Extracorporeal shockwave lithotripsy in the treatment of common bile duct calculi

Fifteen patients with stones in the common bile duct, in whom treatment with endoscopic papillotomy and stone-extraction had been unsuccessful were treated with extracorporeal shockwave lithotripsy. Nine patients were stone-free after one or two sessions, and two patients after further endoscopic treatment. One patient achieved partial clearance and palliation. One patient had a choledochoduodenostomy performed due to ineffectiveness of the shockwave lithotripsy. Two patients, who were thought to have a stone, turned out to have neoplasma in the common bile duct. Complications were frequent but temporary and needed no treatment. We conclude that extracorporeal shockwave lithotripsy is a valuable and safe alternative in those cases where conventional endoscopic treatment has failed, and should be considered before operation, especially to old for high-risk patients.     

The new generation Siemens Multiline lithotripter tube "M": early results in ureteral calculi

The Siemens electromagnetic Lithostar tube "C" and the new multiline tube "M" lithotripters were compared for the in situ treatment of ureteral calculi. A series of 248 patients with a calcium oxalate ureteral stone (proven by stone analysis) more than 4 mm in diameter were treated between December 1994 and September 1995 with the tube M Multiline lithotripter. The results were compared with those of 462 patients treated in prior years with tube C. High energy levels were obtained without sedation in 11% of patients with tube C and in 61% with tube M. The proportion of patients needing additional analgetics was 11% and 6%, respectively. The percentages of patients reporting no pain at all were 7 and 77. In proximal calculi, stone-free status was achieved in 63 of 79 patients (80%) with tube C and in 82 of 91 patients (90%) with tube M (p = 0.057). In distal calculi, stone-free status was achieved in 124 of 173 patients (72%) with tube C and in 134 of 157 patients (85%) with tube M (p = 0.0027). The evacuation rate for distal ureteral stones was significantly higher with tube M, which implies that the new shock head can enable the operator to apply higher energy without sedation because of the better tolerance.     

Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation

Extramedullary hematopoiesis associated with thalassemia causing spinal cord compression is an extremely rare event in the course of the disease. Documentation with an imaging technique, such as MRI, is mandatory. A patient with thalassemia intermedia, who developed paraparesis in spite of transfusion, underwent surgical decompression. Rapid neurological improvement was observed postoperatively and this neurological condition was protected with adequate hemoglobin level. Management of these patients remains controversial. Various modes of therapy such as surgical decompression, radiotherapy, and transfusion are discussed and the related literature is reviewed.     

Long-term follow-up after primary extracorporeal shockwave lithotripsy monotherapy of staghorn calculi: results after more than 6 years

OBJECTIVE: We retrospectively investigated 58 patients suffering from 60 staghorn calculi, who were treated with primary extracorporeal shockwave lithotripsy (ESWL) monotherapy, in order to determine long-term results and the fate of the residual stones. MATERIAL AND METHODS: Mean follow-up was 72.4 months. There were 49 partial staghorn calculi (C4) and 11 complete C5 stones according to Rocco's classification. The mean number of ESWL sessions needed for disintegration was 3.6. The mean amount of shockwaves was 10,244. ESWL monotherapy alone was performed in 26 staghorn calculi (43.3%). In treating the other 34 staghorn calculi 56 auxiliary procedures were necessary. RESULTS: At discharge 28.3% of the patients were free of stones. Fifty-five percent had small remnant particles (< 4 mm) and 16.7% had rest-fragments (> 4 mm). After a mean follow-up period of 72.4 months 36 patients were free of stones (60%). Twenty-four patients still have residual stones. The fragments in 2 patients did not change in size, in 14 patients fragments became bigger and 8 patients had a real recurrence (13.3%). CONCLUSIONS: Primary ESWL monotherapy of staghorn calculi is justified because of the comparable results with open surgery and percutaneous nephrolithotomy (PCNL). Prognostic good factors are small stone mass with most of the stone mass in the upper and middle calices, the absence of dilatation and the absence of anatomical anomalies.     

Fever after extracorporeal shock wave lithotripsy for patients with upper urinary tract calculi associated with bacteriuria before treatment

Twenty five patients with vesicovaginal fistulae were managed at St. Gaspar Hospital, Itigi, Tanzania between February 1993 and March 1994. Most of them, 92% were repaired vaginally routinely using the Martius labial flap and 8% were repaired transabdominally because the fistulae were inaccessible vaginally as they were vesicouterine or vesicocervical fistulae. The success rate was 96% after the first operative attempt.     

Prevalence of autoantibodies associated with glomerulonephritis, unaffected after extracorporeal shock wave lithotripsy for renal calculi, in a three-year follow-up

A very rare case of full trisomy 18 associated with multiple hepatoblastomas is reported. The patient also had ventricular septal defect and patent ductus arteriosus, which were repaired at 6 months of age. After the cardiac surgery, she was noted to have an abdominal mass and an elevated serum alpha-fetoprotein level. A partial hepatic lobectomy was performed at 7 months of age, and the resected tumor was diagnosed as a fetal-type hepatoblastoma. At 2 years and 4 months of age, a chest radiography disclosed an elevated left diaphragm, and abdominal ultrasonography demonstrated a tumor in the left hepatic lobe. The resected tumor was also diagnosed as a fetal-type hepatoblastoma. Chromosomal analysis demonstrated that the karyotypes of peripheral blood and hepatic tumor cell obtained on two occasions were both 47,XX, +18. She has no evidence of recurrence at 3 years of age without specific therapy.     

