- Email: [email protected]
Renal Calculi
RENAL CALCULI
Penile Tumescence Monitoring During Morning Naps: A Pilot Investigation of a Cost~Effective Alternative to Fun Night Sleep Studies in the Assessment of Male Erectile Disorder P. CAREY, Department of Psychology and Center for Health and Behavior, Syracuse University, Syracuse, New York
C. M. GORDON AND M.
Behav. Res. Ther., 31: 503-506, 1993 Permission to Publish Abstract Not Granted Editorial Comment: This pilot study shows that monitoring tumescence during napping in sexually functioning, sleep deprived young men may be useful as an assessment of sleep efficiency and penile tumescence. The sample size was small, and a study in a population of older potent and impotent men is needed to validate the findings. I commend the authors for undertaking this interesting study to try to cut down the costs of studying sleep related erection. However, I cannot help but wonder why psychiatrists and psychologists do not approach the problem directly by devising better psychological tests to define psychogenic impotence. Tom F. Lue, M.D.
The Role of Gap Junctions and Ion Channels in the Modulation of Electrical and Chemical Signals in Human Corpus Cavernosum Smooth Muscle G.
J. CHRIST, P. R. BRINK, A. MELMAN AND D. C. SPRAY, Departments of Urology and Neuroscience, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx and Department of Physiology and Biophysics, SUNY at Stony Brook, Stony Brook, New York
Int. J. Impotence Res., 5: 77-96, 1993 Intercellular communication through aqueous intercellular channels, known as gap junctions, has been postulated to provide an important mechanism for coordinating the rapid and synchronous responses of corporal smooth muscle during human penile erection and detumescence. Mathematical modeling analyses of drug diffusion were utilized to examine the potential physiological importance of the intercellular pathway to the regulation of smooth muscle tone in the human corpus cavernosum. In addition, patch clamp analyses and optical imaging studies were conducted to assess the ionic basis for cellular excitability and homeostasis in cultured corporal smooth muscle cells. In short, the computer modeling studies demonstrated that intercellular communication through gap junctions is likely to be the 'preferred' pathway for coordination of cellular activation and syncytial smooth muscle responses in this tissue. Moreover, the observed ion channel diversity reveals even further complexities to the modulation of corporal smooth muscle tone. Editorial Comment: One may wonder how a small amount of vasodilator, for example 5 ILg. prostaglandin El in 0.5 ml. saline, can result in vasodilation and erection in many patients within several minutes. This excellent summary on gap junction and ion channels in the human corpus caver no sum muscle may be the answer: their dysfunction may be responsible for several types of impotence. This is a must read article for those who are interested in intercellular communication within the penis. Tom F. Lue, M.D.
REN AL CALCULI Natural History and Current Concepts for the Treatment of Small Ureteral Calculi
W. A.
HUBNER,
P.
IRBY AND M.
L.
STOLLER,
Department of Urology, University of California School of
Medicine, San Francisco, California
Eur. Urol., 24: 172-176, 1993 Six studies providing information on 2,704 patients were included into a retrospective analysis. The incidence of spontaneous passage relating both stone size and location was determined from these collated studies. The rate of spontaneous passage for stones smaller than 4 mm. was 38% compared to 1.6% for those larger than 6 mm., irrespective of their position in the ureter at the time of presentation. Calculi discovered in the distal third of the ureter had a spontaneous passage rate of 45%, compared with the mid third of 22%, and the proximal third of 12%. Two thirds of all stones which passed did so within 4 weeks after the onset of symptoms. These data from the literature were compared to the treatment modalities applied for the last 100 consecutive patients treated with the diagnosis of ureteral stone at UCSF. 42% of the stones were found in the proximal,
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RENAL CALCULI
13% in the mid and 45% in the distal third of the ureter. Treatment modalities included ureteroscopic stone extraction (36), ESWL (31) and watchful waiting for stone passage (30). Orallitholysis was performed in 2 cases and percutaneous removal of a proximal stone in 1. No calculus larger than 6 mm passed spontaneously. The passage rate from the proximal ureter was 18%, from the mid ureter 15%, and 38% from the distal ureter disregarding the size of the stones. The rate of complications reached 20% when symptoms exceeded 4 weeks in duration compared to 7% in patients with symptoms lasting less than 4 weeks. Conservative management of ureteral calculi smaller than 6 mm is an appropriate treatment option, successful in about one-third of the cases. Due to the decreased likelihood of spontaneous passage and markedly higher incidence of complications, a patient with symptoms lasting longer than 4 weeks is a prime candidate for intervention.
Editorial Comment: The authors reviewed 6 studies that provide information about the spontaneous passage of ureteral calculi and compare these data to treatment practices at their institution. Some of their conclusions should be emphasized. The risk of spontaneous passage of stones smaller than 4 mm. is about 60%, from 4 to 6 mm. 33% and larger than 6 mm. less than 10%. The rate of spontaneous passage of stones in the upper ureter is about 20%. Watchful waiting for more than 4 weeks resulted in a 20% complication rate, causing sepsis and ureteral stricture. I was surprised by this high complication rate. The authors recommend that ureteral stones smaller than 6 mm. should be managed expectantly for 4 weeks but that all stones in the upper ureter should be managed with urological intervention. Mani Menon, M.D.
