Issues n.1 - 2010

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n.1 - 2010


Histological evaluation of prostatic tissue following transurethral laser resection (TULaR) using the 980 nm diode laser 

Rosario Leonardi, Rosario Caltabiano, Salvatore Lanzafame

Summary

Objectives: In the present study, we performed for the first time an histological evaluation after 980 nm diode laser treatment of bladder outlet obstruction secondary to benign prostatic hypertrophy (BPH). The aim was to demonstrate the possibility of obtaining sufficient tissue for histological examination and the possibility of obtaining an histological diagnosis on the specimen obtained by laser resection.

Materials and methods: 86 patients with BPH were selected for laser surgery and 10 patients for transurethral prostate resection. The prostate tissue samples collected from laser surgery and transurethral resection of the prostate (TURP) were fixed in 10% formalin and serial sections with a slice thickness of 5-7 micron embedded in paraffin and stained with haematoxylin and eosin.

Results: Samples obtained using the 980 nm diode laser ranged in size from 4 mm to 30 mm and showed brownish, smooth margins. Lasered tissue showed a coagulation rim of 0.5 mm (range: 0.2-1 mm) and adjacent to the vaporized tissue, coagulated connective tissue and glandular epithelia were seen. Beyond this zone a complete detachment of glandular epithelia from the connective tissue was observed. Stromal oedema associated with ectasic vessels but without extravasation of red blood cells, haemosiderin deposition and haemorrhagic areas were also retrieved. All cases showed occlusion of small vessels beyond the zone of coagulated tissue. Unlike laser treatment, samples obtained from TURP showed extravasation of red blood cells, haemosiderin deposition and haemorrhagic areas.

Conclusions: The 980 nm diode laser provides high rates of tissue ablation, associated with excellent haemostasis. It has been shown that tissue samples can be obtained with this technique, which allow a histological diagnosis of BPH to be made. The current method involving the 980 nm diode laser induces a vaporesection of prostate tissue and the acronym of TULaR (transurethral laser resection) has therefore been created to describe this technique.


PCA3: A new tool to diagnose prostate cancer (PCa) and a guidance in biopsy decisions.
Preliminary report of the UrOP study

Fabio Galasso, Renato Giannella, Paola Bruni, Rosaria Giulivo, Vittorino Ricci Barbini, Vincenzo Disanto, Rosario Leonardi, Vito Pansadoro, Giuseppe Sepe

Summary

Objectives: PCA3 is a prostate specific non-coding mRNA that is significantly overexpressed in prostate cancer tissue. Urinary PCA3 levels have been associated with prostate cancer grade suggesting a significant role in the diagnosis of prostate cancer. We measured urinary PCA3 score in 925 subjects from several areas of Italy assessing in 114 the association of urinary PCA3 score with the results of prostate biopsy.

Material and Methods: First-catch urine samples were collected after digital rectal examination (DRE). PCA3 and PSA mRNA levels were measured using Trascription-mediated PCR amplification. The PCA3 score was calculated as the ratio of PCA3 and PSA mRNA (PCA3 mRNA/PSA mRNA x 1000) and the cut off was set at 35.

Results: A total of 925 PCA3 tests were performed from December 2008 to January 2010. The rate of informative PCA3 test was 99%, with 915 subjects showing a valid PCA3 score value: 443 patients (48.42%) presented a PCA3 score > = 35 (cut-off) whereas the remaining 472 patients (51.58%) presented a PCA3 score lower the cut-off limit (< 35). Of the 443 patients with PCA3 score > = 35, 105 (23.70%) underwent biopsy or rebiopsy. We found that 27 patients (25.71%) had no tumour at biopsy, 37 (35.24%) had HGPIN or ASAP and 41 (39.05%) had a cancer. Moreover, including the additonal 9 patients with PCA3 < 35, who underwent biopsy post PCA3 results, our data indicate that patients with negative biopsy (n = 31) show lower PCA3 score (mean = 54.9) compared with patients with positive biopsy (n = 45) (mean = 141.6) (p = 0.000183; two-tailed tstudent test). The mean PCA3 score (79.6) for the patients diagnosed with HGPIN/ASAP at biopsy (n = 38) was intermediate between patients with negative and positive biopsy.

