ESWL后影响肾下盏结石排空的解剖学因素

目的 探讨肾下盏解剖学因素对ＥＳＷＬ后结石排空的影响。方法 １９９５年４月～１９９９年１１月应用Ｓｔｏｒｚ Ｍｏｄｕｌｉｔｈ ＳＬ２０型碎石机治疗肾下盏结石１４５例,测量碎石前ＩＶＵ片肾下盏４项解剖指标,包括结石所在肾下盏肾孟夹角,肾下盏长度,盏颈宽度及肾下盏形状（简单或复杂）。随访３个月,碎石后第１天、２、４周及３个月时复查Ｂ超及ＫＵＢ,分析肾下盏解剖因素与结石排空的关系。结果 ３个月总结石排空     

Risk factors for the formation of a steinstrasse after extracorporeal shock wave lithotripsy: a statistical model

PURPOSE: We studied the various stone, renal and therapy factors that could affect steinstrasse formation after extracorporeal shock wave lithotripsy (ESWL), Dornier Medical Systems Inc., Marietta, Georgia to define the predictive factors for its formation. Thus, steinstrasse could be anticipated and prophylactically avoided. MATERIALS AND METHODS: Between February 1989 and May 1999, 4,634 patients were treated with a Dornier MFL 5000 lithotriptor (Dornier Med Tech, GmbH, Germany). Renal stones were encountered in 3,403 patients and ureteral stones in 1,231. Steinstrasse were recorded in 184 patients, of whom 74 required intervention and formed the "complicated group." All patient data, stone and renal characteristics, and data of ESWL were reviewed. Univariate and multivariate statistical analyses of patients, stones and therapy characteristics in correlation with the incidence of steinstrasse formation were performed to assign the factors that had a significant impact on steinstrasse formation. RESULTS: The overall incidence of steinstrasse was 3.97%. The steinstrasse was in the pelvic ureter in 74% of the cases, lumbar ureter in 21.7% and iliac ureter in 4.3%. Steinstrasse incidence significantly correlated with stone size and site, the power level (kV.) used during therapy and radiological renal features. Steinstrasse was more common with renal stones more than 2 cm. in diameter in a dilated system, especially with the use of high power (greater than 22 kV.) for disintegration. A statistical model was constructed to estimate the risk of steinstrasse formation accurately. CONCLUSIONS: Stone size and site, renal morphology and shock wave energy are the significant predictive factors controlling steinstrasse formation. If a patient has a high probability of steinstrasse formation, close followup with early intervention or prophylactic pre-ESWL ureteral stenting is indicated.     

Fate of residual fragments after successful extracorporeal shock wave lithotripsy

PURPOSE: The aim of the present study was to investigate the reason residual fragments from upper urinary tract calculi failed to clear after successful extracorporeal shock wave lithotripsy (ESWL). METHODS: Risk factors were analyzed in 161 patients with residual fragments (< or = 4 mm) that had remained for more than 3 months after ESWL. The factors examined in the present study were gender, a history of urolithiasis, the number, location and size of stones, hydronephrosis 3 months after ESWL and bacteriuria before ESWL. The mean follow-up period was 20.0 months (range 6-69 months). RESULTS: The overall stone-free rate was 14.3%. The stone-free rate in patients with multiple stones or hydronephrosis 3 months after ESWL was significantly lower than that in patients without these conditions (P < 0.05 and P < 0.01, respectively). The cumulative non-clearance rate in patients with hydronephrosis was significantly higher than in patients without this condition (P < 0.05). Results of Cox's proportional hazards model indicated that hydronephrosis was the most important and only significant factor for failure to clear of the seven factors investigated (P < 0.05). CONCLUSION: Hydronephrosis was most highly correlated with the fate of residual fragments after ESWL.     

Efficacy of extracorporeal shock wave lithotripsy for solitary lower calyceal stone: a statistical model

