- Email: [email protected]
Renal Calculi
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RENAL CALCULI
presented in an all-or-nothing fashion. Infm:mation about current treatment alternatives for impotence would significantly influence patient choice of therapy. With the knowledge that postoperative impotence could be treated easily, an informed patient could reasonably be expected to desire the therapy that would offer the greatest chance for life. Tom F. Lue, M. D.
Sexual Concerns After Heart Transplantation J.B. TABLER
AND R. L. FRIERSON, Jewish Hospital Heart and Lung Institute, and Consultation/Liaison Psychiatry Depart ment of the University of Louisville School of Medicine, Louis ville, Kentucky
corporeal blood. In. the acute phase repeated instillatim, of an adrenergic agent, as described in this report, is the treatment of choice. If that is not successful, emboliza tion of the ipsilateral common penile or internal puden da! artery may be necessary. In chronic cases an arte riovenous fistula with a fibrous wall is formed, which requires surgical ligation. Death resulting from compli cations associated with acute hypertension has been re ported after injection of 2 to 4 mg. metaraminol. Close monitoring of blood pressure is mandatory. We prefer less potent a-adrenergic agents, such as 250 mcg./ml. phenyleph:rine injected every 3 to 5 minutes until detumescence. Tom F. Lue, M. D.
J. Heart Transplant., 9: 397-403, 1990 Permission to Publish Abstract Not Granted Editorial Comment: Catastrophic illness is bound to have a profound effect on the psychological well-being of any patient. The authors have documented the severe impact of end stage heart disease and cardiac transplan tation on patient sexuality, Of 45 patients who under went heart transplantation at that institution 21 re sponded to a written questionnaire. Sexual dysfunction was present to some degree in the majo:rity of the pa tients, with impotence, ejaculatory problems and altered libido being the most common. Many patients avoided sexual opportunities out of fear of dying during coitus. The authors document the need to discuss sexuality and sexual practice after transplantation to minimize diffi culty postoperatively. Tom F. Lue, M. D.
Post-Traumatic Priapism Treated With Meta:raminol Bita:rtrate: Case Report K. SHIRAISHI ANDY. SAITO, Department of Urology, Yahata City Hospital, Kitakyushu City, Fukuoka and Naga saki University, Nagasaki City, Nagasaki, Japan
S. KOGA,
J. Trauma, 30: 1591-1593, 1990 A 30-year-old male with post-traumatic priapism for 7 days was treated successfully by metaraminol bitartrate injection into the corpus cavernosum. This result suggests that an alpha adrenagic agent injection into the corpus cavernosum should be considered in post-traumatic priapism at first. Editorial Comment: Perinea! trauma is not an uncom mon cause of high flow (nonischemic) priapism. Lacer ation of the intracavernous portion of the cavernous artery or its branches diverts a large amount of arterial blood to the sinusoidal spaces, bypassing the natural :regulatory function of the arterioles and, thus, resulting in persistent erection without sexual stimulation. Some of these cases subside spontaneously after several days or weeks, while others persist for months or even years if they are not treated. High flow priapism can be con firmed easily by a high oxygen content in aspirated
RENAL CALCULI The Relation of Clinical Catastrophes, Endogenous Ox alate Production, and Urolithiasis R. A. J. CONYERS, R.
BAIS AND A. M. ROFE, Department of Biochemistry, Alfred Hospital, Melbourne and Division of Clinical Chemistry, Institute of Medical and Veterinary Sci ence, Adelaide, Australia
Clin. Chem., 36: 1717-1730, 1990 Permission to Publish Abstract Not Granted Editorial Comment: The authors suggest that a host of carbohydrates (lactose, sucrose, fructose, glucose, galac tose, xylitol and proteins) may be metabolized to oxalate. While the conversion rates are low and given sufficient quantities of the precursor, in intravenous hyperalimen tation for instance, clinically significant deposition of oxalate may occur in the soft tissues. The conversion rates for carbohydrate to oxalate are correlated with serum insulin levels. The obvious implication is that alterations in diet can influence the endogenous produc tion of oxalate. These observations are intriguing and open up a whole new array of possibilities :regarding the role of diet, particularly protein and refined carbohy drates, and hormone status in the pathogenesis of oxa late stones. Mani Menon, M. D.
Ask the Expert F.
B. STAPLETON, Section of Nephrology, The University of Tennessee, Memphis, Tennessee
Ped. Nephrol., 4: 28, 1990 No Abstract Editorial Comment: Doctor Stapleton is an expert on pediatric stone disease and he is the individual who made the initial observation that children with microscopic hematuria often have hypercalciuria. He evaluates chil dren with urolithiasis by measuring 24-hour urinary calcium excretion on a :routine diet on 2 separate occa sions, and a third time after l week of dietary sodium
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and calcium restriction. If levels normalize he recom mends moderate dietary calcium restriction (600 to 800 mg. daily) and a no-added salt diet. If hypercalciuria persists 1 to 2 mg.fkg, hydrochlorothiazide daily is added to this regimen. Doctor Stapleton states that hy percalciuria is only intermittent and that stones do not always form even when therapy is discontinued (see article by Kohri et al). Thus, treatment is recommended for only 1 to 2 years in the absence of stone recurrence. Finally, Doctor Stapleton does not recommend treat ment for patients with the hypercalciuria-hematuria complex but no stones, although he has found that in about 15% of such children urolithiasis will ultimately develop. Mani Menon, M. D.
