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Biomedical subjects

S B Streem

Publications and source records attributed to S B Streem.

At least 55 records · Page 3Linked to original sources
PubMed1996

Medical treatment of cystinuria: results of contemporary clinical practice.

PURPOSE: We determined the efficacy of a contemporary medical regimen for treatment of cystinuria. MATERIALS AND METHODS: A total of 16 patients with cystinuria was followed for 7 to 141 months (mean 78.1). Standard therapy included hydration and alkalization. D-penicillamine or alpha-mercaptoproprionylglycine was added for failure of hydration and alkalization to prevent new stones or stone growth, or to cause dissolution. Captopril was added for failure of or intolerance to D-penicillamine or alpha-mercaptopropionylglycine. Radiography was performed every 6 to 12 months, at which time stone events were documented. RESULTS: During hydration and alkalization 46 stone events occurred in 8 of 9 patients (1.6 events per patient-year). With addition of thiol derivatives 7 of 9 patients experienced 24 stone events, all 6 treated with hydration, alkalization and captopril experienced 10 events, and 4 of 5 treated with alkalization, thiols and captopril experienced 8 events (0.52, 0.71 and 0.54 events per patient-year, respectively). During a total treatment time of 104.1 patient-years 88 stone events occurred in 14 of 16 patients (0.84 events per patient-year). CONCLUSIONS: D-penicillamine and alpha-mercaptopropionylglycine are effective in decreasing the rate of stone formation in patients in whom hydration and alkalization failed. While captopril may also be beneficial in this setting, it does not appear to be as effective as D-penicillamine or alpha-mercaptopropionylglycine, and it does not clearly add clinical benefit to those thiols. Our study demonstrates that patients with cystinuria are at high risk for recurrence when treated with any contemporary medical program. This natural history must be considered when evaluating the long-term efficacy of newer or alternative modes of medical and urological treatment.

Adolescent↗
PubMed1996

Long-term incidence and risks for recurrent stones following contemporary management of upper tract calculi in patients with a urinary diversion.

PURPOSE: The long-term rate of stone recurrence following contemporary minimally invasive management of calculi was determined in patients with urinary diversion and to identify specific risk factors for these recurrences. MATERIALS AND METHODS: We followed for a minimum of 12 months 25 patients (29 renal units) with upper tract calculi associated with urinary diversion, and treated with extracorporeal shock wave lithotripsy and/or percutaneous nephrostolithotomy. The risk of recurrent stones at 5 years was determined by a Kaplan-Meier estimate, while potential risk factors for recurrence were analyzed using a log-rank comparison. RESULTS: Stones recurred in 8 patients (32%) 18 to 61 months (mean 27.0) after treatment. The risk of new stone formation after 5 years was estimated to be 63.3% and was significantly greater in patients with recurrent bacteriuria after treatment. Neither stone history, type of procedure used, stone composition nor radiographic status at completion of treatment significantly influenced this risk. CONCLUSIONS: Contemporary management of upper tract calculi in patients with a urinary diversion is associated with a high recurrence rate, especially among those with recurrent bacteriuria, regardless of whether the patient is initially rendered stone-free. Continued close surveillance and antibiotic prophylaxis seem to be essential in this high risk patient population.

Bacteriuria↗
PubMed1996

Clinical implications of clinically insignificant store fragments after extracorporeal shock wave lithotripsy.

PURPOSE: We determined the natural history and clinical significance of small, asymptomatic, noninfection related stone fragments after extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: We prospectively followed 160 patients with 4 mm. or less asymptomatic calcium oxalate/phosphate stone fragments after ESWL for 1.6 to 88.8 months (mean 23) to stone-free status, censorship or intervention. Kaplan-Meier estimates of probability to anatomical stone-free, decreased or stable status were determined as well as the probability of symptomatic episodes or required urological intervention. RESULTS: Stone-free status or a decreased, stable or increased amount of residual stone occurred in 38 (23.8%), 26 (16.3%), 67 (41.9%) and 29 (18.1%) of the 160 patients, respectively. At 5 years after ESWL the probability of a stone-free, stone-free or decreased status, or stone-free, decreased or stable status was 0.36, 0.53, and 0.80, respectively. A total of 91 patients (56.9%) remained asymptomatic while 69 (43.1%) had a symptomatic episode or required intervention 1.6 to 85.4 months (mean 26) after ESWL (probability estimated at 0.71 at 5 years). CONCLUSIONS: While patients with small noninfection related stone fragments after ESWL may be followed expectantly, a significantly number will require intervention or have symptomatic episodes within 2 years. The term clinically insignificant applied to any residual stone after ESWL is likely a misnomer.

