Percutaneous Renal Stone Manipulation—A Nonoperative Alternative

Nephrostomy tube tracts, established operatively or percutaneously, can provide access to stones in the upper urinary tract. A variety of rigid or flexible urologic instruments can be used to percutaneously disintegrate or extract calculi, thus sparing a patient an operative procedure. This is most important in the case of high-risk patients, those previously operated upon or those who have active nephrolithiasis, in whom recurrent stones are prone to form. Our early experience in percutaneous renal stone disintegration and stone manipulation enabled us to remove most (in four patients) or all (again in four patients) calculi in nine patients. The procedure offers lower morbidity, shorter hospital stay and earlier return to employment than conventional operative stone procedures.     

Risk of renal stone events in primary hyperparathyroidism before and after parathyroid surgery: controlled retrospective follow up study

AimTo study the risk of renal stone episodes and risk factors for renal stones in primary hyperparathyroidism before and after surgery.DesignRegister based, controlled retrospective follow up study.SettingTertiary hospitals in Denmark.Participants674 consecutive patients with surgically verified primary hyperparathyroidism. Each patient was compared with three age- and sex-matched controls randomly drawn from the background population. Hospital admissions for renal stone disease were compared between patients and controls. Risk factors for renal stones among patients were assessed.ResultsRelative risk of a stone episode was 40 (95% confidence interval 31 to 53) before surgery and 16 (12 to 23) after surgery. Risk was increased 10 years before surgery, and became normal more than 10 years after surgery. Stone-free survival 20 years after surgery was 90.4% in patients and 98.7% in controls (risk difference 8.3%, 4.8% to 11.7%). Patients with preoperative stones had 27 times the risk of postoperative stone incidents than controls. Before surgery, males had more stone episodes than females and younger patients had more stone episodes than older patients. Neither parathyroid pathology, weight of removed tissue, plasma calcium levels, nor skeletal pathology (fractures) influenced the risk of renal stones. After surgery, younger age, preoperative stones and ureteral strictures were significant risk factors for stones.ConclusionsThe risk of renal stones is increased in primary hyperparathyroidism and decreases after surgery. The risk profile is normal 10 years after surgery. Preoperative stone events increase the risk of postoperative stones. Stone formers and non-stone formers had the same risk of skeletal complications.

What is already known on this topic

Patients with primary hyperparathyroidism have an increased risk of renal stone eventsThe extent to which parathyroid surgery reduces the risk of further stones is unclear

What this study adds

The risk of a new stone event was 8.3% higher in patients than in controls after surgeryIn patients with stone disease before operation the risk rate for a postoperative stone event was 27times that in controlsThe risk of a renal stone event was higher than the risk among controls until more than 10 years after surgery     

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.     

Ultrasonic Destruction of Kidney Stones

Kidney stones may be removed without using a surgical incision by a combination of techniques and skills recently developed in the fields of urology and radiology. Percutaneous access to the kidney is established under fluoroscopic control. A guide wire placed into the renal pelvis allows a nephroscope to be inserted and the collecting system visualized. A long hollow metal probe is advanced through the nephroscope and placed in contact with the stone. This probe conducts the ultrasonic energy. The stone absorbs the energy and breaks into fine granules, which are evacuated by suction.Twenty-three consecutively seen patients presenting with 27 upper urinary tract calculi for which removal was indicated underwent successful percutaneous ultrasonic lithotripsy. Fifteen stones were located in the renal pelvis, eight in a calix, three at the ureteropelvic junction and one in the upper ureter. One infected staghorn calculus was removed. Two complications resulted in extended hospital stays, but in no patients were surgical incisions required. Of the 23 patients, 9 had previously had a surgical lithotomy. The authors believe that most renal and upper ureteral calculi for which removal is indicated may be extracted percutaneously with the aid of the ultrasonic lithotriptor. The patients may expect a rapid convalescence with diminished pain.     