Surface Phase Transition of Hydrated Calcium Oxalate Crystal in the Presence of Normal and Stone-Formers' Urine
R. TAWASHI, Faculty of Pharmacy, Univer sity of Montreal, Montreal, Quebec, Canada
M. AKBARIEH AND
Scanning Microsc., 4: 387-394, 1990 Crystals of calcium oxalate monohydrate (COM), dihydrate (COD) and trihydrate (COT) were grown by slow diffusion of reacting ions from solutions using interfacially controlled crys tallization. Phase transition of COT to COD and COM, and COD to COM were studied on single crystal by X-ray diffrac tion analysis of the same crystal before and after exposure to normal and stone formers' urine. Phase transition on the surface of single crystals has been demonstrated by SEM energy dispersive X-ray microanalysis using windowless detector, and scanning Auger electron microprobe. Data obtained in this study offer direct experimental evidence for phase transfor mation on the surface of the hydrated calcium oxalate single crystal. In presence of normal urine the surface of COT single crystal undergoes transformation into COD and in presence of recurrent calcium oxalate stone former's urine surface trans formation to COM takes place. Editorial Comment: In this study the authors exam ined the changes in calcium oxalate trihydrate, calcium oxalate dihydrate and calcium oxalate monohydrate crystals incubated with the urine of normal subjects and of stone formers. The crystals were examined using x ray diffraction, scanning electron microscopy with en ergy dispersive spectroscopy and Auger electron micro probe analysis. In normal urine calcium oxalate trihy drate was transformed to calcium oxalate dihydrate but not to calcium oxalate monohydrate. In the urine of stone formers the trihydrate and dihydrate were transformed to monohydrate and magnesium levels were lower than control levels but the calcium, sodium, potassium and chloride levels were comparable. Macromolecules were not measured. Mani Menon, M. D.
Allopurinol and Thiazide Effects on New Urinary Stone Formed After Discontinued Therapy in Patients With Urinary Stones
K. KOHR!, K. KATAOKA, M. KODAMA, Y. KATOH, Y. KATAYAMA, M. IGUCHI, Y. ISHIKAWA, T. KURITA AND M. TAKADA, Department of Urology, Kinki University School of
Medicine, Osaka, Japan Urology, 36: 309-314, 1990 We treated 87 patients with calcium-containing urinary stones with either allopurinol alone (44 patients) or in combi nation with thiazide (43 patients) and studied new stone for mation before, during, and after the discontinuation of the drug therapy. The number of stones formed were 1.18, 0.24, and 0.13 before, during, and after discontinuation of the drug therapy, respectively, in the patients treated with allopurinol alone and 1.32, 0.20, and 0.09 in those treated in combination with thia zide. No differences were observed in these values and the duration of each observation period between the two groups. Decreases in the incidence of stone formation even after inter ruption of drug therapy suggested that recurrence-preventive effects observed following administration of these drugs include the effects of medical guidance. However, allopurinol therapy was effective in preventing recurrence in patients with hyper uricosuria. Editorial Comment: Eighty-seven patients with recur rent calcium oxalate or calcium phosphate stone disease were randomly treated with either allopurinol alone or a combination of allopurinol and thiazides. Treatment was not based on urinary chemistry; thus, both groups had equal proportions of patients with hypercalciuria and hyperuricosuria. The average duration of treatment was greater than 4 years. A subset of patients then discontinued treatment and was followed without ther apy for approximately 2 years. New stone formation rates decreased dramatically during treatment. This beneficial effect continued even after cessation of treat ment. Thus, the average number of stones per patient per year decreased from 1.18 to 0.24 while on treatment with allopurinol and to 0.13 in the period after treat ment. For patients treated with thiazides and allopurinol these rates were 1.37, 0.20 and 0.09, respectively. Looked at in a different way, the number of new stones after discontinuation of treatment was about half of that during treatment and about a tenth of that before treat ment. What is the basis for this astonishing improvement after stopping treatment? First, of course, one has to consider the fact that the period of followup after dis continuation of treatment was less than 2 years, whereas the duration of treatment was greater than 4 years. It is possible, indeed probable, that with another 2 years of followup more stones would have formed. Indeed, this has been the general pattern in other studies with lon gitudinal followup of patients on treatment. A second explanation is the placebo effect, or the "stone clinic" effect. Nonspecific treatment measures, such as in creased fluid intake and dietary guidance, are important adjuncts to drug therapy. Some suggestion that this might be happening is evidenced from the fact that urinary calcium and uric acid excretion, while increas ing upon cessation of treatment, did not quite reach pre treatment levels. It should also be underscored that about half of the patients had at least 1 episode of recurrence during the 10-year followup period, on and
RENAL CALCULI
off treatment. Thus, we have not yet solved the problem of stone disease. Mani Menon, M. D.
