Long-term combined treatment with thiazide and potassium citrate in nephrolithiasis does not lead to hypokalemia or hypochloremic metabolic alkalosis

Long-term combined treatment with thiazide and potassium citrate in nephrolithiasis does not lead to hypokalemia or hypochloremic metabolic alkalosis.BackgroundPotassium citrate is commonly used in combination with a thiazide diuretic in the medical management of recurrent hypercalciuric nephrolithiasis. However, concerns have been raised that administration of this nonchloride potassium alkali with a kaliuretic and natriuretic agent such as thiazide may not be efficacious in correcting or preventing hypokalemia, and may produce hypochloremic metabolic alkalosis. This retrospective analysis was conducted to determine if these two potential complications are encountered in patients on long-term potassium citrate and thiazide therapy.MethodsData were collected on 95 patients who had been on combination therapy for at least 4 months from the stone clinics of the University of Texas Southwestern Medical Center, Duke University Medical Center, and Ochsner Clinic.ResultsMean serum potassium concentration remained within normal limits without a significant decrease during combined therapy. Serum chloride was significantly lower from pretreatment but by only 1 mEq/L and remained within normal limits throughout treatment. There was a small increase in serum bicarbonate concentration compared to the baseline level of less than 1 mEq/L at 8 to 12 and 18 to 24 months, but not at other treatment periods.ConclusionCo-administration of potassium citrate did not induce hypokalemia or hypochloremic metabolic alkalosis in our thiazide-treated patient population

Randomized controlled trial comparing three different modalities of lithotrites for intracorporeal lithotripsy in pcnl

Purpose: To compare the efficiency (stone fragmentation and removal time) and complications of three models of intracorporeal lithotripters in percutaneous nephrolithotomy (PCNL). Materials and Methods: Prospective, randomized controlled trial at nine centers in the North America from 2009 to 2016. Patients were randomized to one of three lithotripter devices: the Cyberwand, a dual probe ultrasonic device; the Swiss Lithoclast Select, a combination pneumatic and ultrasonic device; and the StoneBreaker, a portable pneumatic device powered by CO2 cartridges. Since the StoneBreaker lacks an ultrasonic component, it was used with the LUS‐II ultrasonic lithotripter to allow fair comparison with combination devices. Results: 270 patients were enrolled, 69 were excluded after randomization. 201 patients completed the study: 71 in the Cyberwand group, 66 in the Lithoclast Select, and 64 in the StoneBreaker group. The baseline patient characteristics of the three groups were similar. Mean stone surface area was smaller in the StoneBreaker group at 407.8mm2 vs 577.5mm2 (Lithoclast Select) and 627.9mm2 (Cyberwand). The stone clearance rate was slowest in the StoneBreaker group at 24.0 mm2/min vs 28.9 mm2/min and 32.3 mm2/min in the Lithoclast Select and Cyberwand groups respectively. After statistically adjusting for the smaller mean stone size in the StoneBreaker group, there was no difference in the stone clearance rate among the three groups (p=0.249). Secondary outcomes, including complications and stone free rates, were similar between the groups. Conclusions: The Cyberwand, Lithoclast Select, and the StoneBreaker lithotripters have similar adjusted stone clearance rates in PCNL for stones > 2cm. The safety and efficacy of these devices are comparable

Improving the lens design and performance of a contemporary electromagnetic shock wave lithotripter

Electromagnetic (EM) shock wave lithotripters are widely used for noninvasive treatment of kidney stone patients. Here, we report the design of a new acoustic lens to rectify three fundamental drawbacks in contemporary EM lithotripters, based on in situ pulse superposition, leading to significantly improved stone comminution both in vitro and in vivo with minimal tissue injury. The new lens design improves the pressure distribution around the lithotripter focus with better alignment of the peak pressure and cavitation activities with the kidney stones under clinically relevant treatment conditions. The general principle of the new lens design is applicable to different lenses or reflectors and with further optimizations may enhance the performance and safety of contemporary EM lithotripters

As low as reasonably achievable: Methods for reducing radiation exposure during the management of renal and ureteral stones

Imaging for urolithiasis has evolved over the past 30 years. Currently, non-contrast computed tomography (NCCT) remains the first line imaging modality for the evaluation of patients with suspected urolithiasis. NCCT is a dominant source of ionizing radiation for patients and one of its major limitation. However, new low dose NCCT protocols may help to reduce the risk. Fluoroscopy use during operating room (OR) surgical procedures can be a substantial source of radiation for patients, OR staff and surgeons. It is important to consider the amount of radiation patients are exposed to from fluoroscopy during operative interventions for stones. Radiation reduction can be accomplished by appropriate selection of imaging studies and multiple techniques, which minimize the use of fluoroscopy whenever possible. The purpose of this manuscript is to review common imaging modalities used for diagnosing and management of renal and ureteral stones associated with radiation exposure. We also review alternatives and techniques to reduce radiation exposure

Shock wave lithotripsy or ureteroscopy for the management of proximal ureteral calculi: An old discussion revisited

Purpose: The goal of treating ureteral calculi is to achieve complete stone clearance with minimal patient morbidity. Shock wave lithotripsy and ureteroscopy have become standards of care for ureteral calculi. However, the optimal choice of treatment depends on various factors, including stone size, composition and location, clinical patient factors, equipment availability and surgeon capability. Indications for and outcomes data on shock wave lithotripsy and ureteroscopy for proximal ureteral calculi were reviewed to provide recommendations on the optimal treatment choice for managing symptomatic ureteral calculi. Materials and Methods: A systematic review was performed based on an English literature search using the MEDLINE (R) database between 1997 and 2005. The key words used were proximal ureteral calculi, ureteroscopy and shock wave lithotripsy. Results: A total of 87 articles were identified, of which 33 were selected for inclusion. Shock wave lithotripsy and ureteroscopy provided an excellent stone-free rate (86% to 90%) for stones less than 10 mm, whereas for larger stones ureteroscopy achieved better outcomes vs shock wave lithotripsy (67% vs 73%). Ureteroscopy was preferred over shock wave lithotripsy in patients with pregnancy or bleeding diathesis. Conclusions: Ureteroscopy provides optimal stone clearance in patients with proximal ureteral calculi more than 10 mm. It is also recommended in patients with contraindications for shock wave lithotripsy. In patients with smaller stones (less than 10 mm) shock wave lithotripsy may be considered a reasonable alternative with outcomes similar to those of ureteroscop