Urinary excretion of N-acetyl-beta-D-glucosaminidase in patients with urological disease: with special reference to hydronephrosis

Activity of urinary N-acetyl-beta-D-glucosaminidase (NAG) has been studied in patients with urological diseases. In most patients with benign prostatic hyperplasia, prostate cancer and bladder cancer, activity of urinary NAG was elevated (92.9%), especially in cases of indwelling catheterization or poor visualization of IVU. Urinary NAGs were also elevated for all patients with renal stones, ureter stones, uretero-cutaneous stomy or a single kidney. In hydronephrosis or hydronephrosis with hydroureter patients, urinary NAG level was low pre-operatively, but increased post-operatively. Urinary beta 2-microglobulin (BMG) showed a similar tendency in patients with hydronephrosis or hydronephrosis with hydroureter. Electronmicroscopic observations of the kidney in such patients revealed many primary and secondary lysosomes.     

Modelo novedoso basado en los parámetros de la tomografía para predecir el éxito de la litotricia por ondas de choque en los cálculos ureterales de diferentes localizaciones

ObjectiveTo combine non-contrast computerized tomography (NCCT)-based parameters with stone and patient characteristics that are already known to affect shock wave lithotripsy (SWL) success and assess this novel model's effectiveness in predicting SWL success for single ureteral stones in different locations.Materials and methodsData of patients treated by SWL for a single ureteral stone between January 2017 and January 2019 were retrospectively reviewed. Demographic parameters of patients and stone characteristics were combined with NCCT-based parameters. NCCT-based parameters included the presence or absence of hydronephrosis, perinephric stranding, periureteral edema, diameter of the proximal ureter, ureteral wall thickness (UWT) at ureteral stone site. The logistic regression method was used for the development of a useful predictive model. Subsequently, the receiver operating curve was used to determine cut-off levels, and a scoring system was developed for prediction of SWL success.ResultsStone-free rate was 77,1% (267/346) in the entire cohort. Univariate analysis revealed that age, stone volume, density, perinephric stranding, diameter of proximal ureter, and UWT, were associated with SWL success. In multivariate analysis, proximal ureteral stone location, stone volume, density, and UWT were independent predictors of SWL success. The formula used during logistic regression analysis was: 1/ [1 + exp {-8.856 + 0.008(stone volume) + 0.002 (stone density) + 0.673 (UWT) + 1026 (proximal ureteral stone)}]. The scores of 0, 1, 2, 3 and 4 were associated with 97,8%, 83,4%, 60,8%, 33,2% and 11,1% success rates, respectively, in the prediction model based on these parameters.ConclusionWe conclude that our model can facilitate decision-making for SWL treatment of ureteral stones in different locations.     

Non contrast computerized tomography and dynamic renal scintigraphy in the evaluation of patients with renal colic: are both necessary?

OBJECTIVES: To determine the value of the combined use of non contrast computerized tomography (NCCT) and dynamic renal scintigraphy (DRS) in the evaluation of patients with renal colic.METHODS: Forty-nine consecutive patients with renal colic were evaluated with abdominal plain films (KUB), NCCT and DRS with Tc-99m DTPA or MAG-3. NCCT results showed size and location of the urolithiasis, as well as secondary signs of obstruction. DRS was used to determine the degree of obstruction in the affected renal unit. Patients were submitted to urologic intervention or followed, decision made on the basis of clinical symptoms, degree of obstruction, size, and location of the stone.RESULTS: Three patients had other etiologies than stone for their symptoms and were excluded from the study. Of the remaining 46 patients, KUB detected stones in 24 (52.2%), while NCCT in all. NCCT showed secondary signs of obstruction in 35 patients (76%). Seven patients in this group (15%) had severe hydronephrosis on NCCT and complete obstruction on DRS. Twenty-eight patients (61%) showed moderate hydronephrosis and/or peri-renal and peri-ureteral stranding on the NCCT. In this latter group, DRS diagnosed complete obstruction in 5 (18%) patients, partial obstruction in 16 (57%) and no signs of obstruction in 7 (25%) patients. Overall 34% (12/35) of the patients with secondary signs of obstruction on NCCT had complete obstruction on DRS. NCCT revealed no secondary signs of obstruction in 11 patients (24%) with partial obstruction diagnosed by DRS in one of them (9%). All 12 patients with complete obstruction on the DRS underwent early intervention. Of the 16 patients with partial obstruction of the DRS, two patients (12.5%) necessitated ureteric stent insertion. Three patients with no obstruction on the RNS underwent elective extracorporal shock wave lithotripsy (ESWL) while the rest of the patients were followed and passed their stones spontaneously.CONCLUSIONS: The combination of non-enhanced helical CT and DRS assesses both anatomy and function. When NCCT shows no secondary signs of obstruction, NCCT as the sole imaging study performed may be adequate. If there are secondary signs of obstruction on NCCT, DRS can distinguish patients with different degrees of obstruction and together with the clinical course, size, and location of the lithiasis may help in selecting patients who need earlier intervention from those who may be safely observed.     

