Management of urolithiasis

Urolithiasis is a common urological condition. Its incidence is increasing. It is one of the commonest urological emergencies, and has important, occasionally life-threatening, differential diagnoses. Treatment of an infected obstructed kidney is a urological emergency, and supportive treatment and swift drainage are paramount. Decision making for the treatment of stones depends upon stone size, site, patient and kidney factors, with active surveillance, ESWL, ureteroscopy and laser stone fragmentation and PCNL all possible options. Metabolic investigation of high-risk stone formers and advice regarding the prevention of stone formation are important.     

Xanthogranulomatous pyelonephritis: a systematic review of treatment and mortality in more than 1000 cases

Objectives

To systematically review the current demographics, treatment and mortality rate associated with xanthogranulomatous pyelonephritis (XGP) and to test the hypothesis that the weighted pooled peri-operative mortality rate will be <10%.

Methods

Searches were performed of the Cochrane, Embase and Medline databases and the grey literature for studies published during the period 1 January 2000 to 30 August 2021. Eligible studies reported cohorts of ≥10 predominantly adult patients with XGP and described either average patient age or mortality rate.

Results

In total, 40 eligible studies were identified, representing 1139 patients with XGP. There were 18 deaths, with a weighted pooled peri-operative mortality rate of 1436 per 100 000 patients. The mean age was 49 years, 70% of patients were female and 28% had diabetes mellitus. The left kidney was more commonly affected (60%). Four patients had bilateral XGP, and all of whom survived. Renal or ureteric stones were present in 69% of patients, including 48% with staghorn calculi. Urine culture was positive in 59% of cases. Fistulae were present in 8%. Correct preoperative diagnosis occurred in only 45% of patients. Standard treatment continues to comprise a short cause of antibiotics and open radical (total) nephrectomy. Preoperative decompression occurred in 56% of patients. When considered at all, laparoscopic nephrectomy was performed in 34% of patients. Partial nephrectomy was conducted in 2% of patients.

Conclusions

Xanthogranulomatous pyelonephritis has a lower mortality rate than historically reported. A typical patient is a woman in her fifth or sixth decade of life with urolithiasis. While open radical nephrectomy remains the most common treatment method, laparoscopic, and to a lesser degree partial nephrectomy, are feasible in well selected patients.     

Preliminary experience with the pulsed dye laser for treatment of urolithiasis

We report our initial experience using the pulsed dye laser in 26 patients with urolithiasis. The patients ranged in age from 27 to 82 years; 11 patients were female and 15 were male. Of the 26 patients, 4 stones were in the kidney, 21 were in the ureter, and one was in the bladder. Surgical time ranged from 32 to 130 minutes. All patients were treated under spinal or general anesthesia. The size of ureteral stones ranged from 0.2 to 1.5 cm, and the renal stones 3.0 to 4.0 cm. Chemical analysis of the stones was not available on all patients, but when available, chemical analysis revealed the stones to be calcium monohydrate, calcium dihydrate, or struvite. The use of the Candela miniscope in 11 patients permitted access without ureteral dilation. In 19 patients, ureteral stents were placed. One patient suffered a ureteral perforation. Success was defined as adequate disintegration of the stone for passage of the fragments without the necessity of a secondary procedure. Using this criterion, 22 of 26 patients were successfully treated for an overall success rate of 85%.     

黄色肉芽肿性肾盂肾炎诊断与治疗

目的探讨黄色肉芽肿性肾盂肾炎的诊断及治疗方法。方法对2002年～2010年收治的黄色肉芽肿性肾盂肾炎10例患者的临床资料进行回顾性分析,结合文献复习,就其临床表现、影像学特征、诊断及鉴别诊断、治疗等问题进行讨论。结果 9例患者术前误诊,1例患者经B超引导下肾穿刺活检确诊,所有病例均经病理确诊为黄色肉芽肿性肾盂肾炎,1例予以单纯抗感染治疗,症状消失,9例行手术治疗,其中3例行根治性肾切除术,4例行肾切除术,2例行肾部分切除术。术后效果良好,随访5例,至今无1例复发。结论黄色肉芽肿性肾盂肾炎临床表现复杂多样,缺乏特异性,极易误诊。B超引导下肾穿刺活检,是确诊的良好手段。抗感染及手术是治疗的主要手段。     

