Acute kidney injury after radical gastrectomy: a single center study

Objectives

To investigate the incidence of acute kidney injury (AKI) and identify risk factors for AKI in patients who undergo radical gastrectomy.

Methods

This study included 536 patients underwent radical gastrectomy. Primary outcome was AKI, defined as a ≥50 % increase in serum creatinine relative to baseline during the first three postoperative days. Secondary outcomes were duration of hospitalization and all-cause hospital mortality within 30 days after radical gastrectomy.

Results

A total of 37 (6.9 %) patients developed postoperative AKI. Age, body mass index (BMI), presence of hypertension, hyperlipidemia, poor blood glucose control, and preoperative higher cystatin C were associated with increased frequency of AKI. By multivariable analyses, the independent risk factors for AKI were age, BMI, hypertension, hyperlipidemia, and preoperative cystatin C.

Conclusions

Postoperative AKI is not infrequent after radical gastrectomy. Age, BMI, hypertension, hyperlipidemia, and preoperative cystatin C are independently associated with increased risk of postoperative AKI.     

Urolithiasis in adult spina bifida patients: study in 260 patients and discussion of the literature

Purpose

To describe incidence and risk factors of urinary tract stones in adult spina bifida (SB) patients. Although spina bifida patients have an allegedly higher risk of urinary tract stones, only two small non-English case series are available and do not provide adequate epidemiological data and analyses on risk factors.

Methods

A total of 260 adult SB patients followed in our centre for 10 years were retrospectively analysed for stone disease. Both a univariate analysis (Fisher’s exact, two-sided Student’s t test) and a binary logistic regression analysis were performed to identify independent risk factors for stone disease.

Results

Of the 260 patients, 24 (9.2 %) were identified with a history of urolithiasis. Fourteen patients (5.4 %) had bladder stones in 26 episodes. Sixteen patients (6.2 %) had upper urinary tract stones: 14 kidney stones and two ureteral stones. Lifetime incidence of both bladder stones and upper tract stones was 2.25 per 1,000 patient-years. Recurrent urinary tract infections (OR 4.34, p = 0.013) and incorporation of bowel tissue into a continent reservoir (including enterocystoplasty) (OR 4.80, p = 0.012) were independent risk factors for bladder stone disease in a multivariate model. An indwelling catheter was an independent predictor for upper tract stones (OR 5.89, p = 0.02).

Conclusions

Urolithiasis, especially in the bladder, is a frequent finding in patients with SB. Bladder stones occur about 10 times more often in SB patients than in the population. In patients without risk factors, frequent ultrasound of the urinary tract is not necessary for the sole detection of stones.     

Urolithiasis in infants: evaluation of risk factors

Objective

Urolithiasis in infants is not a very rare situation in Turkey, and the incidence has been increasing in recent years. The purpose of this paper was to investigate the clinical characteristics, metabolic and anatomic risk factors for urolithiasis and microlithiasis in infants.

Methods

The cases of 178 infants (63 girls, 115 boys), who were referred to our department between 1999 and 2009 with urolithiasis, were evaluated.

Results

The mean age at diagnosis of stone disease was 11.5 months (range, 10 days–24 months). The mean follow-up duration was 33.6 months (1.2–110 months). The major clinical symptoms of our patients were restlessness in 24 children (13.5%) and vomiting in 23 (13%). Thirty-five infants (19.7%) had a urinary tract abnormality; vesico-ureteral reflux was the most common abnormality (12.9%). Hypercalciuria and hyperuricosuria were detected in 46 and 56%, respectively. Stone analysis was performed in 56 infants, and calcium oxalate was determined in 36 patients (64.3%). A family history of urolithiasis, presenting symptoms and underlying metabolic abnormalities were similar for patients with microlithiasis and those with larger stones. However, infants with microlithiasis had higher ratios for history of vitamin D administration and feeding with formula. Surgical treatment was performed in 42 infants and extracorporeal shock wave lithotripsy in 30 infants.

