Silent Ureteral Stones: Impact on Kidney Function-Can Treatment of Silent Ureteral Stones Preserve Kidney Function?

OBJECTIVE To report our experience with silent ureteral stones and expose their true influence on renal function. METHODS We analyzed 506 patients who had undergone ureterolithotripsy from January 2005 to May 2010. Silent ureteral stones were calculi found in the absence of any specific or subjective ureteral stone-related symptoms. Of the 506 patients, 27 (5.3%) met these criteria (global cohort). All patients were assessed postoperatively with dimercaptosuccinic acid scintigraphy (DMSA). A difference in relative kidney function of >10% was considered abnormal. Pre- and postoperative comparative DMSA analyses were electively obtained for 9 patients (kidney function cohort). A t test was used to assess the numeric variables, and the chi-square test or Fisher's exact test was used for categorical variables. Two-tailed P < .05 was considered statistically significant. RESULTS Stones were diagnosed by radiologic abdominal evaluation for nonurologic diseases in 40% and after previous nephrolithiasis treatment in 33%. The primary therapy was ureterolithotripsy in 88%. The mean follow-up time was 23 months. The overall ureteral stone-free rate after 1 and 2 procedures was 96% and 100%, respectively. In the global cohort, the mean pre- and postoperative serum creatinine levels were similar (P = .39), and the mean postoperative function on DMSA was 31%. In the kidney function cohort, no difference was found between the pre-and postoperative DMSA findings (22% +/- 12.1% vs 20% +/- 11.8%; P = .83) and serum creatinine (0.8 +/- 0.13 mg/dL vs 1.0 +/- 0.21 mg/dL; P = .45). CONCLUSION Silent ureteral stones are associated with decreased kidney function present at the diagnosis. Hydronephrosis tends to diminish after stone removal, and kidney function remains unaltered. UROLOGY 79: 304-309, 2012. (C) 2012 Elsevier Inc.

Current practices in the management of patients with ureteral calculi in the emergency room of a university hospital

OBJECTIVE: Urinary lithiasis is a common disease. The aim of the present study is to assess the knowledge regarding the diagnosis, treatment and recommendations given to patients with ureteral colic by professionals of an academic hospital. MATERIALS AND METHODS: Sixty-five physicians were interviewed about previous experience with guidelines regarding ureteral colic and how they manage patients with ureteral colic in regards to diagnosis, treatment and the information provided to the patients. RESULTS: Thirty-six percent of the interviewed physicians were surgeons, and 64% were clinicians. Forty-one percent of the physicians reported experience with ureterolithiasis guidelines. Seventy-two percent indicated that they use noncontrast CT scans for the diagnosis of lithiasis. All of the respondents prescribe hydration, primarily for the improvement of stone elimination (39.3%). The average number of drugs used was 3.5. The combination of nonsteroidal anti-inflammatory drugs and opioids was reported by 54% of the physicians (i. e., 59% of surgeons and 25.6% of clinicians used this combination of drugs) (p = 0.014). Only 21.3% prescribe alpha blockers. CONCLUSION: Reported experience with guidelines had little impact on several habitual practices. For example, only 21.3% of the respondents indicated that they prescribed alpha blockers; however, alpha blockers may increase stone elimination by up to 54%. Furthermore, although a meta-analysis demonstrated that hydration had no effect on the transit time of the stone or on the pain, the majority of the physicians reported that they prescribed more than 500 ml of fluid. Dipyrone, hyoscine, nonsteroidal anti-inflammatory drugs, and opioids were identified as the most frequently prescribed drug combination. The information regarding the time for the passage of urinary stones was inconsistent. The development of continuing education programs regarding ureteral colic in the emergency room is necessary.

