Low-grade left varicocele in patients over 30 years old:the effect of spermatic vein ligation on fertility

OBJECTIVES

To evaluate the effect of spermatic vein ligation in patients over 30 years old and with low-grade left varicocele, and thus help to establish whether such patients might benefit from surgery.

PATIENTS AND METHODS

A randomized study was conducted on 68 infertile patients (30-38 years old) with evidence of sperm abnormalities and who had low-grade varicocele (grade I according to Hirsch), comparing left spermatic vein ligation with no treatment. The outcome was assessed by standard sperm analysis and eventual paternity.

RESULTS

There was no improvement in sperm quality in either of the groups one year after surgery, and no significant difference in paternity.

CONCLUSIONS

Left spermatic vein ligation for low-grade varicocele in patients more than 30 years old cannot be recommended.

Abdominal pain associated with an intra-abdominal gonad in an adult

Controversy still surrounds management of cryptorchidism in adults. Options include orchiectomy, orchiopexy, and close observation. What about fertility if orchiectomy is chosen? How is the risk of cancer affected when observation is the choice? Follow the reasoning for the management strategy for this adult presenting with abdominal pain.

Ureteroscopic management of upper urinary tract urothelial malignancies

The endoscope has made the transition from diagnostic tool to therapeutic aid in the upper urinary tract in recent years. Because of success using the ureteropyeloscope in the treatment of patients with upper tract stones and strictures, investigators are now looking at endoscopic management of urothelial malignancies above the bladder.

Enteroviral infection causing fatal myocarditis and subclinical myopathy

Enteroviral RNA detection in myocarditis and dilated cardiomyopathy is rare. Enteroviral particles and RNA have recently been identified in patient's skeletal muscle, suggesting that skeletal more than heart muscle hosts the virus in chronic infection. Enteroviral RNA and virus-like particles were found in the myocardium and in the skeletal muscle of two patients with fatal myocarditis: a 39 year old man who died five days after the onset of febrile flu; and a 49 year old woman, assisted for 50 days with a left ventricular assist device, who then died from cerebral haemorrhage. Automated sequencing, alignment, and sequence comparison confirmed the enteroviral origin of polymerase chain reaction products and excluded contamination. These findings agree with prior observations of enteroviral localisation in the skeletal muscle of patients with dilated cardiomyopathy, and further support the hypothesis that skeletal rather than heart muscle may host the virus and serve as a reservoir in cardiomyopathies related to chronic infection.

KEYWORDS

enterovirus; myocarditis; viral particles; skeletal muscle

Retrograde ureteropyeloscopy for lower pole caliceal calculi

PURPOSE

Contemporary treatment of lower pole renal calculi includes extracorporeal shock wave lithotripsy, percutaneous nephrostolithotomy and retrograde ureteropyeloscopy. Success rates for shock wave lithotripsy are reduced in this setting, especially for stones greater than 1 cm. and/or in patients with anatomical variants. Percutaneous treatment, although effective, subjects the patient to increased morbidity. We studied the safety and efficacy of retrograde ureteroscopic treatment of lower pole intrarenal calculi.

MATERIALS AND METHODS

We evaluated 90 stone burdens localized to the lower pole and treated with a small diameter, actively deflectable, flexible ureteropyeloscope and a 200 micron holmium laser fiber. Stone burdens were classified as group 1--10 or less, group 2--11 to 20 and group 3--greater than 20 mm. in largest diameter. Patients with calculi less than 2.5 cm. were treated as outpatients unless concurrent medical conditions required hospitalization. Larger stones and partial staghorn calculi (group 3) frequently required 2-stage endoscopic procedures with retrograde intrarenal irrigation for 36 hours to clear debris. An acceptable immediate surgical outcome was defined as complete fragmentation reducing the stone burden to dust and 2 mm. or less fragments. Success was defined as clear imaging (that is stone-free) on renal sonography with minimum 3-month followup. Extreme anatomical variants, including a long infundibulum, acute infundibulopelvic angle and a dilated collecting system, were noted and correlated with surgical failures.

