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Endourology
Urological Survey
Urolithiasis/Endourology ETView Tracheoscopic Ventilation Tube for Surveillance After Tube Position in Patients Undergoing Percutaneous Nephrolithotomy M. Barak, V. Putilov, S. Meretyk and S. Halachmi Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel Br J Anaesth 2010; 104: 501–504.
Background: Tracheal tube (TT) displacement during general anaesthesia may result in life-threatening complications and continuous direct vision of the position of the tube may enable safer management. The ETView tracheoscopic ventilation tube (TVT) is a single-use TT incorporating a video camera and a light source in its tip. The view from the tip appears continuously on a portable monitor in the anaesthetist’s vicinity. This study was designed to test the ETView TVT in monitoring the TT position during general anaesthesia. Methods: In this prospective study, the ETView TVT was used to ventilate the lungs of 30 adult patients undergoing percutaneous nephrolithotomy (PCNL), which required changing patient position three times. During surgery, the anaesthetist followed the carinal view on the ETView TVT portable monitor. Tube movement within 1 cm was recorded, as was the need for repositioning of the tube when the carina was not seen on the camera monitor. Results: During anaesthesia, tiny movements synchronous with heart beats and lung ventilation were observed. Tube movement of 1 cm was detected in eight (26%) patients. In two (7%) patients, the carina was no longer viewed after moving to the lithotomy position and the tube was repositioned. None of the events was associated with changes in oxygen saturation, end-tidal CO(2), or airway pressure. Conclusions: We found that the ETView TVT facilitated surveillance of tube position by providing a clear high-quality view of the carina, throughout PCNL with several changes of patient position. Editorial Comment: Patients undergoing percutaneous nephrostolithotomy typically receive general anesthesia, and there is a risk of displacement of the endotracheal tube with positioning. This displacement could result in right main stem intubation, which may have profound physiological consequences. This device may permit prompt identification of such occurrences. Dean Assimos, M.D.
A Randomized Comparison of Totally Tubeless and Standard Percutaneous Nephrolithotomy in Elderly Patients C. Kara, B. Resorlu, M. Bayindir and A. Unsal Department of Urology, Ministry of Health, Kecioren Training and Research Hospital, Ankara, Turkey Urology 2010; Epub ahead of print.
Objectives: To evaluate the safety, effectiveness, and feasibility of totally (tubeless and stentless) tubeless percutaneous nephrolithotomy (PCNL) in elderly patients. Tubeless PCNL is performed widely in adult patients. Methods: A total of 60 patients with renal stones were enrolled in this study. Patients were randomized to either a totally tubeless approach (group 1, 30 patients) or placement of an 18F nephrostomy tube (group 2, 30 patients). Patients were considered uncomplicated and suitable 0022-5347/10/1844-1377/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Vol. 184, 1377-1380, October 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.06.063
www.jurology.com
1377
1378
UROLITHIASIS/ENDOUROLOGY
for randomization at the end of the operation if there was no significant bleeding or residual stone, and the pelvicaliceal system was intact. The incidence of complications, hospital stay, analgesic requirements, and stone-free rates were compared in 2 groups. Results: The mean age of the patients at receipt of the surgical procedure was 67.7 years (range, 60 –77) vs 66.5 years (range, 61–74), respectively. The mean stone size was 25.6 vs 22.3 mm and stone-free rate was 86% vs 83% for group 1 and 2, respectively (P ⬎ .05). The mean hospitalization time was 1.5 and 3.2 days (P ⬍ .001), the mean analgesia requirement (pethidine HCl) was 0.5 and 1.4 mg/kg, respectively (P ⬍ .01). Decrease in hematocrit was similar in 2 groups. No blood transfusions were needed. Conclusions: Totally tubeless PCNL is safe and effective procedure even in elderly patients with renal stones. The hospitalization and analgesic requirements are less than standard PCNL. However, the tubeless decision should be taken intraoperatively in selected patients. Editorial Comment: Tubeless percutaneous nephrostolithotomy is becoming more popular. The key for success is proper patient selection. Dean Assimos, M.D.