Colonization of artificial substrata by macro-invertebrates in a stream and variations according to stone size

SUMMARY. Plastic cages containing artificial substrata were placed on the stony bottom of a stream in a section where the environmental conditions appeared to be homogeneous. The section was divided into eight equal sub-sections (A-H) and four cages were placed in each sub-section. The stone-size of the artificial substrata was similar within each cage but differed between the four cages with average diameters of 14, 24, 48 and 96 mm, respectively. The baskets were removed one month later and the catches of macro-invertebrates were recorded.
Analysis of the catches (density and number of taxa in each cage) revealed no significant differences in connection with the position of the cages in the section of stream. Cages with 48-mm stones contained the least abundant fauna. The taxa which colonized cages with 14- or 24-mrn stones were more numerous than those collected from cages with 48- or 96-mm stones.
Statistical analysis by laxon confirmed the preceding results. Variability in connection with the position of the cages along the section of stream was never significant. A little more than half the taxa were distributed independently of stone size but always showed a contagious type distribution. The density of the other taxa was higher, either in cages with 14- or 24-mm stones (particularly Gammarus ) or only in cages with 96-mm stones (especially Hydropsyche ). Only one taxon was more abundant in cages with 48-mm stones, the type of substratum in which the overall density was lowest.
Catches in the cages were not the same as those taken with a Surber sampler because the two samplers did not take samples from the same habitats and also because the baskets offered a more specialized habitat than the surrounding bottom. The basket with 24-mm stones gave the least distorted picture of the natural population.     

钬激光在胆总管下段嵌顿结石术中的应用

目的探讨钬激光在胆总管下段嵌顿性结石手术中的应用价值。方法通过腹腔镜下胆道镜工作通道,应用钬激光,功率为0．6—0．8J／10Hz,直径为200um光导纤维,在直视下接触结石,将嵌顿结石击碎后注水冲出,或用取石篮套出。结果11例均取石碎石成功,手术时间75—205min,平均95．5min,出血80—130ml,平均89．4ml。平均住院8．2d。术后无胆道出血,胆漏。术后2W照影无结石残留,胆总管下段通畅无胆道狭窄。术后肝功能2W恢复正常6例,5例1月均恢复正常。随访3—6月未见结石复发。结论钬激光治疗胆总管下段嵌顿结石,具有创伤小、恢复快、碎石确切、操作容易、安全有效等优点,为治疗复杂性胆总管结石开辟了一条新的治疗途径。     

Endoscopic papillotomy and removal of gall stones.

Endoscopic papillotomy was attempted in 59 patients with extrahepatic obstruction of the biliary duct system and was actually performed in 50 patients. A special high-frequency diathermy knife was introduced via a duodenoscope into the terminal common bile duct and the roof of the papilla was incised. In 33 out of 39 patients with choledocholithiasis the stones passed into the duodenum spontaneously or were removed endoscopically. Papillary stenosis without ductal stones was successfully treated with this method in eight out of 11 patients. One perforation of the duodenocholedochal junction occurred and was repaired surgically. Endoscopic papillotomy and stone extraction is a relatively safe and effective method of treating extrahepatic jaundice.     

Comparison of Children versus Adults Undergoing Mini-Percutaneous Nephrolithotomy: Large-Scale Analysis of a Single Institution

Objective

As almost any version of percutaneous nephrolithotomy (PCNL) was safely and efficiently applied for adults as well as children without age being a limiting risk factor, the aim of the study was to compare the different characteristics as well as the efficacy, outcome, and safety of the pediatric and adult patients who had undergone mini-PCNL (MPCNL) in a single institution.

Methods

We retrospective reviewed 331 renal units in children and 8537 renal units in adults that had undergone MPCNL for upper urinary tract stones between the years of 2000–2012. The safety, efficacy, and outcome were analyzed and compared.

Results

The children had a smaller stone size (2.3 vs. 3.1 cm) but had smilar stone distribution (number and locations). The children required fewer percutaneous accesses, smaller nephrostomy tract, shorter operative time and less hemoglobin drop. The children also had higher initial stone free rate (SFR) (80.4% vs. 78.6%) after single session of MPCNL (p<0.05); but no difference was noted in the final SFR (94.7% vs. 93.5%) after auxiliary procedures. The complication rate (15.6% vs. 16.3%) and blood transfusion rate (3.1% vs. 2.9%) were similar in both group (p>0.05). Both groups had low rate of high grade Clavien complications. There was no grade III, IV, V complications and no angiographic embolization required in pediatric group. One important caveat, children who required multiple percutaneous nephrostomy tracts had significant higher transfusion rate than in adults (18.8% vs. 4.5%, p = 0.007).