Treatment of Renal Calculi in the Elderly
L. B. KANDEL, Long Island Kidney Stone Unit, Department of
Urology, State University of New York at Stony Brook, Stony Brook, New York
Amer. J. Kidney Dis., 16: 329-331, 1990 The management of renal calculi in the geriatric patient population poses some unique problems that include anesthetic risks, underlying medical disease, and general risk/benefit con cerns. A variety of relatively noninvasive procedures are avail able, including extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrostolithotomy (PCNL). A practical management plan is presented that is based primarily on stone size and takes into consideration problems unique to the elderly patient. Editorial Comment: This article reviews the treatment of renal calculi in the elderly. It makes 2 suppositions: 1) stones require treatment and 2) elderly patients have underlying medical problems that increase the anes thetic risk. Under these circumstances, the author sug gests that stones less than 1.5 cm. should be treated without anesthesia using the piezo ceramic lithotriptor, stones from 1.5 to 2.5 cm. should be treated with ESWL* and stones greater than 2.5 cm. should be treated after stenting with either ESWL or percutaneous nephroli thotomy. Staghorn calculi require combined percuta neous techniques and ESWL or anatrophic nephroli thotomy. Alternately, if the contralateral kidney is nor mal nephrectomy may be considered. I believe that the management plan outlined in this article is eminently sensible. Mani Menon, M. D. * Dornier Medical Systems, Inc., Marietta, Georgia. Extracorporeal Surgery and Autotransplantation for Complicated Renal Calculous Disease in 108 Kidneys H. BONDEVIK, D. ALBRECHTSEN, G. S0DAL, A. JAKOBSEN, I. BREKKE AND A. FLATMARK, Surgical Department B, Riks hospitalet, National Hospital, Oslo, Norway
Scand. J. Urol. Nephrol., 24: 301-306, 1990 One hundred and eight kidneys in 97 patients with staghorn (72%) or multiple pyelocalyceal (28%) calculi were treated by extracorporeal surgery and autotransplantation, and followed up for 1-12 (mean 3) years. Twenty-seven patients had a solitary kidney, and 11 were operated on bilaterally. Sixty-nine % had a history of previous stone surgery, 74% had urinary tract infection and 30% renal dysfunction. Postoperative and late mortality rates were 3.1 and 2.1%, respectively. In addition, three kidneys were lost postoperatively and two later. Only one case of renal calculus recurrence was observed. Sixty-nine per cent of preoperatively infected patients were cured of infection, and 18% improved. Ninety-two per cent of patients with func tioning autograft had preserved or improved renal function at
501
follow-up. We find extracorporeal calculus removal a highly effective procedure with an acceptable risk. Editorial Comment: This article summarizes one of the world's largest experiences with bench surgery and autotransplantation for renal stone disease. The au thors, all of whom have extensive experience in renal allotransplantation, performed these operations on 108 patients between 1973 and 1985. The mortality rate was approximately 5%, and 6 kidneys were lost from infectious or vascular complications. These procedures were done before extracorporeal shock wave lithotripsy and percutaneous nephrolithot omy came into vogue in Norway. The aim of formidable procedures such as these had been to render the kidneys stone-free. This goal is less important today with the realization that even when kidneys are considered stone-free by radiological evaluation, nephroscopy often shows minute residual fragments and most stone frag ments less than 2 mm. are innocuous. Currently, it is the rare patient who requires bench surgery and autotrans plantation for calculous disease. Mani Menon, M. D.
Evalutation of a System for Classification of Stones and Their Sites in Kidneys Treated With Extracorporeal Shock Wave Lithotripsy B. PETTERSSON, H.-G. TISELIUS AND M. RAHMQVIST, Depart
ment of Urology and Centre for Medical Technology Assess ment, University of Linkoping, Linkoping, Sweden
Scand. J. Urol. Nephrol., 24: 293-299, 1990 The results of treatment with extracorporeal shock wave lithotripsy (ESWL) were recorded in 1067 patients with renal calculi during their first admission to hospital. All treatments were performed in an unmodified Dornier HM3 lithotripter according to the original recommendations whereby the gen erator voltage was usually set between 18 and 23 kV. The stones in kidneys treated with ESWL alone were first classified into four different types (A, B, C, D) and after which a further subgrouping was carried out according to the number and sites of stones in the renal pelvis or calyces. The number of shock waves, the energy index, the duration of treatment, and length of hospital stay as well as the therapeutic results after four weeks and six months, were recorded for the different subgroups. An approximate estimate of the stone volume was calculated from measurements on a plain abdominal radio graph. The mean stone volume, number of shock waves, energy index, duration of treatment, and length of hospital stay in creased progressively and significantly from group A to· group D. The stone volumes and the energy indexes in the different subgroups within each type were distributed around levels that clearly differed between the types. Although minor variations were observed similar patterns also were recorded for the re treatment rate, the total duration of treatment, and the length of hospital stay. The therapeutic result, expressed as satisfac tory disintegration, showed roughly similar results within each group but, as expected, the success rate decreased when more complicated stones were treated. Although stones located in the renal pelvis were often bigger than calyceal stones, the former seemed to disintegrate more easily. A further distinction
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RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
between stones located in the pelvis and in the calyces might therefore be of clinical value. In summary the overall result of this evaluation gave further support to the clinical usefulness and validity of this classification of patients with renal stones. Editorial Comment: The authors had previously re ported on a simple system for classifying stone burden.1 The present report is an evaluation of the success rates of ESWL in patients with stones classified by the origi nal criteria. The authors found that as the stones became more complex, success rates for treatment decreased, as might be expected. Success and disintegration were in versely proportional to stone volume, with the impor tant exception that pelvic stones were broken more eas ily than caliceal stones, even adjusting for volume. The authors' classification appears to be reasonable for rou tine clinical evaluation and followup of patients treated with ESWL. Mani Menon, M. D. 1. Tiselius, H. G., Pettersson, B., Hellgren, E. and Carlsson, P.: Classification of patients subjected to extracorporeal shock wave lithotripsy. Scand. J. Urol. Nephrol., 22: 65, 1988.
