Treatment of bladder stones without associated prostate surgery: results of a prospective study.

OBJECTIVES: To assess the effectiveness of noninvasive bladder lithiasis treatment without associated prostate surgery to know whether bladder lithiasis is an absolute indication for prostate surgery. METHODS: Fifty patients with bladder lithiasis were entered in a prospective trial and were treated with extracorporeal shock wave lithotripsy if lithiasis was smaller than 4 cm2. Independent of the presence or absence of bladder outlet obstruction, in no case was prostate surgery associated. The variables studied were the effectiveness of the treatment, changes in the International Prostate Symptom Score (IPSS), and the subsequent need for desobstructive prostate surgery. The statistical study was performed using Student's t test and the proportional hazards model. RESULTS: Bladder lithiasis was successfully eliminated in 93% of the cases (in 77% of them with a single extracorporeal shock wave lithotripsy session). The mean IPSS decreased from 17.7 to 9.7 points (P = 0.0001) after lithiasis elimination. After a mean follow-up of 22 months, a mere 8% of the patients needed subsequent prostate surgery because their IPSS had increased to 20 points or more. The sole prognostic factor for the need for ensuing prostate surgery was the pretreatment IPSS score (P = 0.042). CONCLUSIONS: Noninvasive management of bladder lithiasis with no associated prostate surgery is highly efficient and results in marked symptomatic improvement. Furthermore, the number of patients needing subsequent prostate surgery was very low at mid-term follow-up. Because of all of the above, the existence of bladder lithiasis is not an absolute indication for prostate surgery.

Urodynamic findings before and after noninvasive management of bladder calculi.

OBJECTIVES: To determine the most frequent urodynamic observations associated with bladder calculi, and to assess whether the presence of calculi alters these observations. PATIENTS AND METHODS: Fifty patients with bladder stones were included in a prospective study in which two urodynamic tests were used, one at inclusion and another once the patient was stone- free after treatment by noninvasive methods (mainly extracorporeal shockwave lithotripsy). RESULTS: The results from the urodynamic evaluation with the stone in the bladder were: bladder outlet obstruction in 51%, detrusor overactivity in 68%, detrusor under-activity in 10%, and a normal study in 18%. There were no significant differences between the urodynamic study before or after treatment in maximum flow rate and postvoid residual volume, detrusor overactivity and detrusor pressure at maximum flow. CONCLUSIONS: Conversely to what has been accepted for years, bladder calculi are not always associated with bladder outlet obstruction and the urodynamic results are not influenced by the presence of bladder stones during the urodynamic testing.

[Assisted extraction using extracorporeal lithotripsy of the calcified ureteral catheter overlooked for 2 years]. / Extracción asistida mediante litotricia extracorpórea de un catéter ureteral calcificado olvidado 2 años.

A 45 year old man with a 2 year forgotten left double-pigtail ureteric stent was referred to our hospital. Because of distal calcifications, the stent could not be removed by means of a cystoscopy. So, extracorporeal wave lithotripsies were performed and then the stent were easily removed in two fragments by cystoscopy and ureteroscopy.

[Pilot study of coadjuvant treatment of recurrent cystitis in women by means of AM3 (Immnoferon)]. / Estudio piloto del tratamiento coadyuvante de la cistitis recidivante de la mujer mediante AM3 (Inmunoferon).

OBJECTIVES: The aim is to evaluate the effectiveness of AM3 (Inmunoferon) in the treatment of the recurrent cystitis in women in order to know the rate of good results, previously to design a clinical trial. MATERIAL AND METHODS: Twenty-four women who had been diagnosed of two cystitis episodes in the previous 6 months without cure by antibiotic treatment were admitted to the study. Standard antibiotic treatment and 3 daily grammes of AM3 was given for 9 months. Infection and irritative symptoms during micturition rate were evaluated at the inclusion date and afterwards, at the first, third, sixth and nineth month. RESULTS: Nineteen patients finished the study. The infection rate decreased from 100% at the inclusion date to 26% in the first month and then it became stable about 50%. Irritative symptoms during micturition decreased from 46% at the inclusion date to a rate lower than 10% in the 4 controls running. CONCLUSION: AM3 reduced evident urinary infection in a 50% and irritative symptoms during micturition in a 90%. Control clinical trials are needed to confirm the AM3 effects on this pathology.

