Extracorporeal shock wave lithotripsy for urolithiasis. Experience with 3000 patients

Extracorporeal shock wave lithotripsy (ESWL) has dramatically changed the current therapeutic spectrum for urolithiasis and is currently the frontline modality for most upper tract calculi. We report our experiences of treating 3000 patients of urinary calculus disease with shock wave therapy on the Siemens Lithostar at our institution. There were 1350 patients with ureteric stones and 73 had vesical calculi. 20.2% patients had recurrent stones and 25.6% had associated medical disorders. The calculus size varied from 4-115 mm. 81 patients had coexisting congenital upper tract anomalies and 84 had a solitary kidney. General anesthesia was required in 4.1%. Pre ESWL auxiliary procedures were necessary in 96.4% with JJ stenting in 2852 patients. The overall 6-month stone free rate was 86.8% with major complication rate of 0.8%.

A comparative study of cystolithotripsy and extracorporeal shock wave therapy for bladder stones

This study compares the safety and efficacy of mechanical cystolithotripsy (MCLT) and extracorporeal shock wave lithotripsy (ESWL) in the treatment of vesical stones. In the last four years we have treated 144 bladder lithiasis patients with MCLT (86; group A) and ESWL (58; group B). All patients in group A were treated under spinal anaesthesia while 47 patients in group B needed intravenous sedation. The early complication rates in groups A and B were 19.7 and 6.8%, respectively. The corresponding mean hospital stay was 60 and 18 hours. ESWL should be considered as an effective, safe and least invasive alternative to MCLT in the therapeutic options for vesical lithiasis.

Adrenal tumor complicating untreated 21-hydroxylase deficiency in a 5 1/2-year-old boy

OBJECTIVE

A 5 1/2-year-old boy presenting with virilization was diagnosed as having classic 21-hydroxylase deficiency complicated by an adrenal tumor. We attempted to document a reduction in the size of the tumor with glucocorticoid therapy.

DESIGN

Case study.

SETTING

Referral center.

INTERVENTION

Glucocorticoid therapy was instituted for congenital adrenal hyperplasia. Surgery for the adrenal mass was deferred, and the size of the mass was monitored by serial ultrasonography.

RESULTS

Baseline values of serum 17 alpha-hydroxyprogesterone (186.6 nmol/L) and testosterone (24.7 nmol/L [7.1 ng/mL]) were elevated. After instituting steroid treatment, 17 alpha-hydroxyprogesterone was suppressed (13.0 nmol/L), and testosterone remained undetectable on follow-up. However, the size of the mass increased during 6 months. Unilateral adrenalectomy performed at that time revealed a well-encapsulated adenoma in a hyperplastic gland.

CONCLUSIONS

Untreated classic congenital adrenal hyperplasia may be complicated by an adrenal tumor even at a young age. Suppression of adrenal androgens by glucocorticoid therapy was not accompanied by regression of the tumor in our patient.

Urethral steinstrasse--clinical experience and radiographic findings

Urethral steinstrasse is rare and requires immediate intervention. The radiographic and cystoscopic findings in two patients with urethral steinstrasse are described.

Pan proximal migration of ureteral stent: case report

The upward migration of double J stent is rare. We recently had the opportunity to study one case with complete proximal migration of "double coil" JJ stent, a situation not previously described to our knowledge.

Extracorporeal shock wave lithotripsy for vesical lithiasis: initial experience

The classical treatment for vesical lithiasis consists of surgery or endoscopic transurethral disintegration. These procedures require anaesthesia and hospitalisation. We report our experience with the Siemens Lithostar in 18 male patients with bladder stones. Complete fragmentation was achieved after a single session in 14 patients and 4 required 2 sessions. A 3-way Foley catheter with saline irrigation was used during treatment. Patients were treated in the prone position followed by immediate evacuation of stone fragments in 9 cases. Morbidity was minimal. Two patients developed impacted fragments and required stone retrieval. Extracorporeal shock wave lithotripsy (ESWL) for vesical lithiasis appears to be a simple, well tolerated and effective form of treatment.

