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OBJECTIVE: To compare recovery outcomes between laparoscopic donor nephrectomy (LDN) and open donor nephrectomy within a specified enhanced recovery program (ERP) for left kidney donations. PATIENTS AND METHODS: A phase III randomized trial was conducted between January 2013 and June 2015; eligible left-side donors were randomized to laparoscopic or open donor nephrectomy in a 1:1 ratio with recovery optimized within a standardized ERP. The primary outcome was patient-reported measure of physical fatigue, as measured by the physical fatigue domain of the translated Multidimensional Fatigue Inventory 20. Secondary outcomes included other donor recovery outcomes, postoperative pain scores, hospital stay, perioperative complications, and graft outcomes. RESULTS: A total of 224 donors (laparoscopy, n = 113; open surgery, n = 111) were randomly allocated. Six weeks postoperatively, physical fatigue domain scores in Multidimensional Fatigue Inventory 20 were significantly lower in the LDN group (mean: laparoscopy, 8.2 ± 3.2 vs open surgery, 13.05 ± 2.9) (P = .007). Median total hospital stay was also significantly shorter in the LDN group (median: laparoscopy, 2; interquartile range, 1-5 vs open surgery, 4; interquartile range, 2-9 days) (P = .002). LDN was associated with less pain scores and less non-opioid analgesic requirements. Warm ischemia times were not significantly different in both groups (mean: laparoscopy, 2.5 ± 0.8 vs open surgery, 2.2 ± 0.6) (P = .431). CONCLUSION: Even when optimized within an ERP, LDN was associated with less general and physical fatigue and better physical function at 6 weeks postoperatively when compared with open surgery for left kidney donations.

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[This corrects the article DOI: 10.1016/j.aju.2012.03.002.].

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OBJECTIVE: To evaluate the long-term functional outcome of percutaneous nephrolithotomy (PNL) for calculi in solitary kidneys and to determine factors leading to renal function deterioration. MATERIALS AND METHODS: The computerized files of patients with solitary kidneys who underwent PNL between January 2002 and December 2009 were retrospectively reviewed. Patients with follow-up <2 years were excluded. Complications, secondary procedures, and stone-free rates were recorded. Changes in the renal function were judged by comparing preoperative and postoperative estimated glomerular filtration rates. Preoperative, intraoperative, and postoperative factors that may affect renal function were tested using univariate and multivariate analyses to define risk factors for deterioration of renal function on long-term follow-up. RESULTS: The study included 200 patients (133 men [66.5%] and 67 women [33.5%] with mean age 52.3 ± 11.7 years). Complications were reported in 34 patients (17%). Severe bleeding was noticed in 10 patients (5%). The overall stone-free rate was 89.5%. After a mean follow-up of 3 ± 1.4 years (range, 2-8), there was significant improvement of the estimated glomerular filtration rate from 57 to 64 mL/min (P <.001). Thirty-one patients (15.5%) showed deterioration of the renal function. Multiple punctures and postoperative bleeding were independent risk factors for renal function deterioration (odds ratio was 3.7 and 4.5, respectively). CONCLUSION: PNL for calculi in solitary kidneys provided significant improvement in renal function at long-term follow-up. Multiple punctures and severe bleeding are independent risk factors for deterioration of the kidney function.