Conclusions: Our results indicate that the PCA3 score is a valid tool for prostate cancer detection and its role in making better biopsy decisions. This marker consents to discriminate patients who have to undergo biopsy from patients who only need be actively surveilled: Quantitative PCA3 score is correlated with the probability of a positive result at biopsy.


Surgery for renal cell carcinoma in two European urologic clinics: To compare or compete?

Svetoslav Dechev Dyakov, Giuseppe Lucarelli, Alexander Ivanov Hinev, Petar Kirilov Chankov, Deyan Anakievski, Pasquale Ditonno, Pasquale Martino, Francesco Paolo Selvaggi, Michele Battaglia

Summary

Objectives: To evaluate and compare the incidence, TNM staging and the current strategy for the surgical treatment of renal cell carcinoma (RCC) in two European urologic institutions, situated in Varna, Bulgaria and in Bari, Italy. Both clinics have sound experience of RCC surgery, and modern laparoscopic equipment. A retrospective chart review of all patients with RCC diagnosed and treated in the last year was conducted at the two sites.

Materials and methods: In total, 88 patients (66 males and 22 females, mean age 58 years, range 24-81 years) were enrolled in the study. Comparisons were made between some clinical and pathologic parameters with an established prognostic and therapeutic impact. The type of surgery performed at both sites was analyzed as well. All these comparative studies were performed in relation to the 2008 EAU guidelines on the current management of RCC. Commercially available statistical software was used for the purpose.

Results: The results showed no difference between the two sites regarding the RCC incidence and the patients’ age and gender. Significant differences (p value < 0.0001) emerged in terms of: the median size of the tumors at surgery (8.5 cm in Varna, SD ± 4.04 vs. 4.4 cm in Bari, SD ± 2.02); T-stage of the tumor (Varna T1-33%, T2-30%, T3-22%, T4-15% vs. Bari T1-64%, T2-12%, T3-24%, T4-0%); N-positive disease (24% vs. 2%); distant metastases (20% vs. 2%) and presence of necrosis in the renal masses (37% vs. 19%). Thus, 85% of Varna patients underwent open radical nephrectomy, 11% nephron-sparing surgery and 4% explorative laparotomy, due to inoperability of the renal mass. Only 29% of Bari patients were treated by open radical nephrectomy, 12% underwent laparoscopic nephrectomy, 57% open partial nephrectomy and 2% laparoscopic partial tumor resection.

Conclusions: These numbers demonstrate more advantageous tumour features at the Italian clinic in terms of organ-sparing surgical options (open and laparoscopic), whereas in the Bulgarian clinic the tumour features pose certain limitations to the application of modern surgical techniques. This difference is due to early diagnosis of RCC in Italy, allowing treatment of smaller volume tumors.


Incidental urinary tract pathologies in the one-stop prostate cancer clinic

Mohammed Aza, S. Shergill Iqbal, M. Vandal Muhammad, S. Gujrai Sandeep

Summary

Objective: We determined the prevalence of incidental urinary tract pathologies in patients referred to the one-stop suspected prostate cancer clinic and assessed the evaluation and outcome of these pathologies.

Methods: One hundred and ninety patients were referred to the one-stop suspected prostate cancer clinic over a 6-month period. The records of patients with incidental urinary tract pathologies were retrospectively reviewed for demographic characteristics, mode of clinical presentation, further investigations performed, the final diagnosis and the treatment given.

Results: Incidental urinary tract pathologies were detected in 12 patients (6.3%). Clinically significant pathologies were found in 4.7% patients (n = 9). Significant incidental findings included bladder cancers (n = 8) and renal cell carcinoma (n = 1). All of these patients had additional diagnostic investigations, required in-patient surgical treatment and have remained disease free at follow up. Trans-rectal ultrasound guided prostate biopsies were only performed in three cases and a diagnosis of prostate cancer was only made in one patient.

Conclusion: Incidental urinary tract pathologies among patients referred to the one-stop suspected prostate cancer clinic are common. This reflects the need for further investigating patients with lower urinary tract symptoms whenever necessary so avoid missing significant pathologies.


