with conservative treatment. CONCLUSIONS: Endoscopic treatment should be considered the first line procedure for all post-traumatic posterior urethral strictures. The morbidity of open surgery can be avoided in 61% of patients. Hospital stay, loss of work, morbidity and related complications are also markedly decreased with endoscopic therapy.

Pediatric kidney: functional outcome after extracorporeal shock wave lithotripsy.

PURPOSE: We studied the efficacy, functional outcome and morphological changes following extracorporeal shock wave lithotripsy (ESWL*) of renal calculi in a pediatric population. MATERIALS AND METHODS: We prospectively evaluated 50 patients 2 to 12 years old (mean age 7.64) undergoing ESWL with the Siemens Lithostar Plus. Functional outcome was assessed by comparing total and ipsilateral glomerular filtration rates before and after ESWL. Glomerular filtration rate was measured using Gates' method on a 99mtechnetium-pentetic acid radionuclide renal scan corrected to body surface area times 1.73 m.2. Ultrasound was performed to assess morphological changes after ESWL. RESULTS: The immediate fragmentation rate was 86% and the clearance rate was 82%. At the end of the study 40 patients were evaluable. Immediately after ESWL ultrasonography showed perirenal hematoma in 3 patients, intrarenal hematoma in 2 and subcapsular hematoma in 1. These changes resolved spontaneously at followup. There was no change in total or ipsilateral glomerular filtration rate at a mean followup of 31.7 months. Before and after ESWL total glomerular filtration rates were 86.58 +/- 12.43 and 86.27 +/- 12.82 ml. per minute per 1.73 m.2, respectively. Treated kidney glomerular filtration rate decreased insignificantly from 40.58 +/- 12.61 to 40.41 +/- 12.61 ml. per minute per 1.73 m.2 at 3 months. At the last followup the change in glomerular filtration rate was insignificant. CONCLUSIONS: ESWL is effective in the pediatric population, and it can be safely performed without long-term bio-effects on the function or morphology of the growing kidney.

Spontaneous perforation of the ureter: endourological management with renal preservation.

Spontaneous perforation of the ureter proximal to an obstruction has not been well described in the literature. We present a rare case of spontaneous perforation of the ureter, proximal to a radiolucent upper ureteric stone, in a 58-year-old diabetic female, causing a large infected urinoma and septicaemia in a solitary functioning kidney. The diagnosis was confirmed by computer tomography scan. We managed the case successfully by endourology only. The case emphasizes the importance of the differential diagnosis in a diabetic patient with obstructive uropathy.

Upper urinary tract stone analysis using X-ray diffraction: results from a tertiary referral centre in northern India.

BACKGROUND: The spectrum of urinary stone disease has changed considerably in India from the common childhood bladder stone to the more frequent upper tract calculi. We analysed the gravel retrieved from the upper urinary tract using X-ray diffraction analysis in an attempt to evaluate the composition of the stones. METHODS: We analysed 434 upper urinary tract calculi from May 1993 to June 1994 obtained endourologically, as well as by extracorporeal shock wave lithotripsy and open surgery. The stones were analysed using a Phillips compact X-ray diffractometer (PW1840). The PC-APD software was used for data collection and peak search. The phase matching was done by the software using the JCPDS reference database. RESULTS: Oxalate stones comprised 97% of the total stones with calcium oxalate monohydrate forming 90% and calcium oxalate dihydrate and mixed stones forming the remainder. Struvite stones were found in 1.4%, while uric acid and apatite stones were less than 1%. There were no cystine calculi. Seventy per cent of calcium oxalate monohydrate and 40% of calcium oxalate dihydrate stones were pure. All the struvite and apatite calculi were almost pure. Only 15% of staghorns did not consist of oxalate. Nine of the ten stones in children were of the calcium oxalate monohydrate variety. The stone composition in females was similar to that in males. CONCLUSIONS: X-ray diffraction data indicate that urinary stone disease in north India is different from that in the western world. Calcium oxalate monohydrate stones predominate. These stones are hard to break and have a different metabolic origin from those consisting of calcium oxalate dihydrate. These findings might help in selecting the most appropriate method of treatment in north India and they indicate directions in which further metabolic studies might be planned.

A new endoscopic technique for non deflating Foley balloon.