Conclusion

Our results showed that urolithiasis in infants may present nonspecific symptoms and may even be asymptomatic and that a positive family history for urolithiasis, urologic abnormalities, metabolic disorders, urinary tract infections, vitamin D administration and feeding with formula may increase the occurrence of urolithiasis in infants.     

Acute kidney injury in scrub typhus

Background

We studied the urinary abnormalities and acute kidney injury (AKI) as per RIFLE criteria in scrub typhus.

Methods

A prospective case record-based study of scrub typhus was carried out from January 2009 to December 2010 in a tertiary hospital in South India. Patients were followed up until renal recovery or for at least 3 months after discharge. Univariate, chi-squared tests and multivariate logistic regression analyses were performed to identify the predictors of AKI.

Results

Scrub typhus was diagnosed in 259 patients. Urinary abnormalities were seen in 147 patients (56.7 %) with 60 patients (23.2 %) having AKI. All AKI patients had urinary abnormalities and 17 (28.3 %) were oliguric. Applying RIFLE (risk, injury, failure, loss, end-stage kidney disease) criteria, R, I, F were present in 23 (38.33 %), 13 (21.67 %), and 24 patients (40 %), respectively. Creatine phosphokinase (CPK) was raised in 33 patients (55 %) and hemodialysis was required in 6 patients (10 %). The case fatality rate in this study was 2 out of 259 (0.77 %), both having AKI and others recovering clinically. Significant predictors of AKI were tachycardia [odds ratio (OR) 2.28], breathlessness (OR 2.281), intensive care requirement (OR 2.43), mechanical ventilation (OR 3.33), thrombocytopenia (OR 2.90) and CPK >80 U/L (OR 1.76) by univariate analysis and intensive care requirement (adjusted OR 2.89) and thrombocytopenia (AOR 2.28) by multivariable logistic regression.

Conclusion

Scrub typhus should be part of the differential diagnosis of acute febrile illness with AKI. AKI in scrub typhus is usually mild, non-oliguric, and renal recovery occurs in most patients. Rhabdomyolysis may be contributory to AKI. Thrombocytopenia and intensive care requirement are significant predictors of AKI in scrub typhus.     

Dual energy can accurately differentiate uric acid-containing urinary calculi from calcium stones

Purpose

To retrospectively evaluate the accuracy of dual-energy CT (DECT) in the detection of the chemical composition of urinary calculi in correlation with infrared spectroscopic stone analysis.

Methods

We reviewed the CT scans of 255 patients who underwent DECT due to a clinical suspicion of urolithiasis. Out of this group, we included 64 patients with clinically symptomatic urolithiasis requiring stone removal. After surgical removal of the stone by ureterorenoscopy, chemical composition was analyzed with infrared spectroscopy. We correlated DECT stone characterization results with chemical stone composition based on dual-energy indices (DEI). A total of 213 renal and ureteral stones could be removed and chemically analyzed.

Results

A total of 213 calculi were evaluated. Thirty eight out of sixty four (59 %) patients had >1 stone. DECT was used to differentiate stones by using DEI. Stones harboring calcium (CA) were color-coded in blue, while stones containing uric acid (UA) were colored red. Median DEI in UA-containing stones were 0.001. Non-UA-containing stones had a DEI between 0.073 for pure CA stones and 0.077 containing CA and other substances (p = 0.001; p = 0.03, respectively). Sensitivity of DECT was 98.4 % for differentiation of UA from non-UA-containing calculi. Specificity was 98.1 %. Mean effective radiation dose of DECT was 4.18 mSv (0.44–14.27 mSv), thus comparable to conventional CT scans of the abdomen. Conventional measurement of Hounsfield units did not correlate with stone composition.

Conclusion

DECT with image post-processing reliably discriminates UA-containing calculi from all other stones, but the study offered limitations. Discrimination within the non-UA stones cannot be reliably achieved but is clinically insignificant.

