[Ultrasonographic and x-ray diagnosis of nephrolithiasis]

Neither the ultrasonic, not the x-ray method alone cannot provide the correct diagnosis in nephrolithiasis. Ultrasonic scanning of the kidneys is indicated at the first stage of the diagnosis. In case of a concrement detection without dilatation of the pelvic calyceal system and the presence of a typical pattern of a calcified papilla or coral-like concrement on the picture the diagnosis can be considered made. If ultrasonic scanning detects, besides the concrement shade, a dilatation of the pelvic calyceal system, excretory urography and x-ray television pyeloscopy are necessary to specify the urodynamic state, that is important to predict the concrement of its fragments elimination under the effect of conservative therapy or long-distance lithotripsy.

Retrograde manipulation for proximal ureteric stones before extracorporeal shockwave lithotripsy: technique, observations and results

OBJECTIVE

To determine the factors affecting the success of retrograde manipulation (RM) of upper ureteric stones.

PATIENTS AND METHODS

A total of 601 patients with upper ureteric calculi underwent attempted RM. In 216 patients, RM was performed irrespective of the respiratory phase, stone characteristics and ureteric anatomy (group 1). In the remaining 385 patients RM was performed at the height of expiration (group 2). Patients with large or impacted stones, ureters with a fusiform or funnel shape appearance on urography and grade IV hydronephrosis were not included in group 2.

RESULTS

The success rate was significantly greater in group 2. The rates of fever and perforation in groups 1 and 2 were 6.9/2.3% and 3.2/0.2% respectively. The incidence of residual fragments was also less in group 2.

CONCLUSION

RM at the height of expiration is associated with a higher success rate and lower complication rate.

Mass effect in the renal sinus: an anatomic classification

Before the advent of modern imaging techniques, pathologic processes in the renal sinus were diagnostic enigmas. Many of the conditions create nonspecific deformities of the contrast-filled collecting system. In the past, the discovery of these abnormalities often led to unnecessary exploration. Modern imaging techniques usually allow a specific diagnosis to be made, but because a number of the pathologic conditions affecting the renal sinus have similar appearances on a single type of imaging study, complete delineation may require correlation of a number of diagnostic techniques. An understanding of the normal sinus anatomy allows classification of pathologic processes that occur in this region and ensures an orderly imaging investigation. The anatomic classification is based on the structure from which the mass arises. The source of the mass may be any structure within the renal sinus (intrinsic), the enveloping renal parenchymal (adjacent), or a source outside the kidney itself with subsequent sinus involvement (extrinsic). This classification will be used to review a number of pathologic processes that occur in the renal sinus and pertinent imaging features.

[Complex renal lithiasis: conservative surgery]

We report a case of complicated renal lithiasis which had been successfully treated by conservative surgery. The present case shows that this surgical procedure continues to be a valid therapeutic option for this pathology, although occasionally the new, less invasive treatment modalities that continue to develop are utilized in the treatment of renal lithiasis far beyond the indications.

[The technic and value of the 3-dimensional imaging of renal calyx staghorn calculi with spiral CT]

5 patients with staghorn calculi in the renal pelvis were examined by spiral CT. From the raw data three dimensional reconstructions of the stones were obtained. In all patients it was possible to compare the three dimensional model with the stone following performance of percutaneous litholapaxy and endoscopic removal of the fragments. In all cases the three dimensional reconstruction provided a realistic image of the stones and was of practical value for the urologist for preoperative diagnosis and intraoperative control.

[Extracorporeal shock-wave lithotripsy in polycystic kidneys]

Presentation of 6 cases (8 renal units) of lithiasis in polycystic kidneys treated with extracorporeal shockwave lithotrity (ESWL). One patient required puncture of a compressing cyst, prior to ESWL, to facilitate the stones removal. No complications were seen in any of the cases. Therefore, stones in polycystic kidneys can be safely and effectively treated by ESWL.