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INTRODUCTION: We compare percutaneous nephrolithotomy (PCNL) and open surgery in the treatment of staghorn stones in children. METHODS: We retrospectively reviewed the electronic records of children who underwent treatment for staghorn stones between September 2000 and August 2013. They were divided between Group 1 (patients who underwent PCNL) and Group 2 (patients who underwent open surgery). We compared stone-free and complications rates, need for multiple procedures, and hospital stay. RESULTS: The study included 41 patients (35 boys and 6 girls), with mean age 7.4 ± 3.1 years (range: 2-15). Of these 41 patients, 26 had unilateral renal stone and 15 had bilateral renal stones. The total number of treated renal units was 56: 28 underwent PCNL and 28 underwent open surgery. The complication rate was comparable for both groups (32% for open surgery vs. 28.6%, p = 0.771). Multiple procedures were more needed in PCNL group (60.7% vs. 32% in open surgery, p = 0.032). The stone-free rate was 71.4% after PCNL and 78.6% after open surgery (p = 0.537). A significant difference was observed in shorter hospital stay after PCNL (5 vs. 8.8 days, p < 0.001). Our study's limitations include its retrospective design and relatively small sample size. CONCLUSIONS: For the treatment of staghorn stones in children, PCNL was comparable to open surgery in complication and stone-free rates. PCNL had the advantage of a shorter hospital stay and open surgery showed a decreased need for multiple procedures.

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OBJECTIVE: To assess the clinical relevance of small, asymptomatic, noninfection residual stone fragments (≤5 mm) after percutaneous nephrolithotomy (PNL), evaluated using spiral noncontrast-enhanced computed tomography (NCCT). MATERIALS AND METHODS: The present retrospective study included 75 patients who underwent PNL and were proved to have a single residual caliceal stone ≤5 mm as evaluated postoperatively by NCCT. All patients were free of urinary tract infections. The outcome of these residual fragments (RFs) were reassessed ≥12 months later using NCCT. RESULTS: The mean follow-up period was 36.2 ± 20.1 months (range 12-96). Of the 75 evaluated patients, 25 (33.3%) passed the stones spontaneously during the follow-up period, 22 (29.35%) had stable asymptomatic RFs, 25 (33.3%) showed regrowth of the RFs, and 3 patients (4%) presented with slippage of the stones into the ureter. Asymptomatic patients with stable RFs elected to continue follow-up. For the remaining patients, 14 (18.7%) and 9 (12%) were referred to shock wave lithotripsy and PNL, respectively. The 3 patients with ureteral stones were treated with ureteroscopy. Only the RF size (>3 mm) correlated significantly with RF growth or ureteral obstruction (odds ratio 1.882, 95% confidence interval 0.919-3.854; P = .05). CONCLUSION: Small RFs (≤5 mm) after PNL, as assessed by NCCT, should be expected to require active intervention in one third of the patients at intermediate follow-up. A small, single, RF (≤3 mm), as assessed by NCCT, can be considered clinically insignificant.

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UNLABELLED: WHAT'S KNOWN ON THE SUBJECT? AND WHAT DOES THE STUDY ADD?: Extracorporeal shockwave lithotripsy is effective for the treatment of paediatric renal stones with favourable short-term safety. Extracorporeal shockwave lithotripsy for treatment of paediatric renal stones is also safe for the kidney and the child on long-term follow-up. OBJECTIVE: To evaluate the long-term effects of extracoporeal shockwave lithotripsy (SWL) for treatment of renal stones in paediatric patients. PATIENTS AND METHODS: A database of paediatric patients who underwent SWL monotherapy for treatment of renal stones from September 1990 through to January 2009 was compiled. This study included only patients with follow-up for more than 2 years. The long-term effects of SWL were evaluated at the last follow-up with measurement of patients' arterial blood pressure, estimation of random blood sugar and urine analysis. The results of diastolic blood pressure were plotted against a standardized age reference curve. The treated kidney was examined by ultrasonography for measurement of renal length and detection of stones. The measured renal lengths were plotted against age-calculated normal renal lengths in healthy individuals. RESULTS: The study included 70 patients (44 boys (63%) and 26 girls) with mean age at the time of SWL 6.5 ± 3.6 years (range 1-14). The mean follow-up period was 5.2 ± 3.6 years (range 2.1-17.5). The mean age at last follow-up was 11.7 ± 5.3 years (range 4.4-27.5). No patients developed hypertension or diabetes. Only one treated kidney was smaller than one standard deviation of the calculated length. The cause of this was obstruction by a stone in the pelvic ureter 3 years after SWL. CONCLUSION: The long-term follow-up after SWL for treatment of renal stones in paediatric patients showed no effect on renal growth and no development of hypertension or diabetes.

