Experienţa clinicii de urologie din Târgu-Mureș în tratamentul calculului coralifor

Abstract Percutaneous surgery is a safe and efficient method in the treatment of staghorn calculi. The analysis of our experience in the percutaneous treatment of staghorn calculi over a period of 18 years (1988-2005). During this time practically we have performed open surgery only in a few patient with renal and upper ureteral calculi. From a number of over 6230 patients with renal and upper ureteral calculi treated with the endoscopic method, during the period between 1988-2005, we have performed percutaneous surgery on 1074 patients with staghorn calculi (7 of them were children; 22 patients had bilateral staghorn calculus). The average surgery time was 115 minutes, the average postsurgery hospital care time was 17,5 days. The postoperative “stone free" rate was 914/1074 (85,10%). In 101/1074 (9,40%) cases our patients developed complications and in 3/1074 (0,27%) cases the patient deceased due to hemorrhage and toxico-septic shock. For the successfully treatment of a patient with staghorn calculus using the percutaneous technique it is necessary a good knowledge of the 3D anatomy of the kidney well chosen and correctly executed percutaneous nephrostomy tracks, training, experience and good technical skills in the endourology of the upper urinary tract. Chirurgia percutanată este o metodă sigură şi eficientă în tratamentul litiazei coraliforme. Introducere. Analiza experienţei noastre în tratamentul percutanat al litiazei coraliforme într-o perioadă de 18 ani (1988-2005), în care nu am mai operat deschis, decât un număr foarte mic de pacienţi cu litiază renală şi ureterală superioară. Materiale şi metode. Într-o serie de peste 6230 de pacienţi cu litiază renală şi ureterală superioară rezolvaţi percutanat în intervalul 1988-2005, am operat percutanat 1074 pacienţi cu litiază coraliformă (7 au fost copii; 22 pacienţi au avut litiază coraliformă bilaterală). Rezultate. Timpul operator a fost în medie de 115 minute, durata medie a spitalizării postoperatorii de 17,5 zile. Rata “stone free” postoperator a fost de 914/1074 (85,10%). Am avut complicaţii la 101/1074 (9,40%) pacienţi şi 3/1074 (0,27%) decese prin hemoragie şi şoc toxico-septic. Concluzii. Pentru rezolvarea percutanată cu succes a unui calcul coraliform este necesară o bună cunoaştere a anatomiei tridim ensionale a rinichiului, traiecte de nefrostom ie percutanată bine alese şi corect efectuate, antrenament, experienţă şi o bună tehnicitate în endourologia aparatului urinar superior

Incidenţa complicaţiilor după litotriția extracorporală (ESWL) pentru calculi renali de peste 15 mm

Abstract On this study we want to evaluate the complication that occure after extracorporeal shock wave lithotripsy on the patients with renal stones bigher thean 1,5 cm. In the last 11 years (02.1995­ 03.2006), in the Urologic Clinic of Târgu-Mureş, we performed extracorporeal shock wave lithotripsy to 9024 patients with renoureteral lithiasis. 4330 patients (47,98%) had ureteral stones and 4696 patients (52,02%) had renal stones. 994 (11,02%) had renal calculi biger that 1,5 cm diameter. On theese 994 patients, we performed 1553 lithotripsy treatments, representing an average of 1,54 extracorporeal lithotripsy patient. To 648 patients (65,19%) we have done one lithotripsy treatment. Despite the size of the calculi, the associated manouvres befor lithotripsy were few, only 0,6% (3 patients with double Jcatheter, 3 patients with endoscopic mobilisation of the stone). Extracorporeal lithotripsy was not efficient to 0,6% of patient, beeing needed other surgical procedures for this stones. Post lithotripsy complications were numerouse (47,28%): acute pyelonephritis (4,7%), impacted calculi in the ureter (5%), steinstrasse (31,48%). To 17,55% of patients (175) were needed other endoscopic procedures of resolving the complications (percutaneous nephrolithotomy to 1,2%, retrograde ureteroscopy + double J catheter to 7,53%, meatotomy to 4,1%. In spite of these complications the stone-free rate at 3 months after lithotripsy was 75,75%. We can conclude that ESWL can be practiced with good results evean on renal calculi biger than 1,5 cm diameter. Introducere. Lucrarea de faţă îşi propune să evalueze incidenţa complicaţiilor (obstructive, infecţioase, hemoragice) apărute după practicarea litotriţiei extracorporale la bolnavii cu calculi renali mai mari de 1,5 cm diametru. Materiale şi metode. În ultimii 11 ani (02.1995-03.2006), în Clinica Urologică Tg-Mureş am practicat litotriţie extracorporală la 9024 bolnavi cu litiază reno-ureterală. 4330 bolnavi (47,98%) au avut calculi ureterali şi 4694 (52,02%) - litiază renală. 11,02% (994 pacienţi) au prezentat calculi renali mai mari de 1,5 cm diametru. La aceşti 994 de pacienţi, am practicat 1533 şedinţe de litotriţie extracorporală, ceea ce reprezintă o medie de 1,54 şedinţe/ pacient. La 648 de pacienţi (65,19%) am practicat o singură şedinţă de litotriţie extracorporală. În ciuda dimensiunii, manevrele associate, efectuate înaintea litotriţiei, au fost puţine, 0,6% (3 pacienţi cu sondă autostatică, 3 pacienţi cu calcul mobilizat înaintea litotriţiei). Rezultate. Litotriţia nu a fost eficientă la 0,6% dintre bolnavi, fiind necesare alte intervenţii chirurgicale. Complicaţiile post ESWL au fost mai numeroase (47,28%): pielonefrită acută 4,7% ), hematoame renale (2,2% ), ureterohidronefroză infectată (3,8%), fragmente inclavate în ureter (5%), steinstrasse (31,58%). La 17,55% dintre bolnavi (175) au fost necesare alte metode endoscopice de rezolvare a complicaţiilor (nefrostomie percutanată - la 12%, ureterorenoscopie retrogradă + sondă autostatică - la 7,53%; pielolitotomie - la 4,1%). Concluzii. În pofida acestor complicaţii şi a evoluţiei post ESWL mai îndelungate, rata de stone-free la 3 luni după litotriţie a fost de 75,75% (757 bolnavi), deci putem conclude că litotriţia extracorporală se poate practica cu rezultate bune şi la calculi renali mai mari de 1,5 cm

