Prospective Multicenter Evaluation of Pain Before and After Removal of Nonobstructing Renal Calculi: A CoRE Initiative

PURPOSE

Flank pain associated with stone disease is typically caused by a stone that obstructs urine flow. However, it is plausible that nonobstructing kidney stones may still cause pain. We performed a multicenter, observational trial to evaluate whether treatment of small nonobstructing calyceal stones improves pain and kidney stone-specific health-related quality of life.

MATERIALS AND METHODS

Patients aged 18 years or older with nonobstructing renal stone(s) up to 10 mm in longest diameter and moderate to severe pain were recruited. All participants completed 3 questionnaires: the Brief Pain Inventory (BPI), the Patient-Reported Outcomes Measurement Information System pain interference form 6a, and the Wisconsin Stone Quality of Life questionnaire. Thereafter, all participants underwent ureteroscopy for renal stone treatment. All 3 questionnaires were repeated at 2, 6 to 8, and at 12 weeks postprocedure. The primary outcomes were change in preoperative to 12-week postoperative mean BPI score and worst BPI pain score.

RESULTS

A total of 43 patients with nonobstructing kidney stones and associated flank pain were recruited. All stones were removed. Preoperatively, BPI scores for mean pain and worst pain were 5.5 and 7.2, respectively which decreased to 1.8 and 2.8 respectively at 12 weeks postoperatively. Wisconsin Stone Quality of Life questionnaire mean score increased from 70.4 to 115.3 at 12 weeks postoperatively. A total of 86% and 69% of patients had at least a 20% and 50% reduction in their mean pain scores, respectively.

CONCLUSIONS

This study determined that patients benefit significantly from the removal of calyceal nonobstructing kidney stones for at least 12 weeks with a reduction in pain and an increase in quality of life. Therefore, surgical removal of these stones in this patient population should be offered as a treatment option.

Irreversible Electroporation for Renal Ablation Does Not Cause Significant Injury to Adjacent Ureter or Bowel in a Porcine Model

Objective: To evaluate the safety of irreversible electroporation (IRE) for renal ablation adjacent to the ureter or bowel. Materials and Methods: Six adult pigs each underwent bilateral IRE of the kidney. To simulate adjacence, the left proximal ureter and duodenum were secured onto the left and right kidney capsule, respectively. Two IRE probes were placed into the renal parenchyma and configured to bridge the ureter and bowel. Therapeutic IRE was delivered at 2000 V/cm for 70 pulses in both forward and reverse polarity. The animal was survived and euthanized at 1, 3, or 14 days. Histopathology was obtained for all potentially injured bowel and ureteral segments. Retrograde pyelogram (RPG) was performed on each left-sided ureter. Results: Histologic analysis of the ureter identified reactive changes at the level of the periureteral adipose tissue, which progressed from acute inflammation on day 1 to focal fibrosis by day 14. Urothelial mucosa and surrounding smooth muscle layers were unaffected at all time points. RPGs did not show any abnormalities in all specimens. Histologic analysis of the bowel demonstrated acute inflammation in the serosa and subserosal tissue on day 1. Three days after IRE, inflammation and crypt abscesses were focally present in the deep aspects of the bowel mucosa. Inflammation in the mucosal layer resolved 14 days after IRE. Conclusions: In a porcine model of renal IRE, no significant injury was apparent after intentional ablation adjacent to the ureter and bowel. IRE may be a safe alternative to thermal ablation for tumors near the ureter or bowel.

Contemporary 2-year outcomes of complex gastroschisis

PURPOSE

Outcomes of gastroschisis are influenced by associated intestinal complications. We present a detailed analysis of complex gastroschisis.

METHODS

A retrospective study of all patients with gastroschisis treated at 2 university neonatal intensive care units between January 1, 2001, and March 31, 2007, was performed.

