Ureteric stents compromise stone clearance after shockwave lithotripsy for ureteric stones: results of a matched-pair analysis

OBJECTIVE

To identify the effect of the presence of a ureteric stent on the outcome of extracorporeal shockwave lithotripsy (ESWL), by comparing patients with ureteric stones with matched‐pair analysis.

PATIENTS AND METHODS

Patients undergoing ESWL with the Sonolith Vision lithotripter (Technomed Medical Systems, Vaulx‐en‐Velin, France) were identified from our prospectively maintained database. Only adult patients with a solitary, radio‐opaque, previously untreated ureteric stone were considered for further analysis. A follow‐up of ≥3 months with a plain abdominal film was used to identify residual fragments. Patients were exactly matched for gender, side, location in the ureter and size (in two dimensions, within ±2 mm). If both diameters could not be matched exactly, the size was extended to ±1 mm and then to ±2 mm of both diameters. An effort was finally made to match patients by age. The treatment outcome in terms of stone‐free rates was assessed and compared using McNemar’s test.

RESULTS

In all, 45 patients with a ureteric stent in place during ESWL were identified. The only patient who could not be adequately matched was a 40‐year‐old man with an 8 × 3 mm stone in the upper ureter. The best/closest match for age was selected. Most stones were in the upper ureter (77%); the mean stone size was 8.5 and 8.6 mm, respectively, with no statistical differences between the groups for age and size of stones (P = 0.41 and 0.86, Student’s t‐test). In 12 pairs, only patients with no stent were stone‐free, compared to two pairs where the patient with a stent was stone‐free. Using McNemar’s test, the odds ratio was 6.0 (95% confidence interval 1.3–55.2) and the difference between the groups was statistically significant (P = 0.016).

CONCLUSION

These results show that the presence of a stent is associated with a worse outcome after ESWL for ureteric stones. Ureteric stents should still be used in cases of obstruction, when there is a risk of sepsis, and in patients with intolerable pain or deteriorating renal function. However, their use in patients offered ESWL for ureteric stones should be considered with caution.     

Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications

OBJECTIVE: To compare patients with and with no stenting after ureteroscopy for ureteric calculi, as placing such stents is routine, although many patients complain of pain and urinary symptoms. PATIENTS AND METHODS: In all, 45 patients with ureteric calculi amenable to ureteroscopic management were prospectively randomized into a stented (23) or an unstented (22) group. Standard ureteroscopic basketing and lithotripsy was used, through a ureteroscope (8.5 F) with or without ureteric dilatation. Symptom questionnaires were completed by the patients after treatment, and they were followed radiographically to assess stone-free rate and evidence of obstruction. RESULTS: There was no statistically significant difference in age, stone size, operative duration or hospital stay between the groups (P > 0.05). Furthermore, there was no statistical difference in flank pain or urinary symptoms (P > 0.05), except haematuria, between the groups; haematuria was more severe and prolonged in the stented group (P = 0.001). CONCLUSIONS: Uncomplicated ureteroscopy for removing calculi is safe with no stent after treatment, and after considering complications and side-effects we think that the routine use of ureteric stents after uncomplicated ureteroscopy for stone extraction is unnecessary.     

The ‘buoy’ stent: evaluation of a prototype indwelling ureteric stent in a porcine model

OBJECTIVE

To assess a prototype ureteric ‘buoy’ stent with a 10 F upper body tapering to a 3F tail, developed to potentially reduce stent‐related irritative symptoms while providing an adequate mould for healing after endopyelotomy.

MATERIALS AND METHODS

Eighteen Yucatan minipigs had the stent placed either into the intact ureter (phase I) or after Acucise proximal endoureterotomy (phase II). Buoy stents were compared to 10/7 F endopyelotomy stents and to standard 7 F stents in phases I and II, respectively. The pigs were assessed for vesico‐ureteric reflux, hydronephrosis and infection, before stent insertion and at harvest. Stents were weighed before and after placement and the removal force was measured. Pressure/flow studies, antegrade nephrostograms and specimens for histopathology from the renal pelvis, ureter and vesico‐ureteric junction (VUJ) were obtained at harvest.