The Clavien classification system to optimize the documentation of PCNL morbidity

Jorge Rioja Zuazu, Marcel Hruza, Jens J. Rassweiler, Jean J.M.C.H. de la Rosette

Summary

High success rates exceeding 90% are reported with percutaneous nephrolithotomy (PNL) and modifications have further decreased the morbidity while maintaining efficacy. However, complications after or during PNL may occur with an overall complication rate of up to 83%. Although results from several large series on PNL from outstanding centers are reported in the literature, there is still no consensus on how to define complications and stratify them by severity. Hampering comparison of outcome data may generate difficulties in informing the patients about the severity of PNL complications. We therefore may conclude that standardization of complications of a certain procedure is necessary to allow comparison of outcomes between different centers, within a center over time, or between different instruments used and/or operating techniques. In 1992, Clavien et al proposed general principles to classify complications of surgery based ona therapy-oriented, 4-level severity grading, allowing identifying most complications and preventing down rating. The Clavien Classification system differentiates in five degrees of severity upon the intention to treat. Several Urological teams have studied the use of classifications systems to document and grade outcomes and morbidity of interventions in urology. Also the modified Clavien system has been applied in urological surgery. Urologists have been using this classification to grade perioperative complications following laparoscopic radical prostatectomy, laparoscopic live donor nephrectomy, and retroperitoneoscopy. In the field of endourology, it has been recently applied to PCNL procedures as well, allowing comparison among different series between different hospitals and within the same center. Other benefits that the standardization of the complications by using the Clavien System allows is to give better information to the patient and, assisting them on making the correct therapeutical choice. There may also be a benefit for the health insurance bodies to obtain adequate information of the procedure, and the results achieved by a team. Besides all its benefits, the modified Clavien system was proposed as a grading system for perioperative complications in general surgery and there are some limitations in classifying PCNL complications. A graded classification scheme for reporting the complications of PCNL may be useful for monitoring and reporting outcomes. There are some limitations in classifying PCNL complications. Minor modifications, especially concerning auxiliary treatments, are needed. Further studies are awaited for the development of an accepted classification system applicable to all urologic procedures.


Percutaneous nephrolithotomy: An extreme technical makeover for an old technique

Glenn M. Preminger

Summary

Introduction: Percutaneous nephrolithotomy (PNL) remains the treatment of choice for several forms of stone disease including: large stones, many cystine and struvite calculi, lower pole calyceal calculi, stones associated with anomalous renal anatomy, and stones in morbidly obese patients. Recent advances in the PNL technique appear to improve post-operative outcomes and reduce patient morbidity.

Materials and Methods: A thorough review of the recent urologic literature was performed to identify these alterations in technique and whether or not these changes have improved stone-free outcomes and/or reduced patient morbidity.

Results: Published series from several different centers have recently demonstrated that supine PNL is safe with specific benefits for the patient and several technical advantages for the surgeon. A number of currently available intracorporeal lithotripsy devices, specifically combination pneumatic and ultrasonic lithotrites, have been show to offer improved stone fragmentation and more efficient fragment clearance. Tubeless, stentless PNL appears to offer reduced flank pain and no stent-related symptoms following stone removal.

Conclusions: Further advances in the PNL technique will not only increase stone-free outcomes and reduce post-operative complications, but also significantly reduce peri-operative patient morbidity. Further large scale clinical trails are necessary to better define the benefits of supine PNL, improved intracorporeal lithotripsy devices and tubeless percutaneous nephrolithotomy.


PCNL in Italy

Massimo D’Armiento, Riccardo Autorino, Marco De Sio

Summary

Introduction: The first italian meeting on percutaneous nephrolithotomy (PCNL) was held in Milan in 1984. Since then PCNL has been practised in many centres but its diffusion has not been fast.

Material and methods: A Medline search using as keywords: PCNL, Percutaneous nephrolithotomy, Percutaneous surgery, was performed, time limits 1983 to 2008 to look for contribution of italian authors in indexed journals. The proceeding and abstract book of the SIU (Società Italiana di Urologia) from 1984 were consulted to ascertain the number of communications presented to the italian national congress. The number of PCNL performed and hospital stay in Italy are official data from the Ministero della Salute website www.ministerosalute.it.