Is intravenous urography a prerequisite for renal shockwave lithotripsy?

PURPOSE: To determine whether intravenous urography (IVU) is a prerequisite for shockwave lithotripsy (SWL) of renal stones by addressing whether using non-contrast-enhanced CT (NCCT) instead of IVU for delineating urinary tract anatomy is associated with post-SWL complications. PATIENTS AND METHODS: Thirty-eight patients treated by SWL (Econolith 2000) for radiopaque renal stones underwent either IVU or NCCT. Twenty patients with normal urinary tracts or with mild hydronephrosis proximal to the stone on urography comprised the IVU group. Eighteen patients who underwent NCCT and plain abdominal (KUB) films and had urinary tract systems similar in appearance to the IVU group comprised the NCCT group. The two groups were of similar mean age (45.75 years, range 24-73 years; and 49.0 years, range 26-72 years, respectively) and had a similar mean stone size (10.1-10.2 mm). Patients with internal ureteral or nephrostomy catheters were excluded. Information on episodes of intractable renal colic, urinary tract infections, and hospitalization was recorded at follow-up 2 to 6 weeks post-SWL. RESULTS: The IVU and NCCT patients had similar mean stone fragmentation rates (80% and 74%, respectively) at 2 to 6 weeks post-SWL. Four IVU patients (20%) had intractable renal colic. One NCCT patient (5.5%) had a urinary infection. Complication and hospitalization rates in the two groups were not significantly different (P = 0.34; Fisher' exact test). CONCLUSIONS: Using only NCCT before SWL was not associated with higher complication rates. Thus, IVU is not a prerequisite for SWL of radiopaque renal stones in patients with a normal urinary tract anatomy as seen on NCCT.     

Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain

Objectives. To prospectively compare the diagnostic ability of unenhanced spiral computed tomography (NCCT) and intravenous urogram (IVU) in the evaluation of adults with acute flank pain.Methods. After giving informed consent, 106 adult patients with acute flank pain suspected of having urolithiasis underwent NCCT followed by IVU. Subsequent follow-up was scheduled within 72 hours in the Urology Clinic. Each NCCT was read by a single radiologist who was unaware of clinical history and IVU results. Each IVU was read by a different radiologist who was unaware of clinical history and NCCT results. Sensitivity, specificity, and positive and negative predictive values were determined for NCCT and IVU.Results. The diagnosis of ureterolithiasis was defined as unequivocal evidence of urolithiasis on either NCCT or IVP. Seventy-five of 106 patients evaluated were diagnosed with ureterolithiasis. Clinical follow-up was available in 74 (98%) stone patients and in 31 (100%) of 31 non-stone patients. In 72 of the 75 patients diagnosed with ureteral calculi, the NCCT made the diagnosis. IVU made the diagnosis in 65 of the 75 patients. Of the 31 patients without ureterolithiasis, the NCCT was negative in all cases. IVU was negative in 29 of the 31 cases. Unenhanced spiral CT was 96% sensitive and 100% specific (P <0.001). IVU was 87% sensitive and 94% specific (P <0.001). Compared with IVU, using the log odds ratio and Fisher’s exact test, NCCT was significantly better able to predict the presence of urolithiasis (P = 0.015).Conclusions. NCCT accurately diagnoses ureterolithiasis in patients presenting with acute flank pain. NCCT is significantly better than IVU in determining the presence of urolithiasis.     