Low levels of adherence with proton pump inhibitor therapy contribute to therapeutic failure in gastroesophageal reflux disease

To assess adherence to proton pump inhibitor (PPI) treatment and associated variables in patients with gastroesophageal reflux disease (GERD). Cross-sectional and prospective comprising 240 consecutive adult patients, diagnosed with GERD for whom continuous use of standard or double dose of omeprazole had been prescribed. Patients were ranked as ne-GERD (162: 67.5%) or e-GERD classified according to the Los Angeles classification as A (48:20.0%), B (21:8.6%), C (1:0.5%), D (1:0.5%), and Barrett's esophagus (7:2.9%). The Morisky questionnaire was applied to assess adherence to therapy and a GERD questionnaire to assess symptoms and their impact. Adherence was correlated with demographics, cotherapies, comorbidities, treatment duration, symptoms scores, endoscopic findings, and patient awareness of their disease. 126 patients (52.5%) exhibited high level of adherence and 114 (47.5%) low level. Youngers (P= 0.002) or married (O.R. 2.41, P= 0.03 vs. widowers) patients had lower levels of adherence; symptomatic patients exhibited lower adherence (P= 0.02). All other variables studied had no influence on adherence. Patients with GERD attending a tertiary referral hospital in Sao Paulo exhibited a high rate of low adherence to the prescribed PPI therapy that may play a role in the therapy failure. Age <60 years, marital status and being symptomatic were risk factors for low adherence.

Atorvastatin Prevents the Downregulation of Aquaporin-2 Receptor After Bilateral Ureteral Obstruction and Protects Renal Function in a Rat Model

OBJECTIVE To assess the effects of atorvastatin (ATORV) on renal function after bilateral ureteral obstruction (BUO), measuring inulin clearance and its effect on renal hemodynamic, filtration, and inflammatory response, as well as the expression of Aquaporin-2 (AQP2) in response to BUO and after the release of BUO. METHODS Adult Munich-Wistar male rats were subjected to BUO for 24 hours and monitored during the following 48 hours. Rats were divided into 5 groups: sham operated (n = 6); sham + ATORV (n = 6); BUO (n = 6); BUO + ATORV (10 mg/kg in drinking water started 2 days before BUO [n = 5]; and BUO + ATORV (10 mg/kg in drinking water started on the day of the release of BUO [n = 5]). We measured blood pressure (BP, mm Hg); inulin clearance (glomerular filtration rate [GFR]; mL/min/100 g); and renal blood flow (RBF, mL/min, by transient-time flowmeter). Inflammatory response was evaluated by histologic analysis of the interstitial area. AQP2 expression was evaluated by electrophoresis and immunoblotting. RESULTS Renal function was preserved by ATORV treatment, even if initiated on the day of obstruction release, as expressed by GFR, measured by inulin clearance. Relative interstitial area was decreased in both BUO + ATORV groups. Urine osmolality was improved in the ATORV-treated groups. AQP2 protein expression decreased in BUO animals and was reverted by ATORV treatment. CONCLUSION ATORV administration significantly prevented and restored impairment in GFR and renal vascular resistance. Furthermore, ATORV also improved urinary concentration by reversing the BUO-induced downregulation of AQP2. These findings have significant clinical implication in treating obstructive nephropathy. UROLOGY 80: 485.e15-485.e20, 2012. (c) 2012 Elsevier Inc.

Gastroesophageal reflux, dental erosion, and halitosis in epidemiological surveys: a systematic review

In published studies, it has been suggested that dental wear is associated with gastroesophageal reflux disease (GERD). This systematic review was carried out to evaluate the association of GERD, dental erosion, and halitosis and to compare the indices adopted in epidemiological surveys. The Medline database (until October, 2011) was searched systematically to identify studies evaluating the prevalence of oral alterations, such as dental erosion and halitosis, in patients with GERD symptoms. Two reviewers analyzed all reports and the selected studies were evaluated according to the quality of evidence, using the validated Newcastle–Ottawa Quality Assessment Scale. Full-text copies of a total of 32 publications were obtained in duplicate. Sixteen publications were identified among the citations in the Bibliographic lists of studies that fulfilled the exclusion/inclusion criteria and quality of evidence. The relationship between dental erosion and GERD patients was significant in only seven studies. According to three studies, halitosis could be one of several extraesophageal symptoms or manifestations in GERD patients. In one study, it was found that the mucosa of GERD patients was significantly more acidic in comparison with that of the control group. This systematic review showed that there is a relationship between GERD and oral diseases (dental erosion and halitosis). The epidemiological surveys used different indices to analyze GERD and dental erosion. Further research could investigate the best method for assessing the two diseases.