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OBJECTIVE: To determine factors affecting the stone-free rate and complications of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. METHODS: The computerized database of patients who underwent PNL for treatment of staghorn stones between January 2003 and January 2011 was reviewed. All perioperative complications were recorded and classified according to modified Clavien classification system. The stone-free rate was evaluated with low-dose noncontrast computed tomography (CT). Univariate and multivariate statistical analyses were performed to determine factors affecting stone-free and complication rates. RESULTS: The study included 241 patients (125 male and 116 female) with a mean age of 48.7 ±14.3 years. All patients underwent 251 PNL (10 patients had bilateral stones). The stone-free rate of PNL monotherapy was 56% (142 procedures). At 3 months, the stone-free rate increased to 73% (183 kidneys) after shock wave lithotripsy. Independent risk factors for residual stones were complete staghorn stone and presence of secondary calyceal stones (relative risks were 2.2 and 3.1, respectively). The complication rate was 27% (68 PNL). Independent risk factors for development of complications were performance of the procedure by urologists other than experienced endourologist and positive preoperative urine culture (relative risks were 2.2 and 2.1, respectively). CONCLUSION: Factors affecting the incidence of residual stones after PNL are complete staghorn stones and the presence of secondary calyceal stones. Complications are significantly high if PNL is not performed by an experienced endourologist or if preoperative urine culture is positive.

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OBJECTIVE: To present the results of percutaneous nephrolithotomy (PCNL) for treating staghorn stones. PATIENTS AND METHODS: A database was compiled from the computerised files of patients who underwent PCNL for staghorn stones between 1999 and 2009. The study included 238 patients (128 males and 110 females) with a mean (SD) age of 48.9 (14) years, who underwent 242 PCNLs, and included staghorn stones that were present in the renal pelvis and branched into two or more major calyces. PCNL was performed or supervised by an experienced endourologist. All perioperative complications were recorded. The stone-free status was evaluated after PCNL and again after 3 months. RESULTS: Multiple tracts were needed in 35.5% of the procedures, and several sessions of PCNL were needed in 30% of patients. There were perioperative complications in 54 procedures (22%); blood transfusion was needed in 34 patients (14%). The stone-free rate for PCNL monotherapy was 56.6% (137 patients). Secondary procedures were required for 51 patients (21%), and included shock-wave lithotripsy for 49 and ureteroscopy for two. The 3-month stone-free rate was 72.7% (176 patients). Multiple tracts resulted in an insignificantly higher overall complication rate than with a single tract (P = 0.219), but the reduction in the haemoglobin level was statistically significant with multiple tracts (P = 0.001). CONCLUSIONS: PCNL for staghorn stones must be done by an experienced endourologist in a specialised centre with all the facilities for stone management and treatment of possible complications. The patients must be informed about the range of stone-free and complication rates, and the possibility of multiple sessions or secondary procedures.

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OBJECTIVE: To assess the incidence, imaging, surgical approach and prognosis of adrenal tumors associated with venous thrombosis. MATERIAL AND METHODS: Charts of 206 patients who underwent adrenal surgery were reviewed. Data of patients with pathologically confirmed venous thrombosis, utilized diagnostic modalities, operative treatment and prognosis were reviewed and analyzed. RESULTS: Venous thrombosis was confirmed pathologically in 6 patients (2.9%). All were of male gender with age ranging between 2 and 54 years. The mean size of the masses was 11.5 ± 5.2 cm. Venous thrombosis was diagnosed preoperatively in 2 patients, adrenal vein thrombosis in 1 patient, and renal vein thrombosis in the others. Masses were successfully excised via an open approach in association with nephrectomy in 3 cases. There was no operative mortality or gross morbidity. Pathologically, thrombosis was limited to the adrenal vein in 4 patients and extended to the renal vein in 2. Pathology of the masses revealed neuroblastoma in 2, pheochromocytoma in 2, adrenocortical carcinoma in 1, and pleomorphic sarcoma in 1 case. Metastasis developed within 6 months in 3 of these patients. CONCLUSION: Venous thrombosis with adrenal tumors is a rare pathological condition in which open surgery is the standard of care. Primary malignant adrenal masses with venous thrombosis have a poor prognostic outcome.

