- Email: [email protected]
Renal Calculi
1076
RENAL CALCULI
It is a valuable reference when the exact type of prosthesis must be identified for revision or other reasons. Tom F. Lue, M.D.
REN AL CALCULI Low-Renin Hypertension After Extracorporeal Shock Wave Lithotripsy C.
w. C. THOMAS, JR., C. M. BUCCI AND C. S. Veterans Administration Medical Center, University of Florida College of Medicine, Gainesville, Florida M.
WILLIAMS,
WILCOX,
J.A.M.A., 262: 1952, 1989 No Abstract Permanently Decreased Renal Blood Flow and Hypertension After Lithotripsy C.
M. WILLIAMS AND W. C. THOMAS, Veterans Administration Medical Center, University of Florida College of Medicine, Gainesville, Florida
New Engl. J. Med., 321: 1269-1270, 1989 No Abstract Editorial Comment: I believe that the content of these 2 letters to the editor is of such importance to urologists that I have selected them for review. Both letters are from the same group of physicians in Gainesville, Florida and both relate to the occurrence of hypertension after extracorporeal shock wave lithotripsy (ESWL*). It is known that up to 8% of all patients will have hypertension after ESWL but the exact mechanism for this is not clear. 1 Williams and associates examined the renin system of a patient with hypertension after ESWL. The effective renal plasma flow to the right kidney was 63% and the blood pressure was 136/82 mm. Hg. before ESWL of the right kidney. Four years after uneventful ESWL (1,600 shocks) the effective renal plasma flow was 47% and the blood pressure was 186/103 mm. Hg. Arteriography revealed an entirely normal arterial tree and computerized tomography showed no infarct or hematoma. Both studies suggested that the renal volume had decreased by 35%. Renal vein renin studies before and after captopril demonstrated that the hypertension was not renin-mediated. Williams and Thomas reported on 16 patients who had quantitative radionuclide renography with 131 iodine-orthoiodohippurate and blood pressure measurements before, and 2 and 4 years after unilateral ESWL. All treatments were uneventful. The mean effective renal plasma flow of the treated kidneys decreased by 8%, with 4 patients (25%) showing decreases of greater than 10%. The mean blood pressure was 124/79 mm. Hg. before ESWL and 149/86 mm. Hg. 4 years later-a significant difference. Hypertension requiring treatment developed in 4 of 16 patients (25%) 4 years after ESWL. All patients with a greater than 10% decrease in effective renal plasma flow became hypertensive. The largest study on hypertension after ESWL 2 has shown that the prevalence of hypertension is 8%, 12 to * Dornier Medical Systems, Inc., Marietta, Georgia.
18 months after ESWL. This study has much smaller numbers but longer followup and suggests that the prevalence of hypertension or decreased renal plasma flow may be much higher, approximately 25%. Hypertension was not renin-mediated in the only patient in whom this was studied. These comments do not in any way imply that ESWL is not of great value in the treatment of renal stones but suggest that the indications for ESWL should not be relaxed prematurely. Mani Menon, M.D. l. Williams, C. M., Kaude, J. V., Newman, R. C., Peterson,
J. C. and Thomas, W. C.: Extracorporeal shock-wave lithotripsy: long-term complications. AJR, 150: 311, 1988. 2. Lingeman, J.E. and Kulb, T. B.: Hypertension following extracorporeal shock wave lithotripsy. J. Urol., part 2, 137: 142A, abstract 154, 1987.
Extra Corporeal Shock Wave Lithotripsy: Medical, Technical, Economic, and Policy Implication
P.
CARLSSON AND H. G. TISELIUS, Center for Medical Technology Assessment and Department of Urology, University Hospital, Linkoping, Sweden
Scand. J. Urol. Nephrol., suppl. 122, 1989 No Abstract Editorial Comment: This supplement summarizes the proceedings from an international meeting on ESWL held in Linkoping, Sweden. While the entire supplement makes interesting reading, 1 or 2 points bear emphasis. The authors were able to treat 98.5% of the last 1,230 patients without anesthesia with an unmodified Dornier HM3 lithotriptor by reducing the voltage of treatment to 14 to 16 kv., premedicating the patient and applying lidocaine jelly to the surface area. In Sweden the costs for ESWL and percutaneous nephrolithotomy were similar for ureteral and small kidney stones; percutaneous neph.rolithotomy costs less than ESWL for large kidney stones. Both treatments were equally effective but percutaneous nephrolithotomy had more complications. In the Netherlands the costs for ESWL were lower than those for percutaneous nephrolithotomy. Mani Menon, M.D. Oxalate Metabolism in Renal Stone Disease With Specific Reference to Calcium Metabolism and Intestinal Absorbtion M. LINDSJO, Department of Internal Medicine, Uppsala University, Uppsala, Sweden
Scand. J. Urol. Nephrol., suppl. 119, pp. 1-54, 1989 Hyperoxaluria and hypercalciuria are common features of renal calcium stone disease. The purpose of the present investigation was to examine the relationships between the intestinal absorption and the renal handling of oxalate and calcium in patients with idiopathic renal stone disease and in patients with enteric hyperoxaluria following jejunoileal bypass (JIB), in comparison with healthy controls. Hyperoxaluria was associated with a higher frequency of both stone episodes and stone operations than a lower urinary oxalate concentration. Patients with idiopathic stone disease