Extracción asistida mediante litotricia extracorpórea de un catéter ureteral calcificado olvidado 2 años / Extracorporeal wave lithotripsy assisted drawing of a calcified ureteral stent left out for two years

Se presenta el caso de un varón de 45 años que llevaba olvidado durante 2 años un catéter ureteral doble J izquierdo. El catéter presentaba ambos extremos calcificados no pudiéndose extraer mediante cistoscopia y pinzas. Se realizaron sesiones de litotricia extracorpórea en ambos extremos consiguiéndose la fragmentación de la litiasis y posteriormente pudo ser extraído en dos trozos mediante cistoscopia y ureteroscopia (AU)

A 45 year old man with a 2 year forgotten left double-pigtail ureteric stent was referred to our hospital. Because of distal calcifications, the stent could not be removed by means of a cystoscopy. So, extracorporeal wave lithotripsies were performed and then the stent were easily removed in two fragments by cystoscopy and ureteroscopy (AU)

Estudio piloto del tratamiento coadyuvante de la cistitis recidivante de la mujer mediante AM3(Inmunoferon®) / Model study of the treatment of recurrent cystitis in women by means of AM3 (Inmunoferon®)

OBJETIVOS: Evaluar la eficacia del AM3 (Inmunoferon®) como coadyuvante del tratamiento antibiótico en la cistitis recidivante de la mujer (CRM) para conocer la proporción de respuesta al mismo con la intención de diseñar posteriormente un ensayo clínico. MATERIAL Y MÉTODOS: Se estudiaron consecutivamente 24 mujeres que presentaron en los seis últimos meses dos episodios documentados de cistitis no asociada a otra patología y que no respondieron al tratamiento antibiótico. Se les pautó tratamiento antibiótico y 3 g diarios de AM3 durante 9 meses. Se evaluó la presencia de infección y de sintomatología miccional irritativa en la visita inicial, y al primer, tercer, sexto y noveno mes. RESULTADOS: Completaron el estudio 19 pacientes. La proporción de infección disminuyó del 100 por ciento en la visita inicial al 26 por ciento al primer mes para estabilizarse en torno al 50 por ciento en los meses sucesivos. La sintomatología miccional irritativa disminuyó del 46 por ciento en la visita inicial a proporciones inferiores al 10 por ciento en los meses sucesivos. CONCLUSIÓN: El AM3 redujo la presencia de infección urinaria manifiesta en un 50 por ciento y la sintomatología miccional irritativa característica de CRM en un 90 por ciento. Estos hechos sugieren la necesidad de realizar estudios controlados para confirmar el efecto de AM3 en esta patología (AU)

[Treatment of bladder lithiasis with shock-wave extracorporeal lithotripsy]. / Tratamiento de la litiasis vesical mediante litotricia extracorpórea por ondas de choque.

PURPOSE: To evaluate the effectiveness and the prognostic factors of the bladder stones (BS) treatment by means of extracorporeal shock wave lythotripsy (ESWL). METHODS: 183 patients with BS treated using ESWL were retrospectively analysed. Independent variables were: gender, age, obstruction, BS size, BS number and amount of waves. Dependent variable was total BS resolution. Statistical analysis was provided by Cox's regression multivariate analysis, Kaplan-Meier analysis and the t Student test. RESULTS: Total effectiveness of the treatment was 73%. Initial BS size was the only prognostic factor on multivariate analysis (p = 0.0035) with smaller stones obtaining the best results (log rank p = 0.00001): 92% of effectiveness in BS smaller than 1 cm2, 73% in 1-2 cm2, 57% in 2-3 cm2 and 42% in larger than 3 cm2. BS mean size decreased 2 cm2 after the first ESWL (p = 0.00001). CONCLUSIONS: Initial BS size was the only prognostic factor of resolution. Total effectiveness was 73% and it highly increased in BS smaller than 2 cm2.