Extracorporeal shock wave lithotripsy monotherapy for staghorn calculi

Forty-eight patients with large renal staghorn calculi of more than 35 mm in maximum length on plain X-rays were treated by extracorporeal shock wave lithotripsy (ESWL) monotherapy for a period of 2 years. Thirty patients, with a follow-up of more than 6 months after the last treatment, were included in this study. The surface area of the calculi was 1,290 mm2 on average. Based on plain X-rays, 9 cases (30%) became free of calculi while 12 patients (40%) had a small amount of residual fragments (less than 100 mm2 in area). Adding these cases to those in which all the residual calculi were eliminated, the total turned out to be 21 cases (70%) and the treatment of staghorn calculi with ESWL was thus considered to have been fairly effective in the present series. The remaining 9 cases (30%) contained a considerable amount of residuals (more than 100 mm2). The present study in the ESWL of large staghorn calculi revealed no clear relationship between the surface area of the stones and evacuation of the fragments. The amount of the residual fragments was significantly small when either the renal collecting system was less than 2,000 mm2 in area (p < 0.05), or when the ureteropelvic junction (UPJ) was equal or greater than 5 mm in diameter (p < 0.02) according to intravenous pyelography (IVP) before treatment. The complications associated with this treatment were minimal, with a high fever in only 3 patients that were treated easily by antibiotic therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of renal morphology and vascular function by color flow Doppler sonography immediately after extracorporeal shock wave lithotripsy

Thirteen male and seven female patients with renal calculi were evaluated by color flow Doppler sonography (CFDS) for renal morphology and function before and after receiving 1000 to 2350 shocks with the Dornier MPL 9000 lithotripter. No significant morphologic change was encountered except for renal enlargement thought to be secondary to edema induced by shock wave application. Similarly, no significant differences were recorded in the systolic and diastolic flow rates or pulsatility (PI) or resistive (RI) indices of the renal vessels before and after treatment (P > 0.05). Color flow Doppler sonography appears to be a safe, noninvasive, and reliable means of evaluating kidneys subjected to extracorporeal shock wave lithotripsy.

[The scintigraphic effect of extracorporeal lithotripsy: prospective series of 25 cases]

25 patients with non complicated renal stones were treated by extracorporeal shockwave lithotripsy (ESWL) using Sonolith 3000 an electrohydraulic generator type. They were evaluated before, 15 days and 3 months after ESWL by renal scintigraphy, using for 15 of them technetium -99m dimer captosuccinic acid and technetium -99m-diethylene-triamine acetate for the last 10. This follow up scintigraphic study shows no reduction of glomerular filtration rate after ESWL but some focal parenchymal lesions. Very few of these lesions persist at 3 months. These parenchymal damages seem to be less frequent and less persistent than with piezo-electric lithotripter.

Combination therapy for a partial staghorn calculus in an infant

Branched renal calculi are extremely unusual in infants. We report a case of a partial staghorn calculus in a 9-month-old boy and discuss how techniques routinely used in the treatment of staghorn calculi in adults (extracorporeal shock wave lithotripsy, nephrostolithotomy, percutaneous irrigation) can be applied to the infant kidney.

Color flow Doppler sonography for extracorporeal shock wave lithotripsy

This report documents the usefulness of color Doppler sonography for early verification of urinary stone fragmentation during extracorporeal shock wave lithotripsy with ultrasonographic focusing. In the experimental study lithotripsy was performed on human urinary stones placed in pig kidneys. Increasing color flow within the stone mass created by movement of small fragments indicated fragmentation earlier than pixel movement on the standard gray scale sonogram. The success of treatment was demonstrated macroscopically. In the clinical study 25 patients with radiopaque kidney stones were treated by color Doppler guided shock wave lithotripsy and compared to a control group of 32 patients with similar stone characteristics in whom the end point of treatment was chosen based on B-mode sonography alone. The amount of color flow within the stone reflex determined the end point of treatment. The degree of fragmentation was confirmed by fluoroscopy immediately after treatment. Disintegration was successful in all cases and fragments passed spontaneously. Color Doppler imaging during shock wave lithotripsy provides reliable information on the spatial and temporal characteristics of stone fragmentation, and is superior to B-mode sonography by providing more immediate, objective information on stone fragmentation and allowing better evaluation of the focal zone. With the help of this technique, the number of applied shock waves could be reduced by 20% compared with the control group.