Five Years Experience in Experimental Laser Lithotripsy
W. CECCHETTI, A. TASCA, F. ZATTONI, G. VILLI, C. A. LEVORATO AND F. PAGANO, Department of Chemistry-Physics, University of Venice, Venice and Institute of Urology, University of Padua, Padua, Italy Eur. Urol., 24: 185-189, 1993 In the first part of our experience approximately 300 stones of different composition have been treated in vitro with three different laser sources: Nd-YAG laser (1,064 nm), dye laser (504 nm) and alexandrite laser (755 nm). Calcium oxalate monohydrate and brushite stones appeared to be the most resistent to lithotripsy. Highest fragmentation rates were obtained for calcium oxalate dihydrate stones followed by struvite, uric acid and hydroxyapatite stones. The Nd-YAG laser did not appear to be ideal for lithotripsy since early damage to the fiber tip was observed when this source was used. Both the dye and the alexandrite lasers were almost always effective in fragmenting the various types of stones. We subsequently treated some cystine stones while immersed in water or in solutions of carmine indigo (2%), methylene blue (5%), rifamycin (0.6 and 6%) and rifampicin (0.8 and 0.3%) with the dye or the alexandrite laser. The spectra of these solutions, previously analyzed with the spectrophotometer, showed that rifamycin and rifampicin absorbed large amounts of light radiation at the wave length of the dye laser (504 nm). Successful fragmentation occurred only when the dye laser was used to treat stones immersed in the more concentrated solutions of these two substances. The quantity of fragmented material after treating a 10-cm 3 cystine stone previously immersed in the more concentrated solutions of rifamycin and rifampicin (30 and 10 mm 3 , respectively) confirmed previous results. The clinical use of rifamycin and rifampicin as mediators of lasertripsy at 504 nm of hard or 'nonabsorbent' stones is suggested since these substances seem to trigger plasma formation at a low energy level on the surface of the stone that they coated.
Editorial Comment: Laser lithotripsy depends on laser induced plasma formation from absorption of the laser pulse on the target tissue. Cystine stones are notoriously difficult to treat with lithotripsy. The authors determine that rifamycin and rifampicin absorb large amounts of light radiation at the wavelength of the dye laser. When a 6% concentration of these agents was used plasma formation occurred at approximately 40 mJ. and resulted in increased stone fragmentation. The authors suggest that rifamycin be used as an irrigation fluid and that rifampicin be given orally to increase the effectiveness of laser lithotripsy of hard stones. Mani Menon, M.D.
Complete Local Tumor Remission After Therapy With Extra-Corporeally Applied High-Energy Shock Waves (HESW)
F.
GAMARRA, F. SPELSBERG, M. DELLIAN AND A. E. GOETZ, Institutes for Surgical Research and Anesthesiology, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany
Int. J. Cancer, 55: 153-156,1993
RENAL CALCULI
High-energy shock waves have been as a mear:s of non-invasive tumor Here we report the first successful local treatment of experimental tumors means of multifocal and repeated application of HESW. The experiments weTe on 29 Syrian golden hamsters amelanotic hamster melanomas in the dOIsal skin. HESW, general electrohydraulically, were applied multifocally to the center and to 5 sites on the margin of the tumors. A group of animals undergoing surgical resection and an untreated group served as controls. Complete remission of local tumor was achieved in more than 90% of the HESW-treated hamsters and in the same number of surgically treated animals, while untreated tumors continued to grow. Frequency of metastasis was the same in both groups after HESW treatment or surgery. Tumor therapy with multifocally and repeatedly applied HESW was thus as successful as surgery.
Editorial Comment: The results presented in this study are impressive. The authors compare the results of high energy shock waves to surgery in. the treatment of amehulOtic melanoma that was induced experimentally in Syrian golden hamsters. This is an early metastasizi:i.1.g, exponentially growing tumor that results in widespread meta§tasis within 21 days. Of the animals treated with high energy shock waves complete local remissiml of the tumor was noted in 90% and partial remission in 10%. Thus, the local remission rate was 100% with shock wave therapy, which hl exactly the response with surgical removal. This dramatic response was not seen in metastatic rate, si.nce metastasis developed in 64% of the animals. However, an impressive 36% of animals were tumor~fl"ee at 4 months, although i.t is not clear whether the authors confirmed this apparent cure rate by histological analysis of the tissues. The authors have created an ingenious experimental model that applies shock waves multifocally and repeatedly at short i.ntervals. Under these experimental conditions they find that high energy shock waves are as effective as surgery for the contltol of this particular tumor.
lExtracorporeal Shock Wave Lithotripsy Induces the Release of Prostaglandins Which Increase Ureteric Peristalsis P. G. HORGAN, D. HANLEY, J. BURKE, N. F. COUSE AND J. M. FITZPATRICK, Department of Urology/ Surgery, Mater Misericordiae Hospital and University College, Dublin, Ireland Brit. J. Urol., 71: 648-652, 1993 The aim of this study was to identify the changes in secretion of prostaglandins into the urinary tract as a result of treatment extracorporeal shock wave lithotripsy (ESWL) and to determine their effects on ureteric motility. Sixteen patients with renal or upper ureteric calculi were studied. A peripheral blood and urine sample was collected immediately before and after ESWL, with further samples taken 24 h later. The following variables were assessed radioimmunoassay: prostaglandin prostaglandin F,O' B2 An in vitro canine was then designed to the of isolated intact canine ureter model. U!;,Hl.HC.
Editorial Comment: This study examines the effects of ESWL* on ill'eteral motility, Peripheral blood and urine samples were collected immediately before and after E§WL, and 24 hours lateR' in 16 patients with renal or upper ureteral calculi. Significant elevatiom; of thromboxane B2 were seen immediately after ESWL, and prostaglandin FlO' 24 hours after ESWL. In contrast, prosta~ glandin E2 was unchanged in urine and decreased in serum. In vitro studies showed that throm~ boxane B2 and prostaglandin FlO' produced increased frequency of ureteral contractions. The authors conclude that ESWL results in the release of prostaglandins from the urinary tract, which may increase ureteral peristalsis. While this is a reasonable conclusion, all alternate possibility is that the process of stone passage may increase production of these prostaglandins and ureteral motility, Mani Menon, M.D. '" Dorni.ell" Medical Systems, Inc., Marietta, Georgia.