Tratamiento de la litiasis vesical mediante litotricia extracorpórea por ondas de choque / Bladder stone treatment with extracorporeal shock wave lithotripsy

FUNDAMENTO: Valorar la eficacia y los factores pronósticos de éxito del tratamiento de la litiasis vesical (LV), mediante litotricia extracorpórea por ondas de choque (LEOC). MÉTODOS: Estudio retrospectivo de 183 pacientes afectos de LV tratados mediante LEOC. Las variables independientes estudiadas fueron sexo, edad, obstrucción, tamaño de la LV, número de LV y número de ondas. La variable dependiente fue la desaparición total de la LV. Estudio de los factores pronósticos mediante análisis multivariante por regresión de Cox, y análisis de Kaplan-Meier. Variación del tamaño de la LV estudiada mediante la prueba t de Student. RESULTADOS: Eficacia global del 73 por ciento. El análisis multivariante mostró que el único factor pronóstico fue el tamaño inicial de la litiasis (p = 0,0035). A menor tamaño de la LV mejor resultado (log rank p = 0,00001): eficacia del 92 por ciento en las LV menores de 1 cm 2 , 73 por ciento entre 1-2 cm 2 , 57 por ciento de 2-3 cm 2 y 42 por ciento en mayores de 3 cm 2 . Disminución media del tamaño de la LV tras la primera sesión de LEOC de 2 cm 2 (p = 0,0001). CONCLUSIONES: El único factor pronóstico fue el tamaño inicial de la LV. La eficacia global de la técnica es del 73 por ciento, aumentando considerablemente en LV menores a 2 cm 2 (AU)

[Analysis and clinical course of residual lithiasis after shock wave renal treatment]. / Análisis y evolución de la litiasis residual tras la aplicación renal de ondas de choque.

OBJECTIVE: Although residual lithiasis after the application of shock waves is a situation that coexists with the procedure, in some cases it can be considered to be a failure of ESWL. The natural history and outcome of 244 cases of residual renal stone followed over a 5-year period are analyzed, and the approach based on a pre-established classification is discussed. METHODS: Of 1,407 patients treated by ESWL for renal lithiasis during 1995, 244 cases with a renal calculus larger than 3 mm were followed for a period of 5 years after treatment and evaluated by clinical, radiological, ultrasound and analytical methods. RESULTS: At 3 months post-ESWL, 1,013 cases (72%) were completely stone-free and 394 (28%) showed residual stone; of these, 244 (62%) had residual stone fragments greater than 3 mm. At 5 years, 190 (78%) remained stable and the remaining 54 (22%) showed stone regrowth that warranted additional treatments: 52 ESWL, 1 PNL and 1 partial nephrectomy. Despite the retreatments, only 42% became completely stone-free. CONCLUSIONS: A classification of residual renal stone can be established based on the data obtained to orient the approach in each case, although the frequency of residual stone can be reduced by the appropriate indication of ESWL. Once a renal stone has formed retreatments with ESWL cannot ensure complete elimination of the stone.

Current management of calculi in horseshoe kidneys.

OBJECTIVES: To assess treatment options for calculi in horseshoe kidneys and the impact of extracorporeal shockwave lithotripsy (ESWL) on the management of renal stones. MATERIAL AND METHODS: From June 1971 to January 1998, 52 patients with horseshoe kidneys and calculi received treatment at our Urologic Stone Unit. There were 40 men (77%) and 12 women (23%). Average patient age was 41 years (range: 10-70 years). Clinical onset, treatment received and outcome were evaluated retrospectively. A successful outcome was defined as a patient without residual calculi or with fragments <0.4 cm in size. RESULTS: Clinical onset was mainly low back pain in 37 patients (71%). Eighty-nine stones were treated, i.e. an average of 1.7 treatments per patient. Before the ESWL era (May 1987), we performed two heminephrectomies, 16 pyelolithotomies, 12 pyelolithotomies combined with ureteropyeloplasty and one percutaneous nephrolithotomy. Since the advent of ESWL, seven pyelolithotomies and three pyelolithotomies combined with ureteropyloplasty have been done. ESWL was used to treat 48 calculi. In three cases the patient was placed in the prone position due to difficulties in stone focusing. In 37 cases (77%) patients were either rendered stone-free or had residual fragments <0.4 cm in size. Urinary diversion for obstruction was carried out in two cases (4%). CONCLUSIONS: At present ESWL is the first-choice treatment for calculi in horseshoe kidneys. It involves no significant focusing difficulties and is associated with a low incidence of obstructive complications. Open surgery is indicated in cases of stone-related pyeloureteral stenosis and in the presence of calculi >2-2.5 cm in size.