Female↗
PubMed1996

Extracorporeal shock wave lithotripsy for lower pole calculi: long-term radiographic and clinical outcome.

PURPOSE: We evaluated the efficacy of extracorporeal shock wave lithotripsy (ESWL) for lower pole calculi regarding immediate and long-term radiographic and clinical outcomes. MATERIALS AND METHODS: A total of 206 patients with isolated lower pole calculi in 220 renal units underwent ESWL for stones 4 to 625 mm2 (mean 88). Clinical and radiographic followup was obtained at 1 month and every 6 to 12 months thereafter. An initial stone-free rate was determined, as was the subsequent radiographic outcome. Clinical outcome with regard to a symptomatic episode or requiring intervention was also determined. Kaplan-Meier estimates of the probabilities of these outcomes with time were developed. RESULTS: Of the 206 patients 99 (48%) were rendered stone-free by 1 month after ESWL. Another 13 patients (6.3%) spontaneously became stone-free within another 1 to 95 months (mean 17.5). Of the remaining patients residual stones were decreased, stable or increased in 13 (6.3%), 71 (34%) and 10 (4.8%), respectively, after 1 to 91 months (mean 14.5). Among all 206 patients 180 (87.4%) remained asymptomatic for 1 to 99 months, while 7 (3.4%) suffered a symptomatic episode requiring medical attention 1 to 40 months (mean 21.1) after ESWL and 19 (9.2%) required intervention after 1 to 91 months (mean 23.9). Kaplan-Meier estimates of the probabilities of a symptomatic episode or requiring intervention at 5 years were 0.24 and 0.52, respectively. CONCLUSIONS: ESWL is the initial treatment of choice for lower pole calculi smaller than 2 cm.2 because the stone-free rate is comparable to that for stones at other caliceal locations and, perhaps more importantly, the risk of a symptomatic episode or requiring secondary intervention is low even in the setting of residual fragments.

Adolescent↗
PubMed1995

Definitive tumor resection and percutaneous bacille Calmette-Guérin for management of renal pelvic transitional cell carcinoma in solitary kidneys.

OBJECTIVES: This study was done to evaluate the safety and initial efficacy of definitive tumor resection combined with percutaneous bacille Calmette-Guérin (BCG) for management of renal pelvic transitional cell carcinoma (TCC) in patients with solitary kidneys. METHODS: Eight patients with anatomically solitary kidneys, all of whom had a prior history of TCC elsewhere in the urinary tract, were treated with either partial nephrectomy (n = 2) or percutaneous resection (n = 6) combined with a 6-week course of topical BCG administered percutaneously. Seven (87.5%) of the 8 patients tolerated the complete BCG course without adverse effects. One patient required cessation of treatment for renal insufficiency, which resolved with discontinuation of therapy. Follow-up nephroscopy was performed 3 months after the initial tumor resection in 6 of the 8 patients, and all patients underwent regular follow-up surveillance at 3- to 6-month intervals thereafter with radiographic, cytologic, and, in some cases, ureteroscopic examinations. RESULTS: With follow-up ranging from 9 to 59 (mean, 22) months, local tumor recurrence has become evident in only 1 patient. Two other patients have developed distant metastatic disease, both of whom had invasive TCC elsewhere in the urinary tract prior to treatment of the upper tract tumor. CONCLUSIONS: Combining a 6-week course of percutaneously administered topical BCG with definitive tumor resection is generally well tolerated, and, ultimately, this protocol may result in a decreased incidence of local tumor recurrence in these high-risk patients.

Aged↗
PubMed1995

Long-term incidence and risk factors for recurrent stones following percutaneous nephrostolithotomy or percutaneous nephrostolithotomy/extracorporeal shock wave lithotripsy for infection related calculi.