RESULTS

Endoscopic access and complete stone fragmentation were achieved in 94, 95 and 45% of groups 1, 2 and 3, respectively. After a second treatment the success rate increased to 82% in group 3, with an overall rate of 91%. Of the 19 surgical failures 8 were secondary to inability to access the lower pole and 11 were secondary to inability to render the patient stone-free. In 2 of the 19 cases infundibular strictures hindered ureteroscopic access. In addition, of the anatomical variants a long lower pole infundibulum was the most statistically significant predictor of failure. Mean operative time ranged from 38 minutes for small to 126 for the largest calculi. There were no major complications. Overall stone-free rates with minimum 3-month followup were 82, 71 and 65% in groups 1, 2 and 3, respectively, and 88, 77 and 81%, respectively, in patients with an acceptable initial surgical outcome (that is excluding those with access failures from analysis).

CONCLUSIONS

Retrograde ureteropyeloscopy is a safe and effective surgical treatment for lower pole intrarenal calculi.

Conservative surgery in small renal tumors: our experience

OBJECTIVE

We evaluated the effectiveness and safety of the nephron-sparing surgery in the treatment of low stage, easily accessible renal cell carcinoma versus radical nephrectomy, the "gold standard" therapy according to data in the literature.

METHODS

From 1988 to 1996, 36 patients (11 women and 25 men; mean age 59.6 years) with a small (< or = 5 cm) solitary renal cell carcinoma and a normal contralateral kidney were submitted to tumor enucleation through a transperitoneal approach. Hot ischemia was performed in 14 cases for an average of 16 minutes. In order to control the extent of surgical resection, in all cases frozen step sections of surgical margins were submitted to histopathological examination. The mean follow-up was 40 months.

RESULTS

Complete local resection of the renal cell carcinoma was performed in all patients, with preservation to the furthest extent of the parenchyma not affected by the disease. Renal function remained normal in all cases. Bleeding was easily controlled without clamping the renal artery in 22 cases, while hot renal ischemia was necessary in the remaining 14 cases (mean ischemia time 16 minutes). Average blood loss was 450 cc. Frozen sections of the surgical margins were negative in all cases. Only one case of local recurrence was observed one year after the nephron-sparing operation, which was treated by radical nephrectomy. All patients are alive and cancer-free today.

CONCLUSIONS

Elective tumor enucleation for low stage and easily accessible renal cell carcinoma can be performed safely and with a low risk of local recurrence. Definition of the appropriate pre-operative diagnostic approach, maximum tumor size, surgical mini-invasive approach and a longer follow-up are required before this procedure can be widely recommended.

Holmium:YAG lithotripsy in children

PURPOSE

We determined the safety and efficacy of holmium:YAG lithotripsy in children.

MATERIALS AND METHODS

We retrospectively reviewed the records of all holmium:YAG lithotripsy done in patients 17 years old or younger. Demographic, preoperative, intraoperative and postoperative data were collected.

RESULTS

A total of 9 boys and 10 girls (26 stones) with a mean age of 11 years (range 1 to 17) were treated with holmium:YAG lithotripsy, which was chosen as initial therapy in 10 (53%). Retrograde ureteroscopy was performed in 15 patients to treat 13 ureteral and 6 renal calculi, and percutaneous nephrolithotripsy was done in 4 to treat 3 ureteral and 4 renal calculi. A complete stone-free outcome after 1 procedure was achieved in 16 children (84%) and 3 patients were rendered stone-free after 2 procedures. No patient had an intraoperative injury. Followup ranged from 0.5 to 12 months (mean 3). Followup imaging has shown no evidence of stricture or hydronephrosis.

CONCLUSIONS

Holmium:YAG lithotripsy is safe and effective in children. It is a reasonable option for failed shock wave lithotripsy, or in children with a known durile stone composition or contraindications to shock wave lithotripsy.

Examining the obstructed ureter with intraluminal sonography

PURPOSE

Intraluminal sonography was used to define, differentiate and direct better treatment of obstructing ureteral lesions.

MATERIALS AND METHODS

A total of 63 patients with a history of ureteral obstruction and suspected stricture were accrued for evaluation. All patients underwent retrograde contrast imaging, ureteroscopy and intraluminal sonography as part of a diagnostic algorithm. Specific sonographic criteria to differentiate lesions and stricture types were developed. Associated complicating variables defined on sonography included foreign bodies, submucosal stone fragments, ureteral wall fibrosis, mass lesions and adjacent vasculature. Endoscopic treatment was then performed with ultrasound guidance if technically feasible.