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RENAL CALCULI
Evidence of a Link Between Erythrocyte Band 3 Phosphorylation and Anion Transport in Patients With 'Idiopathic' Calcium Oxalate Nephrolithiasis B. BAGGIO, L. BORDIN, G. GAMBARO, A. PICCOLI, G. MARZARO AND G. CLARI, Institutes of Internal Medicine and Biological Chemistry, University of Padova School of Medicine, Padova, Italy
Min. Electrolyte Metab., 19: 17-20, 1993 This study was carried out to verify the hypothesis of a link between faster endogenous phosphorylation of band 3 protein, the anion carrier, and anomalous oxalate transmembrane self-exchange found in erythrocyte from calcium oxalate renal stone formers. Agents able to modify 32P-Iabelling of band 3 protein induced a concurrent modification in oxalate transmembrane flux. Cyclic AMP- and phospholipid-sensitive Ca2 +-independent protein kinases seem to be critical modulators of band 3 function. These observations demonstrate a close link between the band 3 phosphorylation state and its anion transport function, and provide new insights into the pathogenetic mechanisms of the cellular anomalies observed in calcium-oxalate renal stone disease. Editorial Comment: Patients with idiopathic calcium oxalate nephrolithiasis exhibit higher oxalate and urate transmembrane self-exchange rates, and faster endogenous phosphorylation of band 3 protein, which is the anion carrier. It has been suggested that increased phosphorylation of band 3 is linked to increased transmembrane oxalate transport. This study shows that agents that modify phosphorylation of band 3 induce a concurrent modification in oxalate transmembrane flux, while agents that mediate phosphorylation of bands 4.1 and 4.9 do not induce a similar change. Mani Menon, M.D.
Stone Recurrences in Kidneys Made Stone-Free by Percutaneous Extraction
C. HENRIKSSON, K. GETERUD, S. PETTERSSON AND B. F. ZACHRISSON, Department of Surgery, Division of Urology and Department of Radiology, Sahlgrenska sjukhuset, University of Goteborg, Goteborg, Sweden Scand. J. Urol. Nephrol., 27: 151-153, 1993 Of 100 renal units which were made stone-free by percutaneous stone extraction in 1985, 86 (86.0%) were re-examined radiologically up to 5 years after operation. The re-examination was performed because of symptoms or as part of a regular check-up or after calling the patient. Intrarenal calcifications were diagnosed in 27 of 86 (31.4%) of the renal units, but only in 11 (12.8%) were there stones requiring treatment. Editorial Comment: The authors examined stone recurrences in 85 patients who were stone-free after percutaneous stone extraction. At a maximum followup of 5 years about a third of the patients were found to have recurrent calcifications on plain film radiography. Of these calcifications 12.8% were considered to be large enough to require urological intervention. In the days of open stone surgery 1 dogma defined success as a stone-free kidney. This determination was based on nephrotomography and not plain film studies. It is possible that some of the kidneys originally determined to be stone-free by these authors might have harbored small calcifications that were undetected on plain film radiography. It is becoming increasingly apparent that the mere presence of a small calcification in the kidney is not an indication of failure or an indication for aggressive treatment. The authors used extraction and disintegration techniques as the initial urological procedures. It will be interesting to reanalyze the data to determine if there is an increase in recurrence after stone disintegration compared with total stone extraction. Mani Menon, M.D.
Crystalluria and its Possible Significance: A Patient-Control Study R. E. ABDEL-HALIM, Department of Urology, King Abdel-Aziz University, Jeddah, Saudi Arabia
Scand. J. Urol. Nephrol., 27: 145-149,1993 The significance of crystalluria in the diagnosis and prognosis of urolithiasis remains a controversial subject in the current urological literature. In this study, in addition to the standard urolithiasis clinical and biochemical work-up, routine urine microscopy was performed to study crystals in 1 fresh and 2 stored morning urine samples from 140 urinary stone patients and 42 controls. Crystalluria was more frequently detected in patients (9.3% of the fresh samples) than in controls (2%). Storing the samples for 6 hours did not increase the frequency percent of detected crystalluria either in patients or controls. However, in the samples stored for 24 hours, the frequency of crystalluria increased to 27.1 % in patients and only to 12% in controls, though the pH did not change from that of the fresh sample. In addition, while calcium oxalate crystals in patients formed
RENAL CALCULI
aggregates whether in fresh or 24 hour samples, those of controls did not. This denotes a characteristic change in the physico-chemical properties of the urine of stone formers from that of controls. Accordingly, the study of crystalluria in patients with urolithiasis seems to help in the proper evaluation and, maybe, treatment of the disease.
Editorial Comment: Calcium oxalate crystalluria was seen in less than 10% of freshly voided urine specimens that were obtained from 140 patients with renal stones and in 2% of controls. It is important to note that more than 90% of patients with calcium oxalate stones do not have crystalluria if urine specimens are measured immediately after voiding. The frequency of crystalluria increased to 27% in patients and 12% in controls after storage of samples for 24 hours. Crystal aggregates were seen only in stone formers but not in controls. Mani Menon, M.D.
Pathophysiology of Incomplete Renal Tubular Acidosis in Recurrent Renal Stone Formers: Evidence of Disturbed Calcium, Bone and Citrate Metabolism P. J. OSTHER, J. BOLLERSLEV, A. B. HANSEN, K. ENGEL AND P. KILDEBERG, Departments of Urology, Medical Endocrinology, Clinical Chemistry and Pediatrics, Odense University Hospital, Odense, Denmark Urol. Res., 21: 169-173, 1993 Urinary acidification, bone metabolism and urinary excretion of calcium and citrate were evaluated in 10 recurrent stone formers with incomplete renal tubular acidosis (iRTA), 10 recurrent stone formers with normal urinary acidification (NUA) and 10 normal controls (NC). Patients with iRTA had lower plasma standard bicarbonate after fasting (P < 0.01) and lower urinary excretion of titratable acid (P < 0.05) and citrate (P < 0.01) compared with NUA patients and NC, and higher urinary excretion of ammonia (P < 0.05) compared with NC (P < 0.05). Hypercalciuria was found in 6 of 10 patients with iRTA compared with 3 of 10 with NUA, and 0 of 10 NC. The citrate/calcium ratio in urine was significantly reduced in iRTA compared with the value in NUA (P < 0.01), and in NUA compared with NC (P < 0.05). Biochemical markers of bone formation (serum osteocalcin) and bone resorption (urinary hydroxyproline) were significantly increased in iRTA compared with NUA and NC (P < 0.01), indicating increased bone turnover in stone formers with iRTA. Stone formers with iRTA thus presented with disturbed calcium, bone and citrate metabolism-the same metabolic abnormalities which characterize classic type 1 RT A. Mild non-carbonic acidosis during fasting may be a pathophysiological factor of both nephrolithiasis and disturbed bone metabolism in stone formers with iRTA.
