Cases reported "Kidney Calculi"

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1/9. Surgical challenge of massive bilateral staghorn renal calculi in a spinal cord injury patient.

    We report a rare case of massive bilateral staghorn calculi in a spinal cord injury patient with significant renal compromise. The patient was successfully treated with percutaneous nephrolithotomy to achieve a stone-free status. The various options of treatment are discussed with special attention to the technical aspects necessary to achieve complete eradication of the stone burden during percutaneous nephrolithotomy. Furthermore, the importance of treating bladder dysfunction and urinary metabolic abnormalities is emphasized.
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2/9. Laparoscopic management of caliceal diverticular calculi.

    PURPOSE: We describe laparoscopic techniques for the definitive management of symptomatic caliceal diverticular stone disease. MATERIALS AND methods: Five patients underwent retroperitoneoscopic management of a symptomatic, stone bearing caliceal diverticulum. Techniques for intraoperative localization of the stone bearing diverticulum included retrograde injection of indigo carmine, fluoroscopy and/or laparoscopic ultrasound. In 2 cases the patent neck of the diverticulum was sutured via laparoscopy. RESULTS: Complete stone clearance and obliteration of the diverticular cavity was achieved in all cases without any open conversion. Mean operative time was 133.8 minutes. Mean estimated blood loss was less than 50 cc in 4 cases and 150 cc in 1. Mean hospital stay was 36 hours. There were no laparoscopic or postoperative complications. CONCLUSIONS: The laparoscopic approach to symptomatic caliceal diverticula represents an effective and minimally invasive modality for complete clearance of the stone burden and definitive management of the anatomical abnormality. However, patient selection is paramount. We reserve the laparoscopic approach for symptomatic caliceal diverticula with thin overlying renal parenchyma, or for anterior lesions inaccessible to or unsuccessfully managed by endourological techniques. A decision tree algorithm for managing symptomatic caliceal diverticular calculi is proposed.
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3/9. Lateral decubitus position for percutaneous nephrolithotripsy in the morbidly obese or kyphotic patient.

    BACKGROUND AND PURPOSE: Morbidly obese or debilitated patients do not tolerate the prone position used for percutaneous nephrolithotripsy (PCNL) well and may suffer from severe cardiorespiratory compromise in this position. The purpose of this study is to demonstrate a simple way to overcome this difficulty. patients AND methods: Two morbidly obese patients, ages 48 and 32 years, with Body Mass Indices of 47.5 and 43.2 and a 68-year old patient severely debilitated by multiple cerebral infarctions, ischemic heart disease, and kyphosis suffered from relatively high renal stone burdens. For PCNL, the patients were placed in the lateral decubitus position. To obtain an anteroposterior projection in this position, the C-arm fluoroscopy unit was tilted to one side and the operating table to the other. Tract dilation, stone fragmentation, and fragment extraction were performed with the patient in this position. RESULTS: An attempt to perform PCNL in the prone position in the first patient was aborted because of severe hypoxemia and hypercarbia. In the lateral decubitus position, the procedures were easily performed in all patients without any complications. It was noted that by rotating the C-arm to a perpendicular position, it was possible to perform nephroscopy and use fluoroscopy simultaneously. CONCLUSION: We highly recommend using the lateral position for PCNL in morbidly obese patients and in patients suffering from kyphosis. This position is safe and convenient.
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4/9. Sealing percutaneous nephrolithotomy tracts with gelatin matrix hemostatic sealant: initial clinical use.

    PURPOSE: Tubeless percutaneous nephrolithotomy (PCNL) has been performed at several centers with good success. However, these cases have been carefully selected with regard to short duration and smaller stone burden to prevent complications associated with the loss of access to the collecting system. We describe the use of gelatin matrix hemostatic sealant (FloSeal Baxter Medical, Fremont, california) as an adjunct to tubeless percutaneous nephrolithotomy to help preclude bleeding complications. MATERIALS AND methods: Two patients were treated with PCNL through a single nephrostomy tract. At the satisfactory conclusion of the cases the tract was occluded retrograde with an occlusion balloon catheter and gelatin matrix hemostatic sealant was injected down the nephrostomy tract. An indwelling stent and bladder catheter were placed following which all guidewires were removed and skin sutures were placed. RESULTS: The operative times were 75 and 180 minutes, respectively. Both patients had stable postoperative hemoglobin and no evidence of bleeding or obstruction on postoperative computerized tomography. CONCLUSIONS: Injection of gelatin matrix hemostatic sealant into the nephrostomy tract may be of value in preventing bleeding after PCNL. In this pilot experience it provided immediate and effective hemostasis.
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5/9. Use of a ureteral access sheath to facilitate removal of large stone burden during extracorporeal shock wave lithotripsy.