Influence of biliary anastomosis on recovery from secondary biliary cirrhosis

Objective The influence of choledochoduodenostomy and choledochojejunostomy on the repair of hepatic lesions secondary to biliary obstruction is not well known. The aim of the present study was to compare the effects of choledochoduodenostomy and choledochojejunostomy on the recovery of these lesions in rats with biliary obstruction. Methods Rats subjected to 4 weeks of biliary obstruction underwent choledochoduodenostomy (n=10) or choledochojejunostomy (n=10). The following variables were measured: total bilirubin, alkaline phosphatase, aminotransferases, and albumin. Hepatic mitochondrial energy metabolism was evaluated by calculating the respiratory control ratio and the oxidative phosphorylation index. Hepatic morphometry was used to estimate the mass of the hepatocytes, bile ducts, and fibrosis, as well as the hepatic stellate cell count. Results After choledochoduodenostomy and choledochojejunostomy, there was a regression in cholestasis and a reduction in the oxidative phosphorylation index. However, the total bilirubin, alkaline phosphatase, albumin, and respiratory control ratio values improved only after choledochojejunostomy. The mass of the liver, spleen, and fibrosis was reduced after both choledochoduodenostomy and choledochojejunostomy, but the number of hepatic stellate cells increased. After choledochojejunostomy, the hepatic mass recovered completely, and the spleen mass was significantly reduced compared with that after choledochoduodenostomy. After both choledochoduodenostomy and choledochojejunostomy, enterobiliary reflux, biliary contamination, and an exacerbation in hepatic inflammation developed. Conclusion Choledochojejunostomy was more effective than choledochoduodenostomy, but both techniques induced enterobiliary reflux and biliary contamination, which may explain the maintenance of hepatic alterations, especially after choledochoduodenostomy. Eur J Gastroenterol Hepatol 24: 1039-1050 (C) 2012 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins.

Clinical and nutritional status in the late postoperative of pancreaticoduodenectomy. Influence of pylorus preservation procedure

PURPOSE: To evaluate the nutritional status of patients in the late postoperative period of pancreaticoduodenectomy (PD) and compare the long-term outcome according to pylorus-preserving (PPPD) or the standard technique (SPD) in which the pylorus is resected. METHODS: This prospective study was conducted twelve months prior or more in patients who had underwent PD (PD Group, n=15) and health volunteers (Control Group, n=15). At a post hoc analysis, the PD Group was divided in PPPD Subgroup (n=9) and SPD Subgroup (n=6), according to the PD techniques. Gastrointestinal complaints and nutritional status were evaluated, apart from a biochemical assessment; Student t-test or Mann-Whitney test were used. RESULTS: The patients recovered their body weight and the gastrointestinal complaints were uncommon. The PD Group showed higher energy and protein intake even though BMI was lower than in Control Group. There were no differences in laboratorial data, except for higher glycemia, serum alkaline phosfatase and C-reactive protein in PD Group. There was no difference in the various parameters evaluated when the Subgroups (PPPD and SPD) were compared. CONCLUSION: For long-term pancreaticoduodenectomy, the gastrointestinal symptoms are minimal and the patients had the clinical and nutritional status preserved, regardless of pylorus preservation.