Urinary NAG Excretion After Anesthesia-Free Extra corporeal Lithotripsy of Renal Stones: A Marker of Early Tubular Damage A.
TRINCHIERI, G. ZANETTI, P. TOMBOLINI, A. MANDRESSI, M. RUOPPOLO, M. TURA, E. MONTANARI AND E. PISANI,
Institute of Urology, University of Milan, Milan and Policlin ico S. Marco, Zingonia, Italy
Urol. Res., 18: 259-262, 1990 Second generation lithotripters require a higher number of shocks per session as well as an increased rate of secondary treatments for complete stone disintegration compared to the original spark gap lithotripter. The clinical relevance of biolog ical side effects caused by such treatment are less known. We evaluated urinary excretion of N-acetyl-glucosaminidase (NAG) before and after lithotripsy in 50 patients treated with a low pressure spark gap lithotripter (Dornier HM3) and in 36 patients treated with a piezoelectric lithotripter (Wolf Piezolith 2200) in an attempt to evaluate their side effects on renal tissue. The urinary excretion of NAG increased after both spark gap lithotripsy using the modified HM3 and piezoelectric lith otripsy. These changes may be associated with slight tubular damage that would occur after anesthesia-free lithotripsy in patients subjected both to a high number of shocks and to secondary treatments. Editorial Comment: Urinary excretion of NAG is a reliable marker of acute renal tubular damage. The authors evaluated changes in urinary NAG excretion after lithotripsy in patients being treated with the mod ified Dornier HM3 and in another group of patients treated with the piezoelectric lithotriptor. Patients treated with the Dornier lithotriptor generally had larger stones than those treated with the piezoelectric lithotriptor. The urinary NAG excretion was greater in the patients treated with the HM3 than with the piezoe lectric machine; however, there was a wide range of excretion. The data were not corrected for variables, such as stone number, size and location, or the number
or intensity of the shock waves. This article demon strates, then, that piezoelectric lithotripsy is associated with tubular damage. Whether the extent of this damage is less than with extracorporeal shock wave lithotripsy cannot be determined from this study. Mani Menon, M. D.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Renal Carcinoma in a Solitary Kidney GOHJI, S. KAMIDONO AND N. YAMANAKA, Departments of Urology, Kobe University School of Medicine and Shinko Clinic, Kobe, Japan
K.
Brit. J. Urol., 66: 248-253, 1990 We studied the clinical and pathological features of 26 pa tients with renal carcinoma of a solitary kidney, including 6 treated at this hospital. Four patients had a contracted kidney and 22 had previously undergone nephrectomy. Partial ne phrectomy was performed in 16 patients, enucleation of the tumour in 5 and radical nephrectomy in 5 because of the size of the tumour. Ex vivo surgery was carried out in 4 patients. The duration of ischaemia ranged from 15 to 365 min but was longer in those who underwent ex vivo surgery (149 to 365 min). Of the 21 patients who underwent partial nephrectomy or enucleation, the serum creatinine level increased (2::2.0 mg/ dl) post-operatively in 16 patients, of whom 9 required tempo rary haemodialysis. No recurrence has been noted in those who underwent partial nephrectomy, but 1 patient who underwent enucleation of the tumour developed a solitary pancreatic me tastasis 2 years 6 months after surgery and was treated by a partial pancreatectomy. Kidney-preserving surgical procedures are considered to improve the quality of life, but careful follow up is necessary. Editorial Comment: The authors describe 26 patients with renal cell carcinoma in a solitary kidney. Partial nephrectomy was performed in 16, enucleation in 5 and radical nephrectomy in 5 patients. Of the 16 patients who underwent partial resection 9 required temporary dialysis. This incidence seems somewhat high. Initiating diuresis before temporary occlusion of the renal vascu lature is a helpful protective maneuver during the op eration. There was no recurrence in the partial nephrec tomy group and in 1 patient in the enucleation group pancreatic metastasis developed. In patients with larger, higher grade tumors the risk of microscopic ex tension, vascular invasion or multifocal disease makes enucleation potentially dangerous. On the other hand, even in the central tumors requiring wedge resection we have usually been able to perform this dissection in situ rather than resorting to the more dangerous ex vivo dissection with subsequent autotransplantation. Fray F. Marshall, M. D.