Intra-Tubular Deposits, Urine and Stone Composition are Divergent in Patients With Ileostomy A. P. Evan, J. E. Lingeman, F. L. Coe, S. B. Bledsoe, A. J. Sommer, J. C. Williams, Jr., A. E. Krambeck and E. M. Worcester Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana Kidney Int 2009; 76: 1081–1088.
Patients with ileostomy typically have recurrent renal stones and produce scanty, acidic, sodium-poor urine because of abnormally large enteric losses of water and sodium bicarbonate. Here we used a combination of intra-operative digital photography and biopsy of the renal papilla and cortex to measure changes associated with stone formation in seven patients with ileostomy. Papillary deformity was present in four patients and was associated with decreased estimated glomerular filtration rates. All patients had interstitial apatite plaque, as predicted from their generally acid, low-volume urine. Two patients had stones attached to plaque; however, all patients had crystal deposits that plugged the ducts of Bellini and inner medullary collecting ducts (IMCDs). Despite acid urine, all crystal deposits contained apatite, and five patients had deposits of sodium and ammonium acid urates. Stones were either uric acid or calcium oxalate as predicted by supersaturation, however, there was a general lack of supersaturation for calcium phosphate as brushite, sodium, or ammonium acid urate because of the overall low urine pH. This suggests that local tubular pH exceeds that of bulk urine. Despite low urine pH, patients with an ileostomy resemble those with obesity bypass, in whom IMCD apatite crystal plugs are found. They are, however, unlike these bypass patients in having interstitial apatite plaque. IMCD plugging with sodium and ammonium acid urate has not been found previously and appears to correlate with formation of uric acid stones. Editorial Comment: Patients with bowel disease, including those with ileostomy, are at risk for stones, typically calcium oxalate and uric acid, as reported by these investigators. This group has previously characterized the histological phenotype of several different categories of stone formers. These cases had some of the characteristics of idiopathic calcium oxalate stone formers (interstitial apatite plaque) and jejunoileal bypass cases (intratubular apatite plugging). Measurement of pH within the tubules of these patients should be considered to assess if there is a disconnect between pH in this area and that in the collecting system. Dean Assimos, M.D.
Urolithiasis/Endourology ETView Tracheoscopic Ventilation Tube for Surveillance After Tube Position in Patients Undergoing Percutaneous Nephrolithotomy M. Barak, V. Putilov, S. Meretyk and S. Halachmi Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel Br J Anaesth 2010; 104: 501–504.
Background: Tracheal tube (TT) displacement during general anaesthesia may result in life-threatening complications and continuous direct vision of the position of the tube may enable safer management. The ETView tracheoscopic ventilation tube (TVT) is a single-use TT incorporating a video camera and a light source in its tip. The view from the tip appears continuously on a portable monitor in the anaesthetist’s vicinity. This study was designed to test the ETView TVT in monitoring the TT position during general anaesthesia. Methods: In this prospective study, the ETView TVT was used to ventilate the lungs of 30 adult patients undergoing percutaneous nephrolithotomy (PCNL), which required changing patient position three times. During surgery, the anaesthetist followed the carinal view on the ETView TVT portable monitor. Tube movement within 1 cm was recorded, as was the need for repositioning of the tube when the carina was not seen on the camera monitor. Results: During anaesthesia, tiny movements synchronous with heart beats and lung ventilation were observed. Tube movement of 1 cm was detected in eight (26%) patients. In two (7%) patients, the carina was no longer viewed after moving to the lithotomy position and the tube was repositioned. None of the events was associated with changes in oxygen saturation, end-tidal CO(2), or airway pressure. Conclusions: We found that the ETView TVT facilitated surveillance of tube position by providing a clear high-quality view of the carina, throughout PCNL with several changes of patient position. Editorial Comment: Patients undergoing percutaneous nephrostolithotomy typically receive general anesthesia, and there is a risk of displacement of the endotracheal tube with positioning. This displacement could result in right main stem intubation, which may have profound physiological consequences. This device may permit prompt identification of such occurrences. Dean Assimos, M.D.
A Randomized Comparison of Totally Tubeless and Standard Percutaneous Nephrolithotomy in Elderly Patients C. Kara, B. Resorlu, M. Bayindir and A. Unsal Department of Urology, Ministry of Health, Kecioren Training and Research Hospital, Ankara, Turkey Urology 2010; Epub ahead of print.