A study was done to determine the long-term incidence and cause of recurrent stones following percutaneous nephrostolithotomy alone (13 patients) or combined with extracorporeal shock wave lithotripsy (31) for management of documented infection related struvite renal calculi. The patients were followed for 12 to 111 months (mean 41.7) to censorship or time of new stone formation. Of these patients 12 (27%) had recurrent stones at 12 to 61 months (mean 32.3) after treatment. As determined by a Kaplan-Meier estimate, the risk of new stone formation 5 years after treatment was 36.8%. Potential risk factors for recurrence, including history of stones, associated anatomical abnormalities, procedure used, radiographic status at completion of treatment and recurrent infection during followup, were analyzed with Cox's proportional hazards model. Of these potential risk factors, only an associated anatomical abnormality was found to influence significantly the rate of recurrent stone formation (p = 0.005). We conclude that continued surveillance for recurrent stones is mandatory even for patients initially rendered stone-free and those who maintain sterile urine. In addition, because the presence of a significant anatomical or functional urinary tract abnormality places a patient at much higher risk for recurrence, we suggest that subsequent studies be stratified as to the presence or absence of these abnormalities.

Adult↗
PubMed1995

Long-term radiographic and functional outcome of extracorporeal shock wave lithotripsy induced perirenal hematomas.

PURPOSE: We determined the long-term radiographic and functional outcome of extracorporeal shock wave lithotripsy (ESWL) related perirenal hematomas. MATERIALS AND METHODS: We followed 19 patients with 21 ESWL induced hematomas for 4 to 61 months (mean 19.6) after ESWL with serial ultrasound, blood pressure and serum creatinine determinations. RESULTS: Complete radiographic resolution of the hematoma was evident in 18 cases (85.7%), while 2 (9.5%) were significantly smaller and 1 (4.8%) remained unchanged. Of 10 patients who were normotensive before ESWL none experienced sustained new onset hypertension. Of 9 patients with preexisting hypertension none had a sustained exacerbation. Finally, during followup serum creatinine levels overall remained unchanged from pre-ESWL values. CONCLUSIONS: We conclude that, by far, the most likely outcome for patients with ESWL related hematomas is spontaneous radiographic resolution within 2 years without clinically evident adverse effects on blood pressure or renal function.

Adult↗
PubMed1995

Prevention and management of hemorrhage associated with cautery wire balloon incision of ureteropelvic junction obstruction.

The functional significance of crossing lower pole vessels in patients with ureteropelvic junction obstruction is controversial. However, there is clear evidence that the incidence of such vessels in patients with ureteropelvic junction obstruction is significantly higher than in the general population. We report on a patient with secondary ureteropelvic junction obstruction treated with retrograde cautery wire balloon incision in whom significant hemorrhage developed as a result of disruption of a lower pole accessory artery crossing the ureteropelvic junction. Angiographic intervention with selective arterial embolization resulted in immediate, complete resolution with salvage of the kidney. Because the incidence of crossing vessels is relatively high in this patient population, steps should be taken to identify and possibly exclude affected patients before the use of blind incisional procedures.

Adult↗
PubMed1995

Clinical effect of captopril on the formation and growth of cystine calculi.

We determined the clinical efficacy of captopril for the prevention of new or stone growth in patients with homozygous cystinuria. Nine patients with a history of multiple cystine stones despite standard fluid and alkalization therapy received 50 mg. captopril, 3 times daily in addition to the standard therapy. Before treatment the rate of new stone formation or stone growth ranged from 0.7 to 2.0 events (mean 1.2) per patient-year for 1 to 3 years of observation (mean 1.9). During treatment the rate ranged from 0 to 3.0 events (mean 1.03) per patient-year for 0.5 to 6 years (mean 2.9). Although statistical significance was not evident for the group as a whole (p = 0.35), our findings suggest that captopril may be clinically efficacious in at least some patients with difficult to control cystinuria. Recommendations regarding its indications in this setting are made.

Adult↗
PubMed1995

Percutaneous management of upper-tract transitional cell carcinoma.

