Comparison of escalating, constant, and reduction energy output in ESWL for renal stones: multi-arm prospective randomized study.

This study was designed to find out the optimized energy delivery strategy in Shock Wave Lithotripsy (SWL) that yield to the best stone-free rate (SFR). In this clinical trial, 150 consecutive patients were randomized into three groups: (a) Dose escalation, 1500 SW at 18 kV, followed by 1500 SW at 20 kV then 1500 SW at 22 kV. (b) Constant dose, 4500 SW at 20 kV. All patients undergo plain X-ray film of the urinary tract at day 1, 14, and 90 to assess stone-free rate (SFR) which was defined as no stones or painless fragments less than 4 mm. (c) Dose reduction, 1500 SW at 22 kV, followed by 1500 SW at 20 kV and then 1500 SW at 18 kV. The three treatment groups were comparable in terms of age, sex, stone size and distribution of the kidneys, and the need for Double J stent use. On day 90, the SFR achieved was 82, 90, and 84 % in the escalating, constant, and reduction energy groups, respectively. However, this rate was not statistically significant (x 2 = 1.38, p level = 0.28). At a slow rate of 60 shocks, there was no difference in stone-free rate between different voltages at 1, 14, and 90 days. Our randomized clinical trial showed no statistically significant difference in SFR between the three groups while using the slow SWL rate. Our trial is the first randomized trial comparing the three strategies. As such, a dose adjustment strategy while delivering SWL in slow rate was not recommended.

Lymphatic preservation using methylene blue dye during laparoscopic varicocelectomy: early results.

BACKGROUND AND OBJECTIVES: Hydrocele caused by the division of lymphatic vessels during varicocelectomy is a common complication. Preservation of these lymphatics is the aim of many studies. We evaluated patient outcomes after laparoscopic varicocelectomy that involved intratunical methylene blue dye injection just prior to the procedure. MATERIALS AND METHODS: This prospective study included all adult patients (over age 14 years) with clinically palpable varicocele who presented to our clinic between December 2005 and July 2007. Prior to laparoscopic surgery, methylene blue dye was injected in the intratunical space between the tunica albuginea and the tunica vaginalis. Laparoscopic intraperitoneal varicocele ligation was performed. Patients were assessed for early postoperative complications and consumption of analgesia. They were reassessed at 1 and 6 months postoperatively by clinical and radiological evaluations to detect hydrocele formation, recurrent varicocele, and testicular pain or atrophy. RESULTS: Twenty-three consecutive patients with 40 clinically palpable varicoceles were evaluated. The patients had a mean age of 28.4 years. The mean operating time was 37 minutes, (range, 25 to 50 minutes). The patients did not have any intraoperative or early postoperative complications, including any complications related to methylene blue dye injection. Follow up examinations at 6 months revealed hydrocele formation in 2 of the 40 patients (5%) and recurrent varicocele in 1 of the 40 patients (2.5%). CONCLUSION: This preliminary study suggests that intratunical injection of methylene blue dye just prior to laparoscopic ligation of varicocele can aid in the identification and sparing of lymphatic vessels, although it did not preserve lymphatic vessels in all patients in this study. It appears to be a safe technique that does not prolong operating time.

Slow versus fast shock wave lithotripsy rate for urolithiasis: a prospective randomized study.

PURPOSE: We determined the effect of shock wave lithotripsy (SWL) rate on treatment outcome in patients with renal and ureteral stones. MATERIALS AND METHODS: A total of 156 patients were prospectively randomized to receive SWL using a slow (60 pulses per minute) or fast wave rate (120 pulses per minute). Inclusion criteria were patients with a single radiopaque renal or ureteral stone not exceeding 30 mm in maximum diameter. Patient characteristics, stone and therapy features were reviewed, and the relation to success rate and total number of shock waves required was assessed using the chi-square, Fisher exact and Mann-Whitney tests. Factors proven to be significant in univariate analysis were entered in a multivariate logistic regression analysis. RESULTS: The study included 114 male (73.1%) and 42 female (26.9%) patients with a mean age +/- SD of 42.1 +/- 13.3 years. Stone length measured in maximum diameter was 13.2 +/- 5.9 mm (range 5 to 30). Renal stones were encountered in 94 (60.3%) patients and ureteral stones in 62 (39.7%). The slow SWL rate was used in 76 (48.7%) patients and the fast rate in 80 (51.3%). Baseline variables were comparable in both groups. However, the total number of shock waves required was statistically significantly lower in the slow rate group (p = 0.004) and the treatment time was significantly longer (p = 0.000). The rate of success, defined as being completely stone-free or having clinically insignificant gravel less than 2 mm, was significantly higher with the slow rate (p = 0.034), an increased number of sessions (p = 0.001), decreased stone length (p = 0.000) and greater total number of shock waves (p = 0.011). However, only the slow SWL rate and stone length maintained a statistically significant impact in multivariate analysis. CONCLUSIONS: The slow SWL rate is associated with a significantly higher success rate at a lower number of total shock waves compared to the fast SWL rate.