Simultaneous combined use of flexible ureteroscopy and percutaneous nephrolithotomy to reduce the number of access tracts in the management of complex renal calculi

OBJECTIVE: To present early experience in managing complex renal calculi using a combined ureteroscopic and percutaneous approach, as complex and branched renal calculi often require multiple access tracts during percutaneous nephrolithotomy (PNL), and the combined use of flexible ureteroscopy and PNL has the potential to reduce the inherent morbidity of several tracts. PATIENTS AND METHODS: The study included seven patients (mean age 54 years) with multiple, branched, large-volume renal calculi suitable for management with PNL. Preoperative data, including patient demographics, stone location and stone surface area, were recorded. After informed consent, the patients underwent combined PNL and ureteroscopy in one session. Intraoperative data, including the location of PNL puncture sites, operative duration and complications, were analysed. Stone-free rates were determined by follow-up imaging at 3 months. RESULTS: All patients had either two or more stones in separate locations in the collecting system, or staghorn stones involving multiple calyces. The mean stone burden was 666 mm(2). All patients had only one percutaneous access tract. The mean operative duration was 142 min and the mean blood loss 79 mL. Two patients had small residual stones (< 3 mm), that required ureteroscopic intervention as they failed to pass spontaneously by 3 months after the initial combined procedure. The convalescence was similar to that in our current PNL practice; imaging showed that five of the patients were stone-free. CONCLUSIONS: Combined PNL and ureteroscopic management can effectively reduce the number of percutaneous access tracts which would otherwise be required for managing complex and branched renal calculi, as stones in an unfavourable location relative to the access tract can be relocated and fragmented within easy reach of the single nephrostomy tract. This manoeuvre reduces potential patient morbidity and blood loss but with no significant effect on stone-free rates and operative durations.     

Percutaneous nephrolithotomy for treating renal calculi in children

OBJECTIVE: To report our experience with the percutaneous management of renal stone disease in children. PATIENTS AND METHODS: The medical and radiological records of children up to 18 years old who were treated for renal calculi by percutaneous nephrolithotomy (PCNL) at our institution between March 1995 and April 2003 were reviewed. For stone removal a special paediatric 18 F access sheath was used. RESULTS: In all, 26 PCNLs were used in 23 patients (10 boys and 13 girls, aged 1.7-16.8 years). The presenting symptoms were urinary tract infection, abdominal pain and/or haematuria. Of the 23 patients, 17 (75%) had associated metabolic disease or underlying urological anatomical abnormalities. Urinary tract infections were found in 15 patients (65%). The mean (range) stone burden was 6.0 (0.5-18.2) cm2, and the operative duration 127 (50-260) min. The primary stone-free rate was 58%, which increased to 81% after treating residual fragments. One blood transfusion was required and one patient developed urosepsis after PCNL, which was treated with antibiotics. CONCLUSION: PCNL is an effective alternative for treating renal stones in children, and is the treatment of choice for stones refractory to extracorporeal shock wave lithotripsy.     

The incidence and treatment of lymphoceles after radical retropubic prostatectomy

OBJECTIVE: To determine the incidence and treatment of lymphoceles after retropubic radical prostatectomy (RP). PATIENTS AND METHODS: Up to January 2004, 260 patients who had a retropubic RP in one institution by one surgeon were assessed retrospectively, using the patients' notes or the computerized results system to determine whether a lymphocele was suspected and then confirmed by imaging studies (computed tomography or ultrasonography). RESULTS: Nine patients developed symptomatic lymphoceles; eight of these were detected by imaging. Four lymphoceles required intervention while the remainder regressed spontaneously. No complications were reported in the group that was treated. CONCLUSION: The rate of symptomatic lymphocele formation was low after RP, with an overall incidence of 3.5%. Ultrasonography was effective in detecting lymphoceles and ultrasonographically guided percutaneous drainage an effective treatment.     