RENAL CALCULI
showed increased intestinal uptake of both oxalate and calcium, which was probably of importance for their propensity to form calcium oxalate-containing stones. Hyperoxaluria in patients with JIB was found to be a result of hyperabsorption of oxalate, and these patients displayed altered oxalate kinetics with continued urinary excretion of orally administered 14C-oxalate for more than 48 hours. The prolonged excretion is assumed to be due to a prolonged absorption and/or an increased oxalate pool. Malabsorption of calcium and low fasting urinary calcium excretion in the JIB patients were associated with high tubular reabsorption of calcium, the latter presumably attributable to a compensatory increase in circulating parathyroid hormone (PTH). In most recurrent renal stone formers the urinary calcium concentration was increased, with an inverse relationship to serum PTH, indicating intestinal hyperabsorption of calcium. A subgroup of hypercalciuric patients showed increased urinary calcium due to reduced tubular reabsorption of calcium. It is suggested that this is a renal defect resulting in a compensatory rise in PTH. Two different mechanisms of similar prevalence might explain enhanced secretion of PTH in normocalcaemic stone disease, namely reduced calcium absorption and a renal defect in the form of reduced tubular reabsorption of calcium. Glycosaminoglycans efficiently inhibit calcium oxalate crystal growth by binding to the surface of calcium oxalate crystals. In this study the binding was dependent on ionic strength. Higher affinity to the crystals may be the reason why highly charged glycosaminoglycans were more efficient inhibitors of calcium oxalate crystal growth. A calcium-containing organic marine hydrocolloid with the capacity to bind oxalate in vitro was shown to reduce enteric hyperoxaluria. In addition to biochemical effects considerable improvements in diarrhoeal symptoms were reported. Editorial Comment: This is a comp:rehensive review about oxalate metabolism and should be read by everyone with an interest in the subject. It has 2 portionsan excellent review of oxalate and calcium metabolism, and a summary of the original studies of the author on oxalate metabolism in patients with stone disease. Several observations were made: 1) stone disease was mo:re severe in patients with in.creased urinary oxalate than in patients in whom urinary oxalate levels were normal, 2) patients with recurrent stones absorbed more oxalate and calcium from the gut, although there was no correlation between the actual amounts of oxalate and calcium absorbed in individual patients, 3) in some cases hyperoxahi.ria or h.ypercafoiu:ria was the result of inc:reased tubular excretion of oxalate or calcium and 4) an organic marine hydrocoHoid had the capacity to bind intestinal oxalate and reduce urinary oxalate excretion. Mani. Menon, M.D.
Renal Calculi in Spinal Cord-Injured Patient: Association With Reflux, Bladder Stones, and Foley Catheter Drainage
M. K.
HALL, R. H. HACKLER, T. A. ZAMPIERI AND J. B. ZAMPIERI, Urology Section, Veterans Administration Medical
Center, Richmond, Virginia Urology, 34: 126-128, 1989 Renal units associated with reflux in the spinal cord-injured (SCI) patient have a greater incidence of kidney stones devel-
1077
oping than in the nonrefluxing units. It is logical to assume that SCI patients with persistent reflux and bladder stones treated with cystolitholapaxy would be at even higher risk for kidney stones developing. Of the 898 SCI patients studied (1,793 renal units), in 14.8 percent kidney stones developed. Kidney stones occurred in 161 of 1,517 (10.6%) of nonrefluxing units. Of the 276 renal units with reflux, in 104 (37. 7%) an ipsilateral stone developed. Of the 198 patients in whom a kidney stone formed, 56.6 percent managed their bladder with a Foley catheter whereas only 28 percent of 700 patients in whom a stone did not form used a Foley catheter. On evaluating 261 patients (520 renal units) with bladder stones treated with cystolitholapaxy, 62.5 percent of these patients were managed with a Foley catheter. The association between cystolitholapaxy treatment, reflux, and the formation of kidney stones was (1) in 22 of 111 (19.8%) refluxing units, an ipsilateral stone formed; (2) in 70 of 409 (17.1 %) units that were nonrefluxing, stones developed; and (3) overall, in 92 (17.7%) renal units, kidney stone developed. We concluded that kidney stone development is significantly increased in the SCI patient with reflux and/or Foley catheter drainage. From these data cystolitholapaxy treatment in the presence of reflux does not appear to increase the development of kidney stones. Editorial Comment: Th.is is a retrospective analy§is of stone formation in a population of 898 patients with spinal cord injury followed fox- up to 8 years. Of the patients with an indwelling Foley catheter 50% had bladder and a third had kidney stones, compared to l 7 and 15%, respectively, of those without an indwelling catheter, Kidney stones occurred in 10% of the patients without vesicou.:retex-al reflux and in 38% with reflux, I agree that it is prudent to avoid catheter d:irninage and to correct reflux whenever possible. Mani Menon, M,D,
Treatment of E:ntedc Hyperoxahuria With Calcium-Containing Organic Marine Hydrocolloid
M.