OBJECTIVE: To describe a new technique to deflate impacted Foley balloon. METHOD: A total endourologic method using urethrotome sheath, ureteric catheter, stylet, sedoanalgesia needle and cold cup biopsy forceps is described. The technique involves minimal maneuverability of urethra. RESULTS: The technique is non traumatic, simple, and successful in almost all cases. This technique requires urology instruments which are easily available at any centre. CONCLUSION: The described technique is safe, effective non traumatic and can easily be used in cases of impacted Foley balloon. There is no damage to the posterior urethra.

Functional bladder neck obstruction: a rare cause of renal failure.

We studied 7 men and 6 women (average age 33 years) who presented in renal failure with obstructive voiding symptoms or retention. Of these patients 11 had a dilated upper tract and 2 had shrunken kidneys. Mean serum creatinine at presentation was 7.0 mg./dl. No abnormality was noted on cysto-panendoscopy, retrograde urethrography and voiding cystourethrography. The patients were initially treated with clean intermittent self-catheterization following 7 to 10 days of indwelling catheterization. The majority of patients had low pressure and low flow rate at initial presentation but high end filling pressure (mean 35.3 cm. water), high voiding pressure (mean 118.9 cm. water), high opening pressure (mean 95.3 cm. water) and low peak flow (mean 5.7 ml. per second) on video pressure flow electromyography. The external sphincter was relaxed during voiding but the bladder neck opened intermittently or inadequately. No proper funneling of the bladder neck was seen. Thus, functional bladder neck obstruction was considered to be responsible for obstructive voiding in these patients. Of the patients 3 void to completion with the help of alpha blockers alone, 5 underwent bladder neck incision and are voiding well, and 5 were practicing clean intermittent self-catheterization at last followup. Serum creatinine returned to near normal in 10 patients. End stage renal failure persisted in 2 patients, 1 of whom underwent renal transplantation and is voiding well but the other died without having undergone renal replacement therapy. In the remaining patient serum creatinine was stable at 3.2 mg./dl. Mean serum creatinine at 6 months of followup was 2.33 mg.%. Bladder neck obstruction is a rare cause of renal failure which can be corrected if treated appropriately.

Percutaneous drainage of renal hydatid cyst: early results and follow-up.

OBJECTIVE: To evaluate a combination of percutaneous drainage and medical prophylaxis in the treatment of renal hydatid cyst to assist renal preservation, decrease morbidity and shorten the duration of hospital stay. PATIENTS AND METHODS: Four patients (three men and a woman, age range 26-31 years) with non-communicating renal hydatid cysts were selected for treatment using percutaneous drainage. This was performed under medical prophylaxis with albendazole and praziquentel. Ethanol (95%) was used as a scolicidal agent. RESULTS: The method was successful in preserving three of four renal units but one unit was ablated because of secondary infection and haematuria. The kidneys of three patients were functioning adequately after a mean follow-up of 21.6 months from percutaneous drainage. CONCLUSIONS: Percutaneous drainage of renal hydatid cysts is a safe and effective method for preventing renal loss, and decreasing morbidity and the duration of hospital stay. It should be employed as the first option for renal hydatid disease.

Purification and characterization of IgG1 and IgG2 from buffalo (Bubalus bubalis) serum and colostrum.

Buffalo IgG1 and IgG2 were purified from serum and colostrum using salt precipitation, dialysis, gel filtration and ion-exchange chromatography. Their purity was monitored by immunodiffusion and immunoelectrophoresis using anti-heavy chain specific sera and SDS-PAGE. Selective binding of IgG2 to protein-A was used to remove IgG2 from IgG1 preparations. The IgG1 and IgG2 had a molecular mass (Mr) of 162.0 and 161.5 kD, respectively and were found to consist of heavy (H) and light (L) chains. The H and L chains had Mr of 58 and 24 kD, respectively. Reduction-alkylation followed by gel filtration was used for the isolation of H and L chains. While intact H chains were obtained, the L chains appeared to be cleaved into 14 kD molecules and smaller fragments. The mean hexoses content of the serum IgG1 and IgG2 was 1.81 +/- 0.02% and 0.70 +/- 0.02%, respectively. The corresponding values for colostral IgG1 and IgG2 were 1.76 +/- 0.01% and 0.78 +/- 0.08%. Both the IgG subclasses activated homologous complement. These results suggest that buffalo and cattle IgG subclasses have many common characteristics and minor differences.