A Phase IA Trial of Sequential Administration Recom binant DNA-Produced Interferons: Combination Re combinant Interferon Gamma and Recombinant Inter-
RENAL CALCULI
presented in an all-or-nothing fashion. Infm:mation about current treatment alternatives for impotence would significantly influence patient choice of therapy. With the knowledge that postoperative impotence could be treated easily, an informed patient could reasonably be expected to desire the therapy that would offer the greatest chance for life. Tom F. Lue, M. D.
Sexual Concerns After Heart Transplantation J.B. TABLER
AND R. L. FRIERSON, Jewish Hospital Heart and Lung Institute, and Consultation/Liaison Psychiatry Depart ment of the University of Louisville School of Medicine, Louis ville, Kentucky
corporeal blood. In. the acute phase repeated instillatim, of an adrenergic agent, as described in this report, is the treatment of choice. If that is not successful, emboliza tion of the ipsilateral common penile or internal puden da! artery may be necessary. In chronic cases an arte riovenous fistula with a fibrous wall is formed, which requires surgical ligation. Death resulting from compli cations associated with acute hypertension has been re ported after injection of 2 to 4 mg. metaraminol. Close monitoring of blood pressure is mandatory. We prefer less potent a-adrenergic agents, such as 250 mcg./ml. phenyleph:rine injected every 3 to 5 minutes until detumescence. Tom F. Lue, M. D.
J. Heart Transplant., 9: 397-403, 1990 Permission to Publish Abstract Not Granted Editorial Comment: Catastrophic illness is bound to have a profound effect on the psychological well-being of any patient. The authors have documented the severe impact of end stage heart disease and cardiac transplan tation on patient sexuality, Of 45 patients who under went heart transplantation at that institution 21 re sponded to a written questionnaire. Sexual dysfunction was present to some degree in the majo:rity of the pa tients, with impotence, ejaculatory problems and altered libido being the most common. Many patients avoided sexual opportunities out of fear of dying during coitus. The authors document the need to discuss sexuality and sexual practice after transplantation to minimize diffi culty postoperatively. Tom F. Lue, M. D.
Post-Traumatic Priapism Treated With Meta:raminol Bita:rtrate: Case Report K. SHIRAISHI ANDY. SAITO, Department of Urology, Yahata City Hospital, Kitakyushu City, Fukuoka and Naga saki University, Nagasaki City, Nagasaki, Japan
S. KOGA,
J. Trauma, 30: 1591-1593, 1990 A 30-year-old male with post-traumatic priapism for 7 days was treated successfully by metaraminol bitartrate injection into the corpus cavernosum. This result suggests that an alpha adrenagic agent injection into the corpus cavernosum should be considered in post-traumatic priapism at first. Editorial Comment: Perinea! trauma is not an uncom mon cause of high flow (nonischemic) priapism. Lacer ation of the intracavernous portion of the cavernous artery or its branches diverts a large amount of arterial blood to the sinusoidal spaces, bypassing the natural :regulatory function of the arterioles and, thus, resulting in persistent erection without sexual stimulation. Some of these cases subside spontaneously after several days or weeks, while others persist for months or even years if they are not treated. High flow priapism can be con firmed easily by a high oxygen content in aspirated
RENAL CALCULI The Relation of Clinical Catastrophes, Endogenous Ox alate Production, and Urolithiasis R. A. J. CONYERS, R.
BAIS AND A. M. ROFE, Department of Biochemistry, Alfred Hospital, Melbourne and Division of Clinical Chemistry, Institute of Medical and Veterinary Sci ence, Adelaide, Australia
Clin. Chem., 36: 1717-1730, 1990 Permission to Publish Abstract Not Granted Editorial Comment: The authors suggest that a host of carbohydrates (lactose, sucrose, fructose, glucose, galac tose, xylitol and proteins) may be metabolized to oxalate. While the conversion rates are low and given sufficient quantities of the precursor, in intravenous hyperalimen tation for instance, clinically significant deposition of oxalate may occur in the soft tissues. The conversion rates for carbohydrate to oxalate are correlated with serum insulin levels. The obvious implication is that alterations in diet can influence the endogenous produc tion of oxalate. These observations are intriguing and open up a whole new array of possibilities :regarding the role of diet, particularly protein and refined carbohy drates, and hormone status in the pathogenesis of oxa late stones. Mani Menon, M. D.
Ask the Expert F.
B. STAPLETON, Section of Nephrology, The University of Tennessee, Memphis, Tennessee
Ped. Nephrol., 4: 28, 1990 No Abstract Editorial Comment: Doctor Stapleton is an expert on pediatric stone disease and he is the individual who made the initial observation that children with microscopic hematuria often have hypercalciuria. He evaluates chil dren with urolithiasis by measuring 24-hour urinary calcium excretion on a :routine diet on 2 separate occa sions, and a third time after l week of dietary sodium
500
RENAL CALCULI
and calcium restriction. If levels normalize he recom mends moderate dietary calcium restriction (600 to 800 mg. daily) and a no-added salt diet. If hypercalciuria persists 1 to 2 mg.fkg, hydrochlorothiazide daily is added to this regimen. Doctor Stapleton states that hy percalciuria is only intermittent and that stones do not always form even when therapy is discontinued (see article by Kohri et al). Thus, treatment is recommended for only 1 to 2 years in the absence of stone recurrence. Finally, Doctor Stapleton does not recommend treat ment for patients with the hypercalciuria-hematuria complex but no stones, although he has found that in about 15% of such children urolithiasis will ultimately develop. Mani Menon, M. D.