The emergency department arrival mode and its relations to ED management and 30-day mortality in acute heart failure: an ancillary analysis from the EURODEM study

Background Acute heart failure patients are often encountered in emergency departments (ED) from 11% to 57% using emergency medical services (EMS). Our aim was to evaluate the association of EMS use with acute heart failure patients' ED management and short-term outcomes. Methods This was a sub-analysis of a European EURODEM study. Data on patients presenting with dyspnoea were collected prospectively from European EDs. Patients with ED diagnosis of acute heart failure were categorized into two groups: those using EMS and those self-presenting (non- EMS). The independent association between EMS use and 30-day mortality was evaluated with logistic regression. Results Of the 500 acute heart failure patients, with information about the arrival mode to the ED, 309 (61.8%) arrived by EMS. These patients were older (median age 80 vs. 75 years, p 30/min in 17.1% patients vs. 7.5%, p = 0.005). The only difference in ED management appeared in the use of ventilatory support: 78.3% of EMS patients vs. 67.5% of non- EMS patients received supplementary oxygen (p = 0.007), and non-invasive ventilation was administered to 12.5% of EMS patients vs. 4.2% non- EMS patients (p = 0.002). EMS patients were more often hospitalized (82.4% vs. 65.9%, p < 0.001), had higher in-hospital mortality (8.7% vs. 3.1%, p = 0.014) and 30-day mortality (14.3% vs. 4.9%, p < 0.001). The use of EMS was an independent predictor of 30-day mortality (OR = 2.54, 95% CI 1.11-5.81, p = 0.027). Conclusion Most acute heart failure patients arrive at ED by EMS. These patients suffer from more severe respiratory distress and receive more often ventilatory support. EMS use is an independent predictor of 30-day mortality

