The use of noxythiolin (Noxyflex 'S') as an antiseptic irrigant in upper urinary tract drainage following percutaneous nephrolithotomy

Percutaneous nephrostomy drainage for the relief of obstruction or stone removal has become a common procedure. Despite the routine use of prophylactic antibiotics, nephrostomy urine frequently becomes infected (approximately 30% of cases). Noxythiolin irrigation has been used to prevent and treat bladder infections. A double-blind, placebo controlled study was carried out in 20 patients undergoing a single-stage percutaneous nephrolithotomy to evaluate the use of noxythiolin as an upper urinary tract antiseptic. In the patients whose nephrostomy tubes were irrigated with a 2.5% solution of noxythiolin, significant bacterial infection was eliminated from the nephrostomy urine and colonisation of the catheter tip was markedly reduced. Noxythiolin also rendered pre-operative infected bladder urine sterile. There were no untoward local or systemic sequelae in either group of patients. This study indicates that irrigation of the upper urinary tract with noxythiolin solution is safe and may be a useful adjunct to reduce the risk of sepsis in patients undergoing percutaneous drainage procedures.     

Can extracorporeal shock wave lithotripsy eradicate persistent urinary infection associated with infected stones?

Infected renal stones can be treated by extracorporeal shock wave lithotripsy but it still is not clear whether successful stone fragmentation and the disappearance of all macroscopic stone fragments guarantee eradication of the infection. Therefore, a prospective study was done in 135 patients with renal or upper ureteral stones associated with persistent urinary tract infection. The urinary infection was localized in each patient by bilateral ureteral catheterization. Upper tract infection in the kidney containing the stone was found in 75.6 per cent of the cases. A total of 94 patients completed treatment with extracorporeal shock wave lithotripsy and were followed for 3 to 16 months (mean followup 6.4 months). A marked correlation between the incidence of residual macroscopic stone fragments and the presence of persistent infection was noted. Of the 51 patients who became free of stones 48 (94 per cent) had sterile urine. Only 3 of the 51 patients had persistent infection in the treated kidney despite complete disappearance of the stones. In 45 of the 59 patients with stones smaller than 2 cm. (76 per cent) the infection was eradicated, whereas of the 35 with larger stones the urine became sterile in only 13 (37 per cent). We conclude that extracorporeal shock wave lithotripsy can be endorsed for treatment of small infected stones but it is inadequate for treatment of stones larger than 2 cm. unless combined with percutaneous nephrolithotripsy or chemical dissolution of the residual infected fragments.     

Antibiotic prophylaxis in percutaneous nephrolithotomy: prospective study in 81 patients

PURPOSE: To compare single-dose and short-course antibiotic prophylaxis protocols in percutaneous nephrolithotomy. PATIENTS AND METHODS: Eighty-one patients with sterile urine preoperatively who underwent percutaneous nephrolithotomy were divided into two groups. The first group (N = 43) received a single intravenous dose of antibiotic (200 mg of ofloxacin) during anesthetic induction, and the second group (N = 38) received treatment doses of antibiotic (400 mg of ofloxacin per day) until the nephrostomy catheter was removed. The two groups were identical according to demographic and treatment characteristics. For each patient, microbiologic evaluation of extracted stones and urine samples was done. If patients developed fever in the postoperative period, blood and urine cultures were taken. Factors that might have affected the development of postoperative fever and infection were analyzed. RESULTS: Nine patients in the first group had postoperative fever. Three had bacteriuria, and one had bacteremia. In the second group, eight patients had fever. One had bacteriuria and bacteremia. Nineteen patients (eleven in the first group, eight in the second) had positive stone cultures. No statistical difference was observed between the two groups in terms of bacteriuria, bacteremia, positive stone cultures, or postoperative fever. The febrile patients had longer operations with the use of more irrigation fluid and longer postoperative hospital stays. CONCLUSIONS: In patients whose preoperative urine cultures are sterile, short-term prophylaxis has no advantage over single-dose prophylaxis as a means of preventing infection. The duration of surgery and the amount of irrigation fluid are significant risk factors for postoperative fever.     

Percutaneous stone extraction from 200 patients

More than 200 patients have undergone percutaneous stone extraction at our institution. With the percutaneous nephrostomy tract as the conduit to the urinary tract we have removed 95 per cent of the pelviocaliceal stones and 80 per cent of the ureteral stones with grasping forceps, baskets, ultrasonic lithotripsy or a combination of these procedures. Complications were few and patients returned to work sooner than after an open operation.     