Surface Phase Transition of Hydrated Calcium Oxalate Crystal in the Presence of Normal and Stone-Formers' Urine
R. TAWASHI, Faculty of Pharmacy, Univer sity of Montreal, Montreal, Quebec, Canada
M. AKBARIEH AND
Scanning Microsc., 4: 387-394, 1990 Crystals of calcium oxalate monohydrate (COM), dihydrate (COD) and trihydrate (COT) were grown by slow diffusion of reacting ions from solutions using interfacially controlled crys tallization. Phase transition of COT to COD and COM, and COD to COM were studied on single crystal by X-ray diffrac tion analysis of the same crystal before and after exposure to normal and stone formers' urine. Phase transition on the surface of single crystals has been demonstrated by SEM energy dispersive X-ray microanalysis using windowless detector, and scanning Auger electron microprobe. Data obtained in this study offer direct experimental evidence for phase transfor mation on the surface of the hydrated calcium oxalate single crystal. In presence of normal urine the surface of COT single crystal undergoes transformation into COD and in presence of recurrent calcium oxalate stone former's urine surface trans formation to COM takes place. Editorial Comment: In this study the authors exam ined the changes in calcium oxalate trihydrate, calcium oxalate dihydrate and calcium oxalate monohydrate crystals incubated with the urine of normal subjects and of stone formers. The crystals were examined using x ray diffraction, scanning electron microscopy with en ergy dispersive spectroscopy and Auger electron micro probe analysis. In normal urine calcium oxalate trihy drate was transformed to calcium oxalate dihydrate but not to calcium oxalate monohydrate. In the urine of stone formers the trihydrate and dihydrate were transformed to monohydrate and magnesium levels were lower than control levels but the calcium, sodium, potassium and chloride levels were comparable. Macromolecules were not measured. Mani Menon, M. D.
Allopurinol and Thiazide Effects on New Urinary Stone Formed After Discontinued Therapy in Patients With Urinary Stones
K. KOHR!, K. KATAOKA, M. KODAMA, Y. KATOH, Y. KATAYAMA, M. IGUCHI, Y. ISHIKAWA, T. KURITA AND M. TAKADA, Department of Urology, Kinki University School of
Medicine, Osaka, Japan Urology, 36: 309-314, 1990 We treated 87 patients with calcium-containing urinary stones with either allopurinol alone (44 patients) or in combi nation with thiazide (43 patients) and studied new stone for mation before, during, and after the discontinuation of the drug therapy. The number of stones formed were 1.18, 0.24, and 0.13 before, during, and after discontinuation of the drug therapy, respectively, in the patients treated with allopurinol alone and 1.32, 0.20, and 0.09 in those treated in combination with thia zide. No differences were observed in these values and the duration of each observation period between the two groups. Decreases in the incidence of stone formation even after inter ruption of drug therapy suggested that recurrence-preventive effects observed following administration of these drugs include the effects of medical guidance. However, allopurinol therapy was effective in preventing recurrence in patients with hyper uricosuria. Editorial Comment: Eighty-seven patients with recur rent calcium oxalate or calcium phosphate stone disease were randomly treated with either allopurinol alone or a combination of allopurinol and thiazides. Treatment was not based on urinary chemistry; thus, both groups had equal proportions of patients with hypercalciuria and hyperuricosuria. The average duration of treatment was greater than 4 years. A subset of patients then discontinued treatment and was followed without ther apy for approximately 2 years. New stone formation rates decreased dramatically during treatment. This beneficial effect continued even after cessation of treat ment. Thus, the average number of stones per patient per year decreased from 1.18 to 0.24 while on treatment with allopurinol and to 0.13 in the period after treat ment. For patients treated with thiazides and allopurinol these rates were 1.37, 0.20 and 0.09, respectively. Looked at in a different way, the number of new stones after discontinuation of treatment was about half of that during treatment and about a tenth of that before treat ment. What is the basis for this astonishing improvement after stopping treatment? First, of course, one has to consider the fact that the period of followup after dis continuation of treatment was less than 2 years, whereas the duration of treatment was greater than 4 years. It is possible, indeed probable, that with another 2 years of followup more stones would have formed. Indeed, this has been the general pattern in other studies with lon gitudinal followup of patients on treatment. A second explanation is the placebo effect, or the "stone clinic" effect. Nonspecific treatment measures, such as in creased fluid intake and dietary guidance, are important adjuncts to drug therapy. Some suggestion that this might be happening is evidenced from the fact that urinary calcium and uric acid excretion, while increas ing upon cessation of treatment, did not quite reach pre treatment levels. It should also be underscored that about half of the patients had at least 1 episode of recurrence during the 10-year followup period, on and
RENAL CALCULI
off treatment. Thus, we have not yet solved the problem of stone disease. Mani Menon, M. D.