RESULTS

Of 83 patients, 19 (23%) had complex gastroschisis, including atresias (68%), gangrene (37%), closing gastroschisis (32%), perforation (21%), strictures (21%), and volvulus (11%). Prenatal ultrasound did not predict complications. Fifty-three percent underwent primary closure. Duration of mechanical ventilation and total parenteral nutrition (TPN) was 14.4 ± 1.9 days and 90.7 ± 9.0 days, respectively. Enteral feeds started at 35.9 ± 4.6 days. Hospital stay was 104.4 ± 9.6 days. Patients underwent a median of 3 abdominal procedures (range, 2-5) before discharge. Ninety-five percent survived to discharge; 33% and 67% were discharged on TPN and gastrostomy feeds, respectively. Two-year survival was 89%, with 82% on full oral feeding, 12% on a combination of oral and gastrostomy feeding, and 1 patient (who received a liver/bowel transplant) on a combination of enteral and parenteral nutrition.

CONCLUSIONS

Complex gastroschisis continues to produce significant morbidity. However, most of the patients are TPN free by 2 years of age.

First prize: Chitosan and the urothelial barrier: effects on ureteral intraluminal drug penetration and peristalsis

INTRODUCTION

Relaxing the ureter prior to endourologic procedures could ease instrument access. In an ex-vivo model, intraluminal nifedipine has been shown to relax the ureter. Chitosan is the deacetylation product of chitin and can alter bladder urothelium. This study examines the effect of nifedipine on peristalsis before and after pretreating the ureter with chitosan.

METHODS

Intact 4-cm tubular porcine ureteral segments were placed in a novel organ bath. To induce peristalsis, phenylephrine (10 μM) was added. Chitosan (0.5% [w/v], 30 minutes) or Krebs (control) was then used to treat the urothelium. The rate and amplitude of ureteral peristalsis was then measured. Intraluminal nifedipine (1 μM) was then added to the intraluminal reservoir. Peristaltic rate and amplitude and the time to aperistalsis were measured. Methylene blue was then added after treatment with chitosan or control to measure diffusion.

RESULTS

After Krebs pretreatment, intraluminal nifedipine (1 μM) significantly reduced peristaltic frequency (p = 0.0184) but did not stop peristalsis after 60 minutes of exposure in six trials. After chitosan, nifedipine (1 μM) stopped ureteral peristalsis within an average of 12.30 ± 4.72 minutes. Chitosan alone did not cause aperistalsis. Intraluminal methylene blue did not diffuse into the extraluminal bath after saline or chitosan pretreatment. Histological analysis of the ureter before and after pretreatment with chitosan showed no urothelial disruption.

CONCLUSIONS

By pretreating the intraluminal surface of the ureter with chitosan, nifedipine blocks ureteral peristalsis at low concentrations. Chitosan changes ureteral urothelial permeability without barrier disruption and has no observed effect on ureteral contraction.

Continence definition after radical prostatectomy using urinary quality of life: evaluation of patient reported validated questionnaires

PURPOSE

After radical prostatectomy continence is commonly defined as no pads except a security pad or 0 to 1 pad. We evaluated the association of pad status and urinary quality of life to determine whether security and 1 pad status differ from pad-free status to better define 0 pads as the post-prostatectomy standard.

MATERIALS AND METHODS

A total of 500 consecutive men underwent robot assisted radical prostatectomy from October 2003 to July 2007. Data were collected prospectively and entered into an electronic database. Postoperatively men completed self-administered validated questionnaires including questions on 1) daily pad use (0, security, 1, or 2 or more), 2) urine leakage (daily, about once weekly, less than once weekly or not at all), 3) urinary control (none, frequent dribbling, occasional dribbling or total control), 4) American Urological Association symptom score and 5) urinary quality of life.

RESULTS

Postoperatively men who indicated 0 pad use had a mean +/- SE symptom score of 5.8 +/- 0.3 and pleased quality of life (1.16 +/- 0.08). In contrast, men with a security pad and 1 pad had a symptom score of 7.6 +/- 0.7 and 9.2 +/- 0.6 but mixed quality of life (2.78 +/- 0.18 and 3.41 +/- 0.15, respectively, p <0.0005).

CONCLUSIONS

Results show a significant decrease in quality of life between no pads (1.16 or pleased), a security pad and 0 or 1 pad (2.78 and 3.41 or mixed, respectively). Findings do not support defining continence with a security pad or 0 to 1 pad. Continence should be strictly defined as 0 pads.