A comparison of unenhanced helical computerized tomography findings and renal obstruction determined by furosemide 99m technetium mercaptoacetyltriglycine diuretic scintirenography for patients with acute renal colic

PURPOSE: We assessed unenhanced helical computerized tomography (CT) secondary findings as predictors of renal obstruction as determined by diuretic scintirenography, and determined their reproducibility. MATERIALS AND METHODS: We performed a retrospective review of the records of 77 consecutive patients with unenhanced helical CT findings (stones and secondary findings, including renal parenchymal edema, hydronephrosis, hydroureter, perinephric fat stranding, periureteral fat stranding and extravasation) of urinary lithiasis who had also undergone concomitant diuretic scintirenography during the initial emergency room evaluation during a 1-year period. Unenhanced helical CT films were independently reviewed by 2 attending radiologists (blinded to clinical outcome) to determine interobserver variability. The results were compared to those of diuretic scintirenography. RESULTS: Considerable interobserver variability, as evidenced by kappa values ranging from 0.26 to 0.60, existed for the diagnosis of secondary findings associated with urinary lithiasis on unenhanced helical CT. There was no significant difference in terms of CT findings between patients diagnosed by diuretic scintirenography as having high grade/complete obstruction and those with partial obstruction (p values 0.24 to 0.85 for the 6 unenhanced helical CT findings analyzed). Analyses of variance followed by Tukey's pairwise comparisons showed no significant difference in average number of unenhanced helical CT findings between patients with high grade/complete obstruction (mean plus or minus standard deviation 4.4 +/- 1.31), partial obstruction (4.4 +/- 1.30), and decompression/no obstruction (4.2 +/- 1.16). However, the mean number of unenhanced helical CT findings for patients with normal scintirenography/no obstruction (1.9 +/- 1.41) was significantly different from each of the other 3 diuretic scintirenography groups. Separate logistic regression analyses showed that each unenhanced helical CT finding, except for renal parenchymal edema and urinary extravasation, was a significant predictor of "any degree of obstruction" (high grade and partial obstruction groups) compared to "no obstruction" (decompressed and no obstruction groups). Odds ratios (95% confidence interval) ranged from 6.15 (2.25, 16.82) for perinephric fat stranding to 3.41 (1.30, 8.97) for hydroureter. When these analyses were repeated after exclusion of 8 patients with bladder/passed stones, only perinephric fat stranding and periureteral fat stranding remained significant predictors of "any degree of obstruction," with respective odds ratios of 4.21 (1.49, 11.91) and 4.08 (1.31, 12.65). CONCLUSIONS: Measures of agreement between trained, independent radiologists with respect to unenhanced helical CT secondary findings show considerable variability. The average number of CT consensus findings is not helpful in differentiating patients with variable degrees of obstruction, except for those with normal scintirenography/no obstruction. Unenhanced helical CT findings, except for renal parenchymal edema and urinary extravasation, are significant predictors of "any degree of obstruction" (high grade or partial obstruction) compared to "no obstruction" (decompressed or no obstruction). Therefore, unenhanced helical CT findings may be useful for identifying patients with any degree of obstruction but do not differentiate between those with high grade and partial obstruction.     

Is there any predictive value of the ratio of the upper to the lower diameter of the ureter for ureteral stone impaction?

Background:We aimed to determine if the ratio of the upper to the lower diameter of the ureter could have any predictive value for ureteral stone impaction.Materials and methods:Patients who had a solitary unilateral ureteric stone, determined by noncontrast computerized tomography, were assessed if they had undergone ureteroscopic lithotripsy. A total of 111 patients, 84 males (76%), and 27 females (24%), were recruited to the study. Demographic data of the patients and preoperative radiological parameters based on noncontrast computerized tomography were recorded. The impaction status was also assessed during the operation.Results:Of the 111 patients, ureteral stones in 63 (57%) patients were determined to be impacted, and ureteral stones in 48 (43%) were nonimpacted. Impacted stones were more common in older patients, female patients, and patients with an American Society of Anesthesiologists score of 2.Conclusions:Significant relationships were found between the impaction status and transverse stone length, longest stone length, upper diameter of the ureter, ratio (upper diameter of the ureter/lower diameter of the ureter), and anteroposterior diameter of the pelvis. These parameters were higher in patients with impacted stones.     

