A randomized controlled trial to assess the incidence of new onset hypertension in patients after shock wave lithotripsy for asymptomatic renal calculi.

PURPOSE: To answer the question of whether extracorporeal shock wave lithotripsy (ESWL*) induces hypertension, a prospective, randomized controlled trial of normotensive patients with asymptomatic renal calculi was designed. MATERIALS AND METHODS: Patients were randomized to receive immediate ESWL versus observation, reserving ESWL for the onset of symptoms. The rates of new onset hypertension were evaluated for both groups. RESULTS: There was no observed difference in the incidence of hypertension between the treatment and observation groups. CONCLUSIONS: The risk of hypertension in patients undergoing ESWL therapy is similar to that of a control cohort of initially observed asymptomatic patients.

Ureteral fibroepithelial polyp with positive urinary cytology.

We report on a patient with two fibroepithelial polyps of the upper ureter in whom the correct diagnosis was confused by finding voided urine as well as ureteral wash, and brush biopsy cytologies positive for malignancy. Fibroepithelial polyps and causes of falsely positive urinary cytology are reviewed.

The use of an abdominal compression belt to reduce stone movement during extracorporeal shock wave lithotripsy.

We used an abdominal compression belt in 50 patients undergoing extracorporeal shock wave lithotripsy with the Siemens Lithostar lithotriptor to limit diaphragmatic excursion and, therefore, renal calculus movement. Stone movement was measured on the monitor with and without the compression belt. Abdominal compression was found to decrease the range of stone movement by an average of 32% (-4 to 63%). This technique was less effective in patients with limited chest expansion. Abdominal compression was also found to be useful during treatment of renal and upper ureteral stones in reducing overall patient movement. The decreased stone movement during extracorporeal shock wave lithotripsy with abdominal compression may increase stone fragmentation and may decrease the number of shocks per treatment.

Lithostar extracorporeal shock wave lithotripsy: the first 1,000 patients. Toronto Lithotripsy Associates.

To our knowledge this study of our first consecutive 1,000 patients treated with the Siemens Lithostar device is the largest prospective series reported to date. Treatment results were determined at 3, 12 and 24 months after completion of therapy. The results at 3 months are presented. Complete followup data were available on 801 patients: 674 with renal and 127 with ureteral calculi. Results were analyzed according to stone size, location and number. The average number of shocks per treatment was 3,804 and the retreatment rate was 18.6%. At 3 months the stone-free rate was determined by a plain film of the kidneys, ureters and bladder and plain tomograms for renal calculi, and by an excretory urogram for ureteral calculi. The stone-free rate was 52% for renal and 76% for ureteral calculi. The overall stone-free rate for all calculi was 55.7%. Success rate, defined as stone-free or asymptomatic residual fragments measuring 4 mm. or less, was 72% for renal and 83% for ureteral calculi. The overall success rate for all calculi was 73.9%.

Laser lithotripsy of the difficult ureteral calculus: results in 122 patients.

We studied 122 patients with ureteral calculi who could not be treated by extracorporeal shock wave lithotripsy (ESWL) because the stones could not be localized or focused for treatment, the patient had failed prior ESWL, the stones were impacted and in situ ESWL was likely to fail or the stones were proximal to a ureteral stricture. These patients underwent laser lithotripsy using the Candela pulsed dye laser. In 107 patients (88%) the calculi were completely fragmented with the laser alone, while 10 (8%) needed another procedure (ESWL in 8 and stone fragment extraction by basket in 2), and 5 (4%) had failed laser therapy and needed some other form of treatment (ESWL in 4 and percutaneous antegrade extraction in 1). At 3 months 116 of 122 patients (95%) were stone-free. There were 2 immediate complications (ureteral perforations) and 1 late complication (ureteral stricture). Laser lithotripsy is a safe and effective method of intracorporeal fragmentation, even of the difficult ureteral calculus, and it is a useful adjunct to ESWL.

Potential for inter-observer and intra-observer variability in x-ray review to establish stone-free rates after lithotripsy.