RESULTS

A total of 63 ureters were evaluated with the preoperative diagnosis of ureteral stricture disease. All ureters were narrowed on contrast imaging in the segment where a stricture was suspected. On sonography 24 ureters (36%) had wall fibrosis with normal periureteral tissues. In general these strictures did well with endoscopic incision. Of the 67 ureters 13 (19%) were thickened or had edematous walls with normal architecture and without fibrosis. These patients all did well with expectant therapy. In contrast, 7 ureters (10%) were obstructed by segmental retroperitoneal fibrosis which did not respond to minimally invasive therapies. In addition, 8 ureters (12%) were obstructed by ureteral wall scarring and periureteral fibrosis, and required open surgical intervention. Ten ureteral strictures had adjacent vasculature, and endoscopic incisions under ultrasound guidance were directed safely away from these structures without associated morbidity. Calculi, stone fragments and foreign bodies embedded in the ureteral wall with associated inflammation were defined with sonography and responded to endoscopic therapies. The intraluminal sonographic diagnosis of ureteral endometriosis was made in 6 patients with a range of lesions from bright, hyperechoic blood filled cysts to an inhomogeneous fluid filled scar involving the wall and periureteral tissues. Primary ureteral carcinoma was also demonstrated in 2 patients after other diagnostic techniques failed. In 1 of these patients intraluminal sonography directed biopsies diagnosed submucosal tumor. Finally, 1 patient had a small periureteral urinoma on intraluminal sonography which was missed on other imaging studies.

CONCLUSIONS

Intraluminal sonography is useful in patients with ureteral obstruction of unclear etiology as well as for selecting patients who may benefit from minimally invasive therapies and safely directing these treatments.

Ureteropyeloscopic diagnosis and treatment of upper urinary tract urothelial malignancies

OBJECTIVES

To study the application of endoscopic techniques in treating upper urinary tract urothelial malignancies and to define subgroups that may benefit from these therapies.

METHODS

During a 3-year period, 20 patients with upper urinary tract transitional cell carcinoma were referred specifically for endoscopic therapy. Indications for treatment included a solitary kidney, bilateral disease, modest renal insufficiency, and/or other significant comorbidities. All patients underwent retrograde ureteropyeloscopy. Lesions were biopsied, and lower grade tumors were treated with electrocautery or laser energy. High-grade lesions not amenable to minimally invasive techniques were palliated or treated with standard open surgery. Surveillance was performed at 3 to 4-month intervals by urine cytology and repeat panendoscopy on a similar schedule to lesions of the bladder treated endoscopically.

RESULTS

Eleven patients (55%) were found to have low-grade, papillary transitional cell carcinoma of the upper urinary tract. Tumors ranged in size from less than 1 cm to filling the entire ureter. All papillary lesions were treated successfully using ureteroscopic techniques without any disease progression. Five small, low-grade recurrences (45%) were defined and treated endoscopically, with a mean follow-up of 17.3 months. Three patients were found at the time of initial diagnostic ureteroscopy to have higher grade lesions and endoscopic treatment was chosen in light of their severe comorbidities. On subsequent imaging, 2 of the 3 patients were suspected of having progression and underwent open surgery, both had carcinoma-in-situ only in the specimen. No tumor progression has been defined in this group to date, with mean follow-up of 16.3 months. A final third group of 6 patients were found to have nonpapillary, high-grade lesions at diagnostic endoscopy and underwent standard surgical resection. The disease of 4 of these 6 patients has progressed with metastases.

CONCLUSIONS

Papillary, low-grade, low-stage tumors of the upper urinary tract are amenable to endoscopic resection irrespective of size and location. Patients with high-grade lesions defined endoscopically should be offered radical surgery in light of the high rate of disease progression.

Mosaicism for the full mutation and a microdeletion involving the CGG repeat and flanking sequences in the FMR1 gene in eight fragile X patients

The molecular mechanism of the fragile X syndrome is based on the expansion of an unstable CGG repeat in the 5' untranslated region of the FMR1 gene in most patients. This expansion is associated with an abnormal DNA methylation leading to the absence of production of FMR1 protein (FMRP). Such expansion apparently predisposes the repeat and flanking regions to further instability that may lead to mosaic conditions with a full mutation and a premutation or, rarely, with normal or reduced alleles that can sometimes be transcriptionally active. In this study we describe eight unrelated fragile X patients who are mosaic for both a full mutation and an allele of normal (four cases) or reduced size (four cases). Sequencing analysis of the deletion breakpoints in 6 patients demonstrated an internal deletion confined to the CGG repeat in four of them, which represents the most likely explanation for the regression of the full mutation to a normal sized allele. In two patients with a reduced allele, the deletion encompassed the entire CGG repeat and part of the flanking regions. Analysis of FMRP by Western blot was performed in one of the mosaics with a normal sized allele and in three of those with a reduced allele. In the first patient's lymphocytes FMRP was detected, whereas in the three other patients the deletion is likely to impair transcription as no FMRP was present in their lymphocytes.