     

AKI in early sepsis is a continuum from transient AKI without tubular damage over transient AKI with minor tubular damage to intrinsic AKI with severe tubular damage

Purpose

The pathophysiology of septic acute kidney injury (AKI) is incompletely understood, and there is controversy on the role of renal hypoperfusion in early sepsis. We hypothesized that renal hypoperfusion plays a role in early sepsis and that there is a continuum between transient AKI without tubular damage, transient AKI with minor tubular damage, and intrinsic AKI.

Methods

A total of 107 consecutive patients with sepsis were included. Fractional excretion of sodium (FENa), urinary, and serum neutrophil gelatinase-associated lipocalin were measured at admission (T0) and 4 h (T4) and 24 h later (T24). Patients were classified according to FENa quartiles (FENaQ). Transient and intrinsic AKI were respectively defined as AKI that did or did not recover to no AKI in the following 5 days.

Results

A total of 57 developed transient AKI, 22 developed intrinsic AKI, and 28 did not have AKI. Of the ten patients with transient AKI classified in the two lowest FENa quartiles (FENa < 0.36 %) and without signs of local tubular damage, seven still did not show signs of tubular damage 24 h later. Also, 50 % of patients with intrinsic AKI classified in the same FENaQ did not show signs of local tubular damage at admission but did so 24 h later.

Conclusions

There is a continuum between transient AKI without tubular damage, transient AKI with minor tubular damage, and intrinsic AKI in sepsis. Renal hypoperfusion seems to be the instigator for the development of AKI in the majority of patients with early sepsis. Other mechanisms in some patients cannot be excluded.     

Short- and long-term outcomes after non-severe acute kidney injury

Background

Severe acute kidney injury (AKI) is associated with chronic kidney disease (CKD), cardiovascular events and increased mortality. However, little is known about the prognosis in hospitalized population suffering from non-severe AKI episodes. The aim of this study is to determine the impact of non-severe AKI episodes in cardiovascular events, mortality and CKD, on short and long term.

Methods

Retrospective cohort study to 360 patients who met the criteria for diagnosis of AKI according ADQI guidelines with full recovery of renal function after the AKI episode, admitted between January 2000 and December 2010 in our hospital. Follow-up was 4 years after the diagnosis of AKI. Covariates included demographic variables, baseline creatinine and diagnosis of comorbidities.

Results

360 AKI survivor patients were included. Twenty five of them (6.7%) had developed CKD after 1-year follow-up. Hypertension (OR 1.62; 95% CI 1.2–2.6, p < 0.05) and serum creatinine >2.6 mg/dL in AKI (OR 1.7; 95% CI 1.2–3.7, p < 0.05) were independent risk factors. After 4-year follow-up, 40 patients (18.3%) had developed CKD; age >66 years was an independent risk factor (OR 1.03, 95% CI 1.03–1.06, p < 0.05). Mortality rate at 4 years was 25.3% and was significantly higher in CKD patients (OR 4.3, 95% CI 1.13–4.90, p < 0.05) and patients >66 years (OR 1.12, 95% CI 1.02–1.06, p < 0.05). The incidence of cardiovascular events also was higher in CKD patients than in non-CKD patients (62.7 vs. 21.7%, p < 0.05).

Conclusion

Even after fully recovered non-severe AKI episodes, some patients develop CKD and those have an increase in the incidence of cardiovascular events and long-term mortality.

     

Predictors of Perioperative Acute Kidney Injury in Obese Patients Undergoing Laparoscopic Bariatric Surgery: a Single-Centre Retrospective Cohort Study

Background

Obesity has been associated with increased risk of perioperative acute kidney injury (AKI). We aim to establish the incidence of AKI among patients undergoing laparoscopic bariatric surgery and identify potential risk factors.