The potential for variability among observers interpreting diagnostic tests is well known but has not been well established for radiological imaging of urolithiasis. We measured the inter-observer and intra-observer variability in the reporting of plain abdominal films and tomograms from patients who had undergone extracorporeal shock wave lithotripsy (ESWL). Unlabeled copies of the plain abdominal films and tomograms for 58 patients were individually submitted to 3 different radiologists. Selected films from 25 patients were resubmitted to the same radiologists. We found differences among radiologists reporting plain abdominal films alone 52% of the time and even by the same radiologist rereading the films 24% of the time. Tomograms alone decreased the uncertainty but differences still occurred among radiologists 24% of the time and with themselves 16% of the time. When plain abdominal films and tomograms were read together there were differences among radiologists 28% of the time and with themselves 7% of the time but these were usually minor. We concluded from this study that the plain abdominal film alone was frequently difficult to interpret, resulting in uncertainty about the presence or absence of residual stone fragments. Tomograms alone or a plain abdominal film plus tomograms is superior to a plain abdominal film alone. Finally, radiological assessment with all modalities probably overestimates stone-free rates after ESWL even without consideration of the potential for reporting variability among observers.

Flow cytometric analysis of cellular deoxyribonucleic acid content of nine renal oncocytomas.

The cellular deoxyribonucleic acid content of formalin-fixed, paraffin-embedded tissue from nine renal oncocytomas was determined using an Epics-C flow cytometer. The tissues were all from surgical specimens, and all neoplasms met stringent light and electron microscopic criteria for the diagnosis of oncocytoma. Thirteen samples of pure tumor, 5 of tumor and normal kidney, and 3 of normal kidney alone were analyzed. All oncocytomas had single, sharp G1 peaks with no evidence of aneuploidy, and this peak was similar to that of normal renal parenchyma. This was true even for three oncocytomas that had multiple major chromosomal anomalies on karyotyping. These data support the concept that renal oncocytomas are euploid neoplasms, consistent with their benign biologic behavior. The apparent discrepancy between the results of flow cytometry and karyotyping is discussed.

Lithostar extracorporeal shock wave lithotripsy in children.

The Siemens Lithostar lithotriptor was used to treat 20 children (4 to 17 years old) with renal or ureteral calculi. Two patients had bilateral renal and 2 had ureteral calculi. Of 34 calculi treated 47% were in the renal pelvis, 29% in the lower calix, 12% in the upper calix, 3% in the middle calix and 9% in the upper ureter. Stone size ranged from 2 X 2 to 40 X 20 mm. and averaged 10 X 7 mm. Of the children 60% were treated while they were under neuroleptic anesthesia. No major complications were encountered. The 3-month rate free of stones after 1 treatment was 60% and increased to 80% with multiple treatments. The success rate, defined as being either free of stones or with residual fragments equal to or less than 4 mm. in diameter, was 95%. We conclude that lithotripsy with the Lithostar device in children, at least for the short term, is safe and effective.

Laser lithotripsy in the treatment of ureteral calculi.

We examined the effectiveness of laser lithotripsy with a flash-lamp-pumped tunable dye laser in the treatment of ureteral calculi that were too large for direct extraction and that could not be treated with or had not responded to extracorporeal shock-wave lithotripsy (ESWL) or forms of ureteroscopic lithotripsy other than laser lithotripsy. In 20 (74%) of the 27 patients the laser alone successfully fragmented the calculi into pieces small enough to pass spontaneously or to be easily extracted with a basket. In five (19%) laser lithotripsy was partially successful: another procedure (ESWL in three and fragment extraction with a basket in two) was needed. In two patients (7%) the stones could not be fragmented with the laser, and either ESWL or percutaneous antegrade extraction was performed. At follow-up 3 months after treatment there was no sign of stone fragments in 26 (96%) of the patients. We believe that laser lithotripsy is a safe and effective method of ureteral stone fragmentation.

Further evidence that renal oncocytoma has malignant potential.

We report a case of bilateral renal oncocytoma. The right tumor infiltrated the renal capsule focally, and the left tumor penetrated through the capsule into the surrounding perinephric fat and extended into the left renal vein. Karyotyping of the left oncocytoma showed loss of chromosomes 1 and Y (-1,-Y). These karyotypic anomalies, along with the capsular, perinephric fat and renal vein involvement, indicate that renal oncocytomas, despite similar gross and microscopic pathological characteristics, are a heterogeneous group of tumors, some of which have malignant (local invasiveness) potential.