RESULTS

Thirteen minipigs survived the entire study. Ureteric flow with the stents in situ was better for buoy stents than for 10/7 F stents (P < 0.005). Ureteric flow after endoureterotomy and subsequent stent removal was similar for buoy stents and standard 7 F stents. None of the stents refluxed. There was no difference between stents in removal force, weight change or incidence of hydronephrosis. At 1 and 12 weeks, buoy stents tended to produce lower histopathological alteration scores than control stents, especially at the VUJ (phase I, 2.0 vs 3.9, P = 0.092; phase II, 0.6 vs 1.7, P = 0.18).

CONCLUSIONS

The novel buoy stents are easily placed and removed via the urethra. They can cause less VUJ inflammation than standard stents while allowing for adequate ureteric flow and healing after proximal endoureterotomy.     

A second cycle of tamsulosin in patients with distal ureteric stones: a prospective randomized trial

OBJECTIVE

To evaluate, in a prospective randomized pilot study, the effectiveness and safety of tamsulosin, administered in patients with distal ureteric stones and who have already undergone an unsuccessful first cycle of medical expulsive therapy (MET).

PATIENTS AND METHODS

We evaluated the effectiveness and safety of tamsulosin, administered as a further therapy, in patients previously unsuccessfully treated with combined expulsive 10‐day therapy (tamsulosin + deflazacort) for distal ureteric stones. Ninety‐one patients were enrolled and randomized into two groups, each receiving a different therapy for 10 days. Group A (46 patients) received a further cycle of tamsulosin (0.4 mg daily), and group B (45) did not. Age, gender, stone size, time to expulsion, number of acute episodes of colic during treatment and analgesic consumption were recorded. Patients who were not stone‐free after the study period had ureteroscopy. The results were compared statistically using Student’s t‐, chi‐square test and Fisher’s exact test.

RESULTS

The groups were comparable inage, gender and stone size (5.93 mm for group A and 6.03 mm for group B). The expulsion rate was significantly higher in group A (80%) than in group B (49%) (P < 0.01), whilst there were no differences between the groups in the number of colic episodes and analgesic use. There were no reported side‐effects of medical therapy.

CONCLUSIONS

A second cycle of 10 days of MET with tamsulosin in nonresponders to a 10‐day first cycle of MET with tamsulosin and deflazacort is safe and effective, and therefore should be considered as an option in the management of uncomplicated distal ureteric stones.     

Postoperative morbidity, functional results and quality of life of patients following orthotopic neobladder reconstruction

AIM: To evaluate postoperative morbidity, functional results and health-related quality of life of patients with an orthotopic neobladder. METHODS: A total of 37 patients with orthotopic neobladder (modified Studer method: 35 cases; Hautmann method: one case; sigmoid neobladder: one case) were included in the present study. Postoperative morbidity and neobladder function were analyzed. To determine quality of life, the Sickness Impact Profile questionnaire was used. The quality of life of patients who underwent orthotopic neobladder was compared with that of patients who underwent ileal conduit. RESULTS: In 37 consecutive patients with neobladder reconstruction, early complications included 10 cases of pyelonephritis (27.0%) and one of stenosis of ureterointestinal anastomosis (2.7%). Two patients died of ARDS and sepsis following peritonitis and pneumonia in the perioperative period. Late complications included pyelonephritis in three patients (8.6%). In 32 cases, except for an early postoperative case and those that died, complete daytime and night-time continence was achieved in 31 patients (96.9%) and 16 patients (50.0%), respectively. Concerning health-related quality of life, the mean sum scores per category of the Sickness Impact Profile were calculated for 32 patients with orthotopic neobladder and 30 patients with ileal conduit. There were no significant differences in overall satisfaction, however, the scores for patients with orthotopic neobladder reconstruction were significantly higher than those for patients with ileal conduit in the three categories of emotions, feelings and sensation, social interaction and recreation. CONCLUSION: Orthotopic neobladder reconstruction exhibited good functional results with acceptable complications. Patients who underwent neobladder reconstruction were satisfied with their voiding. Assessment of quality of life using the Sickness Impact Profile questionnaire demonstrated that orthotopic neobladder improved their quality of life better than ileal conduit, especially with regard to mental, physical and social functioning in daily life.     