OBJECTIVE: To evaluate the effect of inferior calyceal radiographic anatomy, number of extracorporeal shock wave lithotripsy (ESWL) sessions and stone size on the successful clearance of solitary inferior calyceal calculi after ESWL. PATIENTS AND METHODS: In a prospective study between January 2001 and November 2002, 66 renal units with a solitary inferior calyceal calculus of < or = 2 cm were treated with electrohydraulic ESWL. The infundibulopelvic angle (two definitions), infundibulovertebral angle, inferior calyceal infundibular diameter, infundibular length, cortical thickness over the lower pole, number of minor calyces and stone size were determined from intravenous urography before treatment. The number of ESWL sessions was also included in the analysis. Treatments which produced residual fragments not clearing within 3 months of satisfactory fragmentation were considered as failures. All patients in whom the treatment failed were treated successfully by percutaneous nephrolithotomy. The data were then analysed using two different statistical methods; first by intravariable differences using the test of proportion (Fisher's test) and then all the variables together using logistic regression. RESULTS: At 3 months 78.8% of the renal units were clear of stone. All intravariable differences were statistically significant except stone size (<1 cm, 1-2 cm). In a multivariate analysis of all variables, only stone size was the most important predictor for successful stone clearance (P = 0.03). CONCLUSIONS: ESWL is the initial treatment of choice in selected patients with inferior calyceal stones. The stone size appears to be the most important predictor for stone clearance.     

Stone measurement by volumetric three‐dimensional computed tomography for predicting the outcome after extracorporeal shock wave lithotripsy

OBJECTIVE

To evaluate the efficacy of stone volume measured using a three‐dimensional (3D) reconstruction of preoperative non‐contrast computed tomography (NCCT) as an independent predictor of success after extracorporeal shock wave lithotripsy (ESWL) of upper urinary tract calculi.

PATIENTS AND METHODS

We evaluated preoperative NCCT in 94 patients who had ESWL for solitary upper urinary tract calculi of 4–20 mm in diameter. Axial images were used to measure the skin‐to‐stone distance (SSD), Hounsfield Unit (HU) density and axial stone diameter. Stone volume was calculated on a volume‐rendered 3D image for each stone. Maximum stone length was determined by comparative measurements of each stone in coronal, sagittal and axial planes, and was also measured on a plain abdominal film before ESWL. For ESWL we used the DoliS lithotripter (Dornier Medical Systems, Marrietta, GA, USA). A plain film at 6 weeks was used to categorize patients as stone‐free (SF) or with residual stone.

RESULTS

In all, 58 (62%) patients were SF and 36 (38%) had RS; the mean stone volume was significantly different between these groups (274 vs 464 µL, P = 0.002). Logistic regression analysis showed that stone volume was the strongest predictor of SF status (P < 0.001), compared to peak HU (P = 0.015), mean HU (P = 0.04) and axial stone diameter (P = 0.006). The body mass index, SSD and maximum stone length on NCCT or a plain film did not predict success. A stone volume of <500 µL best predicted treatment success (P < 0.001) with 72% of patients with a stone volume of <500 µL having a successful outcome, vs only 27% with a stone volume of >500 µL.

CONCLUSION

Our study suggests that stone volume is an optimal predictor of SF status after ESWL of solitary upper urinary tract calculi.     

Low dose tamsulosin for stone expulsion after extracorporeal shock wave lithotripsy: Efficacy in Japanese male patients with ureteral stone

Objective:   We evaluated the efficacy of low dose tamsulosin after extracorporeal shock wave lithotripsy (ESWL) in Japanese male patients with ureteral stone.
Methods:   One hundred and two Japanese male patients with ureteral stones who underwent ESWL were randomly divided into three groups. Group A (38 patients) was given tamsulosin (0.2 mg/day); group B (30 patients) was given c horeito , a herbal medicine (7.5 g/day); and group C (34 patients) received no medication. Stone clearance was assessed at 1, 7, 14, and 28 days after ESWL using plain abdominal radiography and abdominal ultrasonography. After 28 days, stone delivery was checked every 2 weeks.
Results:   The stone-free rate was 84.21%, 90%, and 88.24% for groups A, B, and C, respectively ( P  = 0.3425). The mean expulsion time was 15.66 ± 6.14 days in group A, 27.74 ± 25.36 days in group B, and 35.47 ± 53.70 days in group C. The expulsion time of group A was significantly shorter than that of groups B ( P  = 0.0116) and C ( P  = 0.0424).
Conclusions:   The addition of tamsulosin to conservative treatment appeared to be effective in shortening the stone expulsion time.     

