Renal Calculi

Renal Calculi

482 RENAL CALCULI plasty without excision of the tunica albuginea. After penile straightening, 34 of the 37 patients (91.9%) were able to resume nor...

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plasty without excision of the tunica albuginea. After penile straightening, 34 of the 37 patients (91.9%) were able to resume normal coitus and 29 (78.4%) had excellent results, cosmetic and sexual. Postoperative progression of Peyronie' s disease and shortening of the erect penis were rare. In 4 patients, partial necrosis of penile shaft skin or of the prepuce complicated the postoperative course, but there were no long-term sequelae in any case. In patients with concomitant preoperative erectile dysfunction, the dysfunction did not improve after corporoplasty; such patients should be treated primarily with a penile implant. We recommend the modified Essed-Schroeder corporoplasty as a safe and simple method to correct penile curvature.

Editorial Comment: The authors describe their results in 37 patients treated with. a plication technique. The modification appears to be inverting the sutures, with apparently improved patient acceptance. Their results are similar to other series, with 640 7% of the Peyronie's group satisfiedo We have simplified this plication. procedure with 2 modifications. 1) We induce erection by intracavernous injection of papaverine before incision, making placement of sutures easier and more accurate. If the penis remains rigid after correction, intracavernous injection of ph.enylephrine is given to prevent p:riapism. 2) We do not dissect the neurovascu.lar bundle or corpus spongiosumo In patients with. ventral curvature sutures can be placed between the dorsal vein and dorsal arteries without the need to elevate the neurovascular bundle. In patients with dorsal curvature we place sutures lateral to the corpus spongiosum and, thus, separation of the corpus spongiosum from the corpus cavernosum is not necessary. Tom F. Lue, M.D.

Inflatable Penile Prosthesis: Effect of Device Modification on Functional Longevity

plantation, 5% at 12 months is still a significant failure rate and it will likely increase at 24 or 36 months. The treatment options for the impotent patient should include these more reliable inflatable prostheses; however, I believe that less invasive and less costly approaches, such as intracavernous injection or a vacuum erection device, should always be explored first. Tom F. Lue, M.D.

Penile Fracture: Emergency Surgery for Preservation of Penile Functions


!'.Jl':... NE,

T. ESEN, S. TELLALOGLU, lVI. SELHANOGLU AND 1\1. Department of Urology, Medical Faculty, Istanbul,


Turkey Andrologia, 23: 309-311, 1991 Traumatic rupture of the corpus cavernosum is a rare injury and occurs following a blunt trauma on erected penis. We herewith present 16 cases which underwent a uniform emergency operation. With this strategy we observed no complications, and all penile functions including erection were preserved.

Editorial Comment: The authors report their experience with 16 cases of traumatic penile fracture during a period of 2.5 yearso They confirm other studies showing excellent results with early surgical repair and few long-term sequelae. Cavernosography correlated well with. the clinical findings in this series. In my experience blood clotting at the fracture site may sometimes give a false negative result on cavernosography. When in doubt, other imaging techniques, such as computerized tomography or magnetic resonance imaging, may be useful. Tom F. Lue, M.D.

B. E. WOODWORTH, C. C. CARSON AND G. D. WEBSTER, Department of Urology, Duke University Medical Center, Durham, North Carolina


Urology, 38: 533-536, 1991 The Scott inflatable penile prosthesis has undergone a continual evolution since its introduction in 1973. A review of 266 patients at Duke University Medical Center who received primary implantation of AMS inflatable penile prostheses from 1979 to 1988 revealed the modifications in the prosthesis have increased the functional longevity and hence the reliability of this surgical treatment for erectile impotence.