Renal hematoma as a complication of extracorporeal shock wave lithotripsy.

OBJECTIVE: To evaluate risk factors, clinical presentation, therapeutic management, and treatment of residual stones and subsequent development of renal hematoma following Extracorporeal Shock Wave Lithotripsy (ESWL). MATERIAL AND METHODS: A retrospective review was made of 31 post-ESWL renal hematoma cases diagnosed between May 1987 and June 1996. Lithotripsy treatments were outpatient procedures without anaesthesia. Our center has three electromagnetic sources, two with biplane X-ray centering and one ultrasound-guided (SIEMENS Lithostar II, SIEMENS Lithostar System C and SIEMENS Lithostar Ultra, respectively). We analysed findings from patient history, physical examination, blood analysis, and renovesical sonographs. Follow-up involved periodical checks, blood analyses and renovesical sonographs, scheduled first at three-month intervals and later at six-month intervals. RESULTS: Our center performed 21 699 lithotripsies on a total of 10 953 patients in this period. Thirty-one renal hematomas were diagnosed, giving an incidence rate of 0.28%. Twenty-four patients presented clinical onsets and the commonest symptom for consultation was low back pain (74%). Eleven patients of this group (46%) were hypertensive. All patients received conservative treatment. With a mean follow-up time of 18 months, ultrasound showed persistent hematoma in 11 patients (36%). There were residual stones in 71% of patients; further lithotripsy was performed on seven patients with no clinical or ultrasonographic signs of change in the hematoma. CONCLUSIONS: Renal hematoma post-ESWL is a rare complication. Main risk factors are hypertension, clotting disorders and previous ESWL sessions. Flank pain is the main symptom at presentation. Elective management is conservative. Presence of hematoma is not a contraindication for further treatments of residual stones.

[Lithiasis in megacalyosis]. / La litiasis en la megacaliosis.

OBJECTIVE: To review our series of lithiasis associated with megacalyosis, a rare disease entity. METHODS/RESULTS: The clinical records of patients treated from 1976 to 1994 were reviewed. Of 39 cases of megacalyosis, 27 were associated with lithiasis and was slightly more prevalent in males (59.3%). Struvite and whewelite calculi were more prevalent and 40.7% also had urinary tract infection, E. coli, Pseudomonas and Proteus being the most frequent pathogens. ESWL with hyperhydration was the most frequently utilized treatment. CONCLUSIONS: Megacalyosis is an embryogenic anomaly of Malpighi's pyramids that is associated with lithiasis in 69.2% of our series, frequently localized to the left side. We have found no significant difference according to sex or a hereditary component. IVP is the principal diagnostic method for megacalyosis. The frequent association of urinary tract infection should be taken into account when instituting treatment.

[Lithiasis in renal transplantation]. / Litiasis en trasplante renal.

Lithiasis as a post-renal transplantation complication is rare and of delayed appearance. After having revised 320 transplantations performed at the Fundación Puigvert 8 cases were found, which implies a two-fold increased incidence over other series studied and greater than the prevalence in the normal population. We confirmed the existence of lithogenous factors in 7 of the 8 cases, and found that in 50% of them the calculus composition was urate, what explained the differences versus normal population in terms of treatment with cyclosporin and the personal background. Two therapeutic schemes may be outlined based on the chemical composition of the calculus, and thus ultrasound-guided ESWL is chosen as chronic therapy when calculi have a calcic origin whereas medical management is used when their nature is uric, even though we understand that treatment must be individualized in each case. We have obtained good results in all 8 cases without compromising neither the renal function nor the graft viability.