- Email: [email protected]
Paediatric Ureteric Calculi: Efficacy of Primary In Situ Extracorporeal Shock Wave Lithotripsy
634
UROLITHLASIS,
ENDOUROLOGY AND LAPAROSCOPIC SURGERY
animals the average number of metastases was 5.5 per mouse. Associated with this difference was suppression of natural killer cell activity related to the presence of suppressor Sp~enocytes in the laparotomy and laparoscopy groups. However, statistically the suppression was significantly greater in the laparotomy group. This suppression was present not only immediately postoperatively but persisted. At 2 weeks postoperatively natural killer cell activity had not returned to control levels in either group. The suppression in the laparotomy group remained statistically significantly greater than in the laparoscopy group. Whether these findings have any clinical bearing remains unknown. Ralph V. Clayman, M.D. Access to the Distal Ureter After Failure of Direct Visual Ureteroscopy
P. &LAN, B. WLOY AND G. M. PREMINGER, Department of Surgery, Division of Urology, Comprehensive Kidney Stone Center, Duke University Medical Center, Durham, North Carolina Brit. J. Urol., 82: 290-291, 1998 No Abstract Editorial Comment: The authors demonstrate the principle that there are 2 routes to the ureter that should be considered complementary rather than mutually exclusive. They salvaged successfully 2 cases of failed retrograde ureteroscopic access to the distal ureter by traversing the distal ureter with an antegrade percutaneously placed guide wire and then proceeded with retrograde ureteroscopy through a 12,14or 18F ureteral access sheath passed retrograde over the cystoscopically retrieved guide wire. This philosophy of combining antegrade and retrograde approaches can be similarly helpful when performing percutaneous removal of staghorn calculi. Ralph V. Clayman, M.D. Paediatric Ureteric Calculi: Efficacy of Primary In Situ Extracorporeal Shock Wave Lithotripsy
S. S. AL BUSAIDY, A. R. PREM, M. MEDHAT, D. GIRIRAJ,P. GOPAKUMAR AND H. S. BHAT,Departments of Urology, Radiology and Anaesthesia at Armed Forces Hospital, Muscat, Sultanate of Oman Brit. J. Urol., 8 2 90-96, 1998 Objective To evaluate the efficacy of primary in situ extracorporeal shockwave lithotripsy (ESWL) for the treatment of ureteric calculi in children. Patients and methods The Wolf 2500 Piezolith was used to treat 63 children (aged 4 months to 12 years) with 76 ureteric calculi, including 10 children with impacted calculi. The calculi were located in 14 upper, 13 mid and 44 lower ureters, and the stone burden varied from 4 to 17.8 mm (mean 12.6). All children aged c 10 years were treated under general anaesthesia; lithotripsy was attempted under intravenous sedation in the older children. Results At the 3-month follow-up, there was an overall successful outcome in 55 children (87%),which included 12 of 13, eight of nine (89%)and 35 of 41 (85%)of the children with upper, mid and lower ureteric calculi, respectively, and nine of the 10 with impacted calculi. Re-treatment was required in 20 (36%) patients, while auxiliary procedures after ESWL were required in three (6%).The major complications encountered were ureteric obstruction with sepsis in two children, bacteraemia in another and urinary retention due to a urethral stone fragment in a fourth child. Conclusions In situ ESWL was an effective treatment modality for ureteric calculi at all levels in children, even when impacted. In the short term, complications were minimal, but the long-term effects need further assessment. Editorial Comment: The authors provide one of the largest reported experiences in the treatment of pediatric ureteral calculi with shock wave lithotripsy. Using a third generation piezoelectric machine equipped with biplanar fluoroscopy, they were able to treat successfully 87% of 63 patients, that is 63%were stone-free and 24% had fragments 3 mm. or less at 3-month followup. When followup was extended to 6 to 24 months, 94% were stone-free.Of note, included in this group were 16 patients with steinstrasse. Re-treatments were needed in 36% of the patients, which is not surprising given the relatively tight focal point and lower power of the piezoelectric machines combined with the rather large average stone size (12.6mm.) in these children. The only major complication was sepsis in 3 cases, which emphasizes the importance of a sterile urine culture before proceeding with shock wave lithotripsy and the use of antibiotic coverage for any patient with a history of an infection stone or recent urinary tract infection. After 3.5 years no adverse effects of the lithotripsy were noted. Notably, the authors included girls with middle and distal ureteral stones in the treatment group, which is not done at many centers in the United States due to concerns, albeit never corroborated, regarding possible ovarian isiury. It again appears that children fare better than adults after shock wave litho-