Editorial Comment: The authors report their extensive experience with 3 generations of AMS inflatable penile prostheses. During a 10-year period 266 patients were seeno Analysis showed a progressive increase in longevity (defined as failure rate at 12 months). The most recent model (AMS 700CX) had the lowest complication rate: 5% at 12 months compared with 9% for the AMS 700 and 21 % for the initial version IPI 742a. The authors describe some of the important design changes in cylinder, pump and tubing construction that have brought about this dramatic improvement in reliability. Although these are excellent results from a group of urologists with extensive experience in prosthesis im-

The Role of Tamm-Horsfall Glycoprotein and Nephrocalcin. in Calcium Oxalate Monohydrate Crystallization Process B.

HESS, Policlinic of Medicine, University Hospital, Berne, Switzerland

Scanning Microsc., 5: 689-696, 1991 Theoretical considerations as well as clinical observations suggest that the aggregation of nucleated crystals is the most dangerous step in the formation of calcium oxalate (CaOx) renal stones. The effects of 2 major urinary glycoproteins, Tamm-Horsfall glycoprotein (THP) and Nephrocalcin (NC), on calcium oxalate monohydrate (COM) crystal aggregation in vitro are studied. At low ionic strength (IS) and high pH (within urinary limits), THP is a powerful crystal aggregation inhibitor (90% inhibition at 40 mg/1). Decreasing pH to 5.7 and raising IS to 0.21 increases THP viscosity, thereby lowering THP crystal aggregation inhibition. Upon addition of calcium (5 mmol/1), some THPs are no more soluble and promote crystal aggregation (up to 70%). In the presence of citrate (5 mmol/1), which is only slightly inhibitory (14%), the promoting effect of


THP is reversed into aggregation inhibition (up to There is evidence for a molecular abnormality in THPs from severe recurrent CaOx stone formers, since they exhibit inci'eased polymerization and reduced solubility. The 14 kD (kilodalton), Gia-containing glycoprotein NC also strongly inhibits crystal aggregation. However, NC isolated from urines of recurrent CaOx stone formers and from CaOx renal stones are 10 times less inhibitory. Both are structurally abnormal in that they lack Gla and are less amphophilic.

Editorial Comment: article reviews a recent study of Tamm-Horsfall protein and nephrocalcin, 2 :naturally occ1.11rrin.g m.acromolecula:r inhibitors of calcium oxalate crystallization. Tamm-Horsfall protein is produced by the epithelial cells of the thick ascending limb of Henle's loop and the eady distal tubule. At a pH greater than 6.0 Tamm-Horsfall p1·otein inhibits nucleation, growth and aggregation of calcium oxalate monohydrate crystals, whereas at a lower pH it p:romotes these processes. Increasing the ionic strength of the crystallization solution decreases the inhibitory capacity of Tamm-Horsfall p:rotefo. Calcium decreases whereas citrate promotes the inhibition of calcium oxalate crystal aggregation by Tamm-Horsfall ],}:rotein. The excretim.1 of Tamm-Hm."sfaH protein fa not decreased but its inhibitmry capacity is in stone formers. Neph.rocald.n is a glycoprotein produced by proximal tuln.1.Ia1· cells and the thick ascending limb of Henle's loop. Its §ec:1:etion is not decreased in stone formers; however, such individuals produce a structurally altered form of :neph.rocalcin. Normal nephrocalcin is a powerful inhibitor of calcium oxalate nucleation and aggregation, a property that is not alte:red by clumge§ in ionic strength or pH. Nephrocalcin i!;olated from :recurrent stone formers is a weak inhibitor of crystal aggregation under phy§iofogical conditions. Mani Menon, M.D.


mine n,··c•oc,,occ1 blood gases remained a m unnary calcium, together with increasing oxaluria, hydroxyapatite supersaturation, and calcium phosphate crystalluria. In the long term (>12 months) PC urinary pH and citrate "dissociated", in that pH returned to pretreatment baseline values, whereas citrate stayed at high levels, In normocitraturics but not in hypocitraturics, urinary urea and sodium increased with PC, Hypocitraturics appeared to be less sensitive to the effects of PC, as reflected by the relatively small rise in urinary pH and citrate, and they maintained higher mean levels of indicators of bone metabolism (osteocalcin, alkaline phosphatase, hydroxyproline) despite continuous administration of PC, It was concluded that although the PC tablet preparation was effective it may not be an ideal anti-stone drug treatment in the long term and that, especially in hypocitraturics, the intrinsic metabolic defect of RCU may not be sufficiently well controlled.