Objectives: To evaluate the safety, effectiveness, and feasibility of totally (tubeless and stentless) tubeless percutaneous nephrolithotomy (PCNL) in elderly patients. Tubeless PCNL is performed widely in adult patients. Methods: A total of 60 patients with renal stones were enrolled in this study. Patients were randomized to either a totally tubeless approach (group 1, 30 patients) or placement of an 18F nephrostomy tube (group 2, 30 patients). Patients were considered uncomplicated and suitable 0022-5347/10/1844-1377/0 THE JOURNAL OF UROLOGY® © 2010 by AMERICAN UROLOGICAL ASSOCIATION EDUCATION
AND
RESEARCH, INC.
Vol. 184, 1377-1380, October 2010 Printed in U.S.A. DOI:10.1016/j.juro.2010.06.063
www.jurology.com
1377
1378
UROLITHIASIS/ENDOUROLOGY
for randomization at the end of the operation if there was no significant bleeding or residual stone, and the pelvicaliceal system was intact. The incidence of complications, hospital stay, analgesic requirements, and stone-free rates were compared in 2 groups. Results: The mean age of the patients at receipt of the surgical procedure was 67.7 years (range, 60 –77) vs 66.5 years (range, 61–74), respectively. The mean stone size was 25.6 vs 22.3 mm and stone-free rate was 86% vs 83% for group 1 and 2, respectively (P ⬎ .05). The mean hospitalization time was 1.5 and 3.2 days (P ⬍ .001), the mean analgesia requirement (pethidine HCl) was 0.5 and 1.4 mg/kg, respectively (P ⬍ .01). Decrease in hematocrit was similar in 2 groups. No blood transfusions were needed. Conclusions: Totally tubeless PCNL is safe and effective procedure even in elderly patients with renal stones. The hospitalization and analgesic requirements are less than standard PCNL. However, the tubeless decision should be taken intraoperatively in selected patients. Editorial Comment: Tubeless percutaneous nephrostolithotomy is becoming more popular. The key for success is proper patient selection. Dean Assimos, M.D.
Intra-Tubular Deposits, Urine and Stone Composition are Divergent in Patients With Ileostomy A. P. Evan, J. E. Lingeman, F. L. Coe, S. B. Bledsoe, A. J. Sommer, J. C. Williams, Jr., A. E. Krambeck and E. M. Worcester Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana Kidney Int 2009; 76: 1081–1088.
Patients with ileostomy typically have recurrent renal stones and produce scanty, acidic, sodium-poor urine because of abnormally large enteric losses of water and sodium bicarbonate. Here we used a combination of intra-operative digital photography and biopsy of the renal papilla and cortex to measure changes associated with stone formation in seven patients with ileostomy. Papillary deformity was present in four patients and was associated with decreased estimated glomerular filtration rates. All patients had interstitial apatite plaque, as predicted from their generally acid, low-volume urine. Two patients had stones attached to plaque; however, all patients had crystal deposits that plugged the ducts of Bellini and inner medullary collecting ducts (IMCDs). Despite acid urine, all crystal deposits contained apatite, and five patients had deposits of sodium and ammonium acid urates. Stones were either uric acid or calcium oxalate as predicted by supersaturation, however, there was a general lack of supersaturation for calcium phosphate as brushite, sodium, or ammonium acid urate because of the overall low urine pH. This suggests that local tubular pH exceeds that of bulk urine. Despite low urine pH, patients with an ileostomy resemble those with obesity bypass, in whom IMCD apatite crystal plugs are found. They are, however, unlike these bypass patients in having interstitial apatite plaque. IMCD plugging with sodium and ammonium acid urate has not been found previously and appears to correlate with formation of uric acid stones. Editorial Comment: Patients with bowel disease, including those with ileostomy, are at risk for stones, typically calcium oxalate and uric acid, as reported by these investigators. This group has previously characterized the histological phenotype of several different categories of stone formers. These cases had some of the characteristics of idiopathic calcium oxalate stone formers (interstitial apatite plaque) and jejunoileal bypass cases (intratubular apatite plugging). Measurement of pH within the tubules of these patients should be considered to assess if there is a disconnect between pH in this area and that in the collecting system. Dean Assimos, M.D.