经皮肾穿刺造瘘术治疗气肿性肾孟肾炎10例

目的介绍经皮肾穿刺造瘘术治疗气肿性肾盂肾炎的手术方法及临床效果。方法对10例气肿性肾盂肾炎患者在连续硬膜外麻醉下实施经皮肾穿刺造瘘术治疗。其中左肾8例,右肾2例。其中4例因肾周积气部位较多放置2根造瘘管引流。术后定期随访6个月到3年。结果 10例患者手术均成功完成,联合内科治疗,其中8例患者生存,2例死亡,8例存活患者术后6个月后静脉肾盂造影和肾功能检查肾功能基本正常。结论气肿性肾盂肾炎成功治疗的关键是手术引流,同时积极控制血糖和广谱抗生素的应用。经皮肾穿刺造瘘术和传统肾脏切除术相比创伤小,有利于更好地保存肾脏功能,为气肿性肾盂肾炎的治疗提供了更好的选择。     

雌激素在梗阻性肾脏疾病中的保护作用

泌尿系结石发病率男性显著高于女性,而绝经后女性泌尿系结石发病率显著升高,且以泌尿系结石为主要原因的梗阻性肾脏疾病在绝经后女性中的发病率显著升高。越来越多证据表明,雌激素与梗阻性肾病的进展密切相关。现通过阐述梗阻性。肾病发病机制及雌激素与其关系,综述雌激素对梗阻性肾病的保护作用。     

Diagnosis and treatment of acute pyelonephritis in anuria caused by urolithiasis

The analysis of observations on 36 patients is presented. Anuria complicated by acute pyelonephritis is considered as an acute surgical pathology requiring emergency operative intervention. The suggested tactics for complex examination and treatment of the patients contributed to decrease in the postoperative lethality down to 5.9%.     

Pediatric urolithiasis: etiology, specific pathogenesis and medical treatment

Pediatric urolithiasis is an endemic disease in certain parts of the world, namely Turkey and the Far East. As a recurrent pathology which may reveal functional as well and morphologic changes in the urinary tract, environmental factors together with urogenital abnormalities should be evaluated thoroughly in each patient. The aims of management should be complete clearance of stones, treatment of urinary tract infections, preservation of renal function and prevention of stone recurrence. In addition to certain minimally invasive stone removal procedures, treatment of pediatric urolithiasis requires a detailed metabolic evaluation in all patients on an individual basis. Obstructive pathologies have to be corrected immediately and children with a positive family history should be followed carefully with respect to a high likelihood of stone re-growth and recurrence. Although specific management of each metabolic abnormality seems to be the key factor in the medical management of stone disease, as general advice each child should be forced to adequate fluid intake which will reveal the urine volume increase in accordance with the body mass index. Moreover, medical therapeutic agents which increase urine citrate levels should be encouraged.     

双J管置入术治疗妊娠期急性梗阻性肾盂肾炎疗效分析

目的探讨双J管置入术治疗妊娠期合并急性梗阻性肾盂肾炎的疗效及安全性。方法收集2014年1月至2015年6月在我院确诊为妊娠合并急性梗阻性肾盂肾炎的110例住院患者,根据治疗方式的不同分为手术治疗组(n=52)与保守治疗组(n=58),比较两种方法的治疗效果。结果手术治疗组与保守治疗组的治愈率分别为100.0%和79.3%,有显著性差异(P0.05);两种治疗方式对于轻度肾积水患者的治愈率比较无显著性差异(P0.05),而对于中、重度肾积水患者,置管术治疗的治愈率(100.0%)显著高于保守治疗的治愈率(50.0%)(P0.05);所有患者均无严重并发症发生,出院后随访,所有患者均顺利诞下婴儿,婴儿无畸形;手术置管患者产后1个月返院均顺利拔除双J管。结论双J管置入术治疗妊娠期急性梗阻性肾盂肾炎,尤其对于患侧中、重度肾积水者,是一种疗效显著、安全、操作简单的微创方法,可作为临床上妊娠期急性梗阻性肾盂肾炎保守治疗无效时的重要辅助治疗手段,值得在临床上广泛推广。     

Prevention and treatment of complicated urinary tract infection

A complicated urinary tract infection (UTI) has relapsing and refractory characteristics, and is sometimes life-threatening because of patient predisposing factors as well as the recent worldwide spread of multi-drug resistant bacteria. Patients with complicated UTI should be treated with effective antimicrobial therapy along with appropriate urological intervention to remove predisposing factors when the symptoms are associated. By contrast, routine use of antimicrobial prophylaxis for asymptomatic bacteriuria (ASB) is not recommended, as that would contribute to an increase in even more resistant pathogens. Here, four classifications of complicated UTI, which are considered to be clinically important for general urologists, are reviewed, including UTI in patients with diabetes mellitus (DM) and those with a neurogenic bladder, as well as catheter-associated UTI (CAUTI) and obstructive pyelonephritis secondary to urolithiasis. Appropriate treatment approaches can only be chosen by proper understanding of the etiologies of complicated UTI, as well as correct diagnostic strategies and treatment options.     

