Non-papillary Percutaneous Puncture: A Safe Approach to Consider

Percutaneous nephrolithotomy (PCNL) is the ‘gold standard’ treatment modality for renal stones larger than 2 cm. It can be also applied to manage smaller renal stones and large, impacted stones located in the proximal ureter. Nevertheless, even in experienced hands, the PCNL procedure is associated with the development of several complications. Despite the existing extensive research in this field, studies evaluating the effect of puncture site on perioperative bleeding are very few. In part, this can be explained by the dogma that the safest way to perform kidney puncture is through the renal papilla. In this paper, the authors summarise their experience of non-papillary PCNL and demonstrate this puncture technique for PCNL tract establishment.

Relationship of endoscopic lesions of the renal papilla with type of renal stone and 24 h urine analysis

BACKGROUND: Our purpose was to study the relationship of the 3 different types of endoscopic calcifications of the renal papilla (Randall’s plaque, intratubular calcification, papillary crater) with the type of stone and urine analysis. METHODS: This prospective study examined 41 patients (age range: 18 to 80 years) who received retrograde intrarenal surgery (RIRS) for renal lithiasis (mean stone size: 15.3 ± 7.2 mm). The renal papilla injuries were endoscopically classified as Randall's plaque, intratubular calcification, or papillary crater. Calculi were classified as uric acid, calcium oxalate monohydrate (COM; papillary and cavity), calcium oxalate dihydrate (COD), or calcium phosphate (CP). A 24 h urine analysis of calcium, oxalate, citrate, phosphate, and pH was performed in all patients. The relationship of each type of papillary injury with type of stone and urine chemistry was determined. Fisher’s exact test and Student’s t-test were used to determine the significance of relationships, and a p value below 0.05 was considered significant. RESULTS The most common injury was tubular calcification (78%), followed by Randall’s plaque (58%), and papillary crater (39%). There was no significant relationship of Randall’s plaque with type of stone. However, endoscopic intratubular calcification (p = 0.025) and papillary crater (p = 0.041) were more common in patients with COD and CP stones. There were also significant relationships of papillary crater with hypercalciuria (p = 0.036) and hyperoxaluria (p = 0.024), and of Randall’s plaque with hypocitraturia (p = 0.005). CONCLUSIONS There are certain specific relationships between the different types of papillary calcifications that were endoscopically detected with stone chemistry and urine analysis. COD and CP stones were associated with endoscopic tubular calcifications and papillary craters. Hypercalciuria was associated with tubular calcification, and hypocitraturia was associated with Randall’s plaque.

Relationship of endoscopic lesions of the renal papilla with type of renal stone and 24 h urine analysis

BACKGROUND: Our purpose was to study the relationships of the 3 different types of endoscopic calcifications of the renal papilla (Randall’s plaque, intratubular calcification, papillary crater) with the type of stone and urine chemistry. METHODS This prospective study examined 41 patients (age range: 18 to 80 years) who received retrograde intrarenal surgery (RIRS) for renal lithiasis (mean stone size: 15.3 ± 7.2 mm). Endoscopic injuries of the renal papilla were classified as Randall’s plaque, intratubular calcification, or papillary crater. Calculi were classified as uric acid, calcium oxalate monohydrate (COM; papillary and cavity), calcium oxalate dihydrate (COD), or calcium phosphate (CP). A 24 h urine analysis of calcium, oxalate, citrate, phosphate, and pH was performed in all patients. The relationship of each type of papillary endoscopic injury with type of stone and urine chemistry was determined. Fisher’s exact test and Student’s t-test were used to determine the significance of relationships, and a p value below 0.05 was considered significant. RESULTS The most common endoscopic injury was tubular calcification (78%), followed by Randall’s plaque (58%), and papillary crater (39%). There was no significant relationship of Randall’s plaque with type of stone. However, endoscopic intratubular calcification (p = 0.025) and papillary crater (p = 0.041) were more common in patients with COD and CP stones. There were also significant relationships of papillary crater with hypercalciuria (p = 0.036) and hyperoxaluria (p = 0.024), and of Randall’s plaque with hypocitraturia (p = 0.005). CONCLUSIONS There are certain specific relationships between the different types of endoscopic papillary calcifications with stone chemistry and urine chemistry. COD and CP stones were associated with endoscopic tubular calcifications and papillary craters. Hypercalciuria was associated with tubular calcification, and hypocitraturia was associated with Randall’s plaque.