Standard management of upper tract transitional cell carcinoma is a nephroureterectomy; however, there is a distinct subgroup of patients who would be rendered dialysis dependent, or at high risk for functionally significant renal insufficiency, and for whom a nephron-sparing approach is warranted. Historically, the options for such "conservative" management have been limited to variations of open pyelotomy or partial nephrectomy. More recently, endourologic techniques have been applied to the treatment of these difficult patients. Though a ureteroscopic approach can occasionally be therapeutic, it may be precluded by the size or location of the tumor, or by a urinary diversion that makes ureteroscopic access difficult or impossible. Many of these patients can, however, be managed with a well planned percutaneous approach that provides excellent access to virtually the entire upper tract. The subsequent addition of topical BCG as an adjunct to percutaneous upper tract tumor resection may then be beneficial in decreasing the incidence of local recurrence.

Carcinoma, Transitional Cell↗
PubMed1995

Changing demographics in renal transplant recipients: the 30 year Cleveland Clinic experience.

While it does appear that the most recent era of transplantation has not resulted in significant improvement in long-term allograft function, this appears to be due, at least in part, to the transplantation of increasing numbers of high-risk patients. It is noted that the improved results accomplished over prior eras of transplantation have been maintained despite the inclusion of these high-risk patients. Patients currently undergoing transplantation are more likely to be older, diabetic, obese or African American. All of these subgroups have poorer patient survival in the most recent transplant era and thus, death with a functioning graft has become a significant contributor to graft loss. Recipients were more likely to receive kidneys from cadaveric donors in the most recent era and within the live-donor groups, sibling donation has decreased. Hopefully, the recent trend of increased live-donor transplants (especially living, unrelated transplants) will continue. Cadaveric recipients were at higher risk for posttransplant ATN which, for the first time in the current era, had a significant adverse impact on graft survival. Long-term survival appeared to be associated with particular characteristics (optimal age at transplantation, optimal donor age, live donor, etc.), and can be achieved despite known risk factors, such as rejection or delayed graft function.

Adolescent↗
PubMed1994

Minimally invasive endourologic management of calculi in continent urinary reservoirs.

This study was done to determine whether minimally invasive endourologic management of calculi in continent reservoirs can be done effectively without compromise of urinary continence. Four patients with continent urinary diversions (1 Indiana pouch and 3 Kock pouches) were managed with trans-stomal pouchoscopic ultrasonic lithotripsy (n = 2), prone position extracorporeal shock wave lithotripsy (n = 1), or a "sandwich" combination of these (n = 1) for stone burdens up to 20 cm2. Total hospital stay ranged from one to four (mean = 2.6) days. All 4 patients were initially rendered stone free, and, with follow-up as long as twenty-five months, only 1 has had a recurrence. No patient experienced stomal leakage or other complications. This study suggests that minimally invasive endourologic management of calculi in continent urinary reservoirs can be done safely and effectively to obviate the need for more invasive percutaneous approaches or open surgery, even for some patients with large stone burdens.

Adult↗
PubMed1994

Selective minimally invasive management of calculi in patients with urinary diversions.

We evaluate the efficacy of selectively applied minimally invasive management of calculi in 30 patients with urinary diversions (ileal/jejunal conduit in 23, cutaneous ureterostomy in 2, nonrefluxing colon conduit in 4 and ureterosigmoidostomy in 1). Upper tract calculi in 38 renal units were managed with extracorporeal shock wave lithotripsy or endo-urologically. Patients were divided into 3 treatment groups determined primarily by stone size and location: group 1-25 renal units with a mean stone burden of 1.78 cm.2 treated with extracorporeal shock wave lithotripsy alone, group 2-7 renal units with a mean stone burden of 12.75 cm.2 treated with percutaneous nephrostolithotomy alone and group 3-6 renal units with a mean stone burden of 19.03 cm.2 treated with a combination of both procedures. Stone-free results were 92%, 100% and 67% in groups 1 to 3, respectively. Total hospital stay averaged 4.3, 11.1 and 13.7 nights, while complications occurred in 1, 3 and 2 patients, respectively. We conclude that selective application of contemporary techniques for minimally invasive management of calculi in patients with a urinary diversion can provide acceptable results, even with progressively large and complex stone burdens, and that these results will be equivalent to those achieved in patients without urinary diversion.

Adult↗
PubMed1994

Pathological effects of extracorporeally generated shock waves on calcified aortic aneurysm tissue.