Treatment of Renal Calculi in the Elderly
L. B. KANDEL, Long Island Kidney Stone Unit, Department of
Urology, State University of New York at Stony Brook, Stony Brook, New York
Amer. J. Kidney Dis., 16: 329-331, 1990 The management of renal calculi in the geriatric patient population poses some unique problems that include anesthetic risks, underlying medical disease, and general risk/benefit con cerns. A variety of relatively noninvasive procedures are avail able, including extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrostolithotomy (PCNL). A practical management plan is presented that is based primarily on stone size and takes into consideration problems unique to the elderly patient. Editorial Comment: This article reviews the treatment of renal calculi in the elderly. It makes 2 suppositions: 1) stones require treatment and 2) elderly patients have underlying medical problems that increase the anes thetic risk. Under these circumstances, the author sug gests that stones less than 1.5 cm. should be treated without anesthesia using the piezo ceramic lithotriptor, stones from 1.5 to 2.5 cm. should be treated with ESWL* and stones greater than 2.5 cm. should be treated after stenting with either ESWL or percutaneous nephroli thotomy. Staghorn calculi require combined percuta neous techniques and ESWL or anatrophic nephroli thotomy. Alternately, if the contralateral kidney is nor mal nephrectomy may be considered. I believe that the management plan outlined in this article is eminently sensible. Mani Menon, M. D. * Dornier Medical Systems, Inc., Marietta, Georgia. Extracorporeal Surgery and Autotransplantation for Complicated Renal Calculous Disease in 108 Kidneys H. BONDEVIK, D. ALBRECHTSEN, G. S0DAL, A. JAKOBSEN, I. BREKKE AND A. FLATMARK, Surgical Department B, Riks hospitalet, National Hospital, Oslo, Norway
Scand. J. Urol. Nephrol., 24: 301-306, 1990 One hundred and eight kidneys in 97 patients with staghorn (72%) or multiple pyelocalyceal (28%) calculi were treated by extracorporeal surgery and autotransplantation, and followed up for 1-12 (mean 3) years. Twenty-seven patients had a solitary kidney, and 11 were operated on bilaterally. Sixty-nine % had a history of previous stone surgery, 74% had urinary tract infection and 30% renal dysfunction. Postoperative and late mortality rates were 3.1 and 2.1%, respectively. In addition, three kidneys were lost postoperatively and two later. Only one case of renal calculus recurrence was observed. Sixty-nine per cent of preoperatively infected patients were cured of infection, and 18% improved. Ninety-two per cent of patients with func tioning autograft had preserved or improved renal function at
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follow-up. We find extracorporeal calculus removal a highly effective procedure with an acceptable risk. Editorial Comment: This article summarizes one of the world's largest experiences with bench surgery and autotransplantation for renal stone disease. The au thors, all of whom have extensive experience in renal allotransplantation, performed these operations on 108 patients between 1973 and 1985. The mortality rate was approximately 5%, and 6 kidneys were lost from infectious or vascular complications. These procedures were done before extracorporeal shock wave lithotripsy and percutaneous nephrolithot omy came into vogue in Norway. The aim of formidable procedures such as these had been to render the kidneys stone-free. This goal is less important today with the realization that even when kidneys are considered stone-free by radiological evaluation, nephroscopy often shows minute residual fragments and most stone frag ments less than 2 mm. are innocuous. Currently, it is the rare patient who requires bench surgery and autotrans plantation for calculous disease. Mani Menon, M. D.
Evalutation of a System for Classification of Stones and Their Sites in Kidneys Treated With Extracorporeal Shock Wave Lithotripsy B. PETTERSSON, H.-G. TISELIUS AND M. RAHMQVIST, Depart
ment of Urology and Centre for Medical Technology Assess ment, University of Linkoping, Linkoping, Sweden
Scand. J. Urol. Nephrol., 24: 293-299, 1990 The results of treatment with extracorporeal shock wave lithotripsy (ESWL) were recorded in 1067 patients with renal calculi during their first admission to hospital. All treatments were performed in an unmodified Dornier HM3 lithotripter according to the original recommendations whereby the gen erator voltage was usually set between 18 and 23 kV. The stones in kidneys treated with ESWL alone were first classified into four different types (A, B, C, D) and after which a further subgrouping was carried out according to the number and sites of stones in the renal pelvis or calyces. The number of shock waves, the energy index, the duration of treatment, and length of hospital stay as well as the therapeutic results after four weeks and six months, were recorded for the different subgroups. An approximate estimate of the stone volume was calculated from measurements on a plain abdominal radio graph. The mean stone volume, number of shock waves, energy index, duration of treatment, and length of hospital stay in creased progressively and significantly from group A to· group D. The stone volumes and the energy indexes in the different subgroups within each type were distributed around levels that clearly differed between the types. Although minor variations were observed similar patterns also were recorded for the re treatment rate, the total duration of treatment, and the length of hospital stay. The therapeutic result, expressed as satisfac tory disintegration, showed roughly similar results within each group but, as expected, the success rate decreased when more complicated stones were treated. Although stones located in the renal pelvis were often bigger than calyceal stones, the former seemed to disintegrate more easily. A further distinction
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RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION
between stones located in the pelvis and in the calyces might therefore be of clinical value. In summary the overall result of this evaluation gave further support to the clinical usefulness and validity of this classification of patients with renal stones. Editorial Comment: The authors had previously re ported on a simple system for classifying stone burden.1 The present report is an evaluation of the success rates of ESWL in patients with stones classified by the origi nal criteria. The authors found that as the stones became more complex, success rates for treatment decreased, as might be expected. Success and disintegration were in versely proportional to stone volume, with the impor tant exception that pelvic stones were broken more eas ily than caliceal stones, even adjusting for volume. The authors' classification appears to be reasonable for rou tine clinical evaluation and followup of patients treated with ESWL. Mani Menon, M. D. 1. Tiselius, H. G., Pettersson, B., Hellgren, E. and Carlsson, P.: Classification of patients subjected to extracorporeal shock wave lithotripsy. Scand. J. Urol. Nephrol., 22: 65, 1988.