Urolithiasis with blind-ending ureteral duplication and azotemia treated with shock wave therapy

A case of bilateral urolithiasis and renal insufficiency with a blind-ending branch of the right bifid ureter is presented. The diagnosis was made by retrograde ureterogram which revealed a blind-ending branch originating in the middle third of the right ureter. Stones were treated with phased extracorporeal shock wave lithotripsy after preliminary bilateral JJ stenting. The renal parameters reverted to normal and the patient was stone-free.

Calculus disease in duplex system--role of extracorporeal shockwave lithotripsy

We report 8 patients with urolithiasis in a duplex system. These patients (7 males and 1 female) underwent 16 extracorporeal shock wave lithotripsy (ESWL) treatments. Five had renal and 3 had ureteral stones. The mean stone size was 21 mm (12-54 mm). Five patients had incomplete and 3 had complete duplication, of which one had an associated horseshoe kidney. Retrograde ureteropyelography was done in all the patients and in 7 a JJ stent was inserted. The JJ stent could not be inserted in 1 patient with incomplete duplication and retrograde catheterization with saline infusion was used as an auxiliary procedure. One patient with complete duplication had stones in both the ipsilateral ureters with a stone bulk of 54 mm and required two JJ stents. Only 1 paediatric patient required general anaesthesia. The 3-month stone-free rate was 100%.

Renal milk of calcium: review of the literature and report of 5 cases

To our knowledge only a few cases of renal milk of calcium have been reported. We have encountered 5 such patients. The diagnosis depends upon the demonstration of half-moon-shaped calcification in the lateral decubitus or upright roentgenograms. This condition should be differentiated from a renal calculus to avoid unwarranted surgery or extracorporeal shock wave lithotripsy.

Severe hypoglycemia in youth with insulin-dependent diabetes mellitus: frequency and causative factors

Hypoglycemia is the most common acute complication of insulin-dependent diabetes mellitus, yet data are sparse concerning its frequency and the factors that predispose children and adolescents to its occurrence. This study was undertaken, during a 2-year period, to determine the frequency of severe hypoglycemia and to identify its causative factors in 196 youth with insulin-dependent diabetes mellitus (mean age and duration of diabetes, 13.5 +/- 4.3 and 4.8 +/- 3.2 years, respectively) treated conventionally. The mean daily insulin dose was 0.85 +/- 0.23 U/kg, and 92% of patients received insulin twice daily. Severe hypoglycemia occurred at least once in 2 years in 29 of 196 (14.8%) patients, of whom 9 (31%) had two or more episodes. The mean level of glycosylated hemoglobin closest to the event was significantly lower than that of patients who did not have severe hypoglycemia, 10.6 +/- 1.8 vs 11.4 +/- 2.0, P less than .02; however, the mean insulin dose, 0.88 +/- 0.19 vs 0.85 +/- 0.23 U/kg every 24 hours, was similar. Severe hypoglycemia occurred with equal frequency during waking and sleeping, and it was not related to the species of insulin used. The use of human insulin, per se, did not increase the risk of severe hypoglycemia. Asymptomatic hypoglycemia was reported significantly more often in those who experienced severe hypoglycemia, 24% vs 8%, P = .01. Severe hypoglycemia was common (12.2 episodes per 100 patient-years), and symptomatic hypoglycemia universal in youth with insulin-dependent diabetes mellitus treated with conventional insulin therapy. Approximately two thirds of episodes were attributable to lapses in the application of basic principles of diabetes self-care.

Seroepidemiological study of leprosy in a highly endemic population of south India based on an ELISA using synthetic PGL-I

As part of a continuing longitudinal immuno-epidemiological study, blood samples were collected by finger prick from 4243 individuals living in a highly endemic area for leprosy in South India. The samples were tested for IgM antibodies against phenolic glycolipid-I using an ELISA. Seropositivity defined as optical density greater than or equal to 0.2000 was marginally higher in the age group 10-30 years and in females. There was no evidence for a higher level in contacts than in non-contacts. The future prospect for the large scale use of this ELISA in high-endemic populations in special epidemiological investigations or routine control programs as a serological tool to detect leprosy infection appears questionable.

