Re: The use of bowel for ureteral replacement for complex ureteral reconstruction: long-term results.
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Biomedical subjects
Ojas D Shah
Publications and source records attributed to Ojas D Shah.
Ureterocalicostomy: a contemporary experience.
OBJECTIVES: To report our contemporary experience with ureterocalicostomy to determine whether the indications or results have changed in modern practice. Ureterocalicostomy is a well-established treatment for patients with complicated ureteropelvic junction (UPJ) obstruction and other forms of proximal ureteral obstruction. Although both retrograde and antegrade endourologic interventions have become accepted forms of management, the success rates do not approach those of open or even laparoscopic interventions, potentially leading to a greater number of patients with treatment failure and the need for more complicated reconstruction. METHODS: Between July 1991 and February 2004, 11 patients (4 women and 7 men), aged 19 to 68 years (mean 38), underwent open surgical ureterocalicostomy. The indications for surgery were primary UPJ obstruction in 4, failed cutting balloon incision for UPJ obstruction in 3, proximal ureteral stricture after ureteroscopic stone removal in 2, and obliterated UPJ after percutaneous nephrolithotomy and failed antegrade endopyelotomy in 1 patient each. RESULTS: Hospitalization ranged from 4 to 7 days (mean 5.1). No patient experienced a significant perioperative complication. With follow-up ranging from 5 to 32 months (mean 10.1), relief of obstruction was evident in all patients as documented by intravenous urography or nuclear renography. Furthermore, differential function on the involved side improved from a mean of 54.6% preoperatively to 60.1% postoperatively (P <0.05). CONCLUSIONS: The spectrum of indications for ureterocalicostomy has changed, although excellent results can still be achieved. Although laparoscopic approaches are currently being evaluated, most patients currently undergoing this reconstructive procedure still require open operative intervention.
Adult↗
Percutaneous nephrostolithotomy: predictors of length of stay.
PURPOSE: Percutaneous nephrostolithotomy (PNL) is commonly used to treat patients with complex renal calculi. A goal at our medical center is to discharge patients home less than 24 hours after PNL. We performed a study to determine factors that caused patients to be hospitalized longer than this period. MATERIAL AND METHODS: The available hospital records and office charts of 133 consecutive patients undergoing initial PNL at our institution between January 1, 1999 and December 31, 2000 were reviewed. All PNL procedures were performed by one of us using a (DGA) 1-stage technique. Mean patient age was 52 years (range 25 to 84). Of the subjects 85 were male and 48 were female. RESULTS: A total of 91 patients (68%) were discharged home less than 24 hours after surgery. The overall stone-free rate was 91%. Mean length of stay in the entire group was 1.97 days. Mean length of stay in those hospitalized longer than 24 hours was 4.12 days. Mean operative time, including time to obtain access, was 188.6 minutes. Multivariate analysis demonstrated that neurogenic bladder, endocrine comorbidity and perioperative complications were factors associated with a length of stay of greater than 24 hours. Univariate analysis demonstrated that preoperative urinary tract infection and infection related calculi were also associated with a length of stay of greater than 24 hours. CONCLUSIONS: The majority of patients undergoing PNL can be discharged home less than 24 hours after surgery. Patients with neurogenic bladder, those with endocrine comorbidity, those who sustain significant perioperative complications and those harboring stones associated with urinary tract infection or preoperative urinary tract infection are more likely to require longer hospitalization.
Adult↗
Ileal ureter substitution: a contemporary series.
OBJECTIVES: To review our contemporary experience with ileal ureter reconstruction. Despite advancements in surgical technology and technical expertise, ureteral injuries continue to occur. These injuries can be extensive, and ileal ureter reconstruction may be necessary. METHODS: A total of 18 ileal ureter substitutions were performed in 16 adults (10 men and 6 women) by a single surgeon during a 6-year period. The mean patient age was 49.4 years (range 25 to 72). The mean follow-up was 18.6 months (range 7 to 59). All ileal ureter substitutions were performed in an isoperistaltic, refluxing fashion. Follow-up included clinical evaluation, nuclear renography, intravenous urography, and serum chemistry testing. RESULTS: Postoperative nuclear renography demonstrated no relative loss of function of the affected renal unit and no evidence of functional obstruction. An unobstructed state was also confirmed with intravenous urography. No statistically significant metabolic changes were found in any patient, as assessed by serum chemistry testing. None of the patients had evidence of new stone formation. Two patients developed an isolated, symptomatic urinary tract infection during follow-up, and one has had recurrent urinary tract infections, a problem that was present preoperatively. CONCLUSIONS: Ileal ureter substitution remains an effective treatment for patients with complex ureteral strictures or injuries. Stone activity does not appear to increase, and metabolic sequelae are uncommon in properly selected patients.
Adult↗
Computerized tomography guided access for percutaneous nephrostolithotomy.
PURPOSE: Access for percutaneous nephrostolithotomy (PNL) using conventional fluoroscopic guidance may carry an increased risk of damage to surrounding organs in patients with renal calculi and aberrant anatomy. In these situations cross-sectional anatomical imaging may facilitate safe percutaneous access. We describe our experience with computerized tomography (CT) guided percutaneous access for such patients undergoing PNL. MATERIALS AND METHODS: Between June 2000 and December 2001, 154 patients underwent PNL at our institution. Five of these patients (3%) required a total of 6 percutaneous access tracks under CT guidance. All patients in this group had anatomical abnormalities precluding standard access to the collecting system without risk to adjacent organs. These abnormalities included a retrorenal colon in 2 and a severely distorted body habitus due to spinal dysraphism in 3. RESULTS: Percutaneous access was achieved without complication in all cases. At subsequent PNL 5 of the 6 renal units (83%) were rendered completely stone-free. CONCLUSION: CT guided percutaneous access is infrequently required for PNL. However, there is a select group of patients with anatomical anomalies that may predictably require this procedure to facilitate safe and efficacious PNL.
Adult↗
Selecting Treatment for Distal Ureteral Calculi: Shock Wave Lithotripsy versus Ureteroscopy.
Shock wave lithotripsy (SWL) and ureteroscopy (URS) are both effective treatments for removal of distal ureteral calculi, associated with high success rates and limited morbidity. The American Urological Association Ureteral Stones Clinical Guidelines Panel has found both to be acceptable treatment options for patients, based on the stone-free results, morbidity, and retreatment rates for each respective therapy. However, costs and patient satisfaction or preference were not addressed, and the report was based on data derived from older endoscopic and lithotripsy technology. Each of these treatment options has valid advantages and disadvantages. Both modalities are reasonable treatment options for the majority of patients with distal ureteral calculi. Whereas SWL is less invasive, the high, immediate success rate with minimal morbidity and decreased cost makes URS a very valid competitor. The results of treating patients with larger stones favor URS.
Journal Article↗
Drug-induced urinary calculi.
Urinary calculi may be induced by a number of medications used to treat a variety of conditions. These medications may lead to metabolic abnormalities that facilitate the formation of stones. Drugs that induce metabolic calculi include loop diuretics; carbonic anhydrase inhibitors; and laxatives, when abused. Correcting the metabolic abnormality may eliminate or dramatically attenuate stone activity. Urinary calculi can also be induced by medications when the drugs crystallize and become the primary component of the stones. In this case, urinary supersaturation of the agent may promote formation of the calculi. Drugs that induce calculi via this process include magnesium trisilicate; ciprofloxacin; sulfa medications; triamterene; indinavir; and ephedrine, alone or in combination with guaifenesin. When this situation occurs, discontinuation of the medication is usually necessary.
Journal Article↗