Methods

Records of 1230 patients who underwent laparoscopic bariatric surgery in a tertiary centre from 1 December 2009 to 31 January 2014 were retrospectively studied. AKI diagnosis was made by comparing the baseline and post-operative serum creatinine to determine the presence of predefined significant change based on the Kidney Disease: Improving Global Outcomes (KDIGO) definition. Univariate analyses were performed to determine significant clinical factors, and multiple logistic regression analysis was subsequently done to determine independent predictors of AKI.

Results

Thirty-five (2.9 %) patients developed AKI during the first 72 h post-surgery. Multivariate logistic regression analysis revealed impaired renal function (OR 10.429, 95 % CI 3.560 to 30.552), use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers (OR 3.038, 95 % CI 1.352 to 6.824), and body mass index (OR 1.048, 95 % CI 1.005 to 1.093) as independent predictors of perioperative acute kidney injury in the obese patients who underwent laparoscopic bariatric surgery.

Conclusions

We found that the incidence of perioperative AKI among patients who underwent laparoscopic bariatric surgery is at 2.9 %. Impaired renal function, use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers and raised body mass index were found to be independent predictors of AKI. Patients with these risk factors could be considered at risk for developing perioperative AKI, and extra perioperative vigilance should be undertaken.

     

Long-term follow-up study of gallbladder in situ after endoscopic common duct stone removal in Korean patients

Background

Although there has been much debate over the fate of the gallbladder (GB) after endoscopic common bile duct (CBD) stone removal, subsequent cholecystectomy is generally recommended in patients with GB stones to prevent further biliary complications. The aims of this study were to assess the natural course of the patients with GB in situ after endoscopic CBD stone removal and to evaluate the necessity of prophylactic cholecystectomy.

Methods

Four hundred sixty-one patients who had undergone CBD stone removal at Yeungnam University Hospital between January 2000 and December 2004 were retrospectively analyzed, and 232 patients were ultimately enrolled in this study.

Results

The mean duration of follow-up was 73 (range = 7–126) months in the cholecystectomy group and 66 (6–127) months in the GB in situ group (p = 0.168). Ten patients (14.7 %) in the cholecystectomy group and 31 patients (18.9 %) in the GB in situ group developed recurrent CBD stones (p = 0.295). The highest percentage of recurrent CBD stones in both groups was that for brown stones (80 and 80.6 %). In the GB in situ group, cumulative recurrence rates of CBD stones were not significantly different between patients with GB stones and without GB stones (15.9 vs. 20 %, p = 0.798). However, the incidence of acute cholecystitis was significantly higher in patients with GB stones compared to patients without GB stones (13.6 vs. 2.5 %, p = 0.003).

Conclusions

Prophylactic cholecystectomy seems to be unnecessary in patients without GB stones after endoscopic sphincterotomy. However, in patients with GB stones, elective cholecystectomy or close observation is recommended due to the higher risk of cholecystitis.     

L-FABP can be an early marker of acute kidney injury in children

Background

Acute kidney injury (AKI) is a common postoperative complication following cardiopulmonary bypass (CPB) surgery. New biomarkers to identify patients with early AKI (before increases in serum creatinine) are needed to facilitate appropriate treatment. This study aimed to test the role of urinary liver fatty-acid-binding protein (L-FABP) as an early biomarker for AKI in children undergoing CPB surgery.

Methods

This is a case–control study of children undergoing CPB. AKI was defined as 50 % increase in serum creatinine at 48 h after surgery. For each patient, five serum and urine samples were obtained corresponding to time 0 h (presurgery) and 2, 6, 24, and 48 h after surgery.

Results

Twenty-seven patients, median age 360 days, were enrolled. AKI developed in 11 patients (41 %); three needed renal replacement therapy (peritoneal dialysis); there were two deaths. There were significant differences between patients with and without AKI in L-FABP levels at 2, 6, and 48 h after surgery, length of hospital stay, and CPB time; there were no differences in gender, patient age, and body weight. L-FABP was normalized to urinary creatinine concentration at all time points, with area under the receiver operator curve (AUC ROC) 0.867 at 2 and 6 h postoperatively. Correlation coefficient between L-FABP and length of hospital stay after surgery was statistically significant (r?=?0.722, p value?=?0.000).

