A model to guide patient selection when managing ureteric stones with shockwave lithotripsy

Introduction:

The aim of this study was to create a model based upon significant prognostic factors to guide patient selection for shockwave lithotripsy.

Patients and methods:

We identified 150 patients attending for shockwave lithotripsy for ureteric stones between October 2010–February 2016. Data was collected retrospectively from electronic case notes and radiological images. All patients were treated with an on-site Storz Modulith SLX-F2 lithotripter. A model was created using computer software ‘R’.

Results:

One hundred and thirty-three patients were treated and 66% of those were deemed radiologically stone-free with shockwave lithotripsy. Four factors were found to be independently statistically significant with regards to stone-free status; age ( p=0.003), Hounsfield units ( p=0.002), prior nephrostomy insertion ( p=0.022) or prior stent insertion ( p=0.002). Our resulting model is:[Formula: see text]

Discussion and conclusions:

Our shockwave lithotripsy success would likely increase with improved patient selection. Age appears to be a novel significant factor in stone passage. This is an interesting observation worthy of further study given ageing populations in the developed world. The model will require further validation in order to confirm our findings, however the results have proven very encouraging.

Level of evidence:

2c

Role of coagulation factors in urological malignancy: A prospective, controlled study on prostate, renal and bladder cancer

OBJECTIVES

To study the behavior of specific coagulation factors in different types of non-metastatic urological cancers, and to identify their possible role as diagnostic and prognostic markers.

METHODS

This was a prospective controlled study, which included three cancer patient groups and a control group of healthy individuals. The cancer subgroups consisted of renal (n = 44), prostate (n = 56) and bladder cancer (n = 47). We excluded patients receiving anticoagulant therapy, or with significant comorbidity. In all patients, certain coagulation parameters were measured (prothrombin time, international normalized ratio, partial thromboplastin time, D-dimers, fibrinogen, F1 + 2, thrombin-antithrombin complex). Statistical analysis was carried out to explore the association of hemostasis markers with tumor-nodes-metastasis stage, Gleason score, transitional cell carcinoma grade, Fuhrman grade and prostate-specific antigen.

RESULTS

Our final sample consisted in 58 control patients and 147 patients with urological cancer. We found specific patterns of increased coagulation factors in the different cancers that were statistically significant. Renal cancer showed increased levels of D-dimers, partial thromboplastin time and fibrinogen. D-dimers and fibrinogen were increased in prostate cancer; whereas in bladder cancer, only fibrinogen was elevated. Correlations were found between certain factors and tumor stage and grading, with D-dimers being independently associated with higher tumor grade. Thrombin-antithrombin complex was associated with Gleason score. Furthermore, D-dimers, fibrinogen and F1 + 2 were associated with higher tumor stages (II-IV).

CONCLUSIONS

The coagulation pathway seems to be activated in urological malignancies. Specific panels of coagulation factors might play a role as screening or prognostic tools in earlier stages of renal, prostate and bladder cancer. Further research should also focus on their role in the association of cancer with thromboembolic events.

Idiopathic spontaneous perforation of the upper urinary tract. A presentation of 4 cases

Spontaneous perforation of the collecting system constitutes a rare entity masked by the presentation of a typical renal colic. However, it should not be forgotten when managing patients with colic, since missed diagnoses may carry significant morbidity. We herein present a series of spontaneous perforation of the collecting system without an apparent obstruction site evident in helical CT urography. Four consecutive patients who presented with typical renal colic were initially subjected to KUB and renal ultrasound imaging and were ultimately diagnosed with perforation of the collecting system via contrast enhanced- helical CT urography. Despite thorough evaluation, the cause responsible obstructive was not discovered and an exclusion diagnosis of idiopathic collecting system perforation was assigned to all patients. Due to the rarity of a spontaneous perforation traditional retrograde urography was performed in an effort to identify the possible cause but was also unrevealing. All patients were successfully treated with endourological means. Perforation of the collecting system without an evident obstructive cause is a rare entity with obscure etiology. A reasonable but yet unconfirmed speculation is that of a transient obstruction capable of a significant increase of intraluminal pressures.

A rare case of a 39 year old male with a parasite called Dioctophyma renale mimicking renal cancer at the computed tomography of the right kidney. A case report

We present a very rare case of a 39 year old patient with Dioctophyma renale depicted as a Bosniak cyst IV of the right kidney who was finally subjected to a robotic assisted radical nephrectomy.

Hereditary hyperferritinaemia cataract syndrome: does it exist in Switzerland?