Ureteroscopic lithotripsy

The indications for ureteroscopic lithotripsy have increased with endoscope miniaturization and powerful, precise endoscopic lithotrites like the holmium: yttrium-aluminum-garnet laser. Successful ureteropyeloscopic treatment with the currently available instrumentation and techniques is independent of the size, composition, and location of stones in the upper urinary tract. Extracorporeal shockwave lithotripsy maintains a major role in treating uncomplicated, moderately sized upper urinary tract calculi. Complex upper urinary tract calculi, however, are best treated endoscopically. In addition, the endoscopic treatment of ureteral calculi is efficacious and definitive, albeit more invasive than extracorporeal shock wave lithotripsy.

Divergence between stone composition and urine supersaturation: clinical and laboratory implications

PURPOSE

In general high urine supersaturation with respect to calcium oxalate, calcium phosphate or uric acid is associated with that phase in stones. We explore the exceptions when supersaturation is high and a corresponding solid phase is absent (type 1), and when the solid phase is present but supersaturation is absent or low (type 2).

MATERIALS AND METHODS

Urine supersaturation values for calcium oxalate, calcium phosphate and uric acid, and other accepted stone risk factors were measured in 538 patients at a research clinic and 178 at stone prevention sites in a network served by a single laboratory.

RESULTS

Of the patients 14% lacked high supersaturation for the main stone constituent (type 2 structural divergence) because of high urine volume and low calcium excretion, perhaps from changes in diet and fluid intake prompted by stones. Higher calcium excretion and low urine volume caused type 1 divergences, which posed no clinical concern.

CONCLUSIONS

Type 1 divergence appears to represent a condition of low urine volume which raises supersaturation in general. Almost all of these patients are calcium oxalate stone formers with the expected high supersaturation with calcium oxalate as well as high uric acid and calcium phosphate supersaturations without either phase in stones. Type 2 divergence appears to represent an increase in urine volume and decrease in urine calcium excretion between stone formation and urine testing.

Vaccine storage in the community: a study in central Italy

Maintaining the vaccine cold chain is an essential part of a successful immunization programme, but in developed countries faulty procedures may occur more commonly than is generally believed. A survey was conducted in a health district in central Italy to assess the methods of vaccine transportation and storage. Of 52 primary vaccination offices inspected, 39 (76.5%) had a refrigerator for vaccine storage but only 17 (33.3%) kept records of received and stored doses. None of the seven main offices selected for monitoring had a maximum and minimum thermometer and none monitored the internal temperature of the refrigerator. Moreover, other faulty procedures, such as the storage of food and laboratory specimens in vaccine refrigerators and the storage of vaccines on refrigerator door shelves, indicated that the knowledge and practice of vaccine storage and handling were often inadequate.

Coexistence of mitochondrial DNA and beta myosin heavy chain mutations in hypertrophic cardiomyopathy with late congestive heart failure

OBJECTIVE

To investigate the possible coexistence of mitochondrial DNA (mtDNA) mutations in patients with beta myosin heavy chain (beta MHC) linked hypertrophic cardiomyopathy (HCM) who develop congestive heart failure.

DESIGN

Molecular analysis of beta MHC and mtDNA gene defects in patients with HCM.

SETTING

Cardiovascular molecular diagnostic and heart transplantation reference centre in north Italy.

PATIENTS

Four patients with HCM who underwent heart transplantation for end stage heart failure, and after pedigree analysis of 60 relatives, eight additional affected patients and 27 unaffected relatives. A total of 111 unrelated healthy adult volunteers served as controls. Disease controls included an additional 27 patients with HCM and 102 with dilated cardiomyopathy.

INTERVENTION

Molecular analysis of DNA from myocardial and skeletal muscle tissue and from peripheral blood specimens.

MAIN OUTCOME MEASURES

Screening for mutations in beta MHC (exons 3-23) and mtDNA tRNA (n = 22) genes with denaturing gradient gel electrophoresis or single strand conformational polymorphism followed by automated DNA sequencing.