Extracorporeal shock wave lithotripsy of caliceal diverticula calculi.

We reviewed 10 patients with calculi in caliceal diverticula to determine whether they could be treated successfully by extracorporeal shock wave lithotripsy. Of the patients 7 required 1 and 3 required 2 treatment attempts to fragment the calculi completely. After a minimum followup of 3 months (mean 5.9 months) 2 patients (20 per cent) had passed successfully all of the stone fragments, while 3 (30 per cent) had passed more than half and 5 (50 per cent) had passed less than half of the fragments. Of the 8 patients with residual fragments only 3 had persistent symptoms indicating that symptom relief is not dependent on complete stone removal. The possibility of producing a satisfactory result (70 per cent free of symptoms) and the low morbidity of extracorporeal shock wave lithotripsy suggest that this treatment may be appropriate for calculi in caliceal diverticula.

Ureteral stump metastases from renal adenocarcinoma.

The thirty-second documented case of ureteral stump metastasis from renal adenocarcinoma is presented. It demonstrates well the variable and often unusual presentation of renal adenocarcinoma and the utility of our current diagnostic instrumentation (here ureteroscopy and skinny needle biopsy) in documenting metastatic disease. Also, and in contrast to prior reports, it documents lengthy survival and a lack of extensive metastases in this high risk group of patients. The literature is reviewed and the presentation, metastatic pathways, and management of ureteral stump metastases from renal adenocarcinoma are briefly discussed.

Ureteral obstruction by a rare venous anomaly: a case report.

Aberrant blood vessels are a rare cause of ureteral obstruction. A case is reported of right upper ureteral obstruction that simulated radiologically a retrocaval ureter. At operation the ureter was obstructed by an aberrant vein going from the right spermatic vein to the inferior vena cava. The obstruction was relieved by dividing this vessel. Aberrant blood vessels should be considered in the differential diagnosis of extrinsic ureteral obstruction.

Chromosome anomalies suggestive of malignant transformation in bilateral renal oncocytoma.

A patient with bilateral renal oncocytoma is presented, and the clinical, radiological and pathological characteristics of this uncommon, clinically benign renal tumor are discussed briefly. Chromosomal analysis studies revealed the following clonal abnormalities: trisomy of chromosome 7, and monosomy of chromosomes 3 and 14, and the X chromosome. A possible clonal abnormality of chromosome 10 and 3 nonclonal anomalies also were identified. The same anomalies were present in both tumors. These karyotypic anomalies are compatible with malignant transformation of the cells of these tumors and, since benign tumors rarely are associated with demonstrable cytogenetic changes, they suggest that oncocytoma, although clinically benign, may have malignant potential.

Complete patent duplication of the urethra.

We reviewed 16 patients with complete patent duplication of the urethra seen between 1945 and 1984. The clinical presentation, radiographic findings and management of each patient are presented. All 16 patients were symptomatic and a double stream was the most common complaint. An operation was necessary in 13 patients. Voiding cystourethrography and retrograde urethrography were necessary to define the anatomy completely and accurately in each patient. The ventral channel, regardless of the position of the meatus, invariably proved to be the more functional urethra.

Primary genitourinary tuberculosis: rapid progression and tissue destruction during treatment.

We report a case of primary genitourinary tuberculosis associated with severe progressive scarring, and obstruction of the left collecting system and proximal ureter, a contracted bladder with persistent vesicoureteral reflux and a bulbar urethral stricture. Scarring commenced soon after initiation of medical therapy, and resulted in left nephrectomy and reconstruction with colocystoplasty, right ureteral reimplantation and urethroplasty. The rapidity of disease progression and severity of tissue destruction in this case suggest that patients with genitourinary tuberculosis require close supervision starting at initiation of drug treatment. When complications do arise appropriate surgical intervention may become mandatory to decrease morbidity and to conserve renal function. The pathophysiology, clinical manifestations, radiological findings and treatment of genitourinary tuberculosis are reviewed.