Conclusions

This contemporary largest-scale analysis confirms that the stone-free rate in pediatric patients is at least as good as in adults without an increase of complication rates. However, multiple percutaneous nephrostomy tracts should be practiced with caution in children.     

微通道经皮肾镜碎石术治疗感染性结石合并尿液CRPA感染两例

目的:总结一期行微通道经皮肾镜碎石术(microchannel percutaneous nephrolithotripsy,m PCNL)治疗上尿路感染性结石合并尿培养为耐碳青霉烯铜绿假单胞菌(carbapenem resistant pseudomonas aeruginosa,CRPA)的经验。方法:选择我院收治两例左肾结石合并尿培养为CRPA的患者,经积极抗感染治疗后,病例一行左侧经皮肾镜碎石术,病例二先行右肾穿刺造瘘术成功后行左侧经皮肾镜碎石术,观察分析两例患者术后结石清除情况,术中术后出现发热、腰痛、大出血、尿路损伤及肾功能衰竭等并发症情况。结果:两例患者术后复查双J管位置良好,结石基本清除;术中、术后均未出现发热、腰痛、大出血、尿路损伤及肾功能衰竭等并发症。结论:经过合适的围手术期处理,一期微通道经皮肾镜碎石术治疗感染性结石合并尿培养为耐药菌的患者是安全可行的。     

Effectiveness of Ureteroscopy-Assisted Retrograde Nephrostomy (UARN) for Percutaneous Nephrolithotomy (PCNL)

Objective

To determine the impact of ureteroscopy-assisted retrograde nephrostomy (UARN) during percutaneous nephrolithotomy (PCNL).

Materials and Methods

From April 2009 to September 2011, a total of 50 patients underwent PCNL for large renal stones (stone burden >2 cm). We performed UARN in the Galdakao-modified Valdivia position for 27 patients (UARN PCNL) and ultrasonography-assisted percutaneous nephrostomy in the prone position for 23 patients (prone PCNL).

Results

UARN PCNL significantly improved the stone-free rate (81.5% vs 52.2%) and the rate of residual stones (<4 mm, 92.6% vs 65.2%, P<0.05). The median length of the operation was significantly shorter for UARN PCNL, at 160 min, compared to 299 min for prone PCNL (P<0.001). There was one intraoperative complication in prone PCNL, namely a hemorrhage that resulted in stopping the initial treatment, but it was cured conservatively. The postoperative complications included a high grade fever that persisted for three days in two UARN PCNL patients (7.4%) and six prone PCNL patients (26.1%). The Clavien grading scores showed significantly lower postoperative complications for UARN PCNL compared to prone PCNL.

Conclusion

UARN is associated with a higher stone-free rate, shorter operation time, and fewer complications during PCNL than prone PCNL.     

Percutaneous nephrostomy--a retrospective study focused on palliative indications

We present an overview of the fast development of less invasive techniques in intrarenal surgery all based on percutaneous nephrostomy. Life-long urinary diversion with nephrostomy is often necessary in patients with malignant disease and such patients have more postnephrostomy complications than patients with kidney stones and their survival is short. In a follow-up of 246 patients with 275 nephrostomies performed consecutively over two years, mean survival after urinary diversion was only 7.9 months in 38 prostate cancer patients with ureteral obstruction and only 5.3 months in 20 patients with advanced bladder cancer. We emphasize the necessity of informing the patient and his/her family of the expected outcome of the procedure and the importance of using carefully chosen and realistic indications.     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的:探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法:在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果:158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论:在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

Kidney Stones in Primary Hyperoxaluria: New Lessons Learnt

To investigate potential differences in stone composition with regard to the type of Primary Hyperoxaluria (PH), and in relation to the patient’s medical therapy (treatment naïve patients versus those on preventive medication) we examined twelve kidney stones from ten PH I and six stones from four PH III patients. Unfortunately, no PH II stones were available for analysis. The study on this set of stones indicates a more diverse composition of PH stones than previously reported and a potential dynamic response of morphology and composition of calculi to treatment with crystallization inhibitors (citrate, magnesium) in PH I. Stones formed by PH I patients under treatment are more compact and consist predominantly of calcium-oxalate monohydrate (COM, whewellite), while calcium-oxalate dihydrate (COD, weddellite) is only rarely present. In contrast, the single stone available from a treatment naïve PH I patient as well as stones from PH III patients prior to and under treatment with alkali citrate contained a wide size range of aggregated COD crystals. No significant effects of the treatment were noted in PH III stones. In disagreement with findings from previous studies, stones from patients with primary hyperoxaluria did not exclusively consist of COM. Progressive replacement of COD by small COM crystals could be caused by prolonged stone growth and residence times in the urinary tract, eventually resulting in complete replacement of calcium-oxalate dihydrate by the monohydrate form. The noted difference to the naïve PH I stone may reflect a reduced growth rate in response to treatment. This pilot study highlights the importance of detailed stone diagnostics and could be of therapeutic relevance in calcium-oxalates urolithiasis, provided that the effects of treatment can be reproduced in subsequent larger studies.     