This study was done to define further the limits of extracorporeal shock wave lithotripsy (ESWL) in the setting of proximate calcified aneurysms. Calcified aortic aneurysmal tissue was harvested from patients undergoing elective abdominal aneurysm repair. The aneurysmal tissue was divided into control and experimental sections, and then suspended in normal saline at the F2 focal point, and at 2 and 5 cm. away from the F2 focal point in the major parallel axis of an unmodified Dornier HM3 lithotriptor. Shock waves (200, 500 or 1,000) were delivered at 18 kv. at F2, F2 plus 2 cm. and F2 plus 5 cm. The specimens were then analyzed histopathologically first to compare control and experimental sections for differences in preexisting calcification, hemorrhage and inflammation, and then to grade them for overall evidence of tissue disruption. No significant pathological difference was found between control and experimental specimens treated under these parameters. Our study suggests that human aortic aneurysmal tissue undergoes little pathological change when subjected to therapeutic range ESWL. These findings support previous clinical observations that the presence of a proximate calcified aneurysm does not necessarily preclude ESWL for the treatment of renal or ureteral calculi. The spatial and power limits used in this study may help provide a basis for future safe management of renal and ureteral calculi with ESWL in this setting.

Aorta, Abdominal↗
PubMed1994

Enteric hyperoxaluria associated with external biliary drainage.

Several chronic disorders of small bowel function have been associated with enteric hyperoxaluria. We report on a patient in whom enteric hyperoxaluria and recurrent calcium oxalate calculi developed during treatment with temporary external biliary drainage for sclerosing cholangitis. The hyperoxaluria subsequently resolved with reestablishment of intraluminal biliary flow at successful liver transplantation. We propose a mechanism for this previously unrecognized cause of hyperoxaluria.

Adult↗
PubMed1994

Safety of transurethral surgery in the early postoperative period following an open cardiac procedure.

A retrospective investigation was performed to determine whether patients undergoing transurethral surgery soon after cardiac surgery experienced increased morbidity or mortality rates. From 1986 to 1990, 24 patients first underwent open heart surgery and then either transurethral prostatectomy, bladder tumor resection or bladder cup biopsy during the same hospital stay. Postoperative complications included significant hematuria in 2 patients (8%), mild stress incontinence in 1 (4%) and bladder perforation in 1. One patient died of a spontaneous pneumothorax 17 days after the urological operation. None of these patients had had a previous myocardial infarction. The outcome of these patients was compared to that of 115 men who underwent transurethral prostatectomy for presumed benign disease during 1990. Complications of transurethral prostatectomy in this group included significant gross hematuria in 5 men, while 6 experienced urinary retention (1), atrial fibrillation (1), delirium (1), myocardial infarction (1), seizure (1) and intraoperative urethral injury (1). There was 1 death from multiple postoperative complications. Morbidity and mortality rates did not differ significantly between the 2 groups. Transurethral surgery performed after cardiac surgery during the same hospital stay appears to be safe, provided the patient is stable.

Aged↗
PubMed1994

Complications of nephron sparing surgery for renal tumors.

The technical results of 259 nephron sparing operations for renal cell carcinoma or renal oncocytoma were reviewed. Local or renal related complications occurred after 78 procedures (30.1%). The incidence of complications was less for operations performed after 1988 (22% versus 37%, p = 0.009) and for incidentally detected versus suspected tumors (p = 0.009). The most common complications were urinary fistula formation (45 operations) and acute renal failure (33). Significant predisposing factors for urinary fistula formation included central tumor location (p = 0.001), tumor size greater than 4 cm. (p = 0.001), the need for major reconstruction of the collecting system (p = 0.001) and ex vivo surgery (p = 0.001). Only 1 urinary fistula required open operative repair, while the remainder resolved either spontaneously (30) or with endoscopic management (14). Significant predisposing factors for acute renal failure included a solitary kidney (p = 0.001), tumor size greater than 7 cm. (p = 0.008), greater than 50% parenchymal excision (p = 0.001), greater than 60 minutes of ischemia time (p = 0.035) and ex vivo surgery (p = 0.001). Acute renal failure resolved in 28 patients, of whom 9 required temporary dialysis, while 5 required permanent dialysis. Overall, 8 complications (3.1%) required repeat open surgery for treatment while all other complications resolved with noninterventive or endourological management. Surgical complications contributed to an adverse clinical outcome in only 7 patients (2.9%). Nephron sparing surgery can be performed safely with preservation of renal function in most patients with renal tumors.

Acute Kidney Injury↗