Combination of percutaneous surgery and extracorporeal shockwave lithotripsy for the treatment of large renal calculi

Open surgery for large or complex renal calculi may be difficult, particularly in patients with recurrent stones, and may require special operative techniques to preserve renal function. With the advent of percutaneous nephrolithotripsy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) new approaches are now available for the treatment of these difficult cases. A review of 67 patients who presented between November 1984 and May 1986 has shown that it was possible to clear large stones in 71% of patients using a combination of PCNL and ESWL. There was no mortality; the morbidity for both procedures was low and was less than when either procedure was used alone for the treatment of complex stones.     

Results of randomized controlled trials of low-versus high-osmolality contrast media

The authors reviewed 100 randomized controlled trials (RCTs) conducted in humans to compare safety or efficacy of new low-osmolality contrast media (LOM) with that of high-osmolality contrast media (HOM). Findings of the 43 RCTs judged to be of the highest quality suggest that the efficacy of LOM in imaging is equal or superior to that of HOM for all routes of administration. Heat sensation occurred less often with LOM for all routes and pain occurred less often with LOM for intraarterial routes. No differences were seen in nephrotoxicity or in frequency of nausea, vomiting, urticaria, bronchospasm, laboratory test abnormalities, or neurologic events. Greater cardiovascular changes were seen with HOM, including increased or decreased heart rate, increased left ventricular end-diastolic pressure, decreased systolic pressure, and QT prolongation, depending on route of administration. To demonstrate whether a reduction in clinically significant adverse outcomes truly occurs with LOM, trials will need to enlist larger numbers of patients and employ appropriate outcome measures. Future trials should stratify patients according to their risk of adverse reactions to provide better information about benefits of LOM in low- versus high-risk patients.     

Ureterorenal endoscopy: which instrument, what cost?

This report describes the design, availability, repair facilities and costs of rigid ureteroscopes. Clinical factors affecting design are detailed. A classification is given. A new test of flow dynamics is described. Short operating ureteroscopes with a stable or integral telescope system appear to be superior to other types, especially as they may be used for antegrade ureteroscopy.     

The treatment of 100 consecutive patients with ureteral calculi in a British stone center

Of all ureteral calculi 20 per cent will require removal. The use of extracorporeal shock wave lithotripsy has changed dramatically the treatment of ureteral stones requiring intervention. We reviewed 111 procedures for 108 stones in 100 consecutive patients. Primary techniques included extracorporeal shock wave lithotripsy after retrograde manipulation (63 cases), percutaneous nephrolithotomy alone (1) and after retrograde manipulation (3), ureteroscopic removal (29), cystoscopic removal (2) and open ureterolithotomy (2). These techniques and the results are discussed. Of the patients 11 required a secondary procedure, including extracorporeal shock wave lithotripsy in 3, ureterorenoscopy for failed extracorporeal shock wave lithotripsy in 2, an open operation for complications of ureterorenoscopy in 2 and correction of associated stricture in 2. All patients ultimately were free of stones. Our experience with in situ extracorporeal shock wave lithotripsy is described. An open operation was done only when less invasive forms of treatment failed or electively to correct an associated anatomical abnormality.     

Extracorporeal shockwave lithotripsy and percutaneous renal surgery. Comparisons, combinations and conclusions

Although percutaneous nephrolithotomy (PCNL) and extracorporeal shockwave lithotripsy (ESWL) were introduced clinically at approximately the same time (1980-1981), their clinical progress appeared to progress along separate paths and to compete with each other. After 5 years it has become apparent that for optimal removal of nearly all renal stones by minimal or noninvasive techniques, PCNL and ESWL are required either separately or as combined procedures. This review traces the development, introduction and progress of these procedures and defines the current indications for extracorporeal, percutaneous and open renal stone surgery.     

Detection of clonal T cell populations by high resolution PCR using fluorescently labelled nucleotides; evaluation using conventional LIS-SSCP.

AIMS: To detect clonal T cell populations by high resolution polymerase chain reaction (PCR) using fluorescently labelled nucleotides and analysis on an ABI 377 DNA sequencer, and to evaluate this method using low ionic strength single strand conformation polymorphism (LIS-SSCP) analysis. METHODS: DNA samples from 11 patients diagnosed with a T cell disease and 15 with no known T cell disorder were amplified using four multiplex T cell receptor gamma (TCR gamma) PCR reactions containing fluorescently labelled nucleotides. PCR products were analysed using both LIS-SSCP electrophoresis and an ABI 377 DNA sequencer using Genescan software. A Jurkat T cell leukaemia cell line was used to determine the sensitivity of the two methods. RESULTS: Clonal TCR gamma populations were detected in all 11 samples from patients with a T cell disease and no clonal populations were detected in samples from patients without a T cell disorder, using both LIS-SSCP and DNA sequencer analysis. Although the sensitivity of the two methods was comparable, the data generated by the sequencer were easier to interpret than the LIS-SSCP gels, and allowed accurate size determination of every product, which was not possible using LIS-SSCP. CONCLUSIONS: The use of fluorescent labelled nucleotides provides a more flexible and economical alternative to end labelled fluorescent primers for the detection of clonal TCR gamma gene rearrangements. This method allows clonal populations to be sized accurately and reproducibly, permitting the detection of identical clonal populations in different samples, and providing a method of monitoring disease progression and response to treatment.     

Head injuries in infants: the risks of bouncy chairs and car seats.

AIMS: To establish whether the incorrect use of bouncy chairs (BC) and car seats (CS) is a significant cause of injuries in babies. METHODS: Prospective study over a 12 month period. All babies under the age of 1 year, presenting to the department with a head injury were eligible. RESULTS: A total of 131 cases were recorded, 17 (13%) of which were associated with either BC or CS, the second largest aetiological group. All BC cases (11/11, 100%) were caused by a fall from a surface with the baby in the chair. In the CS group, 2/6 (33%) were caused by such a fall. The carer was aware in only one of the 13 cases involving a fall from a surface that there was any chance of injury from this mechanism. CONCLUSION: Falls from inappropriately placed bouncy chairs or car seats form a significant proportion of head injuries in infants, resulting in unnecessary and preventable morbidity.     

Flexible tantalum stents implanted in aortas and iliac arteries: effects in normal canines

Vascular endoprostheses made of knitted tantalum wire and expanded over angioplasty balloons were placed into aortas or iliac arteries of 14 normal dogs. Twelve stents were placed into the infrarenal abdominal aorta and two stents in the left common iliac arteries by the left carotid artery approach. To firmly expand the stent against the vascular wall, nominal stent sizes 0.5-1.0 mm larger than the measured arterial diameter were required. Arteriography performed at specified follow-up intervals showed no evidence of thrombi or emboli; all side branches (lumbar arteries) covered by the stents remained patent. Vascular diameter decreased minimally at 8 and 26 weeks, associated with histopathologic evidence of neointimal buildup. This buildup was highest at 8 weeks (mean, 313 microns) and was slightly less at 26 weeks (mean, 223 microns). Almost complete coverage by endothelium was seen as early as 3 weeks. It is concluded that the flexible tantalum wire stents are well tolerated by the arterial wall and become quickly endothelialized. No excessive neointimal buildup was observed during the 6-month study.