Conclusions

Our results suggest that urinary L-FABP can be used to diagnose AKI earlier than rise in serum creatinine in children undergoing CPB.     

Lower pole stones: prone PCNL versus supine PCNL in the International Cooperation in Endourology (ICE) group experience

Purpose

To assess efficacy and safety of prone- and supine percutaneous nephrolithotomy (PCNL) for the treatment of lower pole kidney stones.

Methods

Data from patients affected by lower pole kidney stones and treated with PCNL between December 2005 and August 2010 were collected retrospectively by seven referral centres. Variables analysed included patient demographics, clinical and surgical characteristics, stone-free rates (SFR) and complications. Statistical analysis was conducted to compare the differences for SFRs and complication rates between prone- and supine PCNL.

Results

One hundred seventeen patients underwent PCNL (mean stone size: 19.5 mm) for stones harboured only in the lower renal pole (single stone: 53.6 %; multiple stones: 46.4 %). A higher proportion of patients with ASA score ≥ 3 and harbouring multiple lower pole stones were treated with supine PCNL (5.8 vs. 23.1 %; p = 0.0001, and 25 vs. 81.5 %; p = 0.0001, respectively, for prone- and supine PCNL). One-month SFR was 88.9 %; an auxiliary procedure was needed in 6 patients; the 3-month SFR was 90.2 %. There were 9 post-operative major complications (7.7 %). No differences were observed in terms of 1- and 3-month SFRs (90.4 vs. 87.7 %; p = 0.64; 92.3 vs. 89.2 %; p = 0.4) and complication rates (7.6 vs. 7.7 %; p = 0.83) when comparing prone- versus supine PCNL, respectively.

Conclusions

The results confirm the high success rate and relatively low morbidity of modern PCNL for lower pole stones, regardless the position used. Supine PCNL was more frequently offered in case of patients at higher ASA score and in case of multiple lower pole stones.     

Epidemiology of cardiac surgery-associated acute kidney injury in neonates: a retrospective study

Background

Cardiac surgery is a known risk factor for acute kidney injury (AKI) in children. However, cardiac surgery-associated AKI (CS-AKI) in neonates has not been well studied. The objectives of this study were: (1) to describe the epidemiology of CS-AKI in neonates utilizing the Acute Kidney Injury Network (AKIN) definition, (2) to identify risk factors for neonatal CS-AKI, and (3) to determine if neonatal CS-AKI is associated with increased morbidity and mortality.

Methods

This was a retrospective study involving 122 neonates (≤28 days) undergoing cardiac surgery from 2006 to 2009. Neonates with and without AKI were identified using serum creatinine (SCr) and urine output (UO) data.

Results

Cardiac surgery-AKI occurred in 76 (62 %) neonates, of whom 22 (29 %) were AKIN stage 1, 19 (25 %) were stage 2, and 35 (46 %) were stage 3. AKI mostly occurred early as 75 % of patients achieved their maximal AKIN stage within the first 48 h post-operatively. In the multivariate analysis, cardiopulmonary bypass duration of ≥120 min was independently associated with AKI [odds ratio (OR) 2.53, 95 % confidence interval (CI) 1.03–6.30]. Severe AKI (AKIN stage 3) was independently associated with mortality (OR 6.70, 95 % CI 1.08–41.50) and a longer stay in the pediatric intensive care unit (hazard ratio 9.09, 95 % CI 1.35–60.95). The majority of severe AKI cases (65 %) were identified with AKIN UO criteria alone without significant rises in SCr.

Conclusions

Cardiac surgery-AKI is common in neonates when the AKIN definition is utilized and is associated with higher morbidity and mortality, especially in those with more severe AKI.     

Acute kidney injury according to pediatric RIFLE criteria is associated with negative outcomes after heart surgery in children

Background

The aim of this study was to investigate the association between the occurrence of acute kidney injury (AKI) according to pediatric RIFLE (pRIFLE) criteria and adverse outcomes in children after heart surgery.