JEdi.torial Comment: The authors investigated the metabolic effects of oral potassium citrate in 37 German men with :recurrent calcium oxalate urolithiasis, Of the patients 20 had normocitratu:ria and 15 had h.ypocitratu:ria. Tolerance of citrate, given as wax matrix tablet§ of potassium citrate, wa§ poor: 21 of 3 7 patients stopped taking the medication after 3 months, Hypocitratu:dc patients had a lower in.crease in urinary citrate pH than Jllormocit:raturic subiects. Urin,ary calci1nn excretion decreased at 3 month::. but reverted to normal with longer followup. The relative supersaturation of calcium oxalate, brushite and hydroxyapatite did :not decrease in patient§ with hypocitrmturia. The relative ineffectiveness of oral potassium citrate in co:r:rectl.,ng the metabolic change§ seen in patients with hypocitratu:ria is su:rp:rising and in sharp con.t:rast to data :reported. in North American studies.' 02 Pak et al :repo:rted levels of u:rina:ry citrate increased 2-fold in patiimts with hypocitratu:ria aii!.d the :relative supersaturation of calcium oxalate decreased significantly. 1 What is the explanation fo:r these conflicting results? Citrate and Recu.irrent Idiopathic Calcium Ur'olithiasis: The patie,11.ts in the German study were, in some respects, A Longitudinal Pilot Study on the Metabolic Effects more homogenem1s am.I better cha:ractel'ized than the of Ora! Potas§ium Citrate Administered Ove:r the A:me:rican patients (body weight index, metabolic activShort·, Medium.- ,i,.nd Long-Te:rm Medication of Male ity score), Mean u:dna:ry citrate in tlle §e:rie@ of Pak wa§ 2 Thus, many 319 mg. per day (11ormal greater than Stone Pmtients of the American p,a.Uemi;s had mirrimal P. 0. SCJHWILLE, U, HERRMANN, C. WOLF, I. BERGER AND R. In the Ge:rman study patients with normocitFaturia MEISTER, Mineral Metabolism and Endocrine Research Lab(mean 327 mg. citrate per day) did i'espond to o:ral oratory, Departments Surgery and Urology, University of citrate. The hypocitiraturic patients who did not respond Erlangen, Erlangen, Federal Republic of Germany had a mean 1,udna:ry citrate excretion of 157 mg. per Urol. Res., 20: 145-155, 1992 day. Thus, the degree of hypocit:raturia was much more In idiopathic recurrent calcium urolithiasis (RCU) in men (n profound in the German patients. Importantly, the Ge1·= 37) the metabolic effects of oral tripotassium citrate (PC) man study doei, not address the efficacy of citirate therwere investigated in a longitudinal field study. The patients apy in terms of amelioration of stone disease, which were either normo- (n = 22) or hypocitraturic (n = 15). Labo- ultimately is where proof of the pudding lies. Pak et al ratory examinations were performed before, and after 3, 6, and reported that stone formation is reduced in 90 to l 00% 1 more than 12 months of medication. Acceptance of PC was of treated patients. Man.i Menon, M.D. poor, mainly because of the salty taste of the tablet preparation l. Pak, C. Y, C., Fuller, C., Sakhaee, K., Preminger, G. M. and chosen, and a number of participants dropped out of the study. Britton, F,: Long-term treatment of calcium nephrolithiIn the remaining participants, compliance was acceptable when asis with potassium citrate. J. UroL, 134: 11, 1985. evaluated on the basis of urinary potassium and undesired side 2. Pak, C. Y. C,: Hypocitraturic calcium nephrolithiasis. In: Urolithiasis. A Medical and Surgical Reference. Edited effects did not occur. In the short term (up to 3 months), PC by M. I. Resnick and C, Y. C. Pak. Philadelphia: W. B. evoked compensated metabolic alkalosis (pH and citrate in Saunders Co., chapt. 6, pp. 89-103, 1990.