Low-Level Laser Therapy Decreases Renal Interstitial Fibrosis

Objective: the purpose of this study was to investigate the effect of low-level laser therapy (LLLT) on chronic kidney disease (CKD) in a model of unilateral ureteral obstruction (UUO). Background data: Regardless of the etiology, CKD involves progressive widespread tissue fibrosis, tubular atrophy, and loss of kidney function. This process also occurs in kidney allograft. At present, effective therapies for this condition are lacking. We investigated the effects of LLLT on the interstitial fibrosis that occurs after experimental UUO in rats. Methods: The occluded kidney of half of the 32 Wistar rats that underwent UUO received a single intraoperative dose of LLLT (AlGaAs laser, 780 nm, 22.5 J/cm(2), 30mW, 0.75W/cm(2), 30 sec on each of nine points). After 14 days, renal fibrosis was assessed by Sirius red staining under polarized light. Immunohistochemical analyses quantitated the renal tissue cells that expressed fibroblast (FSP-1) and myofibroblast (alpha-SMA) markers. Reverse transcriptase polymerase chain reaction (RT-PCR) was performed to determine the mRNA expression of interleukin (IL)-6, monocyte chemotactic protein-1 (MCP-1), transforming growth factor (TGF)-beta 1 and Smad3. Results: The UUO and LLLT animals had less fibrosis than the UUO animals, as well having decreased expression inflammatory and pro-fibrotic markers. Conclusions: For the first time, we showed that LLLT had a protective effect regarding renal interstitial fibrosis. It is conceivable that by attenuating inflammation, LLLT can prevent tubular activation and transdifferentiation, which are the two processes that mainly drive the renal fibrosis of the UUO model.

Respiratory physiotherapy can increase lower esophageal sphincter pressure in GERD patients

Background: Inspiratory muscle training (IMT) has been shown to increase diaphragm thickness. We evaluated the effect of IMT on mid-respiratory pressure (MRP) in patients with gastroesophageal reflux disease (GERD) and hypotensive lower esophageal sphincter (LES), and compared the results with a sham group. Methods: Twenty consecutive patients (progressive loading group) and 9 controls (sham group) were included. All patients had end expiratory pressure (EEP) between 5 and 10 mmHg, underwent esophageal manometry and pulmonary function tests before and after 8 weeks of training, and used a threshold IMT twice daily. The threshold IMT was set at 30% of the maximal inspiratory pressure for the progressive loading group; while, the threshold for sham-treated patients was set at 7 cmH(2)O for the whole period. Results: There was an increase in MRP in 15 (75%) patients in the progressive loading group, with an average gain of 46.6% (p<0.01), and in six (66%) patients in the sham group with a mean increase of 26.2% (p<0.01). However, there was no significant difference between the groups (p = 0.507). The EEP also increased compared with measurements before training (p<0.01), but it did not differ between groups (p = 0.727). Conclusion: IMT increased LES pressure in patients with GERD, in both the treatment and sham groups, after an eight-week program. Although there was no statistically significant difference between groups, suggesting the pressure increase in LES occurs regardless of the resistance load of the threshold IMT. These findings need to be confirmed in further studies with a larger sample. Registration number: 0922/09. (C) 2012 Elsevier Ltd. All rights reserved.

MyD88 Signaling Pathway Is Involved in Renal Fibrosis by Favoring a T(H)2 Immune Response and Activating Alternative M2 Macrophages

Inflammation contributes to the pathogenesis of chronic kidney disease (CKD). Molecules released by the inflamed injured tissue can activate toll-like receptors (TLRs), thereby modulating macrophage and CD4+ T-cell activity. We propose that in renal fibrogenesis, M2 macrophages are recruited and activated in a T helper subset 2 cell (TH2)-prone inflammatory milieu in a MyD88- dependent manner. Mice submitted to unilateral ureteral ligation (UUO) demonstrated an increase in macrophage infiltration with collagen deposition after 7 d. Conversely, TLR2, TLR4 and MyD88 knockout (KO) mice had an improved renal function together with diminished TH2 cytokine production and decreased fibrosis formation. Moreover, TLR2, TLR4 and MyD88 KO animals exhibited less M2 macrophage infiltration, namely interleukin (IL)-10+ and CD206+ CD11bhigh cells, at 7 d after surgery. We evaluated the role of a TH2 cytokine in this context, and observed that the absence of IL-4 was associated with better renal function, decreased IL-13 and TGF- β levels, reduced arginase activity and a decrease in fibrosis formation when compared with IL-12 KO and wild-type (WT) animals. Indeed, the better renal outcomes and the decreased fibrosis formation were restricted to the deficiency of IL-4 in the hematopoietic compartment. Finally, macrophage depletion, rather than the absence of T cells, led to reduced lesions of the glomerular filtration barrier and decreased collagen deposition. These results provide evidence that future therapeutic strategies against renal fibrosis should be accompanied by the modulation of the M1:M2 and TH1:TH2 balance, as TH2 and M2 cells are predictive of fibrosis toward mechanisms that are sensed by innate immune response and triggered in a MyD88-dependent pathway.