Silent Renal Stones in Primary Hyperparathyroidism: Prevalence and Clinical Features

Objective(1) To evaluate the prevalence of silent nephrolithiasis in patients with primary hyperparathyroidism (PHPT) compared with controls, and (2) To characterize clinically PHPT patients with silent renal stones.MethodsWe reviewed clinical data for 141 patients with PHPT and without symptoms or history of nephrolithiasis in whom renal ultrasonography was performed at diagnosis. A total of 141 sex- and age- matched subjects with abdomen ultrasonography obtained for reasons different from urinary symptoms served as controls.ResultsSilent nephrolithiasis was more prevalent in PHPT patients than in controls (11.35% vs. 2.13%, P = .003). Among patients with PHPT, those with silent renal stones showed higher serum calcium and parathyroid hormone levels and met surgical criteria, regardless of nephrolithiasis, more frequently than those without renal stones.ConclusionThe prevalence of silent nephrolithiasis is increased in patients with PHPT as compared with controls. Moreover, it seems likely that silent renal stone disease could identify a subset of PHPT patients with more severe disease. Accordingly, we suggest ultrasonographic screening of nephrolithiasis in all PHPT patients. Further studies are needed to better characterize this clinical entity. (Endocr Pract. 2014;20:1137-1142)     

胆道镜结合微爆破碎石治疗复杂性胆道结石

目的：探讨微爆破碎石用于治疗复杂胆道结石的治疗体会。方法：在胆道镜直视下,分别在术中和术后对158例复杂的胆道结石患者进行微爆破碎石,然后用取石网取出碎石,泥沙状结石随液体流出或让其自行流入肠道。结果：158例患者156例取石成功。取石成功率98.73%。明显提高了胆道取石的成功率。无1例出现胆道穿孔、瘘道穿孔及胆道出血等严重并发症。结论：在胆道镜下,采用微爆破碎石术治疗复杂的胆道结石是一种安全、可靠、高效的方法,可以明显提高结石的取净率。     

The use of Thiazides in the Prevention of Renal Calculi

The efficacy of hydrochlorothiazide, in a usual dosage of 50 mg. twice daily, in preventing further stone formation was evaluated in 67 patients with recurrent calcium stones. Fifty-three of these patients had idiopathic hypercalciuria (11 with associated urinary infection), one had medullary sponge kidneys and urinary infection, and two had urinary infection only; no cause for stone formation was detected in 11 patients. Urinary infection was also treated when present. Thirty-three patients (Group 1) were stone-free and 34 patients (Group 2) had stones in the urinary tract when treatment was started. In Group 1 during a total of 343 patient years (py) between the onset of stone symptoms and the institution of thiazide therapy there were 194 episodes (.57 per py) including 83 stones passed spontaneously and 30 major operations, but during 72 py on treatment there were only two episodes (.03 per py), both of which resulted in spontaneous passage of stones. The 34 patients in Group 2 had 365 episodes (1.1 per py) during the 343 py before thiazide therapy but only 34 episodes (.53 per py) during the 64 py on treatment. Many episodes in the Group 2 patients were related to previous stones, and in only four of these patients was there clear-cut evidence of new stone formation. Side effects, usually mild, were experienced by 25 patients; in three patients treatment was discontinued because of side effects.     