Results and discussion: The number of papers published by italian authors on indexed journals, although of good quality, has been poor in the past but is rising in recent years. Also from the proceedings of the italian urological association an increase in the interest for PCNL is testify by the growing number of communications presented to the national congress. Of the 2555 PCNL performed in 2005 in Italy, 2513 were inpatient procedures with a mean hospital stay of 8, 11 days. Even if the number of procedures/year is increasing still there is a wide difference among different italian regions and PCNL can be considered an underutilized procedure.

Conclusions: It is mandatory to increase the number of educational courses on PCNL to increase the number of urologists performing this technique and in order to minimize hospital stay and to reduce the number of repeated extracorporeal lithotripsy for large burden stones and, most of all, the number of open procedures still performed.


The patient position for PNL: Does it matter?

Cecilia Maria Cracco, Cesare Marco Scoffone, Massimiliano Poggio, Roberto Mario Scarpa

Summary

Currently, PNL is the treatment of choice for large and/or otherwise complex urolithiasis. PNL was initially performed with the patient in a supine-oblique position, but later on the prone position became the conventional one for habit and handiness. The prone position provides a larger area for percutaneous renal access, a wider space for instrument manipulation, and a claimed lower risk of splanchnic injury. Nonetheless, it implies important anaesthesiological risks, including circulatory, haemodynamic, and ventilatory difficulties; need of several nurses to be present for intraoperative changes of the decubitus in case of simultaneous retrograde instrumentation of the ureter, implying evident risks related to pressure points; an increased radiological hazard to the urologist’s hands; patient discomfort. To overcome these drawbacks, various safe and effective changes in patient positioning for PNL have been proposed over the years, including the reverse lithotomy position, the prone split-leg position, the lateral decubitus, the supine position, and the Galdakao-modified supine Valdivia (GMSV) position. Among these, the GMSV position is safe and effective, and seems profitable and ergonomic. It allows optimal cardiopulmonary control during general anaesthesia; an easy puncture of the kidney; a reduced risk of colonic injury; simultaneous antero-retrograde approach to the renal cavities (PNL and retrograde ureteroscopy = ECIRS, Endoscopic Combined IntraRenal Surgery), with no need of intraoperative repositioning of the anaesthetized patient, less need for nurses in the operating room, less occupational risk due to shifting of heavy loads, less risk of pressure injuries related to inaccurate repositioning, and reduced duration of the procedure; facilitated spontaneous evacuation of stone fragments; a comfortable sitting position and a restrained X-ray exposure of the hands for the urologist. But, first of all, GMSV position fully supports a new comprehensive attitude of the urologist towards a variety of upper urinary tract pathologies, facing them with a rich armamentarium of rigid and flexible endoscopes and a versatile antero-retrograde approach. Prone position may still be useful in case of important vertebral malformations, specifically hindering the supine position, or for simultaneous bilateral PNL, without having to move the patient intraoperatively, so is still present in the complementary techniques of a skilled endourologist.


PCNL: Tips and tricks in targeting, puncture and dilation.

Antonello De Lisa, Giacomo Caddeo

Summary

Getting an effective and safe percutaneous access is the cornerstone in performing a successful and uneventful PCNL. The choice of the puncture site, according to our experience, is one of the most important factors that may influence the outcome of the procedure Preoperative imaging has a preliminary role in choosing the kind of approach but the most important role has to be given to intraoperative retrograde pyelography following occlusion balloon catheter placing. Ultrasound-guided renal puncture as well may show adequate anatomic details of the collecting system if a retrograde dilation is performed. We routinary perform a single subcostal lower pole access. In our opinion, when the skin incision is located into the four-sided space between 12thrib, spine muscles, iliac crest and posterior axillary line, the risk of most non-haemorrhagic complications may be reduced. When the needle is proceeding towards its target, some radiological sign may confirm its correct insertion. Dilation and operative sheath placing are the last steps of the percutaneous tract creation. Amongst the wide offer of dilating devices, our choice usually goes to the Amplatz fascial dilators associated to the “one-shot” technique and to the balloon hydraulic dilators.