RESULTS

One proband (kindred A) (plus seven affected relatives) had arginine 249 glutamine (Arg249Gln) beta MHC and heteroplasmic mtDNA tRNAIle A4300G mutations. Another unrelated patient (kindred B) with sporadic HCM had identical mutations. The remaining two patients (kindred C), a mother and son, had a novel beta MHC mutation (lysine 450 glutamic acid) (Lys450Glu) and a heteroplasmic missense (T9957C, phenylalanine (Phe)-->leucine (Leu)) mtDNA mutation in subunit III of the cytochrome C oxidase gene. The amount of mutant mtDNA was higher in the myocardium than in skeletal muscle or peripheral blood and in affected patients than in asymptomatic relatives. Mutations were absent in the controls. Pathological and biochemical characteristics of patients with mutations Arg249Gln plus A4300G (kindreds A and B) were identical, but different from those of the two patients with Lys450Glu plus T9957C(Phe-->Leu) mutations (kindred C). Cytochrome C oxidase activity and histoenzymatic staining were severely decreased in the two patients in kindreds A and B, but were unaffected in the two in kindred C.

CONCLUSIONS

beta MHC gene and mtDNA mutations may coexist in patients with HCM and end stage congestive heart failure. Although beta MHC gene mutations seem to be the true determinants of HCM, both mtDNA mutations in these patients have known prerequisites for pathogenicity. Coexistence of other genetic abnormalities in beta MHC linked HCM, such as mtDNA mutations, may contribute to variable phenotypic expression and explain the heterogeneous behaviour of HCM.

Mitochondrial DNA mutations and mitochondrial abnormalities in dilated cardiomyopathy

Mitochondrial (mt)DNA defects, both deletions and tRNA point mutations, have been associated with cardiomyopathies. The aim of the study was to determine the prevalence of pathological mtDNA mutations and to assess associated defects of mitochondrial enzyme activity in dilated cardiomyopathy (DCM) patients with ultrastructural abnormalities of cardiac mitochondria. In a large cohort of 601 DCM patients we performed conventional light and electron microscopy on endomyocardial biopsy samples. Cases with giant organelles, angulated, tubular, and concentric cristae, and crystalloid or osmiophilic inclusion bodies were selected for mtDNA analysis. Mutation screening techniques, automated DNA sequencing, restriction enzyme digestion, and densitometric assays were performed to identify mtDNA mutations, assess heteroplasmy, and quantify the amount of mutant in myocardial and blood DNA. Of 601 patients (16 to 63 years; mean, 43.5 +/- 12.7 years), 85 had ultrastructural evidence of giant organelles, with abnormal cristae and inclusion bodies; 19 of 85 (22.35%) had heteroplasmic mtDNA mutations (9 tRNA, 5 rRNA, and 4 missense, one in two patients) that were not found in 111 normal controls and in 32 DCM patients without the above ultrastructural mitochondrial abnormalities. In all cases, the amount of mutant was higher in heart than in blood. In hearts of patients that later underwent transplantation, cytochrome c oxidase (Cox) activity was significantly lower in cases with mutations than in those without or controls (P = 0.0008). NADH dehydrogenase activity was only slightly reduced in cases with mutations (P = 0.0388), whereas succinic dehydrogenase activity did not significantly differ between DCM patients with mtDNA mutations and those without or controls. The present study represents the first attempt to detect a morphological, easily identifiable marker to guide mtDNA mutation screening. Pathological mtDNA mutations are associated with ultrastructurally abnormal mitochondria, and reduced Cox activity in a small subgroup of non-otherwise-defined, idiopathic DCMs, in which mtDNA defects may constitute the basis for, or contribute to, the development of congestive heart failure.

Small diameter, actively deflectable, flexible ureteropyeloscopy

PURPOSE

We studied and developed ureteroscopic technique and instrumentation beyond our initial experience with small diameter, actively deflectable, flexible ureteropyeloscopy.

MATERIALS AND METHODS

Flexible ureteropyeloscopy was performed at 2 university centers in 492 consecutive patients. Endoscope designs and development were based on strict specifications, including 8F or less tip diameter, 3.6F or greater working channel, 2-way active tip deflection and secondary deflection for lower pole intrarenal access. Flexible ureteroscopes manufactured by 5 companies were studied through various prototypic steps and surgical technique. Complementary accessories were developed for specific treatments, including endoscopic lithotripsy, management of urothelial lesions, treatment of upper urinary tract obstruction (that is strictures) and percutaneous access with ureteroscopic assistance in select complex cases.