经皮肾微造瘘联合二期经皮肾镜碎石术治疗上尿路结石并感染性休克12例报告

目的：探讨经皮肾微造瘘联合二期经皮肾镜碎石术治疗上尿路结石并感染性休克的临床疗效。方法：对12例上尿路石并感染性休克患者在积极抗感染及抗休克治疗的同时行经皮肾微造瘘术,并于术后1～4周行二期经皮肾镜碎石术。结果：12例患者。肾造瘘术均顺利完成,感染及休克症状得到控制。二期手术均顺利完成,结石基本完全清除。结论：对于上尿路结石并感染性休克患者,早期行经皮肾脏微造瘘能有效控制感染及休克症状,联合二期经皮肾镜碎石术能完整清除结石,临床效果满意。     

Is antibiotic administration indicated after outpatient cystoscopy

The incidence of urinary tract infection was examined in 138 patients who underwent diagnostic cystoscopy in an outpatient clinical setting with preoperatively sterile urine. A prospective randomized trial was conducted to compare the incidence of infection in patients who received no antibiotic (controls, group 1) and those who received a postoperative course of oral antibiotics (group 2). The incidence of bacteriuria after cystoscopy was 2.8 per cent in group 1 (control) and 1.5 per cent in group 2, with an over-all incidence of 2.2 per cent. Only 1 patient presented with a symptomatic infection (0.7 per cent). This study has confirmed the safety of outpatient cystoscopy and has demonstrated that routine administration of postoperative antibiotics is not indicated.     

经皮肾镜术后感染性休克一例报告并文献复习

目的探讨经皮肾镜术后感染性休克的防治。方法报告1例62岁女性双肾结石并左肾积水，尿培养发现细菌，术前给予3d抗感染治疗后，行左侧经皮肾镜钬激光碎石术后出现感染性休克，结合文献对经皮肾镜术后出现感染性休克的防治进行复习。结果术中行大通道经皮。肾镜钬激光碎石，手术时间105min。术后12h开始出现血压下降，体温升高，血白细胞升高。经抗感染补液扩容等治疗后治愈出院。结论术前给予充分抗感染治疗，术中灌洗保持低压，术后密切监测生命体征和神志变化并加强抗感染治疗，可有效防治经皮。肾镜术后感染性休克的发生。     

Use of antibiotics in the conjunction with extracorporeal lithotripsy

The first 400 patients treated on an inpatient basis at our center underwent bacteriological follow-up after extracorporeal lithotripsy (ECL) for ureteric or renal stones. 278 patients did not have any urinary tract infection on the urine culture before ECL. They did not receive any antibiotic prophylaxis and 4.8% of the patients developed infectious problems, with significant bacteriuria in only 1.5% of the cases. 89 patients had urinary tract infection on the preoperative cultures. 21.3% developed either fever or significant bacteriuria and this virtually always occurred in patients who were treated for less than 4 days before ECL, with septicemia in 4.5% of the cases. 33 patients with sterile urine received flush antibiotic prophylaxis and none of them developed postoperative infection. Two of these patients had infection at the time of the flush: one of them, who, by error, did not receive antibiotic treatment prior to ECL, developed bacteremia after the procedure. The rational use of antibiotics in conjunction with ECL should ensure effective prevention of urinary tract infections without requiring the excessive use of antibiotics.     

Ceftazidime as prophylactic treatment in renal stone surgery. Clinical evaluation and pharmacokinetics in renal tissue

The effect of ceftazidime in surgery of renal stones associated with urinary tract infection was investigated and its pharmacokinetics in serum and renal tissue was compared in 14 patients (15 kidneys) operated on for renal calculi associated with multiple urinary tract infection. Two to four days preoperatively ureteric catheterization was performed to localize the level of the infection and 2 g of ceftazidime was given intravenously twice daily for 10 days. Renal biopsy, serum samples and in one patient renal lymphatic fluid were taken simultaneously for antibiotic assay. Urine cultures were performed at regular intervals pre- and postoperatively. Ten patients had bacterial growth in the stone-carrying renal pelvis. The same strain was found in the bladder as in the pelvis. Nine patients had sterile urine after 3-5 days of treatment. One patient with bilateral stones did not get sterile urine until after seven days of treatment. Bacterial growth was found in two out of six cultured stones obtained from patients with bacterial growth in the pelvis. The decreases in concentration of ceftazidime in serum and renal tissue seemed to be parallel. Slight reversible elevation of liver transaminases was noted in 5/14 patients. It is concluded that the concentration of ceftazidime in serum parallels that in renal tissue. Ceftazidime seems to be an effective prophylactic in renal stone surgery and the preoperative dose should be given close to the operation.     