Editorial Comment: This study shows that stone formers with incomplete renal tubular acidosis (type 1) who were diagnosed on short ammonium chloride loading testing exhibit the same metabolic abnormalities that characterize complete type 1 renal tubular acidosis. These abnormalities are hypercalciu.ria, hypocitruria, a significantly reduced urinary citrate/calcium ratio, and increased markers of bone formation and bone resorption. Mani Menon, M.D.
Effect of Dietary Oxalate and Calciu.m on Urinary Oxalate and Risk of Formation of Calcium Oxalate Kidney Stones L. K. MASSEY, H. ROHMAN-SMITH AND R. A. SUTTON, Washington State University, Spokane, Washington, Food and Nutrition Services, University Hospital and Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
J. Amer. Diet. Ass., 93: 901-906, 1993 Permission to Publish Abstract Not Granted
Editorial Comment: This excellent article reviews the effects of various dietary components on the risk of calcium oxalate kidney stone formation. Only spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran and strawberries have been known to cause a significant increase in urinary oxalate excretion. Restriction of dietary calcium enhances oxalate absorption and excretion. The authors believe that initial dietary recommendations for patients with recurrent calcium oxalate stones should involve dietary restriction of the 8 oxalate rich foods. Long-term therapy should be recommended only if beneficial results are obtained from oxalate restriction with appropriate calcium intake. The authors do not recommend dietary calcium restriction in patients with recurrent kidney stones, which is an opinion that currently appears to be gaining popularity. Mani Menon, M.D.
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RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
Percutaneous Transvesical Ureteroscopy for Removal of Distal Ureteral Stone in Reimplanted Ureter
R. P. SANTAROSA, T. W. HENSLE AND R. SHABSIGH, Department of Urology, Columbia-Presbyterian Medical Center and Babies Hospital, New York, New York Urology, 42: 313-316, 1993 In the past two decades, the widespread use of cross-trigonal ureteral reimplants for the treatment of children with vesicoureteral reflux has resulted in a large population of patients with transversely lying ureters. As this population gets older they will consequently be entering an age group at higher risk for stone and urothelial cancer formation, with the potential for diagnostic and/or therapeutic ureteroscopy. The anatomic orientation of the ureters resulting from a cross-trigonal reimplantation may create difficulty or even inability to perform transurtheral ureteroscopy. This case presents the technique of percutaneous transvesical ureteroscopy for stone extraction in a seventeen-year-old male with a lower ureteral stone following cross-trigonal ureteral reimplantation. The described technique may serve as an addition to the current endoscopic methods.
Editorial Comment: Accessing the lower ureter in patients who have undergone a cross trigonal reimplantation is difficult and it has been suggested that percutaneous transvesical approaches should be used to achieve this goal. The authors extended this technique to perform percutaneous transvesical ureteroscopy for stone extraction in a 17 -year-old man with a lower ureteral stone after cross trigonal ureteral reimplant at ion. Mani Menon, M.D.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Retroperitoneal Tumors With Vena Caval Extension: A Multidisciplinary Approach B. L. GANZEL, J_ E. GEORGE, J. 1. HARTY AND L. A. GRAY, JR., Divisions of Thoracic and Cardiovascular Surgery and Urology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
South. Med. J., 86: 880-886, 1993 In cases of retroperitoneal tumor with extension to the inferior vena cava (IVC), complete resection improves survival, but may require cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA). Since 1985, eight patients at our institution have had complete resection of retroperitoneal tumors with IVC or right atrial involvement. Preoperative evaluation included intravenous pyelography, computed tomography of the chest and abdomen, renal arteriography, and venography or magnetic resonance imaging of the IVC. Operative technique was determined primarily by the extent of IVC or RA involvement and included combined median sternotomy and laparotomy, control of the intrapericardial IVC, and radical tumor resection. IVC tumor thrombectomy was done using either temporary vascular occlusion, CPB, or CPB with HCA. Complete resection for improved survival of retroperitoneal tumors with IVC extension is technically feasible with acceptable morbidity and mortality rates. A multidisciplinary approach allows optimal management of these extensive tumors.
Editorial Comment: The authors describe the use of cardiopulmonary bypass and hypothermic circulatory arrest in patients with renal cell carcinoma, neuroblastoma and Wilms tumor. A variety of tumors, including pheochromocytoma, retroperitoneal sarcoma, transitional cell carcinoma and adrenal cortical carcinoma, may also be suitable for this treatment. Recently, if significant nodal disease is seen in the absence of other metastatic disease I have biopsied renal cell carcinoma cases. If positive nodal disease is found I think the prognosis is unfavorable enough to often not consider surgery. On the other hand, a protocol using adjuvant therapy might be considered. At operation a few patients may have nodal disease that is discovered with a desmoplastic response, which creates a difficult dissection. It is possible to go on low flow cardiopulmonary bypass and initiate total body cooling. With the use of the cell saver surgery can proceed under better control. In several patients this maneuver has been the only satisfactory way to accomplish this surgery and allow immediate survival. Fray F. Marshall, M.D.