Tubeless percutaneous nephrolithotomy: Our experience

Guido Giusti, Orazio Maugeri, Gianluigi Taverna, Alessio Benetti, Silvia Zandegiacomo, Roberto Peschechera, Pierpaolo Graziotti

Summary

Purpose: To evaluate safety and outcomes of tubeless PCNL in comparison with standard PCNL.

Materials and Methods: Since June 2002 we have performed 99 tubeless PCNL. Tubeless technique involves antegrade placement of a 6Fr double-J stent without nephrostomy tube at the end of the procedure. This series has been compared with a total of 110 patients in which revision of operative reports ruled out the presence of intraoperative conditions necessary to candidate a patient to tubeless procedure but standard PCNL was performed because prior to its introduction or because of surgeon’s attitude afterward. Mean stone burden was 5.4 for standard group and 4.9 cm2 for tubeless group respectively. Mean BMI was 24.1 in the first group and 23.6 in the second one. In this retrospective study, complications rate, postoperative pain, length of hospitalization and convalescence were evaluated by chart review.

Results: Hematocrit drop did not differ significantly between tubeless PCNL and standard PCNL (5.5% vs 5.90%). Conversely, there was statistically significant difference between tubeless and standard PCNL in terms of the amount of analgesics (49.5 vs. 84.2 mg), immediate postoperative patients’ discomfort, hospitalization (2.2 vs 5.3 days) and time to resume normal activities (11.0 vs 16.5 days).

Conclusions: In our series, tubeless approach did not determine increase in complication rate. Conversely, tubeless PCNL reduced analgesics’ requirement, patients’ discomfort, hospitalization and time to recovery. As such, at our Institution, tubeless PCNL has become routine procedure that actually is feasible in almost 2/3 of renal calculi suitable for percutaneous treatment.


High burden and complex renal calculi: Aggressive percutaneous nephrolithotomy versusmulti-modal approaches

Glenn M. Preminger

Summary

Introduction: Percutaneous nephrolithotomy (PNL) remains the treatment of choice for managing patients with large or complex renal calculi, especially staghorn stones composed of struvite. Recent advances in the PNL technique appear to improve post-operative outcomes and reduce patient morbidity.

Materials and methods: A thorough review of the recent urologic literature was performed to identify results and benefits of percutaneous nephrolithotomy versus either combination PNL and shock wave lithotripsy or SWL alone. A brief description of these three modalities is presented.

Results: Published series from several different centers, as well as the 2004 report from the AUA Nephrolithiasis Guidelines Panel have demonstrated superior stone-free rates, improved complication rates and a reduced need for secondary procedure in those patients treated with PNL monotherapy. Combination techniques or SWL treatment may be benefical in patients with low-volume renal stone disease.

Conclusions: Further advances in the PNL technique will not only increase stone-free outcomes and reduce post-operative complications, but also significantly reduce peri-operative patient morbidity. PNL monotherapy should be considered first line therapy for those patients with large or complex renal calculi.


Endoscopic combined intrarenal surgery for high burden renal stones

Cesare Marco Scoffone, Cecilia Maria Cracco, Massimiliano Poggio, Roberto Mario Scarpa