Studies on activation and levels of haemolytic complement of buffalo (Bubalus bubalis). III. C3 haemolytic activity in health and chronic disease.

Estimation of haemolytic complement component C3 activity in serum was done by using buffalo serum functionally depleted of C3, with methylamine. In the one-step alternate pathway (AP) haemolytic assay, C3 activity in the serum was estimated by its capacity to reconstitute the AP haemolytic activity in C3 depleted serum. Levels of haemolytic C3 were determined in the sera of 70 apparently healthy buffaloes and of seven diseased buffaloes of which five were suffering from Johne's disease (JD) and two from JD and tuberculosis (TB). The haemolytic C3 levels in healthy animals varied with age, reaching peak values in the 2.5-3-year-old, declining after 4 years of age. The C3 levels in buffaloes suffering from chronic diseases was significantly higher (P < 0.05) than the levels in healthy buffaloes of the same age group.

Studies on activation and levels of haemolytic complement of buffalo (Bubalus bubalis). II. Alternate complement pathway activity in serum.

Buffalo serum caused lysis of unsensitized red blood cells (RBC) of sheep, goat, rabbit and guinea-pig. There was minimal lysis of cattle RBC, and homologous RBC were resistant. Lysis of sheep and goat RBC was the result of natural antibodies as adsorption with respective RBC and addition of 8 mmol ethylene glycolbistetraacetate (EGTA) in diluent completely abrogated the haemolytic activity. The lysis of guinea-pig and rabbit RBC was only partially decreased by these treatments, indicating the presence of alternate complement pathway (ACP) activity in buffalo serum. The guinea-pig RBC were the most sensitive to lysis, and 50% CH titre units above 40 ml-1 of serum were obtained. The haemolytic activity of buffalo C for unsensitized guinea-pig RBC was reduced from 47 CH50 units to an undetectable level by heating at 50 degrees C for 20 min and at 56 degrees C for 4 min. Similarly, treatment with zymosan also inhibited this haemolytic activity. Maximum activation of buffalo ACP occurred in the presence of 4 mmol Mg2+ in the diluent. Using standardized conditions, ACP activity was determined in sera of 98 healthy buffaloes of different age groups from 1 month to 12 years. Even young calves less than three months of age showed considerable ACP activity (45.60 +/- 1.21 CH50 units ml-1) which increased with age. The peak mean values of 79.79 +/- 1.45 CH50 units was recorded in 2 to 4-year-old animals. However, in all the 11 animals above 4 years of age, the haemolytic activity was greatly reduced and was even less than that in 1 to 3-month-old buffalo calves.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on activation and levels of haemolytic complement of buffalo (Bubalus bubalis). 1. Classical complement pathway.

Optimum conditions for haemolytic complement (HC) assay in buffalo serum were standardized. In all, 11 indicator systems of red blood cells (RBC) and haemolysins were investigated. Maximum HC CH50 titre was obtained with rabbit RBC sensitized with goat haemolysin. The effect of pH, Ca2+ and Mg2+ concentration, ionic strength, time and temperature were studied. Of all the variables, ionic strength influenced the HC activity most significantly. The standard system for titrating the HC consisted of rabbit RBC sensitized with goat haemolysin, sucrose-veronal buffer with pH 7.5, ionic strength 0.023 M and Ca2+ and Mg2+ concentrations 6 x 10(-4) and 2 x 10(-3) M, respectively. Incubation at 37 degrees C for 2 h gave highest haemolytic activity. With this protocol 5-7-fold higher HC activity was recorded than with prestandardized conditions. Levels of HC were determined in the sera of 98 buffaloes aged from 1 month to 12 years. The lowest mean CH50 units of 401 +/- 0.35 per ml were recorded in buffalo calves below 3 months of age. The mean HC levels increased with age, reaching peak values of 2349 +/- 62.25 CH50 units/ml in 2-3-year-old buffalo. Animals in the age group 5-12 years had significantly decreased (P less than 0.05) mean HC levels of 1545 +/- 68.94.