Relationship of endoscopic lesions of the renal papilla with type of renal stone and 24 h urine chemistry

BACKGROUND: Our purpose was to study the relationships of the 3 different types of endoscopic calcifications of the renal papilla (Randall’s plaque, intratubular calcification, papillary crater) with the type of stone and urine chemistry.METHODS This prospective study examined 41 patients (age range: 18 to 80 years) who received retrograde intrarenal surgery (RIRS) for renal lithiasis (mean stone size: 15.3 ± 7.2 mm). Endoscopic injuries of the renal papilla were classified as Randall’s plaque, intratubular calcification, or papillary crater. Calculi were classified as uric acid, calcium oxalate monohydrate (COM; papillary and cavity), calcium oxalate dihydrate (COD), or calcium phosphate (CP). A 24 h urine analysis of calcium, oxalate, citrate, phosphate, and pH was performed in all patients. The relationship of each type of papillary endoscopic injury with type of stone and urine chemistry was determined. Fisher’s exact test and Student’s t-test were used to determine the significance of relationships, and a p value below 0.05 was considered significant. RESULTS The most common endoscopic injury was tubular calcification (78%), followed by Randall’s plaque (58%), and papillary crater (39%). There was no significant relationship of Randall’s plaque with type of stone. However, endoscopic intratubular calcification (p = 0.025) and papillary crater (p = 0.041) were more common in patients with COD and CP stones. There were also significant relationships of papillary crater with hypercalciuria (p = 0.036) and hyperoxaluria (p = 0.024), and of Randall’s plaque with hypocitraturia (p = 0.005).CONCLUSIONS There are certain specific relationships between the different types of endoscopic papillary calcifications with stone chemistry and urine chemistry. COD and CP stones were associated with endoscopic tubular calcifications and papillary craters. Hypercalciuria was associated with tubular calcification, and hypocitraturia was associated with Randall’s plaque.

Risk Factors for Urosepsis after Minimally Invasive Percutaneous Nephrolithotomy in Patients with Preoperative Urinary Tract Infection

The purpose of this study was to assess risk factors of urosepsis after minimally invasive percutaneous nephrolithotomy (MPCNL) for the treatment of upper urinary tract stones in patients with preoperative urinary tract infection (UTI) and to explore preventive measures. Between 2008 and 2016, patients with preoperative UTI who underwent MPCNL for upper urinary tract stones were retrospectively collected. Patients were divided into nonurosepsis and urosepsis groups. Perioperative outcomes of all patients were evaluated and compared between the two groups. Risk factors for post-MPCNL urosepsis were investigated using univariate and multivariate regression analysis. A total of 843 patients including 22 patients with postoperative urosepsis (urosepsis group) and 821 patients without urosepsis (nonurosepsis group) were finally included in this study. All patients with postoperative urosepsis were cured and discharged after treatment. In univariate analysis it was demonstrated that the incidence of urosepsis after MPCNL was significantly correlated with channel size (P=0.001), surgical time (P=0.003), as well as the tear of the collection system and percutaneous renal channel crossing the renal papilla (P=0.004). Moreover, multivariate analysis showed that smaller channel size (OR = 11.192, 95% CI: 2.425–51.650, P=0.002), longer surgical time (OR = 6.762, 95% CI: 1.712–17.844, P=0.008), and tear of collection system and percutaneous renal channel crossing the renal papilla (OR = 5.531, 95% CI 1.228–14.469, P=0.012) were independent risk factors for urosepsis following MPCNL in patients with preoperative UTI. In conclusion, in patients with preoperative UTI undergoing MPCNL for upper urinary tract stones, smaller channel size, prolonged operation time, as well as tear of the collection system and percutaneous renal channel crossing the renal papilla are independent risk factors for postoperative urosepsis. Therefore, it is indicated that, in clinical practice, it is of great significance to choose appropriate channel size and avoid renal injury and control surgical time to prevent the urosepsis after MPCNL in patients with preoperative UTI.