Urinary NAG Excretion After Anesthesia-Free Extra corporeal Lithotripsy of Renal Stones: A Marker of Early Tubular Damage A.
TRINCHIERI, G. ZANETTI, P. TOMBOLINI, A. MANDRESSI, M. RUOPPOLO, M. TURA, E. MONTANARI AND E. PISANI,
Institute of Urology, University of Milan, Milan and Policlin ico S. Marco, Zingonia, Italy
Urol. Res., 18: 259-262, 1990 Second generation lithotripters require a higher number of shocks per session as well as an increased rate of secondary treatments for complete stone disintegration compared to the original spark gap lithotripter. The clinical relevance of biolog ical side effects caused by such treatment are less known. We evaluated urinary excretion of N-acetyl-glucosaminidase (NAG) before and after lithotripsy in 50 patients treated with a low pressure spark gap lithotripter (Dornier HM3) and in 36 patients treated with a piezoelectric lithotripter (Wolf Piezolith 2200) in an attempt to evaluate their side effects on renal tissue. The urinary excretion of NAG increased after both spark gap lithotripsy using the modified HM3 and piezoelectric lith otripsy. These changes may be associated with slight tubular damage that would occur after anesthesia-free lithotripsy in patients subjected both to a high number of shocks and to secondary treatments. Editorial Comment: Urinary excretion of NAG is a reliable marker of acute renal tubular damage. The authors evaluated changes in urinary NAG excretion after lithotripsy in patients being treated with the mod ified Dornier HM3 and in another group of patients treated with the piezoelectric lithotriptor. Patients treated with the Dornier lithotriptor generally had larger stones than those treated with the piezoelectric lithotriptor. The urinary NAG excretion was greater in the patients treated with the HM3 than with the piezoe lectric machine; however, there was a wide range of excretion. The data were not corrected for variables, such as stone number, size and location, or the number
or intensity of the shock waves. This article demon strates, then, that piezoelectric lithotripsy is associated with tubular damage. Whether the extent of this damage is less than with extracorporeal shock wave lithotripsy cannot be determined from this study. Mani Menon, M. D.
RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Renal Carcinoma in a Solitary Kidney GOHJI, S. KAMIDONO AND N. YAMANAKA, Departments of Urology, Kobe University School of Medicine and Shinko Clinic, Kobe, Japan
K.
Brit. J. Urol., 66: 248-253, 1990 We studied the clinical and pathological features of 26 pa tients with renal carcinoma of a solitary kidney, including 6 treated at this hospital. Four patients had a contracted kidney and 22 had previously undergone nephrectomy. Partial ne phrectomy was performed in 16 patients, enucleation of the tumour in 5 and radical nephrectomy in 5 because of the size of the tumour. Ex vivo surgery was carried out in 4 patients. The duration of ischaemia ranged from 15 to 365 min but was longer in those who underwent ex vivo surgery (149 to 365 min). Of the 21 patients who underwent partial nephrectomy or enucleation, the serum creatinine level increased (2::2.0 mg/ dl) post-operatively in 16 patients, of whom 9 required tempo rary haemodialysis. No recurrence has been noted in those who underwent partial nephrectomy, but 1 patient who underwent enucleation of the tumour developed a solitary pancreatic me tastasis 2 years 6 months after surgery and was treated by a partial pancreatectomy. Kidney-preserving surgical procedures are considered to improve the quality of life, but careful follow up is necessary. Editorial Comment: The authors describe 26 patients with renal cell carcinoma in a solitary kidney. Partial nephrectomy was performed in 16, enucleation in 5 and radical nephrectomy in 5 patients. Of the 16 patients who underwent partial resection 9 required temporary dialysis. This incidence seems somewhat high. Initiating diuresis before temporary occlusion of the renal vascu lature is a helpful protective maneuver during the op eration. There was no recurrence in the partial nephrec tomy group and in 1 patient in the enucleation group pancreatic metastasis developed. In patients with larger, higher grade tumors the risk of microscopic ex tension, vascular invasion or multifocal disease makes enucleation potentially dangerous. On the other hand, even in the central tumors requiring wedge resection we have usually been able to perform this dissection in situ rather than resorting to the more dangerous ex vivo dissection with subsequent autotransplantation. Fray F. Marshall, M. D.
A Phase IA Trial of Sequential Administration Recom binant DNA-Produced Interferons: Combination Re combinant Interferon Gamma and Recombinant Inter-