Summary

“High burden stones” include single or multiple large calculi (altogether surface area > 300 mm2, or largest diameter > 20 mm), and staghorn calculi (any branched stone occupying more than one portion of the renal collecting system, i.e. pelvis with one or more calyceal extensions). Since clinically threatening, their active removal is mandatory. All updated guidelines recommend four modalities as potential treatment for large/staghorn urolithiasis, including PNL monotherapy, ESWL monotherapy, combinations of PNL and ESWL, and open surgery. The technical enhancement and increasing spread of PNL, ESWL and ureteroscopy in the past twenty years has led to displacement of the surgical therapy of renoureteral calculi in the daily urological practice (nowadays 1-5.4% of cases in developed countries and in well-equipped, dedicated centres), but open or laparoscopic management of urolithiasis is still a viable option that should be considered in few, highly selected circumstances. Currently, PNL is the preferred first-line, minimally invasive treatment for complete one-step removal of high burden urolithiasis. It has been suggested that two or more access sites may be required for complete clearance, yet implying greater blood loss. The use of single-tract PNL with adjuvant procedures such as flexible ureteroscopy/nephroscopy may decrease the disadvantages of the multiple-tract PNL without compromising on stone-free rates. ECIRS (= endoscopic combined intrarenal surgery) is a new, versatile approach for the treatment of large and/or complex urolithiasis. Combining the anterograde and retrograde approach to the renal cavities, ECIRS allows the combined use of all the rigid and flexible endourological armamentarium, and optimal endovision percutaneous renal puncture, preliminary evaluation of renal stones features, negligible need of multiple percutaneous accesses, immediate treatment of concomitant ureteral calculi or ureteropyelic junction stenoses; final visual control of the stone-free status. ECIRS is usually performed in the Galdakao-modified supine Valdivia position, the only patient position supporting this comprehensive attitude of the urologist towards upper urinary tract pathologies. Optimal planning of a safe and effective ECIRS procedure also benefits from an accurate preliminary threedimensional study by means of tomography urography of the pelvicalyceal anatomy (which is complex and often highly variable) and of the stone features (site, number, size).


High burden stones: The role of SWL

Gianpaolo Zanetti, Stefano Paparella, Mario Ferruti, Marco Gelosa, Davide Abed, Francesco Rocco

Summary

Percutaneous nephrolitotomy (PCNL), PCNL and Shock Wave Lithotripsy (SWL), SWL monotherapy and open surgery are nowadays the potential treatment alternatives for patients with staghorn stones. Several groups have proposed classification schemes to better define staghorn calculi dimensions taking into account size, morphology and composition of the stones. More recently the use of a CT imaging with three-dimensional reconstruction or of a coronal reconstruction of axial CT images was reported to obtain an accurate stone volume calculation. The difficulty in accurately assessing stone burden explains the wide range of reported stone-free rates for SWL monotherapy from 22 to 85%. A recent AUA guideline of the management of staghorn calculi stated that stone free rate is 78% for PCNL and 54% for SWL monotherapy and these values are similar to those reported in Segura guideline but the rate for combination treatment (PNL+SWL) is now lower (66% versus 81%) than in the previous guideline. This reduction is probably due to the fact that in the recent meta-analysis SWL was the last procedure and in the previous generally a sandwich therapy was performed with PCNL followed by a SWL and a secondary PCNL. Improved PCNL techniques with use of flexible nephroscopy and multitract PCNL allow to achieve complete stone clearance by PCNL alone. Complete removal of stone is crucial to eradicate infection and prevent further stone regrowth. Residual fragments may perpetuate postreatment infection and stone regrowth has been reported up to 78% in such patients after SWL monotherapy. In our previous experience (prior to 2000) we observed 45 pts with high burden stones: 31/45 pts (68%) underwent combined therapy PCNL and SWL with a successful rate of 65% (stone free and fragments < 4mm). In our more recent experience (’03-’08) we treated 34 patients with high burden stones: we performed combined therapy PCNL and SWL in 11 pts (32%) with an overall success rate of 63%. PCNL was undertaken initially with the attempt to remove as much stone as possible with the aid of flexible nephroscopy and SWL was used only for residual stones because the passage, even of fragments < 4mm, does not always occur in dilated renal cavities. SWL monotherapy should not be used for most patients and may be considered only in patients with small volume staghorn stones with normal collecting system


Stone treatment in children: Where we are today?

Paolo Caione, Ennio Matarazzo, Sandra Battaglia

Summary

Objective: Stone disease in children differs in pathogenesis, presentation and in treatment from adults. In recent years, big changes on its management have occurred. We reviewed our experience on upper tract urinary calculi in paediatric age.

Material and Methods: Patients observed for upper tract urinary stones from June 2002 to June 2008 were reviewed. Bladder-urethral calculi were excluded. Presenting symptoms had a wide range: macro- or micro-hematuria, recurrent abdominal or flank pain, or non-specific symptoms such as irritability and failure to thrive. Renal and urinary tract ultrasonography, plain abdomen X-ray were performed in case of suggestive symptoms. Spiral CT without contrast was recommended to better define the stone disease. Metabolic evaluation is mandatory for any child presenting history of urinary calculi or nephrocalcinosis. Idiopathic hypercalciuria has been recognized as predominant ethiological factor of paediatric nephrolithiasis, excluding stones correlated with urinary tract malformations (up to 45%).