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OBJECTIVE: To determine factors affecting the success of bilateral same-session ureteroscopy (BSU) in the treatment of ureteral calculi. MATERIAL AND METHODS: From January 2003 to December 2008, BSU was carried out in 89 patients (178 renal units). A successful outcome was considered when both ureters were free of stones without intraoperative complications. Stone-free rate was evaluated with a kidney-ureter-bladder plain X-ray or non-contrast computed tomography. Factors interfering with successful completion of BSU were tested using univariate (chi-squared test and t test) and multivariate (logistic regression) analyses. Data on unilateral ureteroscopy for the treatment of multiple ureteral calculi carried out in 105 patients during the same period were compared with BSU. RESULTS: Intraoperative complications were recorded in 11 procedures (6.2%) in the form of ureteral perforation in three and mucosal injury in eight. After BSU, 153 renal units were stone free (86%) as 17 had residual fragments, stones migrated to the kidney in six and failure was encountered in two. A successful outcome was observed in 62 patients (70%). Stone impaction, stones located in the proximal ureter and stone surface area were the significant risk factors for unsuccessful BSU (relative risks 3.6, 3.3 and 1.47, respectively). Compared with unilateral ureteroscopy, no difference were found with regard to complication rate (6.7%, p = 0.5) or stone-free rate (80%, p = 0.2). CONCLUSIONS: Bilateral same-session ureteroscopy is a safe and effective procedure in the management of bilateral ureteral stones. Proximal ureteral calculi, large and impacted stones carry the highest risk of unsuccessful results.

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OBJECTIVE: • To study long-term results of percutaneous nephrolithotomy (PNL) for treatment of staghorn stones. PATIENTS AND METHODS: • The records of patients who underwent PNL for staghorn stones between January 1998 and January 2008 were retrospectively reviewed. • Patients who completed follow-up for one year or more were included. Follow-up with KUB and renal ultrasonography were performed every 3-6 months. • Renal radioisotopic scan was performed for patients who had already undergone this study before doing PNL. RESULTS: • The study included 122 patients (69 male and 53 female) with mean age 47.6 ± 14.5 years (5-74). They underwent 126 PNL. • Perioperative complications were encountered in 28 procedures (22%). The mean period of follow-up was 3.5 ± 2.3 years (1-11.3). Among 71 stone-free kidneys, 18 (25%) developed stone recurrence. Of 55 kidneys with residuals at the start of follow-up, 36 (65%) showed growth of these residuals. • Preoperative and postoperative renograms were performed for 71 patients. • At the last follow-up, differential GFR was stable in 53 (74.5%), improved in 12 (17%) and deteriorated in 6 (8.5%). Among patients with deteriorated renal function, 3 had undergone embolization to control severe bleeding, one developed secondary UPJO, and one had recurrent stone obstructing the kidney. CONCLUSION: • Long-term functional results of PNL for staghorn stones are satisfactory as 91.5% of kidneys showed stable or improved GFR. Long-term follow-up is mandatory especially for patients with residual stones.