Distal ureteral atresia associated with crossed renal ectopia with fusion: recovery of renal function after release of a 10-year ureteral obstruction

We report on a 10-year-old boy with distal ureteral atresia associated with crossed renal ectopia with fusion. He was admitted with a high fever associated with a urinary tract infection. The diagnosis was established by antegrade and retrograde pyelography. The upper hydronephrotic portion of the kidney, obstructed for 10 years, recovered its function after nephrostomy placement. To our knowledge, this is the first patient whose renal function has recovered despite an ureteral obstruction of 10-years' duration. Therefore, we recommend a transient nephrostomy placement even for far advanced pediatric hydronephrosis, to test for the possibility of functional recovery.     

Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives

Demographic data, personal and familial characteristics, as well as DSM-III-R-based psychiatric diagnoses were collected in 369 adolescents and young adults aged between 15 and 29 years, referred to an Emergency Department for psychological problems. In total, 60% of them were suicide attempters. Separations before the age of 12 years and depression in the family emerged as the main features distinguishing the suicidal group from the psychiatric control group. Fifty per cent of suicide attempters were repeaters. Fostering during childhood, suicide attempts and depression in the family were found to be risk factors for repeated self-attempts. These results support the view that significant levels of dysfunction, together with increased psychiatric morbidity, especially suicidal behaviour, characterize the families of young self-attempters.     

Physician-patient relations--participation of patients with ureteral calculi in clinical decision making and level of anxiety

In a study examining the relationship between patient participation in clinical decision making and levels of anxiety, patients were offered a choice of treatment for ureteral calculus. 42 received information about 2 treatment options, ultrasound fragmentation of the stone through a ureteroscope and extracorporeal shock wave lithotripsy (ESWL), and were asked to choose the method that they preferred. 54 received treatment decided on by the physician without their participation in the decision making process. Anxiety was measured before meeting with the physician, immediately after the meeting and on hospitalization for treatment. The contribution of the patient's perception of participation in the decision-making process and level of education was also examined. There was a decrease in level of anxiety after meeting with the physician only among those who did not actually participate in the decision-making process (p < 0.05). There was no change in the level of anxiety among those offered choice of treatment. However, a decrease in anxiety was evident among patients who perceived that they had received information about their illness and its treatment (p < 0.01). This was not the case for patients who perceived themselves as participants in decision making unless they had a relatively high-level of education (p = 0.05).     

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.     

Artificial ureteral replacement for ureteral necrosis after renal transplantation: report of 3 cases

PURPOSE: We applied a new minimally invasive technique of artificial ureteral replacement for renal transplant ureteral necrosis. MATERIALS AND METHODS: Artificial ureteral replacement was performed in 3 renal transplant recipients with ureteral necrosis (complete in 1 and distal in 2) after failure of primary endoscopic treatment. Under fluoroscopic guidance a percutaneous tract is created and progressively dilated. The ureteral silicone polytetrafluoroethylene bonded tube is introduced into the pyelocaliceal renal graft cavities, tracked subcutaneously down to the suprapubic area and introduced into the bladder via a short incision. RESULTS: There were no immediate postoperative complications except for transient postoperative acute prostatitis in 1 patient. No secondary complications were observed with a mean followup of 2.5 years. All grafts have good late function and all tubes are patent with no evidence of encrustation or obstruction. The tubes are well tolerated underneath the skin. Reflux was present in all 3 cases with no clinical manifestation. An asymptomatic episode of lower urinary tract infection was observed in the female patient. CONCLUSIONS: In select cases of ureteral necrosis after renal transplantation artificial ureteral replacement by subcutaneous pyelovesical bypass offers a possible alternative to open ureteral reconstruction.     

Extracorporeal piezoelectric shock wave lithotripsy as mono and multiple therapy of large renal calculi including staghorn stones in unanaesthetized patients under semi-ambulant conditions

OBJECTIVE: To examine the effectiveness and complication rate of extracorporeal piezoelectric shock wave lithotripsy (EPL) as monotherapy for the treatment of large renal calculi. PATIENTS AND METHODS: Treatment consisted of semiambulant EPL as monotherapy combined with protective ureteric stenting in 84 patients. Three groups were established according to stone volume (borderline-stone, partial and complete staghorn). An average of 18,230 shock waves was applied in 3.76 sessions to each patient. RESULTS: No major complications were observed but there were minor complications in 33% of patients. Invasive auxiliary methods were necessary in only 12%. After a mean follow-up of 9 months (n = 72), 54% of patients were stone-free and in 22% the fragments passed spontaneously. Thus the success rate was 76%. Analysis of the three groups showed no difference in stone status during follow-up. There was no relation between the outcome of treatment and stone volume. Analysis of the patients who failed to respond to treatment showed that they were treated for longer than the stone-free group, with significantly fewer sessions per week (0.71 vs 1.28 sessions/week). It appears that higher rates of stone removal can be achieved with more frequent treatment sessions at shorter intervals. CONCLUSION: We consider semi-ambulant EPL monotherapy to be a minimally invasive alternative treatment in patients with large renal calculi, including staghorn stones.     