Penile Tumescence Monitoring During Morning Naps: A Pilot Investigation of a Cost~Effective Alternative to Fun Night Sleep Studies in the Assessment of Male Erectile Disorder P. CAREY, Department of Psychology and Center for Health and Behavior, Syracuse University, Syracuse, New York
C. M. GORDON AND M.
Behav. Res. Ther., 31: 503-506, 1993 Permission to Publish Abstract Not Granted Editorial Comment: This pilot study shows that monitoring tumescence during napping in sexually functioning, sleep deprived young men may be useful as an assessment of sleep efficiency and penile tumescence. The sample size was small, and a study in a population of older potent and impotent men is needed to validate the findings. I commend the authors for undertaking this interesting study to try to cut down the costs of studying sleep related erection. However, I cannot help but wonder why psychiatrists and psychologists do not approach the problem directly by devising better psychological tests to define psychogenic impotence. Tom F. Lue, M.D.
The Role of Gap Junctions and Ion Channels in the Modulation of Electrical and Chemical Signals in Human Corpus Cavernosum Smooth Muscle G.
J. CHRIST, P. R. BRINK, A. MELMAN AND D. C. SPRAY, Departments of Urology and Neuroscience, Albert Einstein College of Medicine-Montefiore Medical Center, Bronx and Department of Physiology and Biophysics, SUNY at Stony Brook, Stony Brook, New York
Int. J. Impotence Res., 5: 77-96, 1993 Intercellular communication through aqueous intercellular channels, known as gap junctions, has been postulated to provide an important mechanism for coordinating the rapid and synchronous responses of corporal smooth muscle during human penile erection and detumescence. Mathematical modeling analyses of drug diffusion were utilized to examine the potential physiological importance of the intercellular pathway to the regulation of smooth muscle tone in the human corpus cavernosum. In addition, patch clamp analyses and optical imaging studies were conducted to assess the ionic basis for cellular excitability and homeostasis in cultured corporal smooth muscle cells. In short, the computer modeling studies demonstrated that intercellular communication through gap junctions is likely to be the 'preferred' pathway for coordination of cellular activation and syncytial smooth muscle responses in this tissue. Moreover, the observed ion channel diversity reveals even further complexities to the modulation of corporal smooth muscle tone. Editorial Comment: One may wonder how a small amount of vasodilator, for example 5 ILg. prostaglandin El in 0.5 ml. saline, can result in vasodilation and erection in many patients within several minutes. This excellent summary on gap junction and ion channels in the human corpus caver no sum muscle may be the answer: their dysfunction may be responsible for several types of impotence. This is a must read article for those who are interested in intercellular communication within the penis. Tom F. Lue, M.D.
REN AL CALCULI Natural History and Current Concepts for the Treatment of Small Ureteral Calculi
W. A.
HUBNER,
P.
IRBY AND M.
L.
STOLLER,
Department of Urology, University of California School of
Medicine, San Francisco, California
Eur. Urol., 24: 172-176, 1993 Six studies providing information on 2,704 patients were included into a retrospective analysis. The incidence of spontaneous passage relating both stone size and location was determined from these collated studies. The rate of spontaneous passage for stones smaller than 4 mm. was 38% compared to 1.6% for those larger than 6 mm., irrespective of their position in the ureter at the time of presentation. Calculi discovered in the distal third of the ureter had a spontaneous passage rate of 45%, compared with the mid third of 22%, and the proximal third of 12%. Two thirds of all stones which passed did so within 4 weeks after the onset of symptoms. These data from the literature were compared to the treatment modalities applied for the last 100 consecutive patients treated with the diagnosis of ureteral stone at UCSF. 42% of the stones were found in the proximal,
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RENAL CALCULI
13% in the mid and 45% in the distal third of the ureter. Treatment modalities included ureteroscopic stone extraction (36), ESWL (31) and watchful waiting for stone passage (30). Orallitholysis was performed in 2 cases and percutaneous removal of a proximal stone in 1. No calculus larger than 6 mm passed spontaneously. The passage rate from the proximal ureter was 18%, from the mid ureter 15%, and 38% from the distal ureter disregarding the size of the stones. The rate of complications reached 20% when symptoms exceeded 4 weeks in duration compared to 7% in patients with symptoms lasting less than 4 weeks. Conservative management of ureteral calculi smaller than 6 mm is an appropriate treatment option, successful in about one-third of the cases. Due to the decreased likelihood of spontaneous passage and markedly higher incidence of complications, a patient with symptoms lasting longer than 4 weeks is a prime candidate for intervention.
Editorial Comment: The authors reviewed 6 studies that provide information about the spontaneous passage of ureteral calculi and compare these data to treatment practices at their institution. Some of their conclusions should be emphasized. The risk of spontaneous passage of stones smaller than 4 mm. is about 60%, from 4 to 6 mm. 33% and larger than 6 mm. less than 10%. The rate of spontaneous passage of stones in the upper ureter is about 20%. Watchful waiting for more than 4 weeks resulted in a 20% complication rate, causing sepsis and ureteral stricture. I was surprised by this high complication rate. The authors recommend that ureteral stones smaller than 6 mm. should be managed expectantly for 4 weeks but that all stones in the upper ureter should be managed with urological intervention. Mani Menon, M.D.