Obesity exacerbates sepsis-induced inflammation and microvascular dysfunction in mouse brain

OBJECTIVE: Obese patients with sepsis have higher morbidity and mortality than lean counterparts, but the mechanisms involved are unknown. The authors examined the inflammatory and thrombogenic responses of the cerebral microvasculature to sepsis induced by cecal ligation and perforation in obese and lean wild-type mice. METHODS: Leukocyte and platelet adhesion in cerebral microvasculature and behavioral responses were measured in wild-type and obese mice 4 h postperforation. P-selectin expression in different vascular beds was assessed 6 h postperforation. The effects of immunoblockade of P-selectin, ICAM-1, and CD18 on leukocyte and platelet recruitment were evaluated in obese septic animals. RESULTS: Cerebral venules of obese and wild-type mice assumed a proinflammatory and prothrombogenic phenotype 4 h post-perforation, with greatly exaggerated responses in obese mice compared to the lean counterparts. These enhanced responses were attenuated by blocking P-selectin, CD18, or ICAM-1. Obese mice also exhibited a more profound behavioral deficit after sepsis, which appears to be unrelated to the recruitment of leukocytes and platelets. Cecal ligation and perforation-induced P-selectin expression was greater in obese mice compared with lean counterparts. CONCLUSIONS: These findings suggest that the increased morbidity to sepsis in obesity may result from exaggerated microvascular inflammatory and thrombogenic responses that include the activation of endothelial cells with subsequent expression of adhesion molecules, such as P-selectin.     

Percutaneous transluminal coronary angioplasty: Analysis of unsuccessful procedures as a guide toward improved results

Technical success in percutaneous transluminal coronary angioplasty (PTCA) is a function of patient selection, operator experience, and the capabilities of the angioplasty equipment employed. When unsuccessful PTCA occurs, it is the result of one several factors: (1) a failure to cross the stenosis: (2) a failure to dilate the stenosis; (3) an ischemic complication; or (4) a late recurrence of the anginal syndrome. In this paper, we discuss the relative frequency of these types of failure, and the ways in which improvements in technique and/or equipment may be employed to improve the chance of a successful procedure.     

Staging systems in hepatocellular carcinoma

Staging systems are key to predict the prognosis of patients with cancer, to stratify the patients according to prognostic variables in the setting of clinical trials, to allow the exchange of information among researchers, and finally to guide the therapeutic approach. The current knowledge of the disease, however, prevents recommendation of a staging system that can be used world-wide. The conventional staging systems for hepatocellular carcinoma (HCC), such as the Okuda stage or the TNM stage have shown important limitations in classifying patients. Several new systems have been proposed recently, and only three of them have been validated at this point. The BCLC staging classification links the stage of the disease to a specific treatment strategy. The JIS score has been proposed and used in Japan, although it needs Western validation. The CLIP score is used in patients with advanced tumors. Several reasons explain the difficulty in identifying a world-wide system. First, HCC is a complex neoplasm inserted on a pre-neoplastic cirrhotic liver, and thus variables of both diseases leading to death should be taken into account. Second, the disease is very heterogeneous around the world, and this reflects different underlying epidemiological backgrounds and risk factors. Third, HCC is the sole cancer treated by transplantation in a small proportion of patients. Fourth, only around 20% of the cases are currently treated by surgery, thus precluding the wide use of pathology-based systems, such as TNM. Finally, the potential relevance of a molecular signature identified in terms of outcome prediction is unknown, and further research is needed to obtain this valuable biological information that may aid in classifying the patients.     

Complications of lumbar puncture in a child treated for leukaemia

Lumbar puncture may lead to neurological complications. These include intracranial hypotension, cervical epidural haematomas, and cranial and lumbar subdural haematomas. MRI is the modality of choice to diagnose these complications. This report documents MRI findings of such complications in a child treated for leukaemia.     

L-asparaginase-induced severe necrotizing pancreatitis successfully treated with percutaneous drainage

L-asparaginase is a key component of the antileukemic therapy in children with acute lymphoblastic leukemia (ALL). Pancreatitis has been noted to be a complication in 2-16% of patients undergoing treatment with L-asparaginase for a variety of pediatric neoplasms. Most cases of pancreatitis associated with L-asparaginase toxicity are self-limiting and respond favorably to nasogastric decompression and intravenous hyperalimentation. However, in rare instances, hemorrhagic pancreatitis or necrosis may occur. L-asparaginase-induced pancreatitis is an uncommon but potential lethal complication of the treatment of leukemia. We present a pediatric patient with leukemia and a severe, L-asparaginase-induced necrotizing pancreatitis, treated successfully with percutaneous drainage used to flush the infected necrotic parts.     

Double microcatheter technique for endovascular coiling of wide-neck aneurysms using a new guiding device for the transcarotid approach: technical note

In the endovascular treatment of cerebrovascular diseases, positioning the guiding catheter is of great importance. In cases where vessel tortuosity prohibits positioning the guiding catheter in the carotid artery via the femoral approach, we use a direct carotid approach via common carotid artery puncture. For direct puncture of the common carotid artery we devised a 6-Fr sheath with double insertion points. This new device facilitates the use of double microcatheters and provides safe and effective vascular access.