First clinical experience and in situ treatment of ureteric stones using Lithostar Multiline lithotripter

This article reviews the first experience using the Siemens Lithostar Multiline lithotripter in 372 consecutive treatments of ureteric and kidney stones. The disintegration rate was 97.7%, and a stone-free rate of 87% was achieved at the end of 3 months. Auxillary procedures were required in only 11% of the patients. No medication was required for pain management in 60.4% of the patients. The results were especially impressive in the management of ureteric stones, with a success rate of 91%, these patients being stone free after 1 week using the new booster technique. Analysis of the data indicates that the Siemens Lithostar Multiline is a safe, effective, and economically sound device to treat patients with ureteric and renal stones.     

Clinical studies on renal pelvic and ureteral carcinoma

In the past decade the use of theophylline was less extensive because of its narrow therapeutically index and due to its side effects. The widening of possibilities of monitoring the treatment by serum level determination, the introduction of slow release formula, and the demonstration of antiinflammatory effects made theophylline to become actual again. Theophylline is indicated for the chronic treatment of asthma in association with other medication. The authors study the efficacy and serum level of theophylline in 13 children with asthma who received slow release theophylline in a dosage of 15.2 mg/body weight/24 hours in average, administered 3 times a day. The efficacy was estimated by a clinical score and the serum level was determined by isotopic mass spectrometry with 15N-theophylline as internal standard. After a period of at least 2 months of therapy it was recorded the amelioration of clinical score (with 5.09 points, that represents 36.3% of the maximum initial score) and the reducing of circadian variation of peak expiratory flow from 27% to 15%. The serum level of theophylline was of 8.25 +/- 4.16 micrograms/ml at 4 hours after administration and of 5.69 +/- 2.6 micrograms/ml at 8 hours after administration of the last dose. The individual values less than 5 micrograms/ml was found in 3 of 13 children at 4 hours and in 7 of 13 children at 8 hours after the last dose. There were no patients with toxic serum levels of theophylline (> 20 micrograms/ml). The correlation between serum level of theophylline and the dosage was weak both at 4 hours (r = 0.054) and 8 hours (r = 0.229) after the last dose. At the same dose there were found high interindividual variations. These findings are arguments for the usefulness of determination of serum levels of theophylline, that together with clinical and functional parameters allowed the individualization of the dosage.     

Successful treatment with end-to-end ureteral anastomosis for ureteral avulsion caused by abdominal blunt trauma: a case report

The nasopharynx and eustachian tube (auditory tube) were morphologically examined in the white rhinoceros. The narrow nasopharynx cavity was enlarged dorsoventrally. The most lateral part of both sides sharply rises in a dorsal direction and the volume is estimated at 173 cc. The eustachian tube is 145 mm in length from the auditory bulla to the nasopharynx. The hyaline cartilage is well-developed in the middle region of the eustachian tube wall. The results demonstrated that the white rhinoceros does not have a guttural pouch. We suggest that the occurrence of the guttural pouch may not be dependent on the phylogenetic status of perissodactyls such as horse, donkey and tapir.     

Outpatient treatment of middle and lower ureteric stones: extracorporeal shock wave lithotripsy versus ureteroscopic laser lithotripsy

The aim of this retrospective study was to evaluate the efficacy of ureteroscopic lithotripsy (URSL) and extracorporeal shock wave lithotripsy (ESWL) in the treatment of middle and lower ureteric stones. From January 1996 to March 1997, 61 patients treated by URSL and 49 patients treated by ESWL were studied, both were conducted as outpatient procedures. URSL using Holmium laser and semirigid ureteroscope (Fr.8.5) performed under general anaesthesia had single session stone clearance rates of 100% and 95% for middle and lower stones respectively. There were 6 complications including 5 readmissions (2 febrile episodes, 2 severe pain spells, and 1 stent migration) and 1 stricture formation. ESWL using the Dornier MFL 5000 lithotriptor had a single session success rate of 51% and overall success rate of 78% after retreatment (retreatment rate 35%). No significant complication or readmission was noted. Seventy-two per cent of patients required intravenous fentanyl for pain control. The efficiency quotients calculated for the URSL group and the ESWL group were 97% and 58% respectively. In summary, in the treatment of middle and lower ureteric calculi, ESWL carries reasonable success rate, especially with retreatment; and minimal morbidity. On the other hand, URSL is highly effective in rapidly clearing the stones, a low risk of complication is noted. Both can be conducted as an outpatient treatment modality.