Five Years Experience in Experimental Laser Lithotripsy
W. CECCHETTI, A. TASCA, F. ZATTONI, G. VILLI, C. A. LEVORATO AND F. PAGANO, Department of Chemistry-Physics, University of Venice, Venice and Institute of Urology, University of Padua, Padua, Italy Eur. Urol., 24: 185-189, 1993 In the first part of our experience approximately 300 stones of different composition have been treated in vitro with three different laser sources: Nd-YAG laser (1,064 nm), dye laser (504 nm) and alexandrite laser (755 nm). Calcium oxalate monohydrate and brushite stones appeared to be the most resistent to lithotripsy. Highest fragmentation rates were obtained for calcium oxalate dihydrate stones followed by struvite, uric acid and hydroxyapatite stones. The Nd-YAG laser did not appear to be ideal for lithotripsy since early damage to the fiber tip was observed when this source was used. Both the dye and the alexandrite lasers were almost always effective in fragmenting the various types of stones. We subsequently treated some cystine stones while immersed in water or in solutions of carmine indigo (2%), methylene blue (5%), rifamycin (0.6 and 6%) and rifampicin (0.8 and 0.3%) with the dye or the alexandrite laser. The spectra of these solutions, previously analyzed with the spectrophotometer, showed that rifamycin and rifampicin absorbed large amounts of light radiation at the wave length of the dye laser (504 nm). Successful fragmentation occurred only when the dye laser was used to treat stones immersed in the more concentrated solutions of these two substances. The quantity of fragmented material after treating a 10-cm 3 cystine stone previously immersed in the more concentrated solutions of rifamycin and rifampicin (30 and 10 mm 3 , respectively) confirmed previous results. The clinical use of rifamycin and rifampicin as mediators of lasertripsy at 504 nm of hard or 'nonabsorbent' stones is suggested since these substances seem to trigger plasma formation at a low energy level on the surface of the stone that they coated.
Editorial Comment: Laser lithotripsy depends on laser induced plasma formation from absorption of the laser pulse on the target tissue. Cystine stones are notoriously difficult to treat with lithotripsy. The authors determine that rifamycin and rifampicin absorb large amounts of light radiation at the wavelength of the dye laser. When a 6% concentration of these agents was used plasma formation occurred at approximately 40 mJ. and resulted in increased stone fragmentation. The authors suggest that rifamycin be used as an irrigation fluid and that rifampicin be given orally to increase the effectiveness of laser lithotripsy of hard stones. Mani Menon, M.D.
Complete Local Tumor Remission After Therapy With Extra-Corporeally Applied High-Energy Shock Waves (HESW)
F.
GAMARRA, F. SPELSBERG, M. DELLIAN AND A. E. GOETZ, Institutes for Surgical Research and Anesthesiology, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany
Int. J. Cancer, 55: 153-156,1993
RENAL CALCULI
High-energy shock waves have been as a mear:s of non-invasive tumor Here we report the first successful local treatment of experimental tumors means of multifocal and repeated application of HESW. The experiments weTe on 29 Syrian golden hamsters amelanotic hamster melanomas in the dOIsal skin. HESW, general electrohydraulically, were applied multifocally to the center and to 5 sites on the margin of the tumors. A group of animals undergoing surgical resection and an untreated group served as controls. Complete remission of local tumor was achieved in more than 90% of the HESW-treated hamsters and in the same number of surgically treated animals, while untreated tumors continued to grow. Frequency of metastasis was the same in both groups after HESW treatment or surgery. Tumor therapy with multifocally and repeatedly applied HESW was thus as successful as surgery.
Editorial Comment: The results presented in this study are impressive. The authors compare the results of high energy shock waves to surgery in. the treatment of amehulOtic melanoma that was induced experimentally in Syrian golden hamsters. This is an early metastasizi:i.1.g, exponentially growing tumor that results in widespread meta§tasis within 21 days. Of the animals treated with high energy shock waves complete local remissiml of the tumor was noted in 90% and partial remission in 10%. Thus, the local remission rate was 100% with shock wave therapy, which hl exactly the response with surgical removal. This dramatic response was not seen in metastatic rate, si.nce metastasis developed in 64% of the animals. However, an impressive 36% of animals were tumor~fl"ee at 4 months, although i.t is not clear whether the authors confirmed this apparent cure rate by histological analysis of the tissues. The authors have created an ingenious experimental model that applies shock waves multifocally and repeatedly at short i.ntervals. Under these experimental conditions they find that high energy shock waves are as effective as surgery for the contltol of this particular tumor.
lExtracorporeal Shock Wave Lithotripsy Induces the Release of Prostaglandins Which Increase Ureteric Peristalsis P. G. HORGAN, D. HANLEY, J. BURKE, N. F. COUSE AND J. M. FITZPATRICK, Department of Urology/ Surgery, Mater Misericordiae Hospital and University College, Dublin, Ireland Brit. J. Urol., 71: 648-652, 1993 The aim of this study was to identify the changes in secretion of prostaglandins into the urinary tract as a result of treatment extracorporeal shock wave lithotripsy (ESWL) and to determine their effects on ureteric motility. Sixteen patients with renal or upper ureteric calculi were studied. A peripheral blood and urine sample was collected immediately before and after ESWL, with further samples taken 24 h later. The following variables were assessed radioimmunoassay: prostaglandin prostaglandin F,O' B2 An in vitro canine was then designed to the of isolated intact canine ureter model. U!;,Hl.HC.
Editorial Comment: This study examines the effects of ESWL* on ill'eteral motility, Peripheral blood and urine samples were collected immediately before and after E§WL, and 24 hours lateR' in 16 patients with renal or upper ureteral calculi. Significant elevatiom; of thromboxane B2 were seen immediately after ESWL, and prostaglandin FlO' 24 hours after ESWL. In contrast, prosta~ glandin E2 was unchanged in urine and decreased in serum. In vitro studies showed that throm~ boxane B2 and prostaglandin FlO' produced increased frequency of ureteral contractions. The authors conclude that ESWL results in the release of prostaglandins from the urinary tract, which may increase ureteral peristalsis. While this is a reasonable conclusion, all alternate possibility is that the process of stone passage may increase production of these prostaglandins and ureteral motility, Mani Menon, M.D. '" Dorni.ell" Medical Systems, Inc., Marietta, Georgia.