螺旋CT增强扫描对异位输尿管口的定位诊断价值

目的：探讨螺旋CT(SCT)增强扫描对异位输尿管口定位诊断的价值。方法：统计1999—2002年收治的16例异位输尿管口患者的临床资料，其中10例为肾发育不良并异位输尿管口，6例为重肾双输尿管并异位输尿管口；影像学诊断方法有泌尿系B超、IVU、SCT增加扫描、逆行插管造影。结果：SCT增强扫描检查患者肾发育不良并异位输尿管口8例，5例明确诊断，其中4例IVU未显影；IVU检查重肾双输尿管6例，5例诊断，但未诊断异位输尿管口；逆行插管造影对肾发育不良并异位输尿管口检查9例，5例诊断，2例显示输尿管；B超对积水的重肾双输尿管诊断1例。结论：对于异位输尿管口的诊断，B超只能作初查，逆行插管造影是一种重要诊断手段，但单靠逆行插管造影诊断有一定盲目性，SCT效果优于IVU，尤其是对肾发育不良并异位输尿管口的诊断。     

Emergency department non-contrast computed tomography for suspicion of obstructive urolithiasis: Yield and consequences

IntroductionWe aimed to analyze patterns of referral, yield, and clinical implications of non-contrast computed tomography (NCCT) in the acute evaluation of flank pain suspected as obstructive urolithiasis (OU) in a high-volume emergency department (ED).MethodsThe study comprised 506 consecutive NCCTs performed in the ED over four months. Detection rates of OU, incidental, and alternative findings were calculated. Imaging signs suspicious for recent passage of stones were considered positive for OU, while renal stones without signs of obstruction were considered unrelated to the acute presentation. OU, other findings requiring hospitalization, and incidental findings warranting further workup were considered situations in which NCCTs were warranted.ResultsNCCTs confirmed an OU diagnosis in 162 (32%) patients and non-clinically significant nephrolithiasis in 125 (25%). They revealed other findings in 108 (21%) patients, including 42 (8%) with clinically significant incidental findings and 26 (5%) with alternative diagnoses requiring hospitalization. NCCTs were entirely negative in 111 (22%) patients. Corroboration of these outcomes, together with overlapping of OU, incidental, and alternative significant findings in some patients resulted in an overall justified NCCT request rate of 44%.ConclusionsThe yield of NCCT performed in acute presentations of flank pain suspected as OU is relatively low, and over one-half of the scans are unwarranted. The pattern of requesting NCCT in the ED needs refinement to avoid abuse that may lead to radiation overexposure, psychological burden, physical harm, and financial overload.     

Circumcaval ureter with synchronous ipsilateral transitional cell carcinoma of the renal pelvis and the urinary bladder: Report of a case and review of the literature

We report a case of concomitant transitional cell carcinoma (TCC) in a circumcaval ureter and invasive bladder cancer. The diagnosis was based on the findings of excretory urography (IVU) and contrast-enhanced computed tomography (CT). IVU showed a typical J-shaped deformity in the dilated right proximal ureteric segment with moderate hydronephrosis and a filling defect in the renal pelvis, while abdominal CT with contrast showed right hydronephrosis with an intrapelvic tumor. The patient underwent radical cystoprostatectomy and nephroureterectomy. No recurrence was detected after 12 months of follow-up.     