LINDSJO, B. FELLSTROM, S. LJUNGHALL, B. WICKSTROM AND B. G. DANIELSON, Department of Internal Medicine,
University Hospital, Uppsala, Sweden Lancet, 2: 701-703, 1989 An organic marine hydrocolloid (OMH) charged with calcium ('Ox-Absorb') was studied in vitro for oxalate binding and in patients with enteric hyperoxaluria to investigate oxalate excretion and the inhibitory activity on crystal formation of the urine. In-vitro experiments showed complete binding of oxalate to OMH. In clinical studies in nineteen patients with intestinal disorders and stone formation, urinary oxalate excretion was significantly lower during OMH treatment than off treatment. The activity product index of calcium oxalate was reduced on treatment. A pronounced rise in the inhibitory activity of urine was seen in two patients with very low pretreatment values. Most patients experienced virtual normalisation of bowel function, and in those with severe stone formation there was substantial clinical improvement. It is concluded that OMH has the capacity to bind oxalate in vitro and to reduce urinary oxalate excretion. These observations suggest a new promising treatment for enteric hyperoxaluria. Editorial Comment: The treatment of enteric hyperoxaluria has always been unsatisfactory. Calcium salts bind intestinal oxalate and :reduce urinary oxalate ex-
1078
RENAL CALCULI
cretion but this has been counterbalanced by the reciprocal increase in urinary calcium excretion, causing the concentration of calcium oxalate in the urine to remain practically unchanged. Other agents, such as cholestyramine and aluminum, are tolerated poorly by the patients. The authors present preliminary information about an organic marine hydrocolloid that binds oxalate. Ten patients with enteric hyperoxaluria were treated with the drug for 6 months to 3 years. Mean urinary oxalate and the activity product for calcium oxalate decreased by 20%, while the inhibitory index increased by 20%, indicating that with treatment the urinary environment was much less favorable for calcium oxalate crystallization. Of 10 patients 7 showed improvement in diarrhea and renal stone formation decreased markedly in the 2 patients treated long-term. This study offers new hope for the jejunoileal bypass patient with calcium oxalate stones who formerly often had to undergo operative reversal of the bypass to obtain relief from stone formation. I was somewhat concerned that mean urinary calcium increased by 20% in patients being treated, although the authors state that this increase was not statistically significant. Mani Menon, M.D. The Relation Between Urinary Tract Infections and Stone Composition in Renal Stone Formers K. HOLMGREN, B. G. DANIELSON, B. FELLSTROM, S. LJUNGHALL, F. NIKLASSON AND B. WIKSTROM, Departments of Urology, Internal Medicine and Clinical Chemistry, University Hospital, Uppsala, Sweden Scand. J. Urol. Nephrol., 23: 131-136, 1989 During a seven-year period (1975-1981) a total of 1325 patients hospitalized for stone disease were studied as to the occurrence of positive urine cultures. Urinary stones from 535 surgically treated patients were analyzed with infrared spectrophotometry and the relationships between stone composition, level of surgery and bacteriological strains were studied. Positive urinary cultures were found in 34 % of the surgically treated patients and in 21 % of those not operated upon. Among the surgically treated patients with urinary tract infection (UTI) E. coli was the most frequent microorganism (35%), followed by Proteus (28%). Patients with Proteus infection had the highest frequency of UTI episodes, most of which occurred before hospitalization. There was a higher frequency of magnesium ammonium phosphate (MAP) calculi among patients with Proteus infection than among those with non-Proteus infection, in whom no difference in stone composition was found. Patients infected with E. coli had more phosphatecontaining stones (CaP+MAP) than non-infected patients. The highest frequency of oxalate calculi (CaOx+CaOx/CaP) was found among patients without infection. No E. coli infections were seen in male patients with CaP and MAP calculi. MAP stones were most often found in the kidney and oxalate stones in the ureter.
Editorial Comment: While it is accepted that ureaseproducing bacteria cause struvite stones, the role of nonurease-producing bacteria in stone disease is less clear. This investigation was aimed at studying the relationship between stone composition and urinary tract infection. Of 1,325 (consecutive ?) patients with stone
disease hospitalized between 1975 and 1981, 374 (28%) had positive urine cultures at some time during followup. Of these patients 535 underwent an operation and stones were available for analysis: 161 (31 %) had positive urine cultures. Half of the women and a quarter of the men were infected. Surprisingly, Escherichia coli was the most common microorganism identified on urine culture, the prevalence being even higher than that of Proteus. Of the 55 patients with pure E. coli infections 78% had phosphate-containing calculi, with 13% of these being magnesium ammonium phosphate. Of all patients with oxalate stones 28% had urinary tract infection compared to 88% with struvite stones. The 28% prevalence of bacteriuria in the stone population is higher than that in the general population. However, many of the positive urine cultures, particularly those caused by nonProteus organisms, occurred in the postoperative period and may have been related to the operation. The authors did not culture the stones for bacterial presence. My bias has been that urinary tract infections occur not infrequently even in patients with noninfected kidney stones and I had hoped that the authors would have given me some hints about the role of nonurea-splitting organisms in stone formation. For the aforementioned reasons, unfortunately, this article does not do so. Mani Menon, M.D. Treatment of Loin Pain Hematuria Syndrome by Renal Autotransplantation P. B. BLOOM, M. MAZALA, P. J. JANNETTA, A. C. STEIBER AND R. L. SIMMONS, The Institute of Pennsyvania Hospital and
Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Cooper Hospital/University Medical Center and the UMDNJ-Robert Wood Johnson Medical School at Camden, Camden, New Jersey; Department of Anesthesiology, Hahnemann University Hospital, Philadelphia, Pennsylvania; and Departments of Neurological Surgery and Surgery, Presbyterian University Hospital and the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Amer. J. Med., 87: 228-232, 1989 Abstract printed in J. Urol., 143: 661-662, 1990