Methods

Children undergoing heart surgery in a tertiary hospital in Southern Brazil were followed during their stay in the pediatric intensive care unit (PICU) or until death. The exposure variable was occurrence of AKI according to pRIFLE criteria which place AKI in three categories: R (risk), I (injury), and F (failure). The outcomes studied were death, length of mechanical ventilation (MV), and length of PICU stay.

Results

Eighty-five children were enrolled in the study. Of these, 47 (55.3 %) did not have AKI, while 22 (25.9 %), seven (8.2 %), and nine (10.6 %) were classified into pRIFLE categories R, I, and F, respectively. The incidence of death was 18.4 and 4.2 % in patients with and without AKI, respectively. Compared to children who did not develop AKI, the adjusted odds ratio for death was 1.05 [95 % confidence interval (CI) 0.09–11.11], 8.36 (95 % CI 1.32–52.63), and 7.85 (95 % CI 1.53–40.29) in the R, I, and F groups, respectively (p?=?0.022). Duration of MV and of PICU stay were significantly higher in those children with AKI.

Conclusions

The occurrence of AKI according to pRIFLE criteria is associated to adverse outcomes in children after heart surgery.     

Acute Kidney Injury Following Bariatric Surgery

Background

Postoperative acute kidney injury (AKI) following bariatric surgery has not been well studied. The aim of this study is to identify factors associated with risk of AKI.

Methods

The medical records of adult patients who underwent bariatric surgery between March 1, 2005 and March 31, 2011 at the Mayo Clinic were reviewed to identify patients who experienced AKI, defined as postoperative increase in serum creatinine (sCr) by 0.3 mg/dL within 72 h. For each AKI case, two controls were matched for surgical approach (laparotomy vs. laparoscopic). A chart review was conducted and conditional logistic regression analyses were performed to identify risk factors for AKI.

Results

There were 1,227 patients who underwent bariatric surgery, and of these, 71 developed AKI (5.8 %). The median sCr increase was 0.4 (interquartile range 0.3–0.6) mg/dL. Independent patient factors associated with increased risk included higher body mass index [odds ratio (OR) 1.24, 95 % CI 1.06–1.46 per 5 unit increase, P?=?0.01] and medically treated diabetes mellitus (OR 2.77, 1.36–5.65, P?=?0.01). Patients experiencing AKI had higher rates of blood transfusions (P?<?0.01), postsurgical complications (P?<?0.01), and longer hospital stays (P?<?0.01). Another 30 patients developed kidney injury after 72 postoperative hours, usually in the setting of dehydration.

Conclusions

Kidney injury following bariatric surgery is not uncommon and is associated with higher body mass index and diabetes. Further, there should be a high risk of suspicion for kidney injury in postoperative patients developing volume depletion.     

Strahlenbelastung der Patienten bei der ureterorenoskopischen Steinentfernung

Background

We determined the intraoperative patient radiation exposure during ureteroscopic extraction of ureteral or renal stones.

Material and methods

The investigation was carried out in 215 patients who underwent ureteroscopy for ureteral or renal stone extraction. Radiation exposure was measured as dose-area product (DAP) within the X-ray beam. The effective abdominal dose was calculated using the specific conversion factor of 0.00323 mSv/µGy×m².

Results

Depending on the stone location (i.e. ureter or kidney), the type of ureteroscopy (i.e. semirigid or flexible) and type of stone removal (i.e. simple stone extraction or intracorporeal laser lithotripsy), the intraoperative patient radiation exposure (effective dose ED) ranged from 0.67 mSv (DAP 221.9 µGy×m²) to 2.23 mSv (DAP 744.2 µGy×m²).

Conclusion

Patient radiation exposure during ureteroscopic stone extraction is comparable to patient radiation exposure using plain film urography or low-dose non-contrast-enhanced computed tomography for diagnosis of urolithiasis.     