Postnatal longitudinal evaluation of children diagnosed with prenatal hydronephrosis: insights in natural history and referral pattern

Objectives Clinical significance and management of prenatal hydronephrosis (PNH) are sources of debate. Existing studies are flawed with biased cohorts or inconsistent follow-up. We aimed to evaluate the incidence of pathology in a large cohort of PNH and assess the biases and outcomes of this population. Methods We reviewed 1034 charts of fetuses with PNH. Records of delivered offspring were reviewed at a pediatric center and analyzed with respect to prenatal and postnatal pathology and management. Results Prenatal resolution of hydronephrosis occurred in 24.7% of pregnancies. On first postnatal ultrasound, some degree of dilatation was present in 80%, 88% and 95% of mild, moderate and severe PNH cases, respectively. At the end of follow-up, hydronephrosis persisted in 10%, 25% and 72% of children, respectively. Incidence of vesicoureteral reflux did not correlate with severity of PNH. Children with postnatal workup had more severe PNH than those without. Conclusions Despite prenatal resolution totalizing 25%, pelvic dilatation persisted on first postnatal imaging in most cases, thus justifying postnatal ultrasound evaluation. Whereas most mild cases resolved spontaneously, a quarter of moderate and more than half of severe cases required surgery. Patients with postnatal imaging and referral had more severe PNH, which could result in overestimation of pathology. (c) 2012 John Wiley & Sons, Ltd.

A Novel Method of Evaluating Ureteropelvic Junction Obstruction: Dynamic Near Infrared Fluorescence Imaging Compared to Standard Modalities to Assess Urinary Obstruction in a Swine Model

Purpose: Dynamic near infrared fluorescence imaging of the urinary tract provides a promising way to diagnose ureteropelvic junction obstruction. Initial studies demonstrated the ability to visualize urine flow and peristalsis in great detail. We analyzed the efficacy of near infrared imaging in evaluating ureteropelvic junction obstruction, renal involvement and the anatomical detail provided compared to conventional imaging modalities. Materials and Methods: Ten swine underwent partial or complete unilateral ureteral obstruction. Groups were survived for the short or the long term. Imaging was performed with mercaptoacetyltriglycine diuretic renogram, magnetic resonance urogram, excretory urogram, ultrasound and near infrared imaging. Scoring systems for ureteropelvic junction obstruction were developed for magnetic resonance urogram and near infrared imaging. Physicians and medical students graded ureteropelvic junction obstruction based on magnetic resonance urogram and near infrared imaging results. Results: Markers of vascular and urinary dynamics were quantitatively consistent among control renal units. The same markers were abnormal in obstructed renal units with significantly different times of renal phase peak, start of pelvic phase and start of renal uptake. Such parameters were consistent with those obtained with mercaptoacetyltriglycine diuretic renography. Near infrared imaging provided live imaging of urinary flow, which was helpful in identifying the area of obstruction for surgical planning. Physicians and medical students categorized the degree of obstruction appropriately for fluorescence imaging and magnetic resonance urogram. Conclusions: Near infrared imaging offers a feasible way to obtain live, dynamic images of urine flow and ureteral peristalsis. Qualitative and quantitative parameters were comparable to those of conventional imaging. Findings support fluorescence imaging as an accurate, easy to use method of diagnosing ureteropelvic junction obstruction.