[Treatment of intradiverticular lithiasis by percutaneous methods (19 caliceal diverticuli)]

The main technical procedures in percutaneous nephrolithotomy are the direct puncture of the diverticulum (precise puncture may be required to place the tract directly on to the stone), and treatment duration the diverticulum could be coagulated and a large nephrostomy catheter could be left in place two days. No complication was encountered. One patient refused the treatment after unsuccessful puncture. The nephrostomy tube was left open for two days of drainage. Mean hospital stay was 5 days. Three patients required E.S.W.L because of persistent symptoms. One month after treatment 13 of 18 patients intravenous urography showed obliteration of the diverticulum (72%); Three months after 84% (15/18) of our patients were stone free and 94% (17/18) symptom free. Percutaneous nephrolithotomy should be performed for symptomatic patients, it has low complication rate and should be reserved for patients with persistent symptoms after E.S.W.L.

Renal stone disease in autosomal dominant polycystic kidney disease

Nephrolithiasis is an important manifestation of autosomal dominant polycystic kidney disease (ADPKD), which occurs in approximately 20% of patients. It should always enter the differential diagnosis of flank pain in patients with ADPKD. The diagnosis is hindered by the distorted anatomy of the polycystic kidneys and the frequent occurrence of parenchymal and cyst wall calcifications, and requires demonstration of the relationship to the collecting system by intravenous urography and/or computed tomography. Computed tomography is the most sensitive imaging technique for detection of stones or calcifications, whereas intravenous urography is the most sensitive for visualization of the intrarenal collecting system. Precaliceal tubular ectasia can be detected in 15% of patients with ADPKD and nephrolithiasis, but this association may not be specific to ADPKD. The composition of the stones is most frequently uric acid and/or calcium oxalate. Metabolic factors are important in their pathogenesis. Distal acidification defects may be important in a few patients, while an abnormal transport of ammonium, low urine pH, and hypocitruria are the most common abnormalities. The treatment of nephrolithiasis in patients with ADPKD is not different from that in patients without ADPKD. Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy in patients with early disease and normal renal function are not contraindicated.

Percutaneous extraction of upper urinary calculi under fluoroscopic control--still a valuable complement to ESWL

Percutaneous extraction of 372 renal and proximal ureteral calculi was performed under fluoroscopic control in 202 consecutive patients. In 193 kidneys (90%) removal of stones was performed under fluoroscopic control only and in 10% initial ultrasonic disintegration was used. A completely stone free kidney was achieved in 74%. If successful outcome is defined as no stones or residual fragments less than 5 mm, the success rate was 91%. With a mean size of 10.3 mm 259 intact stones were extracted under fluoroscopic control. Open surgery was performed in 13 of 202 patients, in 10 of these cases due to unsuccessful removal of an impacted ureteral stone. Complications occurred in 16%, none of them were serious. Open intervention became necessary in 2 patients. Bleeding which required blood transfusion occurred once. Percutaneous renal stone extraction under fluoroscopy is safe and useful in selected patients when ESWL can be expected to produce less favourable results. The ability to perform this technique should therefore be well maintained.

Bilateral spontaneous steinstrasse and nephrocalcinosi associated with distal renal tubular acidosis

Bilateral spontaneous steinstrasse from the ureteropelvic junction to the distal ureter complicating distal renal tubular acidosis has not been described. We report a case and discuss the clinical presentation, radiographic and metabolic findings, and treatment. Relief of obstructive uropathy with extracorporeal shock wave lithotripsy led to the resolution of the heavy steinstrasse burden.

[Gigantic pyohydronephrosis and contralateral ureteral bud. Problems of differential diagnosis]

Both giant hydronephrosis and blind-ending ureteral bud are rare conditions. We report on a patient with an impacted ureteral stone leading to giant pyohydronephrosis (6.51) on the right side, which in turn caused displacement of the ureter containing the stone to the left. An asymptomatic blind-ending ureteral bud initially complicated the diagnosis. After nephrectomy, a unsuspected transitional cell carcinoma of the right renal pelvis and the ureter was found.

Technique and follow-up of percutaneous management of caliceal diverticula

Between June 1985 and July 1992 we treated 20 patients who had symptomatic caliceal diverticula (13 in upper calix, 6 in middle calix, and 1 in lower calix) in whom long-term (3 months to 3 years) evaluation of persistent symptoms, physical condition, and radiologic findings was possible. Of the 20 patients, 19 had had stones in the diverticulum preoperatively, and the other had a huge diverticulum but no stones. Eighteen patients (95%) with stones preoperatively had been rendered stone free, and the other patient demonstrated only small residual stones in the area of the obliterated diverticulum. Sixteen patients (80%) had obtained complete resolution of their diverticula, and the remaining 4 had at least a 50 percent diminution of the original size of the lesion. All patients had been rendered free of infection and symptoms. Percutaneous management of caliceal diverticula is the most effective approach to rendering patients with caliceal diverticula stone free and achieving diverticular ablation.