The optimal timing of continuous renal replacement therapy for patients with sepsis-induced acute kidney injury

Purpose

High mortality in the intensive care unit (ICU) is probably associated with sepsis-induced acute kidney injury (AKI). The aim of this study is to explore which stage of AKI may be the optimal timing for continuous renal replacement therapy (CRRT).

Methods

A retrospective analysis of 160 critically ill patients with septic AKI, treated with or without CRRT was performed in Binzhou medical college affiliated hospital ICU. The parameters including 28-days mortality rate, renal recovery, ventilation time and ICU stay between CRRT group and control group were assessed.

Results

Renal recovery, defined as independence from dialysis at discharge, was documented for 64/76 (84.2 %) of the surviving patients (48.1 % of total subjects included in the study). The mortality rate increased proportionally with acute kidney injury Network stages in CRRT subgroups (P = 0.001) and control groups (P = 0.029). CRRT initiation at stage 2 of AKI significantly reduced the 28-day mortality (P = 0.048) and increased the 28-day survival rate (P = 0.036) compared with those in control group. In addition, the ICU stay and ventilation time were shorter in CRRT group than that of control group in stage 2 of AKI.

Conclusion

The stage 2 AKI might be the optimal timing for performing CRRT.     

Combined semirigid and flexible ureterorenoscopy via a large ureteral access sheath for kidney stones >2 cm: a bicentric prospective assessment

Purpose

The international guidelines on urolithiasis state that the percutaneous approach is superior for kidney stones ≥20 mm. Nevertheless, several groups have reported high stone-free rates (SFRs) with low morbidity for ureteroscopic treatment of calculi >15 mm. We hereby describe a new technique including the combined use of semirigid and flexible ureteroscopy via a large ureteral access sheath (UAS).

Methods

The proposed technique includes (a) preoperative ureteral stenting, (b) use of a large lumen UAS (14/16F, 35 cm), (c) use of a semirigid ureteroscope, (d) holmium laser lithotripsy, (e) passive and (f) active fragment extraction, and finally, the removal of caliceal stones (g) using a flexible scope. We conducted a prospective outcome analysis for 38 patients treated at two tertiary university centers.

Results

Perioperative data were as follows: median cumulative stone size 24.5 mm (20–60), median operating time 95 min (50–205), post-operative ureteral stenting (2–35 days) in 33 patients (86.8 %), Clavien complications 2 and 3 in 7.9 %, primary SFR 63.2 %, and overall computed tomography (CT) controlled SFR after 3 months 81.8 % (including staged procedures). No late complications were observed.

Conclusions

The combined use of semirigid ureteroscopy and an UAS further develops the endoscopic treatment of kidney stones. This is the first series of this kind that confirms high SFRs by CT. The approach has significant advantages: Superior irrigation and outflow enhance both vision and stone clearance, and multiple ureteral passages without putting the ureter at injury risk. These encouraging results make this modality an appealing alternative to percutaneous nephrolithotomy.     

Imaging the urologic patient: the utility of intravenous pyelogram in the CT scan era

Purpose

An opportunity exists to evaluate the quality of care in patients undergoing intravenous pyelogram (IVP) imaging and to define the role of IVP in the computed tomography scan era.

Methods

Medical records were reviewed for patient demographics, inpatient versus outpatient setting, indication for IVP, physician/specialty who ordered IVP, and the need for subsequent imaging within a 30-day period in patients who underwent IVP from October 2007 to December 2011. Chi-square test was used to compare the number of additional radiologic examinations ordered within 30 days of the initial IVP across the different specialties ordering IVPs.

Results

Six hundred and eighty patients underwent IVP imaging during the study period. The primary reason to order an IVP was the evaluation of urolithiasis/flank pain (50 %), followed by urologic evaluation after surgery (23 %). Three hundred and twenty-five patients (48 %) subsequently had an additional 547 radiologic studies within 30 days of the IVP to further evaluate their condition. Of the 325 patients undergoing additional imaging studies, 36 % had differing or additional diagnostic information noted that could change medical decision-making.