Editorial Comment: The loin pain hematuria syndrome is a mysterious disorder that most urologists are faced with at some point in their career. While there is universal agreement that all patients present with loin pain, hematuria and normal renal function, the further diagnostic characteristics are controversial. Some of the first patients reported were women on oral contraceptives but the syndrome has now been reported in both sexes. Some patients have subtle changes on renal arteriography, such as increased tortuosity, beading and stenosis but some have perfectly normal angiograms. Some patients have abnormal renal biopsies that show focal mesangial thickening, periglomerular fibrosis and C3 deposition in the walls of the arterioles, while some do not. Despite this ambiguity in objective findings, the pain and the hematuria are real. The management of the patient with the loin pain hematuria syndrome is frustrating to the patient and
RENAL TUMORS, RETROPERITONEU!v!, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
phy§ician, I have been forced to perform renal dlene:rvation (which failed) and subsequent nephrectomy in l such patient. Although the patient has been free of pain for 6 years I was chagrined to find that the kidney was completely normal on histological and ultrastructural examination. The authors present a 1-yea:r cure rate after renal autotransplantation in a patient with a solitary kidney. Although the followup is short I will consider an autotransplant rather than a nephrectomy the next time I see one of these unfortunate individuals. Mani Menon, M.D.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Secondary Leukemia Following Successful Treatment of Wilms' Tumor
T. J. Moss,
L. C. STRAUSS, L. DAS AND S. A. FEIG, Gwynne Hazen Cherry Memorial Laboratory, The Johnsson Cancer Center, UCLA School of Medicine, Department of Pediatrics, UCLA, Los Angeles, California, Division of Pediatric Oncology, the Johns Hopkins Oncology Center, Baltimore, Maryland, and Department of Pediatrics, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan
Amer. J. Ped. Hemat. Oncol., 11: 158-161, 1989 Leukemia accounts for 15-20% of the secondary malignancies among survivors of Wilms' tumor. We report three patients who developed leukemia after the successful treatment of Wilms' tumor, each of whom demonstrates the importance of close long-term medical surveillance. The first patient developed Philadelphia chromosome positive chronic myelogenous leukemia (CML) 6 years after the diagnosis of Wilms' tumor. This is the second report of CML occurring after Wilms' tumor. The other two patients developed acute nonlymphocytic leukemia (ANLL) 3 and 18 years after successful treatment of Wilms' tumor. In one patient, the clinical manifestations were subtle, and in the other the latency period was the longest reported for secondary leukemia following Wilms' tumor. We conclude that survivors of childhood cancer require frequent medical surveillance even in their adult years.
Editorial Comment: Three patients are described with the development of leukemia 3, 6 and 18 years after apparent cure of Wilms tumor. The leukemia appears to account for a significant percentage of all secondary malignancies in survivors of Wilms tumor. Long-term surveillance of children is recommended after successful treatment of Wilms tumor. Fray F. Marshall, M.D.
1079
Ann. Surg., 210: 387-392, 1989 In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level l); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall, 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.
Editorial Comment: The University of Southern California experience with vena caval tumor thrombus is summarized. The authors emphasize that cardiopulmonary bypass usually can be avoided by isolating the superior mesenteric artery, the inferior :mesenteric artery and the porta hepatis as well as the vena cava. Mean hepatic and renal warm ischemia time was 14 minutes and ranged from 8 to 20 minutes. For many of these patients with intrahepatic or higher tumor thrombi 15 to 20 minutes may not be sufficient for careful tumor thrombus extraction and vena caval :reconstruction. A total of 32 patients had tumor into the liver or heart (level 2 or 3). There were 3 intraoperative deaths in 53 patients, including 2 of exsangui:nation and 1 of massive embolus. There were 4 additional perioperative deaths. Clearly, this patient population h, at high risk. If the tumor thrombus is just within the liver and there is accurate diagnosis of the vena caval extension these maneuvers may be helpful. On the other iJ' the tumor thrombus extend§ well into the liver, above the diaphragm or into the heart we have relied on bypass, hypothermia and temporary cardiac arrest. In 24 patients (level 2 or 3 a§ described in this report) we have not had an intraoperative mortality although we have had 2 postoperative deaths, Fray F. Marshall, M.D. Renal Imaging in Long-Term Dialysis Patients: A Comparison of CT and Sonography
Vena Ca val Involvement by Renal Cell Carcinoma: Surgical Resection Provides Meaningful Long-Term Survival D. G. SKINNER, T. R. PRITCHETT, G. LIESKOVSKY, S. D. BOYD AND Q. R. STILES, University of Southern California Medical
Center, Department of Urology, Department of Surgery, Division of Cardiothoracic Surgery, Los Angeles, California
A. J. TAYLOR, E. P. COHEN, 8. J. ERICKSON, D. L. OLSON AND W. D. FOLEY, Departments of Radiology and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin AJR, 153: 765-767, 1989 Patients undergoing long-term dialysis are subject to cyst formation, hemorrhage, and neoplasia in their native kidneys.
RENAL CALCULI
It is a valuable reference when the exact type of prosthesis must be identified for revision or other reasons. Tom F. Lue, M.D.
REN AL CALCULI Low-Renin Hypertension After Extracorporeal Shock Wave Lithotripsy C.
w. C. THOMAS, JR., C. M. BUCCI AND C. S. Veterans Administration Medical Center, University of Florida College of Medicine, Gainesville, Florida M.
WILLIAMS,
WILCOX,
J.A.M.A., 262: 1952, 1989 No Abstract Permanently Decreased Renal Blood Flow and Hypertension After Lithotripsy C.