Evaluation of risk index according to Tiselius in patients with calcium urinary stones

Daily calcium, oxalates, magnesium, citrates and creatinine excretion with the urine was determined in 36 patients with calcium renal stones and in 25 healthy individuals. Then, risk index according to Tiselius was calculated. It was found that daily calcium excretion is significantly higher and daily citrates excretion is significantly lower in patients with calcium renal stones. Daily excretion of oxalates, magnesium and creatinine with the urine did not differ in both groups. Risk index according to Tiselius was two-fold higher in patients suffering from urolithiasis than in healthy individuals (p greater than 0.001) and better illustrated the tendency to stone formation than the analysis of metabolic disorders.     

Effect of Cystone on urinary composition and stone formation over a one year period

Kidney stones are a common problem for which inadequate prevention exists. We recruited ten recurrent kidney stone formers with documented calcium oxalate stones into a two phased study to assess safety and effectiveness of Cystone^®, an herbal treatment for prevention of kidney stones. The first phase was a randomized double-blinded 12 week cross over study assessing the effect of Cystone^® vs. placebo on urinary supersaturation. The second phase was an open label one year study of Cystone^® to determine if renal stone burden decreased, as assessed by quantitative and subjective assessment of CT. Results revealed no statistically significant effect of Cystone^® on urinary composition short (6 weeks) or long (52 weeks) term. Average renal stone burden increased rather than decreased on Cystone^®. Therefore, this study does not support the efficacy of Cystone^® to treat calcium oxalate stone formers. Future studies will be needed to assess effects on stone passage, or on other stone types.     

Percutaneous cholecystolithotomy

A percutaneous method was used to remove stones from otherwise normal gall bladders, as assessed by cholecystography and ultrasonography. The procedure was performed in a single stage under general anaesthesia, adopting the method and instruments used for one stage percutaneous nephrolithotomy. A Foley catheter was left in the gall bladder and the system checked with contrast at 10 days to ensure free drainage and exclude residual calculi. Seven out of eight patients had a successful percutaneous cholecystolithotomy. An adequate track could not be secured in one man; he had an uneventful cholecystectomy under the same anaesthetic. Follow up at three months of the seven patients showed no calculi and no complications.Percutaneous cholecystolithotomy may prove complementary to extracorporeal shockwave lithotripsy in patients in whom there is difficulty focusing the shock waves on the gall bladder or who have had incomplete disintegration of stones.     

Chinese minimally invasive percutaneous nephrolithotomy for intrarenal stones in patients with solitary kidney: a single-center experience

Objective

To report our experience with Chinese minimally invasive percutaneous nephrolithotomy (Chinese MPCNL) to manage patients with intrarenal stones in solitary kidney, and evaluate the safety, efficiency and feasibility of this technique.

Methods

Forty-one patients with intrarenal stones in solitary kidney underwent Chinese MPCNL in our department from March 2009 to February 2011. Demographic characteristics, operative parameters, number of tracts, stone-free rates (SFRs), stone analyses, hemoglobin levels, nephrostomy tube removal time, hospitalization time, and complications were evaluated. Serum creatinine (Scr) and glomerular filtration rate (GFR) were measured preoperatively, postoperatively at 1 month, and each follow-up visit. The 5-stage classification of chronic kidney disease (CKD) was used according to the National Kidney Foundation guidelines.

Results

The initial stone-free status was achieved in 35 (85.4%) patients after Chinese MPCNL. The mean follow-up time was 16.9±4.7 months (range: 12–24), and the final SFR improved to 97.6% after auxiliary procedures. Among all patients, complex stones were detected in 26 (63.4%) patients, and 9 (22.0%) required multiple tracts. The mean operative time and mean hospitalization time were 71.3±23.5 min (range: 40–139) and 6.1±0.5 days (range: 5–11), respectively. During preoperative period and postoperative period (1 month), Scr were 132.1±41.3 umol/L (range: 78.2–231.4) and 108.9±30.7 umol/L (range: 71.6–136.9), respectively (P<0.05), while GFR were 74.9±24.2 ml/min (range: 35–110) and 83.9±27.4 ml/min (range: 65–110), respectively (P<0.05). According to CKD classification, the renal function was stable, improved, and worse in 29 (70.7%), 11 (26.8%), and 1 (2.5%) patients, compared with the preoperative levels. No patient progressed to end-stage renal disease requiring dialysis.

Conclusions

Our experience with Chinese MPCNL demonstrates that it is safe, feasible and efficient for managing the intrarenal calculi in solitary kidney with a low complication rate. At long-term follow-up, renal function stabilized or even improved in the majority of patients with solitary kidney.