The natural history of incidental renal artery stenosis in patients with aortoiliac vascular disease

PURPOSE

To examine the association between incidentally discovered renal artery stenosis and deterioration of renal function as determined by the change in serum creatinine concentration over time.

SUBJECTS AND METHODS

We performed a retrospective review of consecutive patients who underwent aortography for aortoiliac vascular disease. Angiograms were reviewed for renal artery stenosis, defined as a narrowing of at least 20% compared with adjacent normal renal artery. For patients with at least 180 days of subsequent follow-up, the change in serum creatinine concentration per year was compared in patients who had or did not have renal artery stenosis.

RESULTS

Of the 201 patients, 96 (48%) had some degree of renal artery stenosis in one or both renal arteries, including 53 (26%) who had at least one stenosis > or= 50% and 40 (20%) who had bilateral stenoses. The only clinical predictor of renal artery stenosis was a history of coronary artery disease (odds ratio = 2.0, 95% confidence interval: 1.2 to 3.8, P = 0.001). Among the 174 patients with > or =180 days of follow-up, there was no statistically significant difference (P = 0.88) in the mean change in serum creatinine concentration per year in the 78 patients with renal artery stenosis (0.06+/-0.33 mg/dL per year) as compared with the 96 patients without renal artery stenosis (0.06+/-0.22 mg/dL per year). Grouping the patients by the maximal percentage of stenosis did not reveal any difference in the mean changes in serum creatinine concentration per year.

CONCLUSIONS

Although renal artery stenosis is a common incidental finding in patients with atherosclerotic vascular disease, it is an uncommon cause of progressive renal disease.

Acute and acclimated digestive responses of the cockle Cerastoderma edule (L.) to changes in the food quality and quantity. II. Enzymatic, cellular and tissular responses of the digestive gland

Cockles Cerastoderma edule were fed two different concentrations of two diets with different qualities which were achieved by mixing different proportions of ashed silt particles with cells of the microalgae Tetraselmis suecica. After 3 days (acute response) and 11 days (acclimated response) of exposure to the diets, we analysed the digestive activity of the digestive gland using cyto-histological and enzymatic techniques. We measured (i) the volumetric fraction of digestive and basophilic cells in digestive tubules, (ii) the diverticular radius and the thickness of digestive epithelia, (iii) the stereological parameters characterizing the lysosomal system and, (iv) dry weight, soluble protein content and specific and total amylase, cellulase, laminarinase, and protease activities of the digestive gland. In the conditions of the present study, specific cellulase and laminarinase activities in the digestive gland of cockles were correlated with the volumetric fraction of basophilic cells (r=0.672 and 0.642, respectively), whereas the specific protease was highly correlated (r=0.866) with lysosomal volume density. The implications of these correlations are discussed in relation to the feeding and absorptive parameters reported in the preceding publication. In the acute response, adjustments of the synthesis of constituents of the lysosomal/proteolytic system of the digestive cells seemed to be the only mechanism operating at the digestive level to respond to the changes in food availability. Lysosomal volume density increased with rising ingestion rate of organic matter, however, the occurrence of a limit in this short-term tissular response would account for the recorded trade-off between absorption efficiency and ingestion rate with different food qualities. With regard to acclimation, food quality determined the nature of the response of the digestive gland. With low quality diets, a time-dependent capability of the digestive gland for intensifying lysosomal/proteolytic production explains the increase of food absorption rates that result from higher filtration and ingestion rates. With high quality food, digestive acclimation differed with food particle concentration: with low rations, in spite of constant morphometrical and stereological parameters, the significant changes in the absorptive balance of biochemical components suggests the existence of an increased production of lysosomes that promotes an accelerated turn-over rate of the digestive epithelia. With high food concentrations, this response was coupled with increased activities of cellulase and laminarinase enzymes, probably as a consequence of higher rates of enzyme secretions from basophilic cells.

[Pulsed dye laser vs EKL-Compact lithotriptor in the treatment of distal ureteral lithiasis]

OBJECTIVES

Our results in the treatment of distal ureteral calculus with pulsed dye lasertripsy (Pulsolith) and the EKL-Compact (Olympus) electrokinetic lithotriptor are analyzed.

METHODS

The time interval compared was 12 months for both cases; lasertripsy was utilized in 57 and electrokinetic energy in 61 cases. All patients underwent IVP or radiological and/or US evaluation of the urinary tree to determine the size and location of the calculus, and a complete routine presurgical assessment. Epidural anesthesia was administered in all patients, as well as prophylactic antibiotics. The approach and endoscopic technique using the 7.9-9.8 FR ureteroscopes (Olympus), stone removal with long forceps and ureteral dilatation with the Uromat hydraulic pump are described. All but 9 patients had a 5 FR catheter indwelling for 24 hours to avoid the postureteroscopy colic pain caused by perilithiasic ureteral edema.