Recent research in iron metabolism has revealed the existence of iron-responding elements in the 5'UTR of the mRNA of ferritin. Binding of these structures with iron-regulatory proteins regulates ferritin synthesis within the cell, according to the intracellular iron level. Several mutations of the iron-responding elements located at the 5'UTR of the L-ferritin subunit, which lead to the hereditary hyperferritinaemia cataract syndrome, an autosomal dominant hereditary disease, have been described. Patients with congenital bilateral nuclear cataract present high serum ferritin (360-2264 micrograms/l) in the absence of iron overload. The purpose of our study was to look for this syndrome in Switzerland and in particular in the Geneva population. About 3000 cases of cataract operated on during a 4-year period (1995-1998) in the University Clinic of Ophthalmology were screened. We found 135 patients operated on before the age of 51 years. However, only 19 had bilateral nuclear cataract. 15 patients agreed to undergo iron screening. In 2 of them, a slight elevation of ferritin (267 micrograms/l in a female, 416 micrograms/l in a male) was found in the absence of iron overload. In both cases there is a positive family history of cataract. DNA sequencing analysis in these patients showed a normal nucleotide sequence of the whole iron-responding elements region. One of them (male) was found to present the codon 63 mutation at HFE gene in the heterozygous state. Our local study indicates that hereditary hyperferritinaemia cataract syndrome is extremely rare in Switzerland. However, similar studies should be carried out in other regions of the country. Iron status evaluation and ferritin level monitoring should become routine examinations in all new cases presenting with bilateral nuclear cataract before the age of 50 years.

Thrombus and branch retinal vein occlusion

Branch retinal vein occlusion (BRVO) is often associated with arteriosclerosis. Typically the occlusion occurs at an arteriovenous crossing. We report a case of a previously healthy patient who developed a BRVO. Funduscopy and fluorescein angiography suggested an intravascular thrombus as the cause of the occlusion. The investigations performed were positive for systemic hypertension and hyperlipidaemia. After 2 months, fundus examination revealed disappearance of the intravascular thrombus, resolution of the macular edema and improvement of the visual acuity. Certain physiological characteristics of the retinal circulation associated with hyperlipidaemia and systemic hypertension appear to favour thrombus formation.

Current management of duplex-system ureteroceles: experience with 41 patients

Experience is described of 41 infants and children with duplex-system ureteroceles, 25 presenting clinically and 16 by prenatal ultrasonography. Bladder outflow obstruction was rare but lower polar vesicoureteric reflux (VUR), usually of lesser grades, was common. Upper polar function, as assessed by 99mTc-DMSA, was negligible in children with truly ectopic ureteroceles but well preserved in those where the lesion lay wholly intravesically. Lower polar function was good, even in the presence of secondary obstruction, except in 2 infants with major VUR. Twenty-three patients were treated by upper polar nephrectomy plus aspiration of the ureterocele; 2 subsequently required ureterocele excision. Histology of excised specimens indicated that a more conservative approach would not have been rewarded. Where upper polar function was good, conservation was maintained in 3 cases by pyelopyelostomy and in 5 more by excision of the ureterocele plus bipolar ureteric reimplantation. Other operative strategies were employed in 2 cases. Finally, a defined group of 8 children was managed expectantly without untoward results. It was concluded that the variable anatomy and function associated with duplex-system ureteroceles require a flexibile approach to treatment, including, possibly, no treatment at all.

[Diabetic retinopathy]

The risk of blindness in diabetes may be significantly reduced by a suitable ophthalmic therapy. In order to apply this therapy in due time to the population at risk, all diabetics should be referred to ophthalmological follow-up examination at regular intervals. A rapid progression of a retinopathy may occur in young patients, especially during puberty and pregnancy, after change from oral antidiabetics to insulin and, temporarily, following strict control of blood glucose. Besides normoglycemia, the prevention of a high blood pressure is an important prerequisite of an efficient treatment of diabetic retinopathy. Retinal photocoagulation has been proven the most effective mode of therapy. The correct indication and stage-depending dosage of retinal laser coagulation in diabetes is a demanding task which should be reserved to well-trained specialists in this field. Diabetic vitreous bleeding and retinal traction detachment are complications of advanced proliferative diabetic retinopathy, which can be treated successfully in 60-70% of the cases by modern techniques of vitreoretinal surgery.

[Ocular venous thrombosis and general vascular pathology]

A retrospective study was carried out covering 100 patients hospitalized at the Geneva Ophthalmological Clinic between 1973 and 1977, in whom an occlusion of the central retinal vein or one of its branches had been diagnosed. An attempt was made to assess the significance of the occurrence of venous occlusion and the relation between the angiographic fundus aspect, the general pathology, and the survival prognosis. The patients still alive were examined between 1982 and 1983, and the occurrence of general vascular pathology was compared with a control group. The results of this study indicate the important role played by arterial pathology (hypertension, arteriosclerosis, diabetes) in the pathogenesis of retinal vein occlusion. It was found that patients presenting an ischemic type of venous occlusion were in a higher risk category as regards the development of cardiac or cerebral ischemia.

[The influence of PCO2 on the localized ERG in the perfused frog retina (author's transl)]

The increase of PCO2 inhibits the averaged ERG in monkeys. Recordings with microelectrodes of the local ERG in the inner and outer plexiform layers of the perfused frog retina (rana ridibunda) revealed that the effect of CO2 was already present at the first synaptic transmission point in the retina, i.e., between photoreceptors and bipolar cells.

[The metabolic regulation of the retinal blood flow and the role of prostaglandins (author's transl)]

The microioptophoretic injection of PGE1 close to the retinal arterioles procedures a segmental vasodilatation of 40%. The inhibition of prostaglandin synthesis with indomethacin or aspirin blocks the vasodilatatory effect of hypercapnia and, to a lesser extent, of hypoxia. These results suggest that prostaglandins play a role in the regulation of retinal vasomotor activity.