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Evidence of a Link Between Erythrocyte Band 3 Phosphorylation and Anion Transport in Patients With 'Idiopathic' Calcium Oxalate Nephrolithiasis B. BAGGIO, L. BORDIN, G. GAMBARO, A. PICCOLI, G. MARZARO AND G. CLARI, Institutes of Internal Medicine and Biological Chemistry, University of Padova School of Medicine, Padova, Italy
Min. Electrolyte Metab., 19: 17-20, 1993 This study was carried out to verify the hypothesis of a link between faster endogenous phosphorylation of band 3 protein, the anion carrier, and anomalous oxalate transmembrane self-exchange found in erythrocyte from calcium oxalate renal stone formers. Agents able to modify 32P-Iabelling of band 3 protein induced a concurrent modification in oxalate transmembrane flux. Cyclic AMP- and phospholipid-sensitive Ca2 +-independent protein kinases seem to be critical modulators of band 3 function. These observations demonstrate a close link between the band 3 phosphorylation state and its anion transport function, and provide new insights into the pathogenetic mechanisms of the cellular anomalies observed in calcium-oxalate renal stone disease. Editorial Comment: Patients with idiopathic calcium oxalate nephrolithiasis exhibit higher oxalate and urate transmembrane self-exchange rates, and faster endogenous phosphorylation of band 3 protein, which is the anion carrier. It has been suggested that increased phosphorylation of band 3 is linked to increased transmembrane oxalate transport. This study shows that agents that modify phosphorylation of band 3 induce a concurrent modification in oxalate transmembrane flux, while agents that mediate phosphorylation of bands 4.1 and 4.9 do not induce a similar change. Mani Menon, M.D.
Stone Recurrences in Kidneys Made Stone-Free by Percutaneous Extraction
C. HENRIKSSON, K. GETERUD, S. PETTERSSON AND B. F. ZACHRISSON, Department of Surgery, Division of Urology and Department of Radiology, Sahlgrenska sjukhuset, University of Goteborg, Goteborg, Sweden Scand. J. Urol. Nephrol., 27: 151-153, 1993 Of 100 renal units which were made stone-free by percutaneous stone extraction in 1985, 86 (86.0%) were re-examined radiologically up to 5 years after operation. The re-examination was performed because of symptoms or as part of a regular check-up or after calling the patient. Intrarenal calcifications were diagnosed in 27 of 86 (31.4%) of the renal units, but only in 11 (12.8%) were there stones requiring treatment. Editorial Comment: The authors examined stone recurrences in 85 patients who were stone-free after percutaneous stone extraction. At a maximum followup of 5 years about a third of the patients were found to have recurrent calcifications on plain film radiography. Of these calcifications 12.8% were considered to be large enough to require urological intervention. In the days of open stone surgery 1 dogma defined success as a stone-free kidney. This determination was based on nephrotomography and not plain film studies. It is possible that some of the kidneys originally determined to be stone-free by these authors might have harbored small calcifications that were undetected on plain film radiography. It is becoming increasingly apparent that the mere presence of a small calcification in the kidney is not an indication of failure or an indication for aggressive treatment. The authors used extraction and disintegration techniques as the initial urological procedures. It will be interesting to reanalyze the data to determine if there is an increase in recurrence after stone disintegration compared with total stone extraction. Mani Menon, M.D.
Crystalluria and its Possible Significance: A Patient-Control Study R. E. ABDEL-HALIM, Department of Urology, King Abdel-Aziz University, Jeddah, Saudi Arabia
Scand. J. Urol. Nephrol., 27: 145-149,1993 The significance of crystalluria in the diagnosis and prognosis of urolithiasis remains a controversial subject in the current urological literature. In this study, in addition to the standard urolithiasis clinical and biochemical work-up, routine urine microscopy was performed to study crystals in 1 fresh and 2 stored morning urine samples from 140 urinary stone patients and 42 controls. Crystalluria was more frequently detected in patients (9.3% of the fresh samples) than in controls (2%). Storing the samples for 6 hours did not increase the frequency percent of detected crystalluria either in patients or controls. However, in the samples stored for 24 hours, the frequency of crystalluria increased to 27.1 % in patients and only to 12% in controls, though the pH did not change from that of the fresh sample. In addition, while calcium oxalate crystals in patients formed
RENAL CALCULI
aggregates whether in fresh or 24 hour samples, those of controls did not. This denotes a characteristic change in the physico-chemical properties of the urine of stone formers from that of controls. Accordingly, the study of crystalluria in patients with urolithiasis seems to help in the proper evaluation and, maybe, treatment of the disease.
Editorial Comment: Calcium oxalate crystalluria was seen in less than 10% of freshly voided urine specimens that were obtained from 140 patients with renal stones and in 2% of controls. It is important to note that more than 90% of patients with calcium oxalate stones do not have crystalluria if urine specimens are measured immediately after voiding. The frequency of crystalluria increased to 27% in patients and 12% in controls after storage of samples for 24 hours. Crystal aggregates were seen only in stone formers but not in controls. Mani Menon, M.D.
Pathophysiology of Incomplete Renal Tubular Acidosis in Recurrent Renal Stone Formers: Evidence of Disturbed Calcium, Bone and Citrate Metabolism P. J. OSTHER, J. BOLLERSLEV, A. B. HANSEN, K. ENGEL AND P. KILDEBERG, Departments of Urology, Medical Endocrinology, Clinical Chemistry and Pediatrics, Odense University Hospital, Odense, Denmark Urol. Res., 21: 169-173, 1993 Urinary acidification, bone metabolism and urinary excretion of calcium and citrate were evaluated in 10 recurrent stone formers with incomplete renal tubular acidosis (iRTA), 10 recurrent stone formers with normal urinary acidification (NUA) and 10 normal controls (NC). Patients with iRTA had lower plasma standard bicarbonate after fasting (P < 0.01) and lower urinary excretion of titratable acid (P < 0.05) and citrate (P < 0.01) compared with NUA patients and NC, and higher urinary excretion of ammonia (P < 0.05) compared with NC (P < 0.05). Hypercalciuria was found in 6 of 10 patients with iRTA compared with 3 of 10 with NUA, and 0 of 10 NC. The citrate/calcium ratio in urine was significantly reduced in iRTA compared with the value in NUA (P < 0.01), and in NUA compared with NC (P < 0.05). Biochemical markers of bone formation (serum osteocalcin) and bone resorption (urinary hydroxyproline) were significantly increased in iRTA compared with NUA and NC (P < 0.01), indicating increased bone turnover in stone formers with iRTA. Stone formers with iRTA thus presented with disturbed calcium, bone and citrate metabolism-the same metabolic abnormalities which characterize classic type 1 RT A. Mild non-carbonic acidosis during fasting may be a pathophysiological factor of both nephrolithiasis and disturbed bone metabolism in stone formers with iRTA.