逆行插管与静脉造影定位ESWL治疗上尿路阴性结石的比较

为探讨不同部位上尿路阴性结石定位方法的选择，对９８例上尿路阴性结石患者采用大剂量静脉尿路造影（ＩＶＵ）和逆行插管（ＲＧＰ）定位法行体外冲击波碎石术（ＥＳＷＬ），并根据其疗效进行比较。结果：２０例肾阴性结石中，８例行ＩＶＵ定位下ＥＳＷＬ碎石，治愈率为１２．５％；１２例行ＲＧＰ定位下ＥＳＷＬ碎石，治愈率为８．３％；认为对此类患者不宜行Ｘ线定位碎石。５８例输尿管上、中段阴性结石中，２８例行ＩＶＵ定位碎石     

下腔静脉后输尿管(附21例报告)

目的　总结下腔静脉后输尿管的诊治经验。　方法　对 2 1例下腔静脉后输尿管患者的症状、影像学检查、治疗和随访情况进行回顾性分析。　结果　以右腰酸痛为主要症状者 2 0例 ,其中 4例有典型肾绞痛 ,8例有肉眼血尿及肾盂结石 ;无症状者 1例。诊断主要依靠IVU及逆行输尿管肾盂造影 ,特征为上段输尿管呈S形扩张。 1例保守治疗 ,2 0例行输尿管复位矫形术。术后随访 2个月～ 2 8年 ,平均 13年 ,19例症状消失 ,肾积水明显减轻 ,1例因吻合口狭窄再次手术。　结论　对不明原因的右肾及上段输尿管积水者应考虑有本病的可能 ,顺、逆行尿路造影是主要诊断依据 ,输尿管复位矫形术可获得良好疗效。     

Laparoscopic ureterolithotomy: Its role and some controversial technical considerations

OBJECTIVE: To define the role of laparoscopic ureterolithotomy in the management of urolithiasis and evaluate the controversial techniques of this operation. METHODS: Between July 1997 and December 2004, retroperitoneoscopic ureterolithotomy was performed as a primary procedure in 30 patients who had either large or impacted stones in the upper ureter. The other indications were stones which could not be fragmented by shock wave lithotripsy or the patients could not afford the cost of shock wave lithotripsy. The mean (range) age of the patients was 44.07 years (17-78) and the mean (range) stone size was 19.03 mm (10-40). The ureter was closed with intracorporeal laparoscopic suture without placing a stent. RESULTS: The stone was removed in all but one case. The mean (range) operative time was 121.38 min (75-270). No intraoperative complications were recorded. The mean (range) postoperative drain removal was 2.86 days (2-10). Postoperative complications included prolonged urinary leakage in one patient. On the sixth month of follow up, all patients were stone free without any evidence of ureteral stricture. CONCLUSION: Laparoscopic ureterolithotomy is a minimally invasive treatment and may be considered as the useful first-line management for large impacted upper ureteric stones. The technical recommendations were retroperitoneal access and suturing the ureterotomy incision. Ureteral stent should be placed in only cases of severe inflammation of the ureter or inappropriate suturing.     

Secondary signs during non-enhanced helical computed tomography in the diagnosis of ureteral stones

Nonenhanced helical computed tomography (NHCT) is a well-accepted diagnostic method for examining patients with suspected ureterolithiasis. NHCT shows stones within the lumen of the ureter, and it can also be used to evaluate secondary signs associated with ureteral obstruction from stones. Secondary signs include the tissue rim sign, hydroureter, perirenal stranding, and renal density differences between affected and nonaffected kidneys. Identification of secondary signs can help diagnose ureteral stones and contributes to the evaluation of ureteral obstruction.     

成人先天性巨输尿管症(附35例报告)

目的：探讨成人先天性巨输尿管症的诊治特点，方法：35例成人先天性巨输尿管症，其中左侧14,全然中侧11例，双侧10例，所有病例均行B超，IVU检查，手术治疗31例39侧，其中肾输尿管切除术12例，输尿管剪裁整形或折叠后行输尿管膀胱再植术27例，结果：29例获得随访，随访时间1－5年，术侧肾输尿管积水37侧减轻，2侧无明显变化。结论：B超，IVU检查是成人先天性巨输尿管症的首先检查方法。治疗本症的原则是解除梗阻，尽量保留肾功能，手术方式是输尿管剪裁或折叠加输尿管膀胱吻合术，肾功能良好者也可保守治疗。     

An unusual cause of back pain in an achondroplastic man

A case is described of a 47-year-old man with achondroplasia who presented with lower back pain radiating to his left loin. An intravenous urogram (IVU) showed hydronephrosis on the left side and a dilated left ureter passing down into the left inguinal region. A CT scan confirmed a left inguinal hernia containing the left ureter causing ureteric obstruction. The hernia was repaired using the Lichtenstein technique with the ureter replaced retroperitoneally. A postoperative IVU showed recovery in renal function but with a persistently dilated left ureter that was not obstructed. A review of the literature regarding inguinal herniation involving the ureter is presented.     