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPIC SURGERY
tripsy with regard to clearing fragments. T h e success rate in these children, considering the large ureteral stones, is higher than would be expected in adults with stones of similar size. Ralph V. Clayman, M.D. Family History and Risk of Kidney Stones G. C. CURHAN,W. C. WILLETT,E. B. RIMMAND M. J. STAMPFER, Departments of Nutrition and Epidemiology, Harvard School of Public Health, Department of Medicine, Channing Laboratory, Brigham and Women’s Hospital, and Renal Unit, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts J. h e r . SOC. Nephrol., 8: 1568-1573, 1997 Kidney stones develop more frequently in individuals with a family history of kidney stones than in those without a family history; however, little information is available regarding whether the increased risk is attributable to genetic factors, environmental exposures, or some combination. In this report, the relation between family history and risk of kidney stone formation was studied in a cohort of 37,999 male participants in the Health Professionals Follow-up Study. Information on family history, kidney stone formation, and other exposures of interest, including dietary intake, was obtained by mailed questionnaires. A family history of kidney stones was much more common in men with a personal history of stones at baseline in 1986 than in those without a history of stones (age-adjusted prevalence odds ratio, 3.16; 95% confidence interval [CI], 2.90 to 3.45). During 8 yr of follow-up, 795 incident cases of stones were documented. After adjusting for a variety of risk factors the relative risk of incident stone formation in men with a positive family history, compared with those without, was 2.5 (95%CI, 2.19 to 3.02). Family history did not modify the inverse association between dietary calcium intake and the risk of stone formation. These results suggest that a family history of kidney stones substantially increases the risk of stone formation. In addition, these data suggest that dietary calcium restriction may increase the risk of stone formation, even among individuals with a family history of kidney stones. Editorial Comment: There are 2 k e y points in this excellent article. First, among men a positive family history of stones increases the risk of urolithiasis 2.5 to %fold. Second,regardless of family history or other confounding parameters, people on a low calcium diet are at increased risk for urolithiasis. While low calcium intake was the most significant predictor of stone disease, other factors that positively correlated with the development of urolithiasis included a high protein diet (greaterthan 80 gm. daily), high sodium intake (greaterthan 4 gm. daily) and low fluid intake (less than 1,300 cc daily). Ralph V. Clayman, M.D. Prevalence of Renal Stones in a Population-Based Study With Dietary Calcium, M a t e , and Medication Exposures
M. R. SOWERS, M. JANNAUSCH, C. WOOD,S . K. POPE,L. L. LACHANCE AND B. PETERSON, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, and Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas h e r . J. Epidemiol., 147: 914-920, 1998 Little is known about the epidemiology of renal stones, in spite of the relative frequency of this painful condition. This population-based study examined reported renal stone diagnosis in 1,309 women aged 20-92 years to determine whether renal stones are associated with 1) food or water exposures or 2) lower bone mineral density and an increased likelihood of fractures. Results indicated a renal stone prevalence of 3.4%.The average age at diagnosis was 42 years. Renal stone formation was not associated with community of residence, hypertension, bone mineral density, fractures, high-oxalate food consumption, or ascorbic acid from food supplements. Women with renal stones consumed almost 250 mg/day less dietary calcium (p < 0.01) than did women without stones and had a lower energy intake (p < 0.04). The authors’ findings do not support the hypothesis that increased dietary calcium is associated with a greater prevalence of renal stones, nor do they identify renal stones as a risk factor for low bone mineral density. Furthermore, lack of other identifiable environmental correlates and the relatively young age at initial diagnosis suggest that genetic components of renal stone formation need further study.
Beverage Use and Risk f o r Kidney Stones in Women G. C. CURHAN, W. C. WILLETT,F. E. SPEIZER AND M. J. STAMPFER, Brigham and Womens’ Hospital, Harvard School of Public Health, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts Ann. Intern. Med., 128 534-540, 1998 Background: An increase in fluid intake is routinely recommended for patienta who have had kidney stones to decrease the likelihood of recurrence. However, data on the effect of particular beverage8 on stone formation in women are limited.