M. WILLIAMS AND W. C. THOMAS, Veterans Administration Medical Center, University of Florida College of Medicine, Gainesville, Florida
New Engl. J. Med., 321: 1269-1270, 1989 No Abstract Editorial Comment: I believe that the content of these 2 letters to the editor is of such importance to urologists that I have selected them for review. Both letters are from the same group of physicians in Gainesville, Florida and both relate to the occurrence of hypertension after extracorporeal shock wave lithotripsy (ESWL*). It is known that up to 8% of all patients will have hypertension after ESWL but the exact mechanism for this is not clear. 1 Williams and associates examined the renin system of a patient with hypertension after ESWL. The effective renal plasma flow to the right kidney was 63% and the blood pressure was 136/82 mm. Hg. before ESWL of the right kidney. Four years after uneventful ESWL (1,600 shocks) the effective renal plasma flow was 47% and the blood pressure was 186/103 mm. Hg. Arteriography revealed an entirely normal arterial tree and computerized tomography showed no infarct or hematoma. Both studies suggested that the renal volume had decreased by 35%. Renal vein renin studies before and after captopril demonstrated that the hypertension was not renin-mediated. Williams and Thomas reported on 16 patients who had quantitative radionuclide renography with 131 iodine-orthoiodohippurate and blood pressure measurements before, and 2 and 4 years after unilateral ESWL. All treatments were uneventful. The mean effective renal plasma flow of the treated kidneys decreased by 8%, with 4 patients (25%) showing decreases of greater than 10%. The mean blood pressure was 124/79 mm. Hg. before ESWL and 149/86 mm. Hg. 4 years later-a significant difference. Hypertension requiring treatment developed in 4 of 16 patients (25%) 4 years after ESWL. All patients with a greater than 10% decrease in effective renal plasma flow became hypertensive. The largest study on hypertension after ESWL 2 has shown that the prevalence of hypertension is 8%, 12 to * Dornier Medical Systems, Inc., Marietta, Georgia.
18 months after ESWL. This study has much smaller numbers but longer followup and suggests that the prevalence of hypertension or decreased renal plasma flow may be much higher, approximately 25%. Hypertension was not renin-mediated in the only patient in whom this was studied. These comments do not in any way imply that ESWL is not of great value in the treatment of renal stones but suggest that the indications for ESWL should not be relaxed prematurely. Mani Menon, M.D. l. Williams, C. M., Kaude, J. V., Newman, R. C., Peterson,
J. C. and Thomas, W. C.: Extracorporeal shock-wave lithotripsy: long-term complications. AJR, 150: 311, 1988. 2. Lingeman, J.E. and Kulb, T. B.: Hypertension following extracorporeal shock wave lithotripsy. J. Urol., part 2, 137: 142A, abstract 154, 1987.
Extra Corporeal Shock Wave Lithotripsy: Medical, Technical, Economic, and Policy Implication
P.
CARLSSON AND H. G. TISELIUS, Center for Medical Technology Assessment and Department of Urology, University Hospital, Linkoping, Sweden
Scand. J. Urol. Nephrol., suppl. 122, 1989 No Abstract Editorial Comment: This supplement summarizes the proceedings from an international meeting on ESWL held in Linkoping, Sweden. While the entire supplement makes interesting reading, 1 or 2 points bear emphasis. The authors were able to treat 98.5% of the last 1,230 patients without anesthesia with an unmodified Dornier HM3 lithotriptor by reducing the voltage of treatment to 14 to 16 kv., premedicating the patient and applying lidocaine jelly to the surface area. In Sweden the costs for ESWL and percutaneous nephrolithotomy were similar for ureteral and small kidney stones; percutaneous neph.rolithotomy costs less than ESWL for large kidney stones. Both treatments were equally effective but percutaneous nephrolithotomy had more complications. In the Netherlands the costs for ESWL were lower than those for percutaneous nephrolithotomy. Mani Menon, M.D. Oxalate Metabolism in Renal Stone Disease With Specific Reference to Calcium Metabolism and Intestinal Absorbtion M. LINDSJO, Department of Internal Medicine, Uppsala University, Uppsala, Sweden
Scand. J. Urol. Nephrol., suppl. 119, pp. 1-54, 1989 Hyperoxaluria and hypercalciuria are common features of renal calcium stone disease. The purpose of the present investigation was to examine the relationships between the intestinal absorption and the renal handling of oxalate and calcium in patients with idiopathic renal stone disease and in patients with enteric hyperoxaluria following jejunoileal bypass (JIB), in comparison with healthy controls. Hyperoxaluria was associated with a higher frequency of both stone episodes and stone operations than a lower urinary oxalate concentration. Patients with idiopathic stone disease
RENAL CALCULI