Extraintestinal manifestations of idiopathic ulcerative colitis

One hundred and fifty patients of idiopathic ulcerative colitis were studied for extraintestinal manifestations by clinical, radiological and biochemical means. One or more such manifestations occurred in 34.7% of patients. Sacroiliitis (14%) and peripheral arthritis (10.7%) were the commonest manifestations, followed by ocular (8%), mucocutaneous (2.7%), vascular (2%) and hepatobiliary (1.3%) manifestations. We conclude that the incidence and spectrum of extraintestinal manifestations in Indian patients with idiopathic ulcerative colitis are similar to those in western patients.

An apparent cluster of congenital hypopituitarism in central Massachusetts: magnetic resonance imaging and hormonal studies

Between 1980 and 1989, five infants (four males and one female) with congenital hypopituitarism were born within a relatively sparsely populated area of central Massachusetts, an incidence 25-fold greater than expected. In all infants the pituitary stalk was undetectable on magnetic resonance imaging, and a bright spot on T-1 weighted imaging, probably representing posterior pituitary tissue, was found ectopically located inferior to the median eminence. The height of the anterior pituitary remnant on magnetic resonance imaging varied from undetectable to 4 mm, and similarly, on hormonal testing a spectrum of deficiencies of GH, TSH, ACTH, and gonadotropin was observed. The magnitude of the hypopituitarism was less in the three patients whose anterior pituitary remnant was greater than 2 mm, and in them, TRH testing resulted in exaggerated TSH and PRL responses, suggestive of hypothalamic disease. In contrast, in the other two patients in whom the anterior pituitary remnant was less than 2 mm in height, hypopituitarism was more severe, and TRH administration resulted in little if any TSH or PRL response, characteristic of pituitary disease. The size of the anterior pituitary remnant correlated significantly with that of the ectopic posterior pituitary bright spot (P less than 0.005). We conclude that patients with congenital hypopituitarism may exhibit a spectrum of hormonal responses, varying from findings typical of hypothalamic to those characteristic of primary pituitary disease. The pattern of hormonal responsiveness is dependent on the quantity of residual anterior pituitary tissue and probably results from abnormal transport of the hypothalamic hypophyseal releasing hormones rather than to any putative hypothalamic abnormality. The significant correlation between the size and function of the anterior pituitary gland and the size of the ectopic posterior pituitary remnant suggests that the fetal pituitary gland may secrete a factor necessary for the growth and descent of the neuroepithelium to form the infundibulum and posterior pituitary gland.

Association of Candida with carcinoma of esophagus

Twenty-five patients with carcinoma of the esophagus (group I) and 25 patients suffering from non-ulcer dyspepsia with normal endoscopy (group II) were studied to know the incidence of isolation of Candida from their esophagus. Endoscopic brushings were taken from the esophagus in both groups and studied by smear examination and culture. Fungal organisms could be detected in 75% of cases of group I and 32% of cases of group II by culture techniques, and 45.8% and 12% respectively by smear examination. The difference was statistically significant (p less than 0.05) for both the techniques. Candida albicans was the commonest species isolated. No correlation was found between Candida agglutination titres and density of Candida growth on culture. We conclude that an association exists between carcinoma esophagus and the occurrence of Candida in the esophagus.

Retroiliac ureter with contralateral transverse malrotation of kidney: treated by crossed ureterocaliceal anastomosis

We report a case of congenital bilateral urinary tract anomalies presenting as an abdominal mass with chronic renal failure. The anomalies comprised a retroiliac ureter with grade IV vesicoureteral reflux on the right side, which resulted in a nonfunctioning pyonephrotic right kidney, and a transversely malrotated hydronephrotic left kidney with a calculus. An initial attempt to improve the drainage of the left kidney by posterior transposition of the ureter failed. Subsequently, right nephrectomy and crossed ureterocaliceal anastomosis with the right ureter were performed. The reflux was treated by a ureteral tunnel advancement technique.