Pediatric staghorn calculi: the role of extracorporeal shock wave lithotripsy monotherapy with special reference to ureteral stenting

PURPOSE: Treatment for staghorn calculi in children represents a unique challenge. We assessed the efficacy of extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) monotherapy for the management of staghorn calculi in children with special reference to ureteral stenting. MATERIALS AND METHODS: From June 1992 to January 2001 we treated 42 children 9 months to 12 years old with staghorn stones using the Piezolith 2501 (Richard Wolf GmBH, Knittlingen, Germany) lithotriptor. The initial group of 19 patients underwent ESWL without prophylactic ureteral stenting, while in the latter group of 23 a Double-J (Medical Engineering Corp., New York, New York) ureteral stent was inserted immediately before the first ESWL session. Mean patient age, stone size, number of shock waves and ESWL sessions, hospital stay, stone-free rate and major complications were compared in the 2 groups. RESULTS: Overall 33 children (79%) were stone-free after 3 months. The 2 groups were comparable in regard to patient age, stone size, number of shock waves and ESWL sessions, and stone-free rates. Major complications developed in 21% of the unstented group, whereas none were observed in stented cases. This difference was statistically significant (p = 0.035). Seven post-ESWL auxiliary procedures were required in the unstented group to manage complications. Hospital stay was significantly longer in the unstented compared with the stented group (p = 0.022). At a followup of 9 to 102 months (mean 47) stones recurred in 2 children, who were treated with further ESWL. CONCLUSIONS: ESWL monotherapy was an efficient and safe modality for the treatment of staghorn calculi in children. Stented patients had fewer major complications and a shorter hospital stay. Prophylactic ureteral stenting is advisable before ESWL for staghorn calculi in children.     

Interleukin‐1β stimulates stromal‐derived factor‐1α expression in human subacromial bursa

Chemokines produced by synoviocytes of the subacromial bursa are up‐regulated in subacromial bursitis and rotator cuff disease. We hypothesized that SDF‐1α production in bursal synoviocytes may be induced by local cytokines such as interleukin IL‐1β and IL‐6. Subacromial bursa specimens were obtained from patients undergoing shoulder surgery. Bursal specimens were stained with anti‐human antibodies to IL‐1, IL‐6, and SDF‐1α by immunohistochemistry and compared to normal and rheumatoid controls. Bursal cells were also isolated from specimens and cultured. Early passaged cells were then treated with cytokines (IL‐1β and IL‐6) and SDF‐1α expression was measured by ELISA and RT‐PCR. SDF‐1α, IL‐1β, and IL‐6 were expressed at high levels in bursitis specimens from human subacromial bursa compared to normal controls. In cultured bursal synoviocytes, there was a dose‐dependent increase in SDF‐1α production in the supernatants of cells treated with IL‐1β. SDF‐1α mRNA expression was also increased in bursal cells treated with IL‐1β. IL‐6 caused a minimal but not statistically significant increase in SDF‐1α expression. SDF‐1α, IL‐1β, and IL‐6 are expressed in the inflamed human subacromial bursal tissues in patients with subacromial bursitis. In cultured bursal synoviocytes, SDF‐1α gene expression and protein production are stimulated by IL‐1β. IL‐1β produced by bursal syvoviocytes and inflammatory cells in the human subacromial bursa is an important signal in the inflammatory response that occurs in subacromial bursitis and rotator cuff disease. © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29:1695–1699, 2011     

Combined effects of TNF‐α, IL‐1β, and HIF‐1α on MMP‐2 production in ACL fibroblasts under mechanical stretch: An in vitro study

The dynamics between inflammatory factors, mechanical stress, and healing factors, in an intra‐articular joint, are very complex after injury. Injury to intra‐articular tissue [anterior cruciate ligament (ACL), synovium] results in hypoxia, accumulation of various pro‐inflammatory factors, cytokines, and metalloproteases. Although the presence of increased amounts of matrix‐metalloproteinases (MMP) in the joint fluid after knee injury is considered the key factor for ACL poor healing ability; however, the exact role of collective participants of the joint fluid on MMP‐2 activity and production has not been fully studied yet. To investigate the combined effects of mechanical injury, inflammation and hypoxia induced factor‐1α (HIF‐1α) on induction of MMP‐2; we mimicked the microenvironment of joint cavity after ACL injury. The results show that TNF‐α and IL‐1β elevate the activity of MMP‐2 in a dose‐ and time‐dependent manner. In addition, mechanical stretch further enhances the MMP‐2 protein levels with TNF‐α, IL‐1β, and their mixture. CoCl₂‐induced HIF‐1α (100 and 500 µM) also increases the levels and activity of MMP‐2. Mechanical stretch has a strong additional effect on MMP‐2 production with HIF‐1α. Our results conclude that mechanical injury, HIF‐1α and inflammatory factors collectively induce increased MMP‐2 production in ACL fibroblasts, which was inhibited by NF‐κB pathway inhibitor (Bay‐11‐7082). © 2011 Orthopaedic Research Society Published by Wiley Periodicals, Inc. J Orthop Res 29: 1008–1014, 2011     