Development of a social morbidity score in patients with chronic ulcerative colitis as a potential guide to treatment

Aim Present quality of life instruments for inflammatory bowel disease do not evaluate many social aspects of patients’ lives that are potentially important in clinical decision making. We have developed a new Social Impact of Chronic Conditions – Inflammatory Bowel Disease (SICC‐IBD) questionnaire to assess these areas. Method A 34‐item questionnaire was piloted to determine quality of life relating to education, personal relationships, employment, independence and finance. It was compared with the Short Form 36‐Item version 2 (SF‐36v2) and the Inflammatory Bowel Disease Questionnaire (IBDQ) in 150 patients with chronic ulcerative colitis on an endoscopic surveillance register who had never had surgery. Results Reliability and validity testing enabled the questionnaire to be shortened to only eight items. There was a high level of reliability (Cronbach’s α = 0.72). The questionnaire correlated well with the social functioning domain of the SF‐36 (r_s = 0.56) and was able to distinguish clinical severity of disease. Conclusion The SICC‐IBD is a new tool for assessment of patients with ulcerative colitis, which has identified new aspects of social disability for further study and for potential use as an additional tool in therapy decisions.     

Extracorporeal shockwave lithotripsy vs ureteroscopy as first‐line therapy for patients with single,distal ureteric stones: a prospective randomized study

Study Type – Therapy (RCT)
Level of Evidence 1b

OBJECTIVE

To compare extracorporeal shockwave lithotripsy (ESWL) and ureteroscopy (URS) as first‐line treatments for patients with distal ureteric stones.

PATIENTS AND METHODS

In all, 273 patients with single, monolateral, radiopaque, distal ureteric stones of 0.5–1.5 cm were enrolled in a prospective randomized trial. Patients were randomized to undergo ESWL (137) or URS (136). The electromagnetic Modulith SLX lithotripter (Storz Medical, Switzerland) was used for ESWL and a semi‐rigid ureteroscope was used for URS. Patients in both groups were compared for overall stone‐free rates (SFRs), re‐treatment rates, need for auxiliary procedures and complication rates. A subgroup analysis was performed in both groups according to stone size of ≤1 cm and >1 cm.

RESULTS

Patients in the ESWL group achieved a 92.70% overall SFR with a 44.88% re‐treatment rate and an 11.02% auxiliary procedure rate. Complications occurred in 15.32% of patients treated with ESWL. Patients in the URS group achieved a 94.85% overall SFR with a re‐treatment rate of 7.75% and an auxiliary procedure rate of 18.60%. Complications occurred in 19.11% of patients treated with URS. In the ESWL group, the need for re‐treatments and for auxiliary procedures as well as the incidence of complications was significantly higher in patients with stones of >1 cm. In patients with stones of ≤1 cm treated with ESWL the need for re‐treatments and for auxiliary procedures as well as the incidence of complications was significantly lower than for those treated with URS.

CONCLUSION

In centres where both techniques are available, ESWL should be the preferred treatment for patients with single distal ureteric stones of ≤1 cm and URS should be reserved for patients with stones of >1 cm.     

肾移植后患者生活质量评分专用量表的制订及相关因素分析

目的 制订针对国人的肾移植后生活质量评分专用量表（下称专用量表），为评价国人肾移植后生活质量提供量化工具；研究肾移植患者生活质量的影响因素，为提高护理质量提供参考。方法 选取肾移植术后6个月肾功能稳定的357例患者，应用终末期肾脏疾病移植患者症状调查表（ESRD-SCL）、健康状况问卷（SF-36）及自制的一般情况问卷进行调查。对条目池中的各条目做统计学测评，选择条目池中回答阳性率较高（〉20％）的条目，应用因子分析正交旋转进行统计分析，筛选因子载荷≥0．4的条目构成初步量表；然后时初步量表的信度、效度进行分析考评。结果 48个条目入选，分属认知能力（12个条目）、药物相关不良反应（9个条目）、心理及情绪（7个条目）、心肾等器官功能（9个条目）、体质（11个条目）。Cronbach’s α为0．74～0．87。条目形式采用等距等级条目，每个条目有5个选项，评分分别定义为0～4分（0=完全没有，1=轻微，2=比较严重，3=很严重，4=非常严重）。患者的认知能力与其文化程度、药物相关不良反应与性别、心理及情绪方面与文化程度、心肾等器官功能与年龄、体质与体重指数相关性最大（r=-0．21、-0．33、-0．32、0.22、0．30，均P〈0．05）。结论 该专用量表有良好的信度和效度，适用于了解我国肾移植术后患者的生活质量状况；肾移植患者的文化程度、性别、年龄、体重指数、移植后时间及有无糖尿病等对生活质量影响相对较大。     