Crystalluria in Idiopathic Recurrent Calcium Urolithiasis. Dependence on Stone Composition U. HERRMANN AND P. 0. SCHWILLE, Mineral Metabolism and Endocrine Research Laboratory, Departments of Surgery and Urology, University of Erlangen, Erlangen, Federal Republic of Germany

Urol. Res., 20: 157-164, 1992

A retrospective study was done on the nature and degree of crystalluria in fasting and postprandial urine in patients with recurrent idiopathic calcium urolithiasis (RCU) for whom stone analysis was available. RCU was stratified into subgroups in accordance with stone analysis. The crystals were obtained and identified using a fiiter technique and polarization microscopy, respectively. Crystalluria score, relative saturation products (RSPs), and low-molecular-weight inhibitors were assessed. Calcium oxalate crystals were never observed in either male or female patients with stones composed exclusively of calcium oxalate, and only sporadically in patients with mixed stones (the additional component was calcium phosphate in most cases). Other crystalluria phases, such as amorphous calcium phosphate, a urate-containing phase, and a phase presenting as spherolytic particles, were slightly more frequent in patients with mixed stones. In contrast to crystalluria, RSPs and inhibitors differed in male and female patients, suggesting that crystalluria may not be under the exclusive control of these factors. The following conclusions were reached. (1) Calcium oxalate crystalluria is absent from RCU with pure calcium oxalate stones; hence, calcium oxalate crystalluria does not qualify as a diagnostic aid. (2) The co-existence of the isotropic phase and mixed stones may indicate that the formation of these concretions is characteristic for a major RCU subgroup. (3) On the basis of clinical chemistry and physicochemical data in urine and of crystalluria, it appears that the pathogenesis of RCU differs in male and female subjects. Editorial Comment: It is generally accepted that crystals of calcium oxalate are seen more frequently in the urine of patients with calcium oxalate stone disease and that these crystals are larger than those seen in controls. Once again, this group of investigators surprises us by demonstrating that such was not the case in their patient population. In 78 male and 38 female patients with calcium oxalate stone disease crystalluria was not seen in those with pure oxalate stones and only rarely in those with oxalate/phosphate stones. Perhaps the reason is that the authors examined freshly voided urine filtered through a 0.2 µm. nucleopore filter, whereas other investigators have used stored or centrifuged urine. In any case, these observations support the speculation that crystal retention rather than crystalluria is the proximate cause of calcium oxalate stone disease. Mani Menon, M.D.

Urinary Stone Formation in Children With Prenatally Diagnosed Uropathies


M. K. RICKWOOD AND I. REINER, Department of Paediatric Urology, Royal Liverpool Children's Hospital (Alder Hey), Liverpool, England

Brit. J. Urol., 68: 541-542, 1991 Among a series of 312 patients with prenatally diagnosed

uropathies, 4 male children developed urinary calculi at ages varying from 2 to 5 years. All had upper urinary tract dilatation not associated with vesicoureteric reflux or with renographically defined obstruction; 3 followed Proteus urinary infections. Strategies for prevention are discussed.

Editorial Comment: Among a group of 312 infants with prenatally diagnosed neuropathy 51 patients had supravesical obstruction, 40 had vesicoureteral reflux and 39 had nonrefluxing nonobstructive upper tract dilatation. No patient in the first 2 groups had stones but 4 in the last group had urinary calculi. In addition, 4 patients had a Proteus urinary tract infection. The prevalence of stone disease in this group of patients is much higher than expected. The antecedent cause is a Proteus infection. The authors suggest that there may be a role for early circumcision, which reduces the chance of urinary tract infection within the first year of life. Mani Menon, M.D.