Cistita necrotică - dificultăţi diagnostice şi terapeutice

Abstract Necrotic cystitis, also called incrustation cystitis, raises etiopathological and therapeutical problems, with relapse of the necrosis after removal of pathological tissue. Between 01.01.1999 and 31.12.2005 there have been 55 patients institutionalized in our Clinic, presenting lower urinary tract symptoms (LUTS). Instrumental investigations have demonstrated the thickening of the bladder wall, more frequently in the trigonum area. Ultrasound examination and cystography couldn’t exclude an infiltrative bladder tumor. Cystoscopy which showed necrotic bladder tissue, with calcareous incrustations, followed by the resection of the pathologic tissue. In 45 cases the histopathological result was necrotic cystitis and in 10 cases infiltrative urothelial bladder tumor or epidermoid metaplasia. In order to clarify the etiology of the necrosis an investigation protocol have been used, consisting of laboratory tests for autoimmune diseases, vascular or local causes that initiate the necrosis (previous surgery in the area, endoscopic interventions). In 5 cases with autoimmune disease, the treatment was transurethral resection and plasmapheresis. The evolution was favorable in 4 cases. Failure: 1 patient. In 12 cases the cause of the necrosis appears to be a diabetic vasculitis, judging by the deep necrosis, dispersed over several small areas. The posttherapeutic evolution depends on the correct treatment of diabetes. In 10 patients with previous endoscopic surgery, the necrosis has been induced by inadequate electrical currents or mechanical lesions. In 18 patients the causing factor remained unknown. The limited necrosis of the bladder can be caused by autoimmune diseases, vascular diseases (diabetes) and endo-urethral maneuvers. The endoscopic resection of the necrotic bladder wall to the healthy, well vascularised tissue beneath is an important therapeutic procedure. The treatment of the causing factors (autoimmune, vascular) will consolidate the healing. Not knowing the other causes will lead to failure, and repeated endoscopic treatment will result in short term ameliorations. Introducere. Cistita necrotică, denumită în literatură şi “cistita de incrustaţie”, ridică probleme de etiopatogenie, prezentând dificultăţi terapeutice, cu recidiva necrozei după îndepărtarea ţesuturilor patologice. Materiale şi metode. Între 01.01.1999-31.12.2005 au fost internaţi în clinica noastră 55 de pacienţi cu fenomene urinare joase de tip iritativ. Investigaţiile paraclinice au pus în evidenţă peretele vezical îngroşat, situaţie frecventă în trigon. Ecografia şi cistografia nu puteau exclude aspectul unei tumori vezicale infiltrative.Cistoscopia a evidenţiat un ţesut vezical necrozat, cu incrustaţii calcare, fiind urmată de rezecţia ţesutului patologic. La 45 de pacienţi rezultatul histopatologic a fost de cistită necrotică, iar la 10 bolnavi s-a depistat tumoră vezicală urotelială infiltrativă sau metaplazie epidermoidă. Pentru a elucida etiopatogenia necrozei, s-a aplicat un protocol de investigare care include teste de laborator pentru depistarea unui proces autoimun, a unor cauze vasculare sau a unor cauze locale de declanşare a necrozei (intervenţii în antecedente, manevre endoscopice, etc.). Rezultate şi discuţii. La 5 bolnavi cu proces autoimun, tratamentul a constat din rezecţie transuretrală şi din plasmafereză. Evoluţie favorabilă, cu vindecare - la 4 bolnavi. Eşec: 1 pacientă. La 12 bolnavi cauza necrozei este sugerată a fi o vasculită diabetică, după aspectul profund al necrozei în puncte dispersate, evoluţia postterapeutică este influenţată de tratamentul corect al diabetului. La 10 pacienţi cu manevre chirurgicale endoscopice în antecedente, inducţia procesului necrotic a fost provocat de curenţi electrici inadecuaţi sau de leziuni mecanice. La 18 bolnavi cauza a fost necunoscută. Concluzii. Necroza limitată a vezicii urinare poate avea cauze autoimune, vasculare (diabet), manevre endouretrale. Rezecţia endoscopică a peretelui vezical necrozat până în ţesut bine vascularizat este un gest terapeutic important. Tratamentul cauzal (autoimun, vascular, etc.) consolidează vindecarea. Necunoaşterea şi a altor cauze duce la eşec, iar tratamentul endoscopic repetat - la ameliorări pasagere

International Study on Sagliker Syndrome and Uglifying Human Face Appearence in Severe and Late Secondary Hyperparathyroidism in Chronic Kidney Disease Patients

PubMedID: 18089456Objective: It is known that skeletal changes due to secondary hyperparathyroidism (SH) can be severe in chronic kidney disease (CKD). Recently decribed Sagliker syndrome (SS) is a very striking and prominent feature of SH in CKD, including an uglifying appearance to the face, short stature, extremely severe maxillary and mandibulary changes, soft tissue in the mouth, teeth/dental abnormalities, fingertip changes, knee and scapula deformities, hearing abnormalities, and neurological and, more important, severe psychological problems. Design, Setting, Patients: In the past 8 years, we have encountered 40 cases of SS in SH and CKD by performing an international study in Turkey, India, Romania, Egypt, Maleysia, Tunis, and China. Results: The medical history of these patients showed that they did not receive proper therapy. Changes, particularly in children and teenagers, become irreversible, which was disastrous for the patients both aesthetically and psychologically. Conclusion: Treatment must begin early and be the appropriate treatment given in centers with sophisticated skills. Otherwise, the inability to correct all the changes in the skull and face, to remodel a new face, to extending the height, and, most important, to convince the patients to face the dramatic psychological problems can be catastrophic for those patients. © 2008 National Kidney Foundation, Inc

Is survival enough for quality of life in Sagliker Syndrome-uglifying human face appearances in chronic kidney disease?

PubMedID: 18446747Background: It is known that secondary hyperparathyroidism (SH) and particularly skeletal changes is a severe condition in chronic kidney disease (CKD). Sagliker syndrome (SS) is a very prominent feature in CKD including uglifying human face appearances, short stature, extremely severe maxillary and mandibulary changes, soft tissues in the mouth, teeth-dental abnormalities, finger tip changes and severe psychological problems. Methods: In the last 8 years we have confronted 36 extremely incredible SS cases in CKD by performing an international study in Turkey, India, Malaysia, Romania and Egypt. Results: In addition to the uglifying human face appearance, we found extremely severe X-ray and tomographical, pantomographical, histo-pathological changes in the head and whole body. Finally, we compared previous face pictures with recent ones. Just a few years earlier they had been pretty and good-looking young boys and girls. By investigating their history, we understood they had not received proper therapy and were in the late-irreversible period. Conclusion: SS is a serious and severe complication of CKD. Late and unproper treatment leads to abnormalities throughout skeleton particularly in the skull and face. Changes particularly in children and teens become irreversible-disastrous for appearance and psychological health. Appropriate treatment must begin as early as possible in specialized centers. It is possible that SS patients may survive long-term with dialysis, but with all those particular changes could anyone claim this type of life would continue in an acceptable way without extending their height, correcting all the changes in the skull and face, remodeling new faces and most particularly convincing the patients to deal with all those tragy-dramatic psychological problems? © Società Italiana di Nefrologia