RESULTS

A total of 584 procedures were performed with the small diameter, actively deflectable, flexible ureteroscopes. Flexible ureteropyeloscopic access was always preformed over a working guide wire without an operative sheath. In addition, the 10F dual lumen catheter was the primary device used to obtain 2 guide wires (working and safety), and gently and minimally dilate the intramural segment. Larger dilators were required in only 12% of procedures. The entire intrarenal collecting system was accessed in 94% of cases with lower pole access requiring secondary or passive deflection in 60% of procedures. Endoscopic lithotripsy was the most common procedure performed in this series (303, 52%). Small diameter, flexible ureteroscopy and holmium laser lithotripsy were successful in 97% of patients with ureteral and 79% with intrarenal calculi. When a 2-stage ureteropyeloscopy procedure was used for large upper urinary tract calculi, the success rate for intrarenal calculi increased to 91%. Endoscopic biopsy and treatment of upper urinary tract transitional cell carcinoma were performed in 101 procedures (17%), while retrograde ureteroscopic incision for stricture disease was performed in 36 (6%). The overall major complication rate was less than 1% and there were no ureteral perforations, avulsions, sepsis or deaths. These new endoscopes were more fragile than larger predecessors but a maximum of 30 procedures were performed between interval repair.

CONCLUSIONS

Small diameter, actively deflectable, flexible ureteropyeloscopy facilitates various minimally invasive endoscopic therapies. Although this class of endoscope has greater fragility, it is easy to use and has broadened the therapeutic range of ureteroscopic treatment to include intrarenal lesions.

Medical reduction of stone risk in a network of treatment centers compared to a research clinic

PURPOSE

We determined whether a network of 7 comprehensive kidney stone treatment centers supported by specialized stone management software and laboratory resources could achieve reductions in urine supersaturation comparable to those in a single research clinic devoted to metabolic stone prevention.

MATERIALS AND METHODS

Supersaturation values for calcium oxalate, calcium phosphate and uric acid in 24-hour urine samples were calculated from a set of kidney stone risk factor measurements made at a central laboratory site for the network and research laboratory for the clinic. Individual results and group outcomes were presented to each center in time sequential table graphics. The decrease in supersaturation with treatment was compared in the network and clinic using analysis of variance.

RESULTS

Supersaturation was effectively reduced in the network and clinic, and the reduction was proportional to the initial supersaturation value and increase in urine volume. The clinic achieved a greater supersaturation reduction, higher fraction of patient followup and greater increase in urine volume but the treatment effects in the network were, nevertheless, substantial and significant.

CONCLUSIONS

Given proper software and laboratory support, a network of treatment centers can rival but not quite match results in a dedicated metabolic stone research and prevention clinic. Therefore, large scale stone prevention in a network system appears feasible and effective.

Hepatitis C virus genotypes and clinical features in hepatitis C virus-related mixed cryoglobulinemia

Mixed cryoglobulinemia is a systemic disease, almost always associated with hepatitis C virus infection and characterized by purpura and cutaneous vasculitis, asthenia, arthralgias, and often renal and neurological involvement. No significant differences have been described to date in mixed cryoglobulinemia patients with type 1, 2, or 3 hepatitis C virus infection with respect to symptoms, while a higher prevalence of genotype 2a has been reported in patients without clinical and biochemical signs of liver disease or with serum autoantibodies. We examined 33 hepatitis C virus-positive patients with mixed cryoglobulinemia to assess if any clinical or serological feature is related to infection with different genotypes. All subjects underwent viral genotype determination by means of a single-step polymerase chain reaction. Thirteen patients (39%) were infected with hepatitis C virus type 1b, 17 (52%) with type 2a or 2a/c, and 3 (9%) with type 3. There was a significant difference in the frequency of peripheral nervous system involvement: paresthesias or other symptoms of peripheral neuropathy were less frequent in patients with 2a or 2a/c infection (29%) than in patients with type 1b or type 3 infection (88%, P = 0.003). Only patients with hepatitis C virus type 2 had urticaria or cutaneous ulcers. These patients also had a lower frequency of arthralgias, lower cryocrit values (P = 0.02), and lower serum levels of alanine-aminotransferase and gamma-glutamyl-transpeptidase (P < 0.04) than patients with type 1 and type 3 infection. The prevalence of antinuclear antibody positivity was similar in the three groups.