Editorial Comment: This study shows that stone formers with incomplete renal tubular acidosis (type 1) who were diagnosed on short ammonium chloride loading testing exhibit the same metabolic abnormalities that characterize complete type 1 renal tubular acidosis. These abnormalities are hypercalciu.ria, hypocitruria, a significantly reduced urinary citrate/calcium ratio, and increased markers of bone formation and bone resorption. Mani Menon, M.D.
Effect of Dietary Oxalate and Calciu.m on Urinary Oxalate and Risk of Formation of Calcium Oxalate Kidney Stones L. K. MASSEY, H. ROHMAN-SMITH AND R. A. SUTTON, Washington State University, Spokane, Washington, Food and Nutrition Services, University Hospital and Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
J. Amer. Diet. Ass., 93: 901-906, 1993 Permission to Publish Abstract Not Granted
Editorial Comment: This excellent article reviews the effects of various dietary components on the risk of calcium oxalate kidney stone formation. Only spinach, rhubarb, beets, nuts, chocolate, tea, wheat bran and strawberries have been known to cause a significant increase in urinary oxalate excretion. Restriction of dietary calcium enhances oxalate absorption and excretion. The authors believe that initial dietary recommendations for patients with recurrent calcium oxalate stones should involve dietary restriction of the 8 oxalate rich foods. Long-term therapy should be recommended only if beneficial results are obtained from oxalate restriction with appropriate calcium intake. The authors do not recommend dietary calcium restriction in patients with recurrent kidney stones, which is an opinion that currently appears to be gaining popularity. Mani Menon, M.D.
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Percutaneous Transvesical Ureteroscopy for Removal of Distal Ureteral Stone in Reimplanted Ureter
R. P. SANTAROSA, T. W. HENSLE AND R. SHABSIGH, Department of Urology, Columbia-Presbyterian Medical Center and Babies Hospital, New York, New York Urology, 42: 313-316, 1993 In the past two decades, the widespread use of cross-trigonal ureteral reimplants for the treatment of children with vesicoureteral reflux has resulted in a large population of patients with transversely lying ureters. As this population gets older they will consequently be entering an age group at higher risk for stone and urothelial cancer formation, with the potential for diagnostic and/or therapeutic ureteroscopy. The anatomic orientation of the ureters resulting from a cross-trigonal reimplantation may create difficulty or even inability to perform transurtheral ureteroscopy. This case presents the technique of percutaneous transvesical ureteroscopy for stone extraction in a seventeen-year-old male with a lower ureteral stone following cross-trigonal ureteral reimplantation. The described technique may serve as an addition to the current endoscopic methods.
Editorial Comment: Accessing the lower ureter in patients who have undergone a cross trigonal reimplantation is difficult and it has been suggested that percutaneous transvesical approaches should be used to achieve this goal. The authors extended this technique to perform percutaneous transvesical ureteroscopy for stone extraction in a 17 -year-old man with a lower ureteral stone after cross trigonal ureteral reimplant at ion. Mani Menon, M.D.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Retroperitoneal Tumors With Vena Caval Extension: A Multidisciplinary Approach B. L. GANZEL, J_ E. GEORGE, J. 1. HARTY AND L. A. GRAY, JR., Divisions of Thoracic and Cardiovascular Surgery and Urology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky
South. Med. J., 86: 880-886, 1993 In cases of retroperitoneal tumor with extension to the inferior vena cava (IVC), complete resection improves survival, but may require cardiopulmonary bypass (CPB) and hypothermic circulatory arrest (HCA). Since 1985, eight patients at our institution have had complete resection of retroperitoneal tumors with IVC or right atrial involvement. Preoperative evaluation included intravenous pyelography, computed tomography of the chest and abdomen, renal arteriography, and venography or magnetic resonance imaging of the IVC. Operative technique was determined primarily by the extent of IVC or RA involvement and included combined median sternotomy and laparotomy, control of the intrapericardial IVC, and radical tumor resection. IVC tumor thrombectomy was done using either temporary vascular occlusion, CPB, or CPB with HCA. Complete resection for improved survival of retroperitoneal tumors with IVC extension is technically feasible with acceptable morbidity and mortality rates. A multidisciplinary approach allows optimal management of these extensive tumors.
Editorial Comment: The authors describe the use of cardiopulmonary bypass and hypothermic circulatory arrest in patients with renal cell carcinoma, neuroblastoma and Wilms tumor. A variety of tumors, including pheochromocytoma, retroperitoneal sarcoma, transitional cell carcinoma and adrenal cortical carcinoma, may also be suitable for this treatment. Recently, if significant nodal disease is seen in the absence of other metastatic disease I have biopsied renal cell carcinoma cases. If positive nodal disease is found I think the prognosis is unfavorable enough to often not consider surgery. On the other hand, a protocol using adjuvant therapy might be considered. At operation a few patients may have nodal disease that is discovered with a desmoplastic response, which creates a difficult dissection. It is possible to go on low flow cardiopulmonary bypass and initiate total body cooling. With the use of the cell saver surgery can proceed under better control. In several patients this maneuver has been the only satisfactory way to accomplish this surgery and allow immediate survival. Fray F. Marshall, M.D.