THE EFFECTS OF L-ORNITINE AND L-ARGININE ON THE PROCESSES OF LIPID PEROXIDATION IN THE FUNCTIONAL LAYERS OF KIDNEYS ON THE BACKGROUND OF ACUTE TOXIC HEPATITIS

The aim is to evaluate the effects of L-arginine and L-ornithine on the processes of lipid peroxidation in homogenates of renal cortex, renal medulla and renal papilla under conditions of acute toxic hepatitis. Materials and methods: The study was performed on 40 outbred white male rats with experimental hepatitis, caused by carbon tetrachloride. The animals were divided into five groups: control group (the rats were simulated carbon tetrachloride poisoning and its correction by administering of olive oil and normal saline in equivalent doses), acute carbon tetrachloride hepatitis (single intraperitoneal injection of 50% carbon tetrachloride oil solution at the dose of 2 mlxkg-1 of body weight and simulation of treatment by administration of normal saline in equivalent doses), acute carbon tetrachloride hepatitis + L-ornithine (1000 mgxkg-1), acute carbon tetrachloride hepatitis + L-arginine (500 mgxkg-1) and acute carbon tetrachloride hepatitis + combination of substances. Results: On the background of acute carbon tetrachloride intoxication it was observed the development of renal failure in experimental animals, manifested by activation of lipid peroxidation processes in homogenates of renal cortex, renal medulla and renal papilla. The administration of L-ornithine and L-arginine demonstrates positive impact on renal function and hepato-renal syndrome by stabilization of cell membranes and regeneration of functional capacity of injured renal cells. Conclusions: The results of our study confirm both the presence of unidirectional effects and absence of toxic influences of L-ornithine and L-arginine on renal cells under the conditions of acute carbon tetrachloride intoxication, which are the most important requirements for modern drugs for the treatment of hepato-renal syndrome.

Pathological Changes of Urinary System in a Dog with Urolithiasis and Renal Papillary Necrosis

Background: Urolithiasis is one of the important lower urinary tract diseases in dogs. Uroliths develop when urine becomes "supersaturated”. Struvite urolithiasis in dogs is formed when urine saturated with magnesium, ammonium and phosphate. Renal papillary necrosis is a form of nephropathy involving the necrosis of the renal papilla. The aim of this case is the evaluation of histopathological changes in kidney and urinary bladder caused by urolithiasis with sitruvite, a pathology commonly seen in dogs. Renal papillary necrosis that encountered in the case was evaluated histopathologically. We intend to discuss the relationship between urolithiasis and renal papillary necrosis.Case: The material of the case was a 7.5 year-old Rottweiler female dog that had been operated for the urolithiasis treatment and died after surgery. The animal sent to pathology department was necropsied and evaluated histopathologically. Also the uroliths removed during the surgery were sent for analysis postoperatively. Qualitative composition of uroliths was determined by a series of chemical analyses in Department of Biochemistry. X-ray diffraction was performed as well in General Directorate of Mineral Research and Exploration in the objective of result verification. Macroscopically, 30 pieces uroliths with varying size from 1 mm to 3 cm were seen in urinary bladder. They were 110 g in weight with smooth surface and round and/or ovoid shapes. After necropsy, specimens from kidney and urinary bladder were fixed in 10% neutral buffered formalin, embedded in paraffin wax, cut at 5 μm, and stained with hematoxylin and eosin (HE). Bladder wall thickening and hemorrhage on mucosa were noticed. Kidneys had roughened surface with the capsule being difficult to peel off. Also, renal papillary necrosis, reddish in color was observed in papilla of the right kidney. Microscopically, crystal formations were observed proximal tubule lumens of kidneys. Interstitial nephritis in cortex and medulla had been noticed in both kidneys. Interstitial nephritis has been noticed in both kidneys. Hemorrhagic necrotic area demarcated by connective tissue was encountered in medulla of the right kidney. In the lamina propria of urinary bladder hemorrhage were noted. Desquamation and degeneration of lamina epithelialis and wide hemorrhage area in lamina propria were noted in urinary bladder. Results obtained from biochemical analysis were verified with x-ray diffraction method, uroliths were determined as magnesium ammonium phosphate (struvite).Discussion: Renal papillary necrosis is a form of nephropathy involving the necrosis of the renal papilla, caused by ischemia of the inner medulla of the kidney. According to the first report of renal papillary necrosis, symmetrical soft calyceal concretions and their appearances are typical lesions for diagnosis of renal papillary necrosis. The presence of crystals in the tubule lumen and the formation of struvite stone (which has the same chemical composition with calyceal concretions) established a distinct relationship between urolithiasis and renal papillary necrosis. This case showed that struvite stones can reach large volumes in urinary bladder, and caused bladder wall thickness and hemorrhages. Also, the lower urinary tract obstruction or urolithiasis should be remembered in the renal papillary necrosis together with the risk of hydronephrosis.