肾移植后患者生活质量评分专用量表的制订及相关因素分析

目的 制订针对国人的肾移植后生活质量评分专用量表(下称专用量表),为评价国人肾移植后生活质量提供量化工具;研究肾移植患者生活质量的影响因素,为提高护理质量提供参考.方法 选取肾移植术后6个月肾功能稳定的357例患者,应用终末期肾脏疾病移植患者症状调查表(ESRD-SCL)、健康状况问卷(SF-36)及自制的一般情况问卷进行调查.对条目池中的各条目做统计学测评,选择条目池中回答阳性率较高(＞20%)的条目,应用因子分析正交旋转进行统计分析,筛选因子载荷≥0.4的条目构成初步量表;然后对初步量表的信度、效度进行分析考评.结果 48个条目入选,分属认知能力(12个条目)、药物相关不良反应(9个条目)、心理及情绪(7个条目)、心肾等器官功能(9个条目)、体质(11个条目),Cronbach's α为0.74～0.87.条目形式采用等距等级条目,每个条目有5个选项,评分分别定义为0～4分(0=完全没有,1=轻微,2=比较严重,3=很严重,4=非常严重).患者的认知能力与其文化程度、药物相关不良反应与性别、心理及情绪方面与文化程度、心肾等器官功能与年龄、体质与体重指数相关性最大(r=-0.21、-0.33、-0.32、0.22、0.30,均P＜0.05).结论 该专用量表有良好的信度和效度,适用于了解我国肾移植术后患者的生活质量状况;肾移植患者的文化程度、性别、年龄、体重指数、移植后时间及有无糖尿病等对生活质量影响相对较大.     

Predictors of outcome in treatment of morbid obesity by laparoscopic adjustable gastric banding: results of a prospective study of 380 patients

BACKGROUND: We investigated the outcome predictors of laparoscopic gastric banding (LAGB) for morbidly obese patients. METHODS: From December 1996 to November 2004, a total of 380 consecutive unselected patients (78% female; median age 40 yr, range 17-66; body mass index 44.3 kg/m(2), range 35-75) were prospectively evaluated and underwent LAGB. The follow-up rate after a median of 5 years (range 1.5-9.4) was 98%. A survival model was applied, and a multivariate Cox proportional hazard model was used to calculate the hazard ratios for the influential factors. RESULTS: Of the 380 patients, 128 (33.7%) had their bands removed. Of these 128 patients, 2.4% declined another operation, 18.2% underwent biliopancreatic diversion with duodenal switch, 7.1% underwent laparoscopic Roux-en-Y gastric bypass, and 6% underwent laparoscopic sleeve gastrectomy. The excess weight loss of the remaining 252 patients (66.3%) with a band in situ (including 21 patients after rebanding) was 40%, and only 25% reached an excess weight loss >50%. Older age, binge eating disorder, and sweet-eating behavior were predictors of a poor outcome after LAGB. In contrast, sex, primary body mass index, and co-morbidities had no influence on outcome. CONCLUSION: LAGB was less successful in older patients and in patients with binge eating disorder or sweet-eating behavior. These patients might be candidates for a different bariatric procedure.     

多沙唑嗪对于改善输尿管支架管引起的下尿路症状的作用

目的评价多沙唑嗪对置入输尿管支架管（D-J）患者下尿路症状以及生活质量的改善作用。方法从2010年3月至2010年12月,共收集了28例输尿管镜碎石后留置D-J管的患者入组本研究。患者被随机分为2组（治疗组、对照组）,对照组14例患者未接受多沙唑嗪治疗,治疗组14例患者接受了2～4周的多沙唑嗪（4mg/d）治疗。所有患者均在2～4周后D-J管去除之前接受国际前列腺症状评分和世界卫生组织生存质量测定量表简表对患者下尿路症状及生存质量进行评估。结果对照组IPSS平均分为9.79,治疗组中IPSS平均分为5.07,P〈0.05;对照组中生理领域平均分为13.80,治疗组中为15.43,P〈0.05。结论多沙唑嗪可改善一系列D-J管相关下尿路症状以及患者的生活质量。     

Diverticular disease has an impact on quality of life – results of a preliminary study