Results: In a 6-year period, 232 patients, aged 19 months to 18 years, were treated: 195 children (60.8%), mean age 8.3 years, underwent ESWL. Re-do treatments were 233 (2.3ESWL/patient), with 77% stone free rate. Percutaneous nephrolithotomy (PCNL) was adopted in 33 patients, mean age 13.4 years, with 2 re-treatments. Stone clearance was 74% after single treatment, increased to 88% by secondary ESWL. Blood transfusion was needed in 7 cases (16%). Retrograde ureterolithotripsy (ULT) was performed in 96 patients presenting ureteral stones, for a total of 99 procedures. Stone free rate was 99%, as 1 pushed up stone required subsequent ESWL. No ureteral perforation or other significant complications occurred. Medical treatment was offered as ancillary therapy or to prevent recurrences, according to the metabolic results and the stone biochemistry.

Conclusions: Stone treatment in children is changing dramatically, thanks to progressive transfer of procedures from adult patients and recent advances in miniaturized new technologies. Surgical approach to renal and urinary tract stones in childhood was recently moving from open surgical procedures (nephrolithotomy, ureterolithotomy, cystolithotomy), to less invasive procedures, such as ESWL and endoscopic approaches, as ULT and PCNL. Mini-invasive procedures present high efficacy and safety, also in young children, but require appropriate instrumentation and specific experience


Extracorporeal shock wave lithotripsy for the treatment of urinary stones in children

Marco Castagnetti, Wiafro Rigamonti

Summary

Objective: To provide the reader with an overview about the role of shock wave lithotripsy (SWL) in the management of urinary stones in children, and the complications associated with the procedure.

Material and methods: We performed a non-systematic review of the English literature to ascertain the success rate of SWL, the need for ancillary procedures such as stenting of the urinary tract or endoscopic manipulation, and the possible side effects and complications of the procedure.

Results: Both renal and ureteric stones can be amenable to SWL. The latter can be performed in patients of any age including low birth weight infants. Paediatric series of SWL report 3- month stone-free rates of 70 to 100%. High rates can be achieved also dealing with large stones of 20-30 mm in diameter, staghorn calculi and stones located in the lower-pole. Current data seem to suggest that systematic preoperative insertion of ureteric stents is unnecessary. After the procedure, complications occur in about 20% of cases and include haematuria, steinstrasse, ureteric obstruction, and urinary tract infection with or without fever. Most of these complications are self-limiting and require only medical treatment. Haematoma formation is exceptional after SWL and the procedure does not seem to damage long-term renal growth and function, or cause any damage to the surrounding anatomical structures.

Conclusion: Data from current literature warrant an attempt of treatment of urinary stones by SWL in many paediatric cases including very young patients, patients with big stones or stones in lower-poles, and patients with staghorn calculi. The procedure seems to be safe.


Percutaneous nephrolithotripsy (PCNL) in children: Experience of Parma

Antonio Frattini, Stefania Ferretti, Antonio Salvaggio

Summary

19 Percutaneous nephrolithotripsy procedures were done in 15 children aged from 8 months to 16 years with complex renal stones and/or extracorporeal shock wave lithotripsy refractory stones. The percutaneous techniques were done with the instrument and position (prone and supine) used in adults. 14/15 patients were stone-free (13 pts in one time, 1 pt in 2 procedures and 1 pt, with complex bilateral stones disease, in 5 endourological sessions). No relevant complications developed: 1 patient need a blood transfusion and 1 a temporary indwelling catheter for colic pain due to oedema. We believe that in children the endourological approach is better than traditional open surgery or reiterated extracorporeal shock wave lithotripsy sessions which often need anaesthesia and can not guarantee a complete clearance of the stones.