Retrograde ureteropyeloscopic treatment of 2 cm. or greater upper urinary tract and minor Staghorn calculi

PURPOSE

Upper urinary tract calculi that are too large to treat with extracorporeal shock wave lithotripsy are most commonly cleared with percutaneous endoscopic techniques. In a select group of patients who were poor candidates for percutaneous nephrostolithotomy we used retrograde endoscopic lithotripsy, and define the safety and efficacy of this modality in treating large, noninfectious stone burdens (2 cm. or greater).

MATERIALS AND METHODS

A total of 51 patients with 66 large (2 cm. or greater) upper urinary tract stones were chosen for retrograde ureteroscopic surgery. Many of these patients had co-morbid conditions that precluded or complicated standard percutaneous treatment. Lithotripsy was based on the application of small diameter fiberoptic ureteroscopes and the holmium laser lithotriptor. Specifically, the 200 micro. laser fiber was used when lower pole renal access was required. Successful therapy was defined as total fragmentation of a stone burden with creation of fine sand and 2 mm. or smaller debris. Second look endoscopy was commonly performed in select patients with large branched calculi or stone burdens in excess of 3 cm. to rule out and treat large residual fragments.

RESULTS

Of 51 patients 48 were treated solely in a retrograde ureteroscopic manner and in 3 either failure of lower pole access or infectious material encountered on initial endoscopy led to conversion to more standard percutaneous techniques. In 34 of 45 renal (76%), and 20 of 21 ureteral (95%) complete ureteroscopic fragmentation of the respective stone burden was accomplished after a single session. Second look endoscopy defined significant residual fragments requiring additional endoscopic lithotripsy in 8 of 15 large renal (53%) and 1 of 3 complex ureteral stone burdens. Success, that is complete pulverization of the stone burden to fine dust and small 2 mm. fragments, increased to 41 of 45 renal (91%) and all 21 ureteral calculi after these second look procedures. One patient required a third session to treat completely an exceptionally large (6 cm.) renal stone burden composed of pure cystine, thus increasing the overall success rate for renal calculi to 93%. Six-month followup data were available for 25 patients with large calculi treated ureteroscopically, of whom 15 (60%) had completely clear imaging, 6 (24%) had small lower pole debris that was decreasing on serial imaging and 4 (16%) had new stone growth which was, in part, related either to uncorrectable metabolic disorders or chronic renal scarring and urinary stasis. There were no intraoperative complications. Three postoperative complications included pyelonephritis in 1 patient, prostatic bleeding in 1 on anticoagulant therapy and a cerebral vascular accident 24 hours after the procedure in 1 with severe vascular disease.

CONCLUSIONS

Large and complex upper urinary tract calculi can be addressed safely and efficiently with retrograde endoscopic techniques.

Supersaturation and stone composition in a network of dispersed treatment sites

PURPOSE

We determined the validity of urine supersaturation assessed from 2, 24-hour urine collections from outpatients eating uncontrolled diets and receiving care at a network of treatment sites that uses a central laboratory. We compared supersaturation to stone composition to determine whether supersaturation values correlate with composition.

MATERIALS AND METHODS

Two 24-hour urine samples collected from 183 patients at 6 treatment sites were shipped to a single central laboratory. Complexations and crystallizations in vitro from aging during the transport step were interrupted by pH change in acid and alkaline directions. Relevant analytes were measured, and supersaturation was calculated for calcium oxalate, calcium phosphate as brushite and uric acid. Stone analysis was done at various laboratories.

RESULTS

Urine supersaturation values correlated well with stone composition. Higher calcium phosphate and uric acid supersaturation was noted when stones contained higher amounts of calcium phosphate and any uric acid, respectively. In a validation study values of relevant urine materials were unchanged after 48 hours of aging.

CONCLUSIONS

Despite the need for sample transport, resulting in the inevitable aging of samples, and variations in diet and details of sample collection, supersaturation values measured in only 2, 24-hour urine collections accurately reflected stone composition. This finding indicates that supersaturation values are reasonably stable in most patients during the months to years required for stones to form. In addition, samples collected in standard practice settings and sent to a central laboratory may accurately reflect these supersaturation values.