RESULTS

Our success rate was 93% for both modalities of stone fragmentation. Fragmentation with ultrasound was required in 4 cases of failed lasertripsy and 3 cases of failed lithotripsy with electrokinetic energy. There were 7 cases with mucosal laceration from ureteroscope insertion and punctate mechanical perforation of the ureteral mucosa produced by the laser fiber. There were no complications with the use of EKL-C except for small areas of petechiae.

CONCLUSION

Analysis of our results for both treatment modalities, as well as their advantages and disadvantages, showed stone fragmentation with the EKL-C to be the treatment of choice. We have utilized this system in our unit since December 1994 because of its efficacy. Furthermore, it is easy to use, to transport inside and outside the hospital, easy to assemble and low-cost.

[Treatment of ureteral lithiasis with laser]

We present our experience in the treatment of ureteral lithiasis with pulsed dye lasertripsy (Pulsolith)**. Evaluation of the results achieved in 67 cases of lithiasis that had been treated from January, 1990 to March, 1991 revealed a success rate of 93%. The remaining cases required the use of other complementary energy to achieve stone fragmentation. The approach, the endoscopic technique using the Olympus ureteroscopes (7.2F-9F) and complementary maneuvers are described. The complications were minimal. We consider this to be the procedure of choice for calculi in the pelvic ureter. Furthermore, we discuss the cost/benefit of this therapeutic option within the context of a lithotripsy unit with a high endoscopic dedication and the possibility of using fine caliber ureteroscopes (Olympus) as well as other options for stone fragmentation (shock wave, ultrasound and electrohydraulic energy).

[Treatment of benign prostatic hypertrophy using transurethral thermotherapy. Initial experience]

One hundred patients with benign prostatic hypertrophy have been treated from July 22, 1990 to April 3, 1991 (86 had been treated between July 22, 1990 and February 27, 1991) at the Department of Urology of Clínica La Luz. Measurement of residual urine with a catheter, maximum flow and index, and nocturnal frequency and urgency were determined in all patients. Patient subjective evaluation post-thermotherapy used a score from 0 to 10. Patients with improvement of 4 parameters were classed as excellent, with 3 as good, 2 fair, and 1 or 0 as poor. Of the overall patient group, 62 were evaluable. Of these, excellent or good results were achieved in 39 out of 62 patients (63%), fair in 8 patients (13%), and poor in 15 (24%). Of these 62 patients, if we exclude those with a catheter before treatment, high residual volume, middle lobe, had undergone previous urethral endoscopic surgery, or with prostates larger than 45 mm. longitudinal diameter on the ultrasound, we are left with a group of 25 patients. In this patient group excellent and good results were achieved in 21 of 25 patients (84%) and fair in 16%. We had no poor results.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of the Dornier MPL-9000 lithotripter in the treatment of gallbladder and renal stones. Early experience

The experience of two units (Gastroenterology and Urology) of Clínica La Luz, Madrid, in the treatment of gallbladder and renal lithiasis using the Dornier MPL-9000 lithotripter is reported herein. This lithotriptor has been utilized in the treatment of all cases of gallbladder calculi for which it is indicated and renal calculi localized high up (kidney), and in those cases that are difficult to treat with other lithotriptors such as patients with kyphoscoliosis, radiolucent calculi, elderly patients, children, etc.). During the first year the gallstone lithotripsy unit was utilized, 401 patients were referred for treatment. Of these, 180 met the criteria for patient selection. (Over 360 have been treated to date.) Sixty of these 180 patients had a single gallstone of up to 2.5 cm. These 60 patients were selected for the study since they comprised a group where the best results could be expected. The aim of studying this patient group was to evaluate the results achieved by lithotripsy and the short and medium-term outcome in this ideal group of patients. Concerning renal lithiasis, these are the first 100 cases treated with the MPL-9000 (currently over 420 have been treated). Eighty cases had a single calculus (60 caliceal and 20 pyelic), 15 had multiple calculi, and 5 had a staghorn stone. Treatment for gallbladder and renal lithiasis was exclusively by shock waves; i.e., as monotherapy with no other auxiliary procedure. The average number of shock waves used was 2,350 with a mean kV of 18 for gallbladder lithiasis.(ABSTRACT TRUNCATED AT 250 WORDS)

[Inverted papilloma of the ureter. Unusual presentation and review of the literature]

A case of inverted papilloma localized in the left pelvic ureter is described. The patient was submitted to a URS procedure with excisional biopsy of the tumor and fulguration of its base using the electric ureteral resectoscope. We believe that currently available endourologic techniques are the procedure of choice in the diagnosis of upper GU tract filling defects. An endourologic procedure permits conservative treatment when indicated and direct vision of the tumor site and urothelial mucosa.