Three-dimensional assessment of urinary stone on non-contrast helical computed tomography as the predictor of stonestreet formation after extracorporeal shock wave lithotripsy for stones smaller than 20 mm

The incidence of stonestreet formation after extracorporeal shock wave lithotripsy (ESWL) rises with increasing stone burden. However, stonestreet after ESWL is often experienced even in stones smaller than 20 mm. To examine whether the non-contrast helical computed tomography (CT) data could predict stonestreet formation in these stones, 53 radiopaque stones of 5-20 mm treated with ESWL were evaluated. Maximal dimension was measured on plain radiograph. From an attenuation value histogram graphed from the CT data, total stone volume and mean attenuation value were calculated. Seven stonestreets longer than 25 mm developed. There was no significant difference in maximal dimension and total stone volume between stones that did and stones that did not develop stonestreet. Mean attenuation value was the sole significant predictive factor. Application of mean attenuation value with cut-off level of 650 HU would anticipate stonestreet formation with a sensitivity of 85.7% and a specificity of 71.7%. The estimated risk of stonestreet formation is high in the treatment of stones with higher mean attenuation value.     

Anti‐gal antibodies in α1,3‐galactosyltransferase gene‐knockout pigs

Fang J, Walters A, Hara H, Long C, Yeh P, Ayares D, Cooper DKC, Bianchi J. Anti‐gal antibodies in α1,3‐galactosyltransferase gene‐knockout pigs. Xenotransplantation 2012; 19: 305–310. © 2012 John Wiley & Sons A/S. Abstract Serum anti‐galactose‐α1,3‐galactose (Gal) IgM and IgG antibody levels were measured by ELISA in α1,3‐galactosyltransferase gene‐knockout (GTKO) pigs (78 estimations in 47 pigs). A low level of anti‐Gal IgM was present soon after birth, and rose to a peak at 4–6 m, which was maintained thereafter even in the oldest pigs tested (at >2 yr). Anti‐Gal IgG was also present at birth, peaked at 3 m, and after 6 m steadily decreased until almost undetectable at 20 m. No differences in this pattern were seen between pigs of different gender. Total IgM followed a similar pattern as anti‐Gal IgM, but total IgG did not decrease after 6m. The data provide useful baseline data for future experimental studies in GTKO pigs, e.g., relating to the antibody response to WT pig allografts.     

Chronic kidney disease affects the stone‐free rate after extracorporeal shock wave lithotripsy for proximal ureteric stones

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To investigate the effect of renal function on the stone‐free rate (SFR) of proximal ureteric stones (PUS) after extracorporeal shock wave lithotripsy (ESWL), as urinary obstruction caused by PUS can impair renal function, and elevated serum creatinine levels are associated with decreased ureteric stone passage.

PATIENTS AND METHODS

From January 2005 to December 2007, 1534 patients had ESWL for urolithiasis, 319 having ESWL in situ for PUS; they were reviewed retrospectively. Patients requiring simultaneous treatment of kidney stones, placement of a double pigtail stent, or percutaneous pigtail nephrostomy tube were excluded. We divided patients into groups by chronic kidney disease (CKD) stage according to the estimated glomerular filtration rate (eGFR) of ≥60 and <60 mL/min/1.73 m². Stone‐free status was defined as no visible stone fragments on a plain abdominal film at 3 months after ESWL. A logistic regression model was used to evaluate the possible significant factors that influenced the SFR of PUS after ESWL, and to develop a prediction model.

RESULTS

The overall SFR of PUS (276/319 patients) was 86.5%; the SFR was 93% in patients with an eGFR of ≥60 and 50% in those with an eGFR of <60 (P < 0.001). After univariate and multivariate analysis, the three significant factors affecting SFR were an eGFR of ≥60, stone width, and gender, with odds ratios (95% confidence intervals) of 19.54 (8.25–46.30) (P < 0.001), 0.67 (0.55–0.82) (P < 0.001) and 0.16 (0.05–0.50 (P = 0.002), respectively. A logistic regression model was developed to estimate the probability of SFR after ESWL, the equation being 1/(1 + exp [?(3.8137 ? 0.3967 × (stone width) + 2.9724 × eGFR ? 1.8120 × Male)]), where stone width is the observed value (mm), eGFR = 1 for eGFR ≥60 and 0 for <60, and male = 1 for male, 0 for female.

CONCLUSIONS

Gender, eGFR ≥60 and a stone width of >7 mm were significant predictors affecting the SFR after one session of ESWL for PUS.