    Large renal stone burdens within a nondilated collecting system in patients with a relative contraindication to percutaneous nephrolithotomy can be a challenging problem. We describe a novel technique using a ureteral access sheath combined with extracorporeal shock wave lithotripsy to facilitate passage of stone fragments in such patients.
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6/9. The role of ESWL in the treatment of large kidney stones.

    With extracorporeal shock wave lithotripsy firmly established as the treatment of choice for the majority of kidney stones, the management of large stone burdens and staghorn stones remains a point of discussion(1,2,3,4). Although with increasing experience the original limitations(5,6) posed by the size and the number of kidney stones have gradually become less important, most centres still approach large stones with a combination of percutaneous ultrasound lithotripsy and ESWL. This article reports on a personal series of 96 kidneys with an average stone burden of 51 mm treated by ESWL alone or in combination with indwelling ureteral drainage tubes, so called double J stents. Of these 96 kidneys, twelve were treated in one session, 74 in two, nine in three and one in four sessions. At six to twelve weeks after their last treatment session 42 were stonefree, 30 contained residual fragments smaller than 3 mm and four contained fragments larger than 3 mm. Complications were hematuria, pain, fever, encrustration of stone on the double J stent, spontaneous knotting of the double J stent and subcapsular hematoma. No kidneys were lost in this series and no deaths occurred. The results are comparable to those of combined PCN and ESWL(1). A case is made for ESWL with internal drainage by double J stent as the only auxiliary measure in kidneys with large stone burdens(7,8).
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7/9. Laparoscopic treatment of a stone-filled, caliceal diverticulum: a definitive, minimally invasive therapeutic option.

    We describe the laparoscopic treatment of a symptomatic, stone-filled caliceal diverticulum in a patient who would have otherwise required open surgical excision of the diverticulum. Laparoscopic management was chosen as an alternative to an open operation in this patient because the anterior location of the diverticulum precluded treatment with percutaneous nephrolithotomy, while the stone burden and stenotic orifice precluded management with extracorporeal shock wave lithotripsy. The patient had no morbidity, returned to the preoperative activity level by 2 weeks and remains asymptomatic. The options for managing caliceal diverticula are discussed.
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8/9. Bilateral spontaneous steinstrasse and nephrocalcinosi associated with distal renal tubular acidosis.

    Bilateral spontaneous steinstrasse from the ureteropelvic junction to the distal ureter complicating distal renal tubular acidosis has not been described. We report a case and discuss the clinical presentation, radiographic and metabolic findings, and treatment. Relief of obstructive uropathy with extracorporeal shock wave lithotripsy led to the resolution of the heavy steinstrasse burden.
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9/9. Factitious renal colic.

    OBJECTIVES: We reviewed our experience with patients with factitious disorders who presented with renal colic to identify their common characteristics and to quantify the cost burden placed on the health care system as a result. methods: We retrospectively reviewed the medical records of two philadelphia area hospitals from 1989 to 1995 to find patients with factitious disorders who presented with renal colic. A control group of patients with nephroureterolithiasis was also identified. RESULTS: We identified 12 patients who presented with renal colic and had a final diagnosis of Munchausen's syndrome or malingering. The incidence of factitious renal colic was 0.6%. Eighty-three percent of these 12 patients were men, had an average age of 32 years, and made a total of 18 hospital visits. Ninety-two percent claimed an intravenous contrast allergy, 25% claimed an allergy to a specific narcotic, and 39% of the hospital visits ended with the patient voluntarily discharged against medical advice. Thirty-three percent were treated elsewhere for similar complaints. Only the number of intravenous contrast allergies and the number of patients leaving against medical advice were statistically different from the control group. The total cost for all factitious visits was $52,452, with a mean cost per visit of $2914. The average bill of those patients who received retrograde pyelograms was $3046 greater than for those who did not. CONCLUSIONS: factitious disorders should be considered when evaluating patients with an intravenous contrast allergy and renal colic. These patients are likely to leave against medical advice and place a significant cost burden on hospitals.
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