The necessity of prophylactic antibiotics during extracorporeal shock wave lithotripsy

In this study we treated 340 patients with renal and ureteric stones. They all underwent ESWL with the HM-4 lithotriptor. The patients were divided into two groups, the first one including 250 patients and the second 90. The first group consisted of patients with sterile urine prior to ESWL. These patients did not receive any antibiotic prophylaxis, while 5.2% of them developed infectious problems which were followed by significant bacteriuria in only 2% of the cases. The 90 patients of the second group had urinary tract infection on the preoperative cultures and received antibiotic treatment. Of these patients 27.8% developed infectious problems which were followed by significant bacteriuria in 21.1% of the cases. Evaluating the above results, we estimate that the administration of prophylactic antibiotics in the case of patients with sterile urine before ESWL is not required while it may prove to be useful in the case of patients with urinary tract infection prior to ESWL.     

经皮肾微造瘘联合输尿管镜碎石术治疗输尿管结石并感染性休克75例报告

目的：探讨经皮肾微造瘘联合输尿管镜碎石术治疗输尿管结石并感染性休克的疗效及意义。方法：对75例输尿管结石并感染性休克患者在积极抗感染及抗休克治疗的同时行经皮肾微造瘘,并于术后1～4周行输尿管镜碎石术。结果：75例患者肾造瘘均jr~,,tl完成,感染及休克症状得到控制。输尿管镜手术均顺利完成,结石基本完全清除。结论：对于输尿管结石并感染性休克患者,早期行经皮肾微造瘘能有效控制感染及休克症状,联合输尿管镜碎石术能完整清除结石,临床效果满意,并能有效防I}术后感染并发痒的发牛。     

Percutaneous nephrolithotomy in the spinal cord injury population

We evaluated 23 male spinal cord injury patients who underwent percutaneous nephrolithotomy for the success rate of stone removal and the incidence of operative complications. There were 18 quadriplegic and 5 paraplegic patients, and 5 had bilateral procedures. Of the kidneys 7 had staghorn calculi, 8 had pelvic and caliceal combinations, 6 had large multiple caliceal stones, 4 had large (more than 2.5 cm.) pelvic stones and 3 had pelvic stones less than 2.5 cm. Placement of a nephrostomy tube and stone extraction were performed as a single procedure with the use of general anesthesia in all but 4 patients. Our results showed that 19 of 21 compliant patients (90.4 per cent) were free of stone, with an average of 2.04 procedures per patient. A total of 47 procedures was performed, with an average operative time of 1 hour 45 minutes. Major complications were associated with 4 of the 47 procedures (8.5 per cent), and consisted of a respiratory arrest, 2 perirenal abscesses and a hydrothorax. Minor complications included fever (more than 101.5F) in 64.3 per cent and retained stones in 14.3 per cent of the kidneys operated upon, dislodged nephrostomy tubes in 12.6 per cent of the procedures (21.4 per cent of the kidneys operated upon), and anemia requiring transfusion in 17.0 per cent (8 of 47) of the procedures (27.8 per cent of the kidneys operated upon). The presence of infected stones, prior operative procedures and medical complexity of these patients make complications more frequent. Nevertheless, percutaneous nephrolithotomy is a safe and effective procedure for the spinal cord injury population.     

Prophylactic antimicrobial treatment in transurethral prostatectomy How long should it be instituted?

Eighty-one patients with proved preoperative sterile urine and undergoing transurethral resection of the prostate were studied. The patients were divided into 3 groups: group A received sulfamethoxazole-trimethoprim (ST) preoperatively and postoperatively for ten days; group B received ST in 2 divided doses, one pre- and one postoperatively; group C received no prophylaxis. In groups A and B, we found urinary infection in 3.8 per cent of patients compared with 32 per cent in group C. Performing prostatic chip cultures, we found that most urinary infections were unrelated to a prostatic source. When the prostate was infected, 75 per cent had infected urine postoperatively. We believe that prophylactic antimicrobial treatment should be given to all patients undergoing transurethral prostatectomy. However, it seems that immediate perooperative treatment suffices.     