Conclusions

Inferior imaging of the urologic patient by IVP leads to the acquisition of additional imaging studies to render a diagnosis. IVP has a limited clinical role, and thus, its use should be strictly limited to highly select cases.     

An audit of short- and long-term outcomes after laparoscopic removal of common bile duct stones in Finland

Background and aim

To audit short- and long-term outcomes after laparoscopic common bile duct exploration (LCBDE) and factors influencing the success of the laparoscopic treatment.

Methods

From January 1999 to December 2011, 288 patients (93 males) underwent a single-stage laparoscopic cholecystectomy combined with LCBDE in two Finnish Hospitals. Short-term outcome data were collected prospectively. Long-term outcomes were examined retrospectively. The main measures of outcome were the success of laparoscopic CBD stone clearance and recurrence of CBD stones in the long-term, with 30-day mortality, morbidity, and the length of postoperative hospital stay as secondary outcome measures.

Results

CBD stones were successfully removed by one-stage laparoscopic procedure in 232 of the 279 patients (83.2 %) with verified CBD stones and after conversion to open surgery in additional 28 patients (93.2 %). Nineteen patients (6.8 %) having residual stones after surgery were successfully treated with postoperative ERCP. On multivariate analysis, the independent factors associated with a failed laparoscopic stone clearance were stone size over 7 mm [OR 3.51 (95 % CI 1.53–8.03), p = 0.003], difficult anatomy [OR 18.01 (5.03–64.49), p < 0.001] and transcholedochal approach [OR 2.98 (1.37–4.47), p = 0.006]. Laparoscopic stone clearance also failed in all 11 patients having impacted stones at the ampulla of Vater. Cumulative long-term recurrence rate was 3.6 % at 5 years and 6.0 % at 10 years. Thirty-day mortality was 0.3 % and morbidity 12.2 %. Postoperative hospital stay was median 2 (IQR 1–3) days after transcystic CBD removal and 4 (IQR 3–7) days after transcholedochal CBD removal, p < 0.001.

Conclusion

Our results show that one-stage LC combined with LCBDE stone clearance is safe and effective in most patients thus reducing the number of additional, potentially dangerous endoscopic procedures. Moreover, large or impacted stones are a risk factor for failed stone clearance.     

Extracorporal shock wave lithotripsy in the management of stones in children with oxalosis—still the first choice?

Background

Primary hyperoxaluria (PH) is a recognised cause of nephrolithiasis. The aim of this study was to evaluate the success of extracorporal shock wave lithotripsy (ESWL) in treating nephrolithiasis in children with PH.

Methods

This was a retrospective review of patient characteristics, treatments and outcomes of 36 children with oxalate stones due to PH.

Results

A total of 52 stones were formed in 28 patients, of which 23 stones were treated with ESWL. Of these 23 stones, ten improved and 13 did not; nine were located in the upper pole, nine in the lower pole and four and one in the pelvic and ureteric areas, respectively. All pelvic and ureteric stones improved, while 66.7 % of upper pole stones and 89.9 % of lower pole stones did not; 20 % of PH type 1 stones improved compared to 47 % of PH type 2 stones. The mean pre- and post-eGFR in stone-improvers was 98.82 and 104.7 ml/min/1.73 m², respectively; in the non-improvers, these values were 100.75 and 95.68 ml/min/1.73 m², respectively. Mean pre-ESWL stone size in the improved and non-improved groups was 7.3 mm and 8.5 mm respectively.

Conclusions

Based on our results, ESWL is not the ideal method of stone therapy for patients with PH. ESWL was more effective in treating pelvic and ureteric stones, with upper pole stone response being better than lower pole response. PH2 patients were more than twice as likely to respond to ESWL treatment. Stone size and prior preventive treatment did not affect outcome. eGFR was not affected by ESWL.