多层螺旋CT尿路造影与逆行肾盂造影在诊断输尿管梗阻性疾病中的价值对比

目的：探讨多层螺旋CT尿路造影（CTU）和逆行肾盂造影（RP）在诊断输尿管梗阻性疾病中的准确性和应用价值。方法：对40例输尿管梗阻性病变患者均先后行CTU和RP,以输尿管镜或开放手术或（和）病理检杏结果为标准,两者进行对照分析。结果：40例输尿管梗阻性疾病患者中。肿瘤6例,先天性狭窄9例,结石8例,良性狭窄17例。CTU和RP诊断准确率均为92．5％（37／40）（P〉0．05）,病因诊断符合率分别为90％（36／40）和57．5％（23／40）（P〈0．05）。结论：CTU对输尿管梗阻性病变诊断的准确率和病因符合率高,较RP有更好的病因诊断价值,可作为IVU显影不良者的首选补充检查方法,但仍存在一定局限性,需选择性应用。     

Emphysematous pyelonephritis in a renal allograft: successful treatment with percutaneous drainage and nephrostomy

Emphysematous pyelonephritis in renal transplant allograft occurs rarely. This is a case report on a 55-year-old man who had renal transplantation in 1983 and developed post-transplant diabetes mellitus in 1984. This patient suffered from fever and right low abdominal pain and was subsequently diagnosed as emphysematous pyelonephritis by computerized tomography. He was successfully treated with percutaneous drainage, percutaneous nephrostomy and parenteral antibiotics. Although the management of emphysematous pyelonephritis has been a subject of controversy, we recommend consideration of renal preservation in patients with few risk factors, especially in those patients presenting with chronic renal insufficiency, solitary kidney and transplant allograft.     

移植肾尿路结石46例诊治体会

目的探讨肾移植术后尿路结石的诊断和治疗,提高长期存活率。方法回顾性分析1980年1月至2011年6月46例移植肾结石患者的临床资料。结果 35例为肉眼血尿,10例为体检时B超发现,1例为急性无尿发病,均无肾绞痛。移植肾结石24例,移植输尿管结石22例,结石大小0.7～2.0 cm,结石发病时间为术后3.5（0.4～15）年。42例行体外冲击波碎石（ES-WL）,其中3例无效行输尿管镜下钬激光碎石术和1例行经皮肾镜取石术（PCNL）,4例尿酸结石给予枸橼酸氢钾钠（友来特）药物治疗。随访3个月：42例ESWL中,结石排净36例（85.72%）,结石残留2例（4.76%）,4例（9.52%）无效改用腔镜治疗后结石排出;4例尿酸结石口服枸橼酸氢钾钠结石大部分排出。结论移植肾结石缺乏典型肾绞痛表现,体外冲击波碎石术是治疗移植肾结石安全、有效的主要方法。     

Case of emphysematous pyelonephritis in a renal allograft

Emphysematous pyelonephritis is a rare, but serious complication after renal transplantation. This is a case report of a 49-yr-old female who had a renal transplant for diabetic nephropathy. She presented to ER with about 1 wk history of right lower abdominal pain and fever 15 months after the transplant. She had gross hematuria and mental status changes just prior to presentation. A computed tomography (CT) scan of the abdomen showed extensive retroperitoneal and extraperitoneal air dissecting from the transplanted kidney in the right lower quadrant to the level of the mediastinum. There was air in the urinary bladder. These findings were highly suggestive of extensive emphysematous pyelonephritis. The patient was taken to the operating room emergently and underwent a transplant nephrectomy. Blood culture and urine culture were subsequently positive for Salmonella (serogroup O 6, 8 or C2). Initial blood culture also yielded Enterobacter cloacae. The patient was treated with imipenem, cefepime, flagyl, and diflucan empirically: this was later changed to complete a 6-wk course of ciprofloxacin upon discharge. Her hospital course was complicated by a urinary leak; she was discharged to home on day 21. This is the 12th reported case of emphysematous pyelonephritis occurred in a renal transplant recipient.