showed increased intestinal uptake of both oxalate and calcium, which was probably of importance for their propensity to form calcium oxalate-containing stones. Hyperoxaluria in patients with JIB was found to be a result of hyperabsorption of oxalate, and these patients displayed altered oxalate kinetics with continued urinary excretion of orally administered 14C-oxalate for more than 48 hours. The prolonged excretion is assumed to be due to a prolonged absorption and/or an increased oxalate pool. Malabsorption of calcium and low fasting urinary calcium excretion in the JIB patients were associated with high tubular reabsorption of calcium, the latter presumably attributable to a compensatory increase in circulating parathyroid hormone (PTH). In most recurrent renal stone formers the urinary calcium concentration was increased, with an inverse relationship to serum PTH, indicating intestinal hyperabsorption of calcium. A subgroup of hypercalciuric patients showed increased urinary calcium due to reduced tubular reabsorption of calcium. It is suggested that this is a renal defect resulting in a compensatory rise in PTH. Two different mechanisms of similar prevalence might explain enhanced secretion of PTH in normocalcaemic stone disease, namely reduced calcium absorption and a renal defect in the form of reduced tubular reabsorption of calcium. Glycosaminoglycans efficiently inhibit calcium oxalate crystal growth by binding to the surface of calcium oxalate crystals. In this study the binding was dependent on ionic strength. Higher affinity to the crystals may be the reason why highly charged glycosaminoglycans were more efficient inhibitors of calcium oxalate crystal growth. A calcium-containing organic marine hydrocolloid with the capacity to bind oxalate in vitro was shown to reduce enteric hyperoxaluria. In addition to biochemical effects considerable improvements in diarrhoeal symptoms were reported. Editorial Comment: This is a comp:rehensive review about oxalate metabolism and should be read by everyone with an interest in the subject. It has 2 portionsan excellent review of oxalate and calcium metabolism, and a summary of the original studies of the author on oxalate metabolism in patients with stone disease. Several observations were made: 1) stone disease was mo:re severe in patients with in.creased urinary oxalate than in patients in whom urinary oxalate levels were normal, 2) patients with recurrent stones absorbed more oxalate and calcium from the gut, although there was no correlation between the actual amounts of oxalate and calcium absorbed in individual patients, 3) in some cases hyperoxahi.ria or h.ypercafoiu:ria was the result of inc:reased tubular excretion of oxalate or calcium and 4) an organic marine hydrocoHoid had the capacity to bind intestinal oxalate and reduce urinary oxalate excretion. Mani. Menon, M.D.
Renal Calculi in Spinal Cord-Injured Patient: Association With Reflux, Bladder Stones, and Foley Catheter Drainage
M. K.
HALL, R. H. HACKLER, T. A. ZAMPIERI AND J. B. ZAMPIERI, Urology Section, Veterans Administration Medical
Center, Richmond, Virginia Urology, 34: 126-128, 1989 Renal units associated with reflux in the spinal cord-injured (SCI) patient have a greater incidence of kidney stones devel-
1077
oping than in the nonrefluxing units. It is logical to assume that SCI patients with persistent reflux and bladder stones treated with cystolitholapaxy would be at even higher risk for kidney stones developing. Of the 898 SCI patients studied (1,793 renal units), in 14.8 percent kidney stones developed. Kidney stones occurred in 161 of 1,517 (10.6%) of nonrefluxing units. Of the 276 renal units with reflux, in 104 (37. 7%) an ipsilateral stone developed. Of the 198 patients in whom a kidney stone formed, 56.6 percent managed their bladder with a Foley catheter whereas only 28 percent of 700 patients in whom a stone did not form used a Foley catheter. On evaluating 261 patients (520 renal units) with bladder stones treated with cystolitholapaxy, 62.5 percent of these patients were managed with a Foley catheter. The association between cystolitholapaxy treatment, reflux, and the formation of kidney stones was (1) in 22 of 111 (19.8%) refluxing units, an ipsilateral stone formed; (2) in 70 of 409 (17.1 %) units that were nonrefluxing, stones developed; and (3) overall, in 92 (17.7%) renal units, kidney stone developed. We concluded that kidney stone development is significantly increased in the SCI patient with reflux and/or Foley catheter drainage. From these data cystolitholapaxy treatment in the presence of reflux does not appear to increase the development of kidney stones. Editorial Comment: Th.is is a retrospective analy§is of stone formation in a population of 898 patients with spinal cord injury followed fox- up to 8 years. Of the patients with an indwelling Foley catheter 50% had bladder and a third had kidney stones, compared to l 7 and 15%, respectively, of those without an indwelling catheter, Kidney stones occurred in 10% of the patients without vesicou.:retex-al reflux and in 38% with reflux, I agree that it is prudent to avoid catheter d:irninage and to correct reflux whenever possible. Mani Menon, M,D,
Treatment of E:ntedc Hyperoxahuria With Calcium-Containing Organic Marine Hydrocolloid
M.