Using Mitrofanoff's principle and Monti's technique as a surgical option for bladder augmentation with a continent stoma: a case report

Abstract Introduction Hydronephrosis, reflux and renal failure are serious complications that occur in patients with neurogenic bladder associated with myelomeningocele. When the bladder compliance is lost, it is imperative to carry out surgery aimed at reducing bladder storage pressure. An ileocystoplasty, and for patients not suitable for intermittent catheterization, using the Mitrofanoff principle to form a continent stoma and the subsequent closure of the bladder neck, can be used. We report here, for the first time to the best of our knowledge, an association between two previously described techniques (the Mitrofanoff principle and the technique of Monti), that can solve the problem of a short appendix in obese patients. Case presentation A 33-year-old male Caucasian patient with myelomeningocele and neurogenic bladder developed low bladder compliance (4.0 mL/cm H2O) while still maintaining normal renal function. A bladder augmentation (ileocystoplasty) with continent derivation principle (Mitrofanoff) was performed. During surgery, we found that the patient's appendix was too short and was insufficient to reach the skin. We decided to make an association between the Mitrofanoff conduit and the ileal technique of Monti, through which we performed an anastomosis of the distal stump of the appendix to the bladder (with an antireflux valve). Later, the proximal stump of the appendix was anastomosed to an ileal segment of 2.0 cm that was open longitudinally and reconfigured transversally (Monti technique), modeled by a 12-Fr urethral catheter, and finally, the distal stump was sutured at the patient's navel. After the procedure, a suprapubic cystostomy (22 Fr) and a Foley catheter (10 Fr) through the continent conduit were left in place. The patient had recovered well and was discharged on the tenth day after surgery. He remained with the Foley catheter (through the conduit) for 21 days and cystostomy for 30 days. Six months after surgery he was continent with good bladder compliance without reflux and fully adapted to catheterization through the navel. Conclusion The unpublished association between the Mitrofanoff and Monti techniques is feasible and a very useful alternative in urologic cases of derivation continent in which the ileocecal appendix is too short to reach the skin (i.e., in obese patients).

Meningoencefalite concomitante a herpes zoster oftálmico em escolar previamente hígido

INTRODUÇÃO O vírus Varicella-Zoster é o agente da varicela, doença auto-limitada comum da faixa etária pediátrica. Cerca de 20% dos casos evoluem com herpes zoster em algum momento da vida, devido a reativação do vírus dos gânglios nervosos ou reexposição. O envolvimento do ramo oftálmico do nervo trigêmio, defido como zoster oftálmico, tem como complicação mais descrita a nevralgia pós-herpética, podendo evoluir com outras alterações locais agudas e tardias. Meningoencefalites concomitante a herpes zoster são pouco descritas na literatura. DESCRIÇÃO DO CASO Paciente de 9 anos, com antecedente de varicela com 1 ano de idade, com queixa de vômitos e cefaléia há dois dias, associada a queda do estado gerale hiporexia. Referiu aparecimento de lesões vesico-bolhosas dolorosas em região periorbitária esquerda há 1 dia e evoluiu com agitação psicomotora e confusão mental. No exame físico de entrada apresentava-se sonolento, com lesões vesico-bolhosas em dermátomo do ramo oftálmico do nervo trigêmio, sem sinais de irritação meníngea ou déficits motores, sem alterações visuais ou oculares. Realizada tomografia de crânio e eletroencefalograma sem alterações. Coletado líquor que revelou líquido límpido e incolor, com aumento de celularidade às custas de linfócitos, glicorraquia normal, bacterioscopia negativa e culturas negativas. Feita hipótese diagnóstica inicial de herpes zoster oftálmico complicado com meningoencefalite e introduzido aciclovir. Paciente evoluiu bem, com melhora do estado geral, remissão dos sintomas neurológicos e melhora das lesões de pele. Evidenciado PCR positivo para o vírus varicela-zoster (VVZ) no líquor. DISCUSSÃO Encontramos poucas descrições na literatura de herpes zoster oftálmico associado à alterações neurológicas. A presença da PCR positiva no liquor foi fundamental para o diagnóstico. CONCLUSÃO O VVZ pode reativar na forma de herper zoster oftálmico e acometer o sistema nervoso central. Apesar de evento raro em crianças, especialmente nas imunocompetentes, a presença da PCR positiva liquor confirmou a meningoencefalite.