Hyperoxaluria in Patients With Recurrent Calcium Oxalate Calculi: Dietary and Other Risk Factors

N. A.

LAMINSKI, A. M. MEYERS, M. KRUGER, M. I. SONNEKUS AND L. P. MARGOLIUS, Metabolic Stone Clinic and Depart-

ments of Medicine and Dietetics, Johannesburg Hospital, Johannesburg, South Africa Brit. J. Urol., 68: 454-458, 1991 The presence of mild hyperoxaluria in recurrent calcium oxalate stone formers is controversial. The aim of this study was to identify recurrent stone formers with mild hyperoxaluria and to classify them further by assessing their response to a low oxalate diet. In addition, the prevalence of other risk factors for stone formation in this group of patients was investigated. A total of 207 consecutive patients with recurrent renal calculi were screened and 40 (19%) were found to have mild hyperoxaluria. Of these, 18 (45 %) responded to dietary oxalate restriction by normalising their urinary oxalate. The remaining 22 patients were classified as having idiopathic hyperoxaluria and were subdivided into those in whom urinary oxalate excretion was consistently elevated in all specimens measured and those in whom the elevation was intermittent in nature. Dietary oxalate restriction had a partially beneficial effect in lowering oxalate excretion in the patients with persistent hyperoxaluria. No difference in urinary oxalate excretion was found after dietary restriction in the patients with intermittent hyperoxaluria. Other risk factors, including dietary, absorptive and renal hypercalciuria and hypocitraturia, were documented, the prevalence of which (65 %) was not significantly different from that (62.5%) found in 40 age- and sex-matched calcium stone formers without hyperoxaluria. The prevalence of hyperuricosuria was significantly greater in patients with hyperoxaluria when compared with stone controls. Further studies are required to elucidate the underlying mechanisms of hyperoxaluria in recurrent stone formers. Editorial Comment: This study examined metabolic abnormalities in 207 consecutive patients with recurrent calcium oxalate stone disease. Approximately onefifth of the patients had mild hyperoxaluria, which was corrected with dietary calcium restriction in about half of the cases. Of the patients with hyperoxaluria 77%


had additional risk factors for i,tone formation, such as h.ypercalciuria, hypeiru:dcosuria or hypocit:raturia, The prevalence of associated metabolic abnormalities was not significantly different from that seen in stone formers without hyperoxaluria. Mani Menon, M.D.

National High Blood Pressure Education Program (NHBPEP) Review Paper on Complications of Shock Wave Lithot:ripsy for Urinary Calculi

L. H.



Nephrology and Urology, Mayo Medical School and Clinic, Rochester, Minnesota; University of Arizona, Arizona Medical Center, Tucson, Arizona; Division of Hypertension and Nephrology, Cleveland Clinic and Division of Urology, Case Western Reserve University, Cleveland, Ohio; Institute for Kidney Stone Disease, Methodist Hospital of Indiana, Indianapolis, Indiana, and Division of Urology, Southwestern Medical School, Dallas, Texas


DMSA). Twenty kidneys were treated, and the 19 contralateral kidneys were without stone disease (1 patient had a single kidney). The absolute kidney uptake of Tc-DMSA in the normal kidneys was 21.4% ± 6.2% before and 22.2% ± 6.4% after EPL. For the treated kidneys the absolute update was 16.8% ± 5.3% and 16.8% ± 4.7% before and after, respectively. There was no statistical significant difference between pre- and posttreatment values. The absolute kidney uptake was significantly lower (p < 0.01) in the treated than in the normal kidneys. This study indicates that the EPL procedure did not cause any damage to cortical function detectable by the DMSA uptake. Editorial Comment: A total of 20 patients with renal stones was treated with the EDAP LT-01 piezoelectric lithot:ripto:r. Individual renal uptake of 99 mTc-DMSA was measured using quantitative single photon emission computerized tomography before and 24 to 72 after piezoelectric lithotripsy. The absolute uptake of 99 "'Tc-DMSA in the treated kidneys was 16.8% before and after lithotripsy. The study indicates that piezoelectric lithotripsy did not cause detectable renal cortical damage. Mani Menon, M.D"