635
UROLITHLASIS,
ENDOUROLOGY AND LAPAROSCOPIC SURGERY
animals the average number of metastases was 5.5 per mouse. Associated with this difference was suppression of natural killer cell activity related to the presence of suppressor Sp~enocytes in the laparotomy and laparoscopy groups. However, statistically the suppression was significantly greater in the laparotomy group. This suppression was present not only immediately postoperatively but persisted. At 2 weeks postoperatively natural killer cell activity had not returned to control levels in either group. The suppression in the laparotomy group remained statistically significantly greater than in the laparoscopy group. Whether these findings have any clinical bearing remains unknown. Ralph V. Clayman, M.D. Access to the Distal Ureter After Failure of Direct Visual Ureteroscopy
P. &LAN, B. WLOY AND G. M. PREMINGER, Department of Surgery, Division of Urology, Comprehensive Kidney Stone Center, Duke University Medical Center, Durham, North Carolina Brit. J. Urol., 82: 290-291, 1998 No Abstract Editorial Comment: The authors demonstrate the principle that there are 2 routes to the ureter that should be considered complementary rather than mutually exclusive. They salvaged successfully 2 cases of failed retrograde ureteroscopic access to the distal ureter by traversing the distal ureter with an antegrade percutaneously placed guide wire and then proceeded with retrograde ureteroscopy through a 12,14or 18F ureteral access sheath passed retrograde over the cystoscopically retrieved guide wire. This philosophy of combining antegrade and retrograde approaches can be similarly helpful when performing percutaneous removal of staghorn calculi. Ralph V. Clayman, M.D. Paediatric Ureteric Calculi: Efficacy of Primary In Situ Extracorporeal Shock Wave Lithotripsy
S. S. AL BUSAIDY, A. R. PREM, M. MEDHAT, D. GIRIRAJ,P. GOPAKUMAR AND H. S. BHAT,Departments of Urology, Radiology and Anaesthesia at Armed Forces Hospital, Muscat, Sultanate of Oman Brit. J. Urol., 8 2 90-96, 1998 Objective To evaluate the efficacy of primary in situ extracorporeal shockwave lithotripsy (ESWL) for the treatment of ureteric calculi in children. Patients and methods The Wolf 2500 Piezolith was used to treat 63 children (aged 4 months to 12 years) with 76 ureteric calculi, including 10 children with impacted calculi. The calculi were located in 14 upper, 13 mid and 44 lower ureters, and the stone burden varied from 4 to 17.8 mm (mean 12.6). All children aged c 10 years were treated under general anaesthesia; lithotripsy was attempted under intravenous sedation in the older children. Results At the 3-month follow-up, there was an overall successful outcome in 55 children (87%),which included 12 of 13, eight of nine (89%)and 35 of 41 (85%)of the children with upper, mid and lower ureteric calculi, respectively, and nine of the 10 with impacted calculi. Re-treatment was required in 20 (36%) patients, while auxiliary procedures after ESWL were required in three (6%).The major complications encountered were ureteric obstruction with sepsis in two children, bacteraemia in another and urinary retention due to a urethral stone fragment in a fourth child. Conclusions In situ ESWL was an effective treatment modality for ureteric calculi at all levels in children, even when impacted. In the short term, complications were minimal, but the long-term effects need further assessment. Editorial Comment: The authors provide one of the largest reported experiences in the treatment of pediatric ureteral calculi with shock wave lithotripsy. Using a third generation piezoelectric machine equipped with biplanar fluoroscopy, they were able to treat successfully 87% of 63 patients, that is 63%were stone-free and 24% had fragments 3 mm. or less at 3-month followup. When followup was extended to 6 to 24 months, 94% were stone-free.Of note, included in this group were 16 patients with steinstrasse. Re-treatments were needed in 36% of the patients, which is not surprising given the relatively tight focal point and lower power of the piezoelectric machines combined with the rather large average stone size (12.6mm.) in these children. The only major complication was sepsis in 3 cases, which emphasizes the importance of a sterile urine culture before proceeding with shock wave lithotripsy and the use of antibiotic coverage for any patient with a history of an infection stone or recent urinary tract infection. After 3.5 years no adverse effects of the lithotripsy were noted. Notably, the authors included girls with middle and distal ureteral stones in the treatment group, which is not done at many centers in the United States due to concerns, albeit never corroborated, regarding possible ovarian isiury. It again appears that children fare better than adults after shock wave litho-