Flexible ureteroscopy for kidney stones in children

Lorenzo Defidio, Mauro De Dominicis

Summary

Endoscopic evaluation and management of different pathological conditions involving the upper urinary tract using rigid or flexible endoscopes, is now readily feasible and has been shown to be safe and efficacious even in the smallest children. Paediatric ureteroscopic procedures are similar to their adult counterparts, so that basic endoscopic principles should be observed. Aims of the management should be complete clearance of stones, preservation of renal function and prevention of stone recurrence. In order to select the most appropriate surgical treatment, location, composition, and size of the stone(s), the anatomy of the collecting system, and the presence of obstruction along with the presence of infection of the urinary tract should be considered. Although extracorporeal shockwave lithotripsy (ESWL) is still the most important procedure for treating urinary stones, advances in flexible endoscopes, intracorporeal lithotripsy, and extraction instruments have led to a shift in the range of indications. According to the location of the stone the treatment can be done with the rigid or flexible ureteroscope. To obtain stone fragments is essential for biochemical analysis. The stone composition may give significant information to prevent the high rate of recurrence, with dietary modification and specific therapy. Successful outcomes for the retrograde treatment of renal calculi are similar to the ones obtained in the adult population (stone free rate 91-98%). The retrograde semirigid and flexible ureteropyeloscopy, using a small calibre ureteroscope, are a valuable technique for kidney stones treatment in children. With excellent technique and meticulous attention to details, the significant complications are rare


Indications, prediction of success and methods to improve outcome of shock wave lithotripsy of renal and upper ureteral calculi

Andreas Skolarikos, Heraklis Mitsogiannis, Charalambos Deliveliotis

Summary

Objectives: To clarify the current indications, factors influencing outcome and methods to predict and improve the results of shock wave lithotripsy for the treatment of renal and upper ureteral calculi.

Material and methods: English literature on the Medline and MeSH databases was reviewed. Key words used for search included shock wave lithotripsy, calculi, stones, renal, kidney, ureter, efficacy, prediction, improvement and guidelines.

Results: Shock wave lithotripsy still has certain indications for renal and upper ureteral stones. Major impact on outcome has the stone size, with a diameter of less than 20 mm being the cutoff point. Shock wave monotherapy should not be used for larger stones and should be combined with other treatment modalities such as percutaneous nephrolithotomy or ureteroscopy. Other factors influencing outcome include stone number, composition and location, existence of congenital abnormalities, obesity and bleeding diathesis. Nomograms, artificial neural networks and computed tomography are useful adjuncts in predicting the outcome. Potential methods of improvement are the decrease of shock wave rate, the progressive increase in lithotripter output, the use of two simultaneous or sequential pulses and the use of expulsive and chemolytic treatment.

Conclusions: Shock wave lithotripsy continues to be a significant part in the urologists armamentarium for the treatment of renal and upper ureteral stones.


Laparoscopic and open stone surgery

Marcel Hruza, Jorge Rioja Zuazu, Ali Serdar Goezen, Jean J.M.C.H. de la Rosette, Jens J. Rassweiler

Summary

Introduction: Due to the increasing spread and technical enhancement of endourological methods, open surgery for renal and ureteral calculi almost disappeared.

Materials und Methods: Based on an actual review of literature, we describe indications, technique and clinical importance of the open and laparoscopic management of urolithiasis.

Results: In Europe and Northern America, the surgical therapy of urolithiasis only plays a role in cases of very large or hard stones, after failure of shock wave lithotripsy, percutaneous nephrolithotripsy or ureteroscopic stone removal and in cases of abnormal renal anatomy. However, in emerging markets with different structures and funding of the health care system and with a limited access to endourological procedures, these techniques still have a higher importance. Particularly in Europe laparoscopic surgery is emerging because calculi can be removed from almost all locations within kidney and ureter using a transperitoneal or retroperitoneal access. Functional outcomes and complication rates are comparable to open surgery. The benefits of laparoscopy are: less postoperative pain, shorter hospital stay, faster reconvalescence, and better cosmetic results.

Conclusions: Although open and laparoscopic removal of renal and ureteral calculi is only performed in a limited number of cases in daily urological practice, they may be superior to the endourological techniques in some circumstances. Therefore, they should be considered as a part of the urological armamentarium.