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PURPOSE: To critically analyze the role, accuracy and safety of percutaneous adrenal biopsy for indeterminate adrenal lesions. MATERIALS AND METHODS: Adrenal biopsies were performed in 15 among 214 patients (7%) diagnosed with adrenal masses being indeterminate on preoperative imaging. Definitive histopathology was obtained in all and overall sensitivity and negative predictive value were calculated. Safety of the procedure was reported. RESULTS: The study included 8 male and 7 female patients with a mean age of 33.3 +/- 20.3 years (range 7-65). Biopsy was carried out under computed tomography and ultrasound guidance in 12 and 3 patients, respectively. There were 2 nonrepresentative biopsies that were proved to be adrenocortical carcinoma and myelolipoma after adrenalectomy. Results of biopsy in the remaining 13 patients provided accurate diagnosis as proved by definitive histopathology in all but 2 in whom the final diagnosis was established as adrenocortical carcinoma while biopsy was paraganglioma in one and cortical adenoma in the other. Overall sensitivity and negative predictive value of adrenal biopsy was 73.3 and 60%, respectively. Apart from two mild hypertensive episodes following silent pheochromocytoma biopsy, no complications were reported. CONCLUSIONS: Percutaneous biopsy is a safe procedure for the diagnosis of pathologic conditions of the adrenal gland with a reasonable diagnostic aid.

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OBJECTIVE: It was the aim of this study to review and analyze clinical data on the diagnosis and management of patients with adrenal masses. PATIENTS AND METHODS: Between 1976 and 2005, 238 patients admitted to our institute with adrenal masses were reviewed. Incidence, clinical features, imaging technique findings, surgical approaches, morbidity and mortality, as well as pathological diagnoses were reported. RESULTS: The series comprised 134 males and 104 females (mean age 33.3 +/- 20.3 years). Right-sided masses were more common (63.4%), with a mean size of 7.7 +/- 4 cm. Pain was the most frequent presenting symptom (53.4%), while 62 (26%) had a functional tumor. Incidentaloma was diagnosed in 49 patients (20.6%). Both computed tomography and magnetic resonance imaging showed a high diagnostic yield (sensitivities of 98.9 and 100%, respectively). Open adrenalectomy was performed in 153 patients (64.3%), while a laparoscopic approach was employed in 53 patients (22.3%). The intraoperative complication rate was 14.7%, the postoperative complication rate 6.1% and perioperative mortality 1.7%. Most of the excised masses were pheochromocytomas (26.4%). CONCLUSIONS: Computed tomography is recommended as the first diagnostic modality to define and characterize adrenal masses. Laparoscopic adrenalectomy is currently replacing open surgery as the standard surgical management of adrenal masses.

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OBJECTIVES: To evaluate the role of percutaneous nephrolithotomy in management of the patients with autosomal dominant polycystic kidney disease and associated nephrolithiasis. METHODS: A total of 19 patients with autosomal dominant polycystic kidney disease and upper urinary tract stones were included in the study. One patient had bilateral renal stones. Most of the stones were located in the renal pelvis and/or calices with a stone size >2 cm in the largest diameter. All patients were treated by percutaneous nephrolithotomy at 2 centers. Therefore, 20 percutaneous nephrolithotomy procedures were performed. Most of the procedures were performed in 1 stage by the urology team under fluoroscopic guidance; 6 cases were done in 2 stages. The success rate and morbidity and mortality of the technique and hospital stay were recorded. RESULTS: The pelvicaliceal system was successfully approached in all cases but 1. The overall stone-free rate was 89.4%. Renal function improved in the patients who presented with azotemia and was stable in the others. No patient died. Complications occurred in 3 procedures and consisted of mild postoperative hematuria in 1, bleeding through the nephrostomy tube in 1, and low-grade fever in 1. The mean hospital stay was 3 days. CONCLUSIONS: Percutaneous nephrolithotomy is a safe and effective method for the treatment of patients with autosomal dominant polycystic kidney disease and associated upper urinary tract stones.