Is the preliminary film necessary prior to the micturating cystourethrogram in children?

The aim of the study was to determine the value of the preliminary film in children undergoing a micturating cystourethrogram (MCU). The coded computer reports of 806 children undergoing MCUs in a 12-month period were retrospectively reviewed for abnormalities of the lumbar spine, hips, or for calcifications. Vesicoureteric reflux was present in 185 patients (23%). Four patients had renal calculi (0.5%), and in all cases the abnormality was evident on preceding imaging of the upper urinary tract. Spinal anomalies (other than known meningomyelocele) were present in four patients. The clinically obvious abnormalities present in these were a sacral teratoma, a sacral lipoma, scoliosis with tracheo-oesophageal fistula, and a cutaneous angioma with a sacral pit. No patients (other than those with known meningomyelocele) had dislocated hips diagnosed. If the preliminary film had not been performed in 806 patients, neither spinal anomaly, renal calculus, nor congenital dislocated hip would have been missed. The low incidence of plain film anomalies indicates that in our population a plain film is not justified routinely.

[The percutaneous endoscopic treatment of staghorn nephrolithiasis]

Basing on the data obtained on percutaneous removal of stag-horn nephroliths in 81 patients (44 females and 37 males aged 10-65), the authors discuss the operative technique and surgical results. The patients were divided into 4 groups depending on the stone size, its position in the pelvicaliceal system, the presence and severity of calicectasis. Nephroliths sizes ranged from 3.5 to 10 cm. Better treatment results were obtained in those patients who had the main mass of the stone in renal pelvis and in those with pyelocalicectasis. After the treatment 72 patients (88.8%) were free of the stones. Common among complications were episodes of pyelonephritis after the intervention and displacement of the nephrostomy drainage. The authors gained primary experience which supports benefit of percutaneous surgery of stag-horn nephroliths.

[Changes in renal blood flow after treatment with ESWL in patients with renal stones. Studies using ultrasound color Doppler method]

Recently several authors have observed tissue damages in ESWL treated kidneys, such as interstitial hemorrhage and edema, cavitation of renal tubular cells and vascular spasms. Examination using renal scintigraphy suggested that these damages could cause a decrease of renal blood flow in the treated kidney. Trying to confirm and further investigate this possibility, we studied on changes of renal blood flow velocity using ultrasound color doppler method in 23 consecutive patients with renal stones who underwent ESWL. The studies were conducted before, immediately after and 1 week after an ESWL treatment. Results were as follows; renal blood flow velocity decreased significantly in the area exposed to shock were immediately after the treatment and returned to the pretreatment levels after 1 week. The changes were not significant in the non-exposed area. In parallel with this decrease of renal blood flow velocity, significant increases of resistive index, pulsatility index and significant decreases of ratio were observed. These parameters calculated by measuring of renal blood flow velocity are known to well correlate with parenchymal vascular resistance. We speculate that these changes in renal parenchymal blood flow velocity are triggered by the tissue damages caused by the exposure to shock wave. The recovery of renal blood flow velocity may depend on the recovery of the tissue damages. Ultrasound color doppler method may make it possible to monitor the recovery of tissue damages induced by shock wave and may provide us with an useful information to determine when to repeat ESWL if needed.

[Differential diagnostic problems in a polycystic, atypically calcified renal cell carcinoma]

The renal cell carcinoma as the most common malignant renal tumour in adults may produce diagnostic difficulties if it follows atypical patterns. In the case of a polycystic renal tumour this problem is discussed; the high sensitivity of CT and MRT in detecting even small areas of solid tumour is shown.

Paragonimus calcified ova mimicking left renal staghorn stone

We report on a 49-year-old woman with clusters of Paragonimus calcified ova unusually located in the left retroperitoneal space and renal capsule mimicking a left renal staghorn stone. The diagnosis and treatment are discussed. We also reviewed the endemic condition of paragonimiasis in Taiwan.