Objective Diverticular disease (DD) is common in the western world, and carries a significant morbidity. Although patients can have long standing symptoms no research on quality of life (QoL) in DD exists in the literature. Assessment of QoL may be useful in decision making and selection of patients who would be appropriate candidates for elective surgical treatment. The aim of this study was to examine whether DD has an impact on QoL. Materials and methods A combination of structured interview and questionnaire survey was performed. One hundred people were divided into two groups: Group A, 50 patients with symptomatic DD as their primary diagnosis; Group B, A control group of 50 healthy volunteers. A structured QoL questionnaire, examining bowel symptoms, systemic symptoms, emotional symptoms and social function, was completed by the subjects in both the patient and the control group. Results In the patient group scores fell well below the optimum QoL scores in each of the subscales particularly in the areas of bowel symptoms (43.8 vs 65.4 for controls) and emotional function (55.1 vs 75.9 for controls). Patients with DD had statistically significantly lower QoL scores than controls and this difference was consistent in all four examined areas (P < 0.003 for all categories). Conclusion Our preliminary study suggests that DD does affect a person's QoL. The authors recommend that further research is required in the development of a (QoL) scoring system specific for patients with diverticular disease. Having developed a tool that can accurately measure the subjective health status (QoL) of this disease group we will then be able to develop a more systematic approach to the delivery of treatment, management and care of patients with diverticular disease.     

Pain and morbidity of an extensive prostate 10-biopsy protocol: a prospective study in 289 patients.

PURPOSE: Some studies imply that increasing the number of prostate biopsy cores may improve the cancer detection rate. We performed a prospective study to evaluate pain and morbidity after an extensive transrectal ultrasound guided 10-core biopsy protocol. MATERIALS AND METHODS: A total of 289 consecutive men with abnormal digital rectal examination findings and/or increased prostate specific antigen underwent extensive prostate biopsy involving 6 sextant and 4 peripheral biopsies. Each received an information leaflet a few days before the procedure. A single dose of fluoroquinolone and a rectal enema were administered before biopsy. In no case was the procedure performed using anesthesia. Immediately after biopsy patients were asked to complete a self-administered nonvalidated questionnaire evaluating the degree of pain and/or discomfort using a visual analog scale. In another questionnaire they listed the side effects noticed during month 1 after biopsy. RESULTS: Although 48% of the 275 men who completed the initial questionnaire reported anxiety before the procedure, 78.8% of them were completely reassured by the information brochure. Of the 275 patients 47.6% described the procedure as painful, including only slightly painful (analog visual scale 3 or less) in 67.9%, while 33.8% described it as uncomfortable but not painful and 18.6% thought that it was neither painful nor uncomfortable. Of the 115 patients who engaged in sexual intercourse during month 1 after the procedure 78.3% noticed hematospermia an average of 10.9 days in duration. Of the 164 men who completed questionnaire 2, 74.4% noticed hematuria an average of 2.7 days in duration, 3.7% noticed pyrexia and 1.2% noticed acute prostatitis. In the 59 patients (36%) who reported delayed perineal pain it was slight in 64.4%, moderate in 30.5% and severe in 5.1%. No patient required hospitalization. CONCLUSIONS: Although minor complications are common, the extensive 10-core prostate biopsy protocol is associated with few major complications. The occurrence and intensity of pain and discomfort are in the range reported after the standard 6-core biopsy protocol.     

输尿管留置双J管患者生活质量的初步调查

目的 探讨输尿管留置双J管对患者生活质量的影响因素.方法 60例留置输尿管双J管患者,平均年龄53岁.平均置管时间(21.4±3.8)d.患者门诊膀胱镜下拔管时应用输尿管支架管特殊调查问卷调查,包括泌尿系统症状、国际前列腺症状评分(IPSS)、生活质量评分(QoL)和视觉疼痛评分(VAS).按麻醉方式分为3组,局麻组(12例),局麻加静脉复合麻醉组(10例)和全麻组(38例)进行疼痛评分比较.结果 膀胱镜下置管或拔管时患者疼痛感分别为,局麻组11例(91%),局麻加静脉复合麻醉组8例(80%),全麻组38例均无疼痛感.带管期间54例(90%)患者有泌尿系统症状,依次为夜尿42例(70%)、尿频39例(65%)、尿急36例(60%)、尿不尽35例(58%)、排尿困难31例(52%)、肉眼血尿21例(35%)、尿失禁18例(30%);患者有腰腹痛和下腹痛45例(75%).QoL"不满意"29例(48%),其中由继发性膀胱过度活动症(OAB)所致18例(62%),疼痛所致5例(17%).结论 输尿管支架管引起的泌尿系症状和疼痛严重影响患者日常生活,48%的患者感觉生活质量下降.继发性OAB是引起患者生活质量下降的主要原因.