LINDSJO, B. FELLSTROM, S. LJUNGHALL, B. WICKSTROM AND B. G. DANIELSON, Department of Internal Medicine,
University Hospital, Uppsala, Sweden Lancet, 2: 701-703, 1989 An organic marine hydrocolloid (OMH) charged with calcium ('Ox-Absorb') was studied in vitro for oxalate binding and in patients with enteric hyperoxaluria to investigate oxalate excretion and the inhibitory activity on crystal formation of the urine. In-vitro experiments showed complete binding of oxalate to OMH. In clinical studies in nineteen patients with intestinal disorders and stone formation, urinary oxalate excretion was significantly lower during OMH treatment than off treatment. The activity product index of calcium oxalate was reduced on treatment. A pronounced rise in the inhibitory activity of urine was seen in two patients with very low pretreatment values. Most patients experienced virtual normalisation of bowel function, and in those with severe stone formation there was substantial clinical improvement. It is concluded that OMH has the capacity to bind oxalate in vitro and to reduce urinary oxalate excretion. These observations suggest a new promising treatment for enteric hyperoxaluria. Editorial Comment: The treatment of enteric hyperoxaluria has always been unsatisfactory. Calcium salts bind intestinal oxalate and :reduce urinary oxalate ex-
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RENAL CALCULI
cretion but this has been counterbalanced by the reciprocal increase in urinary calcium excretion, causing the concentration of calcium oxalate in the urine to remain practically unchanged. Other agents, such as cholestyramine and aluminum, are tolerated poorly by the patients. The authors present preliminary information about an organic marine hydrocolloid that binds oxalate. Ten patients with enteric hyperoxaluria were treated with the drug for 6 months to 3 years. Mean urinary oxalate and the activity product for calcium oxalate decreased by 20%, while the inhibitory index increased by 20%, indicating that with treatment the urinary environment was much less favorable for calcium oxalate crystallization. Of 10 patients 7 showed improvement in diarrhea and renal stone formation decreased markedly in the 2 patients treated long-term. This study offers new hope for the jejunoileal bypass patient with calcium oxalate stones who formerly often had to undergo operative reversal of the bypass to obtain relief from stone formation. I was somewhat concerned that mean urinary calcium increased by 20% in patients being treated, although the authors state that this increase was not statistically significant. Mani Menon, M.D. The Relation Between Urinary Tract Infections and Stone Composition in Renal Stone Formers K. HOLMGREN, B. G. DANIELSON, B. FELLSTROM, S. LJUNGHALL, F. NIKLASSON AND B. WIKSTROM, Departments of Urology, Internal Medicine and Clinical Chemistry, University Hospital, Uppsala, Sweden Scand. J. Urol. Nephrol., 23: 131-136, 1989 During a seven-year period (1975-1981) a total of 1325 patients hospitalized for stone disease were studied as to the occurrence of positive urine cultures. Urinary stones from 535 surgically treated patients were analyzed with infrared spectrophotometry and the relationships between stone composition, level of surgery and bacteriological strains were studied. Positive urinary cultures were found in 34 % of the surgically treated patients and in 21 % of those not operated upon. Among the surgically treated patients with urinary tract infection (UTI) E. coli was the most frequent microorganism (35%), followed by Proteus (28%). Patients with Proteus infection had the highest frequency of UTI episodes, most of which occurred before hospitalization. There was a higher frequency of magnesium ammonium phosphate (MAP) calculi among patients with Proteus infection than among those with non-Proteus infection, in whom no difference in stone composition was found. Patients infected with E. coli had more phosphatecontaining stones (CaP+MAP) than non-infected patients. The highest frequency of oxalate calculi (CaOx+CaOx/CaP) was found among patients without infection. No E. coli infections were seen in male patients with CaP and MAP calculi. MAP stones were most often found in the kidney and oxalate stones in the ureter.
Editorial Comment: While it is accepted that ureaseproducing bacteria cause struvite stones, the role of nonurease-producing bacteria in stone disease is less clear. This investigation was aimed at studying the relationship between stone composition and urinary tract infection. Of 1,325 (consecutive ?) patients with stone
disease hospitalized between 1975 and 1981, 374 (28%) had positive urine cultures at some time during followup. Of these patients 535 underwent an operation and stones were available for analysis: 161 (31 %) had positive urine cultures. Half of the women and a quarter of the men were infected. Surprisingly, Escherichia coli was the most common microorganism identified on urine culture, the prevalence being even higher than that of Proteus. Of the 55 patients with pure E. coli infections 78% had phosphate-containing calculi, with 13% of these being magnesium ammonium phosphate. Of all patients with oxalate stones 28% had urinary tract infection compared to 88% with struvite stones. The 28% prevalence of bacteriuria in the stone population is higher than that in the general population. However, many of the positive urine cultures, particularly those caused by nonProteus organisms, occurred in the postoperative period and may have been related to the operation. The authors did not culture the stones for bacterial presence. My bias has been that urinary tract infections occur not infrequently even in patients with noninfected kidney stones and I had hoped that the authors would have given me some hints about the role of nonurea-splitting organisms in stone formation. For the aforementioned reasons, unfortunately, this article does not do so. Mani Menon, M.D. Treatment of Loin Pain Hematuria Syndrome by Renal Autotransplantation P. B. BLOOM, M. MAZALA, P. J. JANNETTA, A. C. STEIBER AND R. L. SIMMONS, The Institute of Pennsyvania Hospital and
Department of Psychiatry, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Medicine, Cooper Hospital/University Medical Center and the UMDNJ-Robert Wood Johnson Medical School at Camden, Camden, New Jersey; Department of Anesthesiology, Hahnemann University Hospital, Philadelphia, Pennsylvania; and Departments of Neurological Surgery and Surgery, Presbyterian University Hospital and the University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Amer. J. Med., 87: 228-232, 1989 Abstract printed in J. Urol., 143: 661-662, 1990