Amer. J. Med., 91: 635-641, 1991 This decade has witnessed dramatic advances in the surgical management of urinary calculi. Today, most stones can be removed by minimally invasive means. In fact, the treatment of choice in 60% to 90% of patients with renal and ureteral calculi that need to be surgically removed is extracorporeal shock wave lithotripsy (ESWL). This article reviews indications for ESWL and discusses deleterious effects of ESWL. Editorial Comment: This review of the complications of ESWL * in the treatment of urinary calculi is a concise summary of the indications for as well as the deleterious effects of ESWL. In particulat, the article contains a comprehensive analysis of the occurrence of new onset hypertension. after ESWL. Mani Menon, M.D.

RENAL TUMORS, RETROPERITONEUM, URETER, AND URINARY DIVERSION AND RECONSTRUCTION Inactivation of the Retinoblastoma Gene in Human Bladder and Renal CeH Carcinomas


ISHIKAWA, H.-J. Xu, 8.-X. Hu, D. W. YANDELL, S. MAEDA, S. KAMIDONO, W. F. BENEDICT AND R. TAKAHASHI, The Center for Biotechnology, Baylor College of Medicine, The Woodlands, Texas; Department of Ophthalmology, Harvard Medical School, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, and Departments of Pathology and Urology, Kobe University School of Medicine, Kobe, Japan

Cancer Res., 51: 5736-5743, 1991 Effect of Extracorpo:real Piezoelectric Lith.otripsy Shock Waves on Renal Function Measured by Tc99m~ DMSA Using SPECT D. GROSHAR, J. GINESSIN, B. Mos:irnvrrz, A. FRENKEL, 0. ISRAEL, D. R. LEV!N AND D. FRONT, Division of Nuclear Medicine, Rebecca Sieff Government Hospital, Safed, and Departments of Nuclear Medicine and Urology, Rambam Medical Center, and Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel

Urology, 38: 537-539, 1991 Extracorporeal shock-wave lithotripsy has altered the therapeutic approach to urinary stone disease. Recently, a method was developed in which shock-wave generation is obtained piezoelectrically. To evaluate the effect of extracorporeal piezoelectric lithotripsy (EPL) on renal function, 20 patients were studied prior to and after EPL of renal calculi. Renal cortical function was evaluated by using a previously described and validated quantitative single photon emission computerized tomography (SPECT) method to measure individual absolute uptake of technetium-99m dimercaptosuccinic acid (Tc-99m-

* Dornier Medical Systems, Inc., Marietta, Georgia.

The retinoblastoma (RB) gene was the first tumor suppressor gene isolated and its inactivation is associated with the pathogenesis of several types of human cancer. In this study, we investigated the involvement of the RB gene in bladder and renal cell carcinomas by determining the loss of heterozygosity (LOH) at the RB locus and by DNA, RNA, and protein analysis of the RB gene. Whenever possible, the latter included Western blotting and immunohistochemical staining of the RB protein. In bladder carcinoma, 2 of the 8 cell lines we studied had an inactivated RB gene; one cell line lacked RB expression without a gross RB deletion, whereas the other cell line expressed only the underphosphorylated form of the RB protein. None of 16 low-grade noninvasive bladder carcinomas showed an alteration in RB protein by direct Western blot analysis, whereas 2 of 14 high-grade, invasive tumors had no RB protein as measured by both Western blotting and immunohistochemical staining. This suggests that the loss of RB function may be more important in the progression of bladder cancer than in its initiation, although more extensive studies are required. LOH within the RB locus was observed in 5 of 27 informative cases of primary bladder, ureter, or renal pelvis carcinoma. However, none of the 5 cases with LOH at the RB locus had a functional loss of RB protein expression. In renal cell carcinoma, one of