Prediction of septicemia following endourological manipulation for stones in the upper urinary tract

We investigated 117 patients undergoing percutaneous nephrolithotomy, percutaneous nephrostomy, ureterorenoscopy, the push-back or push-bang procedure for ureteral stones, Double-J* ureteral stenting plus extracorporeal shock wave lithotripsy (ESWL), ESWL alone or cystoscopy. Blood samples obtained before, during and 1 hour after the procedure were cultured and assayed for endotoxin and tumor necrosis factor. Also, culture was done of the urine preoperatively and postoperatively, and the stones when they could be retrieved. There was a temporal relationship among bacteremia, endotoxemia and elevation of tumor necrosis factor. An unexpected finding was peroperative endotoxemia in a significant number of patients with stones. Risk factors noted for postoperative bacteremia, endotoxemia and/or elevation of tumor necrosis factor included preoperative endotoxin level, type of procedure, presence of preoperative bacteriuria and pyuria. With respect to the procedure the risk was greatest after the push-back method and least after cystoscopy (push-back method greater than percutaneous nephrolithotomy/percutaneous nephrostomy greater than Double-J stenting plus ESWL greater than ureterorenoscopy greater than ESWL greater than cystoscopy). If the risk factors are measured preoperatively it may be possible to identify the risk of postoperative bacteremia/endotoxemia and, therefore, septic shock postoperatively. Our patients appear to be a good clinical model to investigate the problems related to septicemia.     

PERCUTANEOUS NEPHROLITHOTOMY IN THE PEDIATRIC POPULATION

PURPOSE: Percutaneous nephrolithotomy is an established technique used in children with renal calculi. We review our experience with percutaneous nephrolithotomy for treating nephrolithiasis in childhood. MATERIALS AND METHODS: We retrospectively reviewed the records of children who underwent percutaneous nephrolithotomy procedures for renal calculi from 1985 to 1996. Antegrade percutaneous access was obtained in all patients and the tract was dilated to 24F. Grasper forceps, ultrasound and/or electrohydraulic lithotripsy was used to remove and disintegrate stones. In all patients a nephrostomy tube was placed intraoperatively, and a plain abdominal x-ray and nephrostogram were done postoperatively. The nephrostomy tube was removed after ensuring free drainage down the ureter and no untoward effects from clamping. Complete anatomical and metabolic evaluation was performed in all cases. Patients were followed 2 to 6 weeks, and 3 and 6 months postoperatively with a plain abdominal x-ray and excretory urography or renal ultrasound. RESULTS: In 5 boys and 3 girls (9 renal units) 4 to 11 years old (mean age 6.4) a total of 10 percutaneous nephrolithotomy procedures were performed. At presentation 6 children had flank and/or abdominal pain, 5 gross hematuria and 3 urinary tract infection. Three patients had associated metabolic abnormalities. One patient with a staghorn calculus had hydronephrosis and multiple infundibular stenoses. No underlying urological anatomical abnormalities were noted in the remaining cases. Four renal units that were obstructed at presentation required initial nephrostomy tube insertion. Average operative time was 131.8 minutes (range 58 to 240). An 87.5% stone-free rate was achieved using percutaneous nephrolithotomy monotherapy. Percutaneous nephrolithotomy was not successful for eradicating a staghorn stone in 1 patient. Hypothermia developed in 2 patients in whom operative time exceeded 150 minutes. No blood transfusions were required. CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective in children, and should be considered a viable management option. However, staghorn calculi may require alternative management, particularly in the setting of underlying anatomical abnormalities. Children with renal calculi should undergo a complete anatomical and metabolic assessment with the institution of medical therapy, as appropriate.     

Fever after percutaneous nephrolithotomy: contributing factors

BACKGROUND AND PURPOSE: The exact mechanism of fever and urosepsis after percutaneous procedures has not been established. This research studied the frequency of fever after percutaneous nephrolithotomy (PCNL) and the contributing factors. METHODS: In a cross-sectional study, from September 2003 to March 2004, all 217 patients with nephrolithiasis treated with PCNL at the Labbafinegad Specialized Urology Center were studied. Data were collected before, during, and after surgery. RESULTS: The frequency of fever after PCNL was 25.8% (n=56) although in 62.2% of the cases (n=135), no prophylactic antibiotics had been administered. The mean durations of hospitalization in patients with and without fever were 5.4+/-2.3 and 3.4+/-1.7 days, respectively (p=0.001). Significant correlations were observed between fever and female sex (p=0.005), positive urine culture (p=0.02), and nephrostomy tube insertion (p=0.041). Other variables did not prove to be significant. In logistic regression analysis, female sex and nephrostomy tube insertion were independently related to post-operative fever. CONCLUSION: Although a considerable proportion of our patients had not received prophylactic antibiotics, the rate of fever after PCNL was no higher than is reported in the literature. Use of only a short course of antibiotics before surgery for staghorn stones did not result in a higher rate of fever. Female sex created a higher risk for fever, probably because of the greater propensity to urinary tract infection. The significant relation of a nephrostomy tube to fever could be attributed to its role as a foreign body or to use in more complicated cases.     