Editorial Comment: The loin pain hematuria syndrome is a mysterious disorder that most urologists are faced with at some point in their career. While there is universal agreement that all patients present with loin pain, hematuria and normal renal function, the further diagnostic characteristics are controversial. Some of the first patients reported were women on oral contraceptives but the syndrome has now been reported in both sexes. Some patients have subtle changes on renal arteriography, such as increased tortuosity, beading and stenosis but some have perfectly normal angiograms. Some patients have abnormal renal biopsies that show focal mesangial thickening, periglomerular fibrosis and C3 deposition in the walls of the arterioles, while some do not. Despite this ambiguity in objective findings, the pain and the hematuria are real. The management of the patient with the loin pain hematuria syndrome is frustrating to the patient and
RENAL TUMORS, RETROPERITONEU!v!, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
phy§ician, I have been forced to perform renal dlene:rvation (which failed) and subsequent nephrectomy in l such patient. Although the patient has been free of pain for 6 years I was chagrined to find that the kidney was completely normal on histological and ultrastructural examination. The authors present a 1-yea:r cure rate after renal autotransplantation in a patient with a solitary kidney. Although the followup is short I will consider an autotransplant rather than a nephrectomy the next time I see one of these unfortunate individuals. Mani Menon, M.D.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Secondary Leukemia Following Successful Treatment of Wilms' Tumor
T. J. Moss,
L. C. STRAUSS, L. DAS AND S. A. FEIG, Gwynne Hazen Cherry Memorial Laboratory, The Johnsson Cancer Center, UCLA School of Medicine, Department of Pediatrics, UCLA, Los Angeles, California, Division of Pediatric Oncology, the Johns Hopkins Oncology Center, Baltimore, Maryland, and Department of Pediatrics, Children's Hospital of Michigan and Wayne State University School of Medicine, Detroit, Michigan
Amer. J. Ped. Hemat. Oncol., 11: 158-161, 1989 Leukemia accounts for 15-20% of the secondary malignancies among survivors of Wilms' tumor. We report three patients who developed leukemia after the successful treatment of Wilms' tumor, each of whom demonstrates the importance of close long-term medical surveillance. The first patient developed Philadelphia chromosome positive chronic myelogenous leukemia (CML) 6 years after the diagnosis of Wilms' tumor. This is the second report of CML occurring after Wilms' tumor. The other two patients developed acute nonlymphocytic leukemia (ANLL) 3 and 18 years after successful treatment of Wilms' tumor. In one patient, the clinical manifestations were subtle, and in the other the latency period was the longest reported for secondary leukemia following Wilms' tumor. We conclude that survivors of childhood cancer require frequent medical surveillance even in their adult years.
Editorial Comment: Three patients are described with the development of leukemia 3, 6 and 18 years after apparent cure of Wilms tumor. The leukemia appears to account for a significant percentage of all secondary malignancies in survivors of Wilms tumor. Long-term surveillance of children is recommended after successful treatment of Wilms tumor. Fray F. Marshall, M.D.
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Ann. Surg., 210: 387-392, 1989 In 1972 we first reported that vena caval extension by tumor thrombus was a potentially curable lesion provided that complete removal could be achieved. We have developed a technique for safe removal of extensive vena caval thrombi extending up to the right atrium without the need for cardiopulmonary bypass or hypothermic cardioplegia. Cardiopulmonary bypass, however, is advocated for some type III thrombi, but the addition of the pump and heparinization compounds the magnitude of the procedure. We use a right thoracoabdominal approach for tumors arising from either kidney with vascular isolation of the vena cava from its insertion into the right atrium to the iliac bifurcation. From 1972 to 1988, 56 patients ranging in age from 31 to 76 years were evaluated and 53 underwent radical nephrectomy with en bloc vena caval tumor thrombectomy. Of these patients, 21 had subhepatic caval thrombus extension (level l); 24 had extension into the intrahepatic vena cava (level 2), and 8 had thrombi extending into the heart (level 3). Overall, 1-, 3-, and 5-year survival was 56%, 34%, and 25%, respectively. Crucial to survival was complete surgical excision. Successful extirpation of all apparent tumor was possible in 75% of the patients in this series. With an expected 5-year survival rate of 57% for those without metastatic disease to other organs, we continue to advocate an aggressive optimistic approach for patients if there is no preoperative evidence of metastatic disease.
Editorial Comment: The University of Southern California experience with vena caval tumor thrombus is summarized. The authors emphasize that cardiopulmonary bypass usually can be avoided by isolating the superior mesenteric artery, the inferior :mesenteric artery and the porta hepatis as well as the vena cava. Mean hepatic and renal warm ischemia time was 14 minutes and ranged from 8 to 20 minutes. For many of these patients with intrahepatic or higher tumor thrombi 15 to 20 minutes may not be sufficient for careful tumor thrombus extraction and vena caval :reconstruction. A total of 32 patients had tumor into the liver or heart (level 2 or 3). There were 3 intraoperative deaths in 53 patients, including 2 of exsangui:nation and 1 of massive embolus. There were 4 additional perioperative deaths. Clearly, this patient population h, at high risk. If the tumor thrombus is just within the liver and there is accurate diagnosis of the vena caval extension these maneuvers may be helpful. On the other iJ' the tumor thrombus extend§ well into the liver, above the diaphragm or into the heart we have relied on bypass, hypothermia and temporary cardiac arrest. In 24 patients (level 2 or 3 a§ described in this report) we have not had an intraoperative mortality although we have had 2 postoperative deaths, Fray F. Marshall, M.D. Renal Imaging in Long-Term Dialysis Patients: A Comparison of CT and Sonography
Vena Ca val Involvement by Renal Cell Carcinoma: Surgical Resection Provides Meaningful Long-Term Survival D. G. SKINNER, T. R. PRITCHETT, G. LIESKOVSKY, S. D. BOYD AND Q. R. STILES, University of Southern California Medical
Center, Department of Urology, Department of Surgery, Division of Cardiothoracic Surgery, Los Angeles, California
A. J. TAYLOR, E. P. COHEN, 8. J. ERICKSON, D. L. OLSON AND W. D. FOLEY, Departments of Radiology and Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin AJR, 153: 765-767, 1989 Patients undergoing long-term dialysis are subject to cyst formation, hemorrhage, and neoplasia in their native kidneys.