Immediate or delayed SWL in ureteric stones: a prospective and randomized study

The objective is to compare immediate and delayed SWL as a treatment for ureter stones between 5 and 20?mm. Patients who applied to the emergency department with single, radio opaque ureteric stone of 5–20?mm size were included in the study. Patients were randomized into immediate and delayed SWL groups. SWL were carried out after pain relief in the delayed group. Maximum of three SWL sessions were applied to the patients with stones of 5?mm or bigger in diameter, leaving at least 3?days interval in-between. Stone-free rate after first session was similar in two groups. When CIRF was also considered as success, the success rate of SWL in the immediate SWL group was higher after first session (p?=?0.02). Immediate SWL had a greater success rate in upper ureteric stones (p?=?0.019). Overall average time required for elimination of stones was shorter in immediate SWL group than delayed SWL group (p?=?0.033). The success rate after first SWL session (including CIRF) was 59?% for patients with chronic pain in the delayed group and 100?% for patients with acute pain in the immediate group. According to the hydronephrosis grade, success rates were 71 and 44.4?% for patients with grade 1 or no hydronephrosis in the immediate SWL group, and for patients with grade 2 or larger hydronephrosis in the delayed SWL group, respectively, after first SWL session. Immediate SWL insures stone-free status in a shorter time in cases with renal colicky pain and ureteral stones, particularly upper ureteral stones.     

输尿管结石并发输尿管息肉58例分析

目的：探讨输尿管结石并发输尿管息肉的病因及发病机制,提高其诊治效果。方法：行输尿管切开取石加息肉段输尿管切除端端吻合术41例,输尿管切开取石加息肉单纯切除或电灼17例;术后放置输尿管支架引流48例。结果：58例患者术后症状全部消失。B超检查肾积水减轻39例,消失19例。结论：对长期停留在某一部位的输尿管结石,或肾积水程度与结石大小不相符时,应考虑到有并发输尿管息肉之可能。     

输尿管镜下气压弹道碎石术治疗输尿管结石186例

目的 探讨输尿管镜下气压弹道碎石术治疗输尿管结石的临床疗效。方法 采用输尿管镜下气压弹道碎石术治疗输尿管结石186例。结果 一次性结石粉碎率为87．1％(162／186)；并发症发生率3．2％(6／186)，以输尿管穿孔和感染为主。结论 输尿管镜下气压弹道碎石术治疗输尿管结石疗效确切，安全，创伤小。     

In situ extracorporeal shock wave lithotripsy for primary ureteric calculi

Objective. To determine the efficacy of the Lithostar lithotriptor for the in situ treatment of primary ureteric stones.Methods. We reviewed, retrospectively, our experience with 283 patients with primary ureteric stones treated with extracorporeal shock wave lithotripsy (ESWL) using the Lithostar lithotriptor. No attempts were made to manipulate the stones. The majority of the patients were treated using only intravenous analgesia. Auxiliary measures were used in 84 patients (29.6%). There were 112 patients (39.6%) with upper, 53 (18.7%) with middle, and 118 (41.7%) with lower ureteric stones.Results. A single ESWL session was needed for 200 patients (70.6%), two for 49 patients (17.3%), and more than two sessions for 34 patients (12%). Of the 248 patients who had adequate follow-up, 220 (88.7%) were stone free, 14 (5.65%) had some residual stone, while 14 (5.65%) patients failed to respond to the treatment. Patients' gender and body weight influenced the treatment and the clearance rate numerically without any statistical significance. The stone site was the most significant factor influencing the final result. Stones larger than 10 mm and the presence of hydronephrosis adversely affected the treatment.Conclusions. In situ ESWL of ureteral stones with the Lithostar device is a convenient and efficient method of treating calculi within the whole length of the ureter without the need for any manipulation.