The treatment of infection stones with penicillin.

The use of oral penicillin therapy is important in the management of renal stones secondary to Proteus mirabilis urinary tract infections. In 16 of 20 patients (80 per cent) with struvite renal calculi infected with Proteus mirabilis a sterile urine was achieved with appropriate penicillin therapy and diminution in stone size occurred in at least 2 cases. The rationale, supporting data and therapeutic uses are discussed.     

泌尿系结石腔镜碎石术后重症感染的诊治

目的探讨经皮肾镜、输尿管镜碎石术后重症感染的发生原因并总结治疗经验。方法回顾性分析2004年9月～2012年3月11例泌尿系结石腔镜碎石术后重症感染的临床资料。年龄45～68岁,平均52岁。经皮肾镜3例,经输尿管镜8例。术后2～10h出现高热、烦燥不安,血压降至70—80／45～50mmHg,心率110～130次／min,诊断感染性休克,均予以抗感染及抗休克治疗,保持肾造瘘管及导尿管在位通畅。结果生命体征逐渐平稳,尿量恢复正常,均在术后12。48h开始逐渐停用升压药物,5d体温及血常规恢复正常。结论泌尿系结石腔镜碎石术后重症感染的发生多见于术前合并泌尿系梗阻、感染,术中灌注压过高,术后引流不畅及手术时间过长的患者,针对上述原因采取积极有效的措施可降低重症感染的发生几率,而治疗的关键在于对感染性休克的早期诊断和及时处理。     

Clinical experience with extracorporeal shock wave lithotripsy (ESWL) in upper urinary tract stones

We treated 100 patients of upper urinary tract stone using extracorporeal shock wave lithotripsy (ESWL), from April to October 1986. Eighty-six of the patients were treated by ESWL monotherapy, and the other cases required further treatment, such as percutaneous nephrostomy (PCN), percutaneous nephrolithotomy (PNL), and transurethral ureterolithotripsy (TUL). On the X-ray film obtained from one to three months after ESWL, 73 patients had no stones, 8 patients had sandy stones, 7 patients had small fragments less than 5 mm, 2 patients had large stones equal to or greater than 5 mm and 10 patients could not be followed up. Therefore, 97.7% of all patients were successfully treated. In conclusion, ESWL is considered to be an ideal method to treat upper urinary tract stones, and soon will become the first choice of treatment of urolithiasis together with the progress in endourological techniques.     

Percutaneous removal of renal and ureteral stones with and without concomitant transurethral manipulation by a urologist using antegrade and retrograde techniques without a radiologist's assistance

Single-stage percutaneous removal of 59 ureteral and 72 renal stones, with or without transurethral manipulation, was performed in 84 of 85 consecutive patients without the assistance of a radiologist. The Hawkins-Hunter retrograde nephrostomy technique was modified by anchoring the catheter in the renal parenchyma, which prevented displacement from the targeted calix by the puncturing needle. Retrograde nephrostomy (76 patients) or percutaneous puncture (7) was established, for a combined access rate of 99 per cent in 83 patients (2 of the 85 had prior tube placement). Only 1 patient (early in the series in 1982) required an open operation because of percutaneous access failure. Tomography showed that the targeted calculi were removed completely from 61 of 66 patients (92 per cent) with uncomplicated stones and 13 of 19 (68 per cent) with complicated stones. The patients left with fragments have remained asymptomatic for a mean followup of 2.6 years. Because the concomitant use of transurethral and percutaneous approaches to stone removal was facilitated by retrograde nephrostomy, all 59 ureteral stones were removed completely from 46 patients. The mean postoperative hospital stay was 2.6 days for 66 patients with uncomplicated stones and 8.2 days for 19 with complicated stones. The Hawkins-Hunter retrograde nephrostomy technique is the preferred method to establish the tract; it facilitates simultaneous transurethral stone manipulation and the assistance of a radiologist is not essential for safe and effective nephrostolithotomy.