UROLITHIASIS, ENDOUROLOGY AND LAPAROSCOPIC SURGERY
tripsy with regard to clearing fragments. T h e success rate in these children, considering the large ureteral stones, is higher than would be expected in adults with stones of similar size. Ralph V. Clayman, M.D. Family History and Risk of Kidney Stones G. C. CURHAN,W. C. WILLETT,E. B. RIMMAND M. J. STAMPFER, Departments of Nutrition and Epidemiology, Harvard School of Public Health, Department of Medicine, Channing Laboratory, Brigham and Women’s Hospital, and Renal Unit, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts J. h e r . SOC. Nephrol., 8: 1568-1573, 1997 Kidney stones develop more frequently in individuals with a family history of kidney stones than in those without a family history; however, little information is available regarding whether the increased risk is attributable to genetic factors, environmental exposures, or some combination. In this report, the relation between family history and risk of kidney stone formation was studied in a cohort of 37,999 male participants in the Health Professionals Follow-up Study. Information on family history, kidney stone formation, and other exposures of interest, including dietary intake, was obtained by mailed questionnaires. A family history of kidney stones was much more common in men with a personal history of stones at baseline in 1986 than in those without a history of stones (age-adjusted prevalence odds ratio, 3.16; 95% confidence interval [CI], 2.90 to 3.45). During 8 yr of follow-up, 795 incident cases of stones were documented. After adjusting for a variety of risk factors the relative risk of incident stone formation in men with a positive family history, compared with those without, was 2.5 (95%CI, 2.19 to 3.02). Family history did not modify the inverse association between dietary calcium intake and the risk of stone formation. These results suggest that a family history of kidney stones substantially increases the risk of stone formation. In addition, these data suggest that dietary calcium restriction may increase the risk of stone formation, even among individuals with a family history of kidney stones. Editorial Comment: There are 2 k e y points in this excellent article. First, among men a positive family history of stones increases the risk of urolithiasis 2.5 to %fold. Second,regardless of family history or other confounding parameters, people on a low calcium diet are at increased risk for urolithiasis. While low calcium intake was the most significant predictor of stone disease, other factors that positively correlated with the development of urolithiasis included a high protein diet (greaterthan 80 gm. daily), high sodium intake (greaterthan 4 gm. daily) and low fluid intake (less than 1,300 cc daily). Ralph V. Clayman, M.D. Prevalence of Renal Stones in a Population-Based Study With Dietary Calcium, M a t e , and Medication Exposures
M. R. SOWERS, M. JANNAUSCH, C. WOOD,S . K. POPE,L. L. LACHANCE AND B. PETERSON, Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, and Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, Arkansas h e r . J. Epidemiol., 147: 914-920, 1998 Little is known about the epidemiology of renal stones, in spite of the relative frequency of this painful condition. This population-based study examined reported renal stone diagnosis in 1,309 women aged 20-92 years to determine whether renal stones are associated with 1) food or water exposures or 2) lower bone mineral density and an increased likelihood of fractures. Results indicated a renal stone prevalence of 3.4%.The average age at diagnosis was 42 years. Renal stone formation was not associated with community of residence, hypertension, bone mineral density, fractures, high-oxalate food consumption, or ascorbic acid from food supplements. Women with renal stones consumed almost 250 mg/day less dietary calcium (p < 0.01) than did women without stones and had a lower energy intake (p < 0.04). The authors’ findings do not support the hypothesis that increased dietary calcium is associated with a greater prevalence of renal stones, nor do they identify renal stones as a risk factor for low bone mineral density. Furthermore, lack of other identifiable environmental correlates and the relatively young age at initial diagnosis suggest that genetic components of renal stone formation need further study.
Beverage Use and Risk f o r Kidney Stones in Women G. C. CURHAN, W. C. WILLETT,F. E. SPEIZER AND M. J. STAMPFER, Brigham and Womens’ Hospital, Harvard School of Public Health, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts Ann. Intern. Med., 128 534-540, 1998 Background: An increase in fluid intake is routinely recommended for patienta who have had kidney stones to decrease the likelihood of recurrence. However, data on the effect of particular beverage8 on stone formation in women are limited.
635