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OBJECTIVES: To assess the safety and efficacy of different surgical procedures used for managing benign adrenal cysts. PATIENTS AND METHODS: The files of 245 patients presenting with adrenal masses was reviewed retrospectively; all had a thorough history taken and a physical examination. The radiological evaluation included abdominal plain X-rays, grey-scale abdominal ultrasonography and computed tomography with contrast medium. According to their clinical situation, patients had surgical open, laparoscopic intervention or were managed conservatively. The short- and long-term outcome of the open and laparoscopic techniques were evaluated. RESULTS: Twenty-six (11%) patients presented with adrenal cysts; the mean (sd, range) age at the time of presentation for adults was 41.4 (15, 17-82) years, while a 1-month female neonate and 1-year-old boy presented with an adrenal cyst. The mean (sd, range) size of the cysts was 10 (3.5, 5-18) cm. Surgical intervention was the treatment of choice in 21 patients; 11 (42%) had open adrenalectomy, while 10 (38%) had laparoscopic intervention. Both groups were comparable in the term of cyst size and operative time, while the laparoscopically managed group had a shorter hospital stay. Five patients were followed with no surgical intervention. At a mean follow-up of 90 months all patients were symptom free, with no radiological evidence of recurrence. CONCLUSIONS: Laparoscopic adrenalectomy is a safe and effective treatment for benign adrenal cysts. Compared with open techniques it has the advantages of a shorter hospital stay, less blood loss and enhanced cosmesis. Unlike aspiration of cyst contents, the recurrence of adrenal cysts after surgical removal is unlikely.

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OBJECTIVES: To use a matched-pair analysis design to compare the safety and efficacy of shock wave lithotripsy (SWL) and ureteroscopy (URS). Controversy still exists regarding whether SWL or URS is the best management of upper ureteral calculi. METHODS: We reviewed the records of patients with a single radiopaque upper ureteral stone treated by URS or SWL from January 2003 to December 2005. SWL was performed as an outpatient procedure using the electromagnetic lithotripter (Dornier Lithotripter S). URS was performed using an 8F or 8.5F semirigid ureteroscope. Intracorporeal lithotripsy with pneumatic or holmium laser energy was used when needed. A matched-pair analysis was performed using 3 parameters (sex, stone size, and degree of hydronephrosis). The success rates, retreatment rates, auxiliary procedures, and complications were compared in each group. RESULTS: A total of 427 patients were treated for upper ureteral stones. Forty-three matched pairs were identified and compared. The success rate was 83.7% for SWL vs 88.4% for URS (P = .8). The retreatment rate was significantly greater in the SWL group than in the URS group (65% vs 2.3%, respectively; P < .001). The need for auxiliary procedures was equal in both groups (16.3%). The complication rate was 14% in the URS group and 4.7% in the SWL group (P = .1). CONCLUSIONS: SWL and semirigid URS are highly effective in the treatment of proximal ureteral stones <20 mm. The results of our study showed that SWL was safer and less invasive, but that URS was more effective and resulted in a lower retreatment rate.

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PURPOSE: We determined the factors predicting unfavorable results of semirigid ureteroscopy for ureteral calculi. MATERIALS AND METHODS: We reviewed the computerized files of 841 patients who underwent a total of 908 ureteroscopic procedures for ureteral stones from January 2003 through December 2006. A semirigid 6/7.5Fr ureteroscope was used in pediatric patients and an 8/10Fr or 8.5/11.5Fr ureteroscope was used in adults. Patients with favorable results were those who became stone-free after a single ureteroscopic procedure without any complications. They were compared with patients who had unfavorable results using univariate (chi-square and t tests) and multivariate (logistic regression) statistical tests to identify risk factors for unfavorable results. RESULTS: The study included 567 males and 274 females with a mean age of 48.5 years (range 2 to 81). The complication rate was 6.7% (61 procedures). The stone-free rate after a single ureteroscopic intervention was 87% (791 procedures). Favorable results were documented in 751 procedures (82.7%). Significant factors for unfavorable results were proximal ureteral stones, ureteroscopy done by surgeons other than experienced endourologists, stone impaction and stone width (relative risk 4, 2.5, 1.8 and 1.2, respectively). CONCLUSIONS: Semirigid ureteroscopy is a safe and highly effective treatment modality for ureteral stones.

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PURPOSE: This study was conducted to evaluate the safety and efficacy of the supracostal approach for percutaneous nephrolithotomy in pediatric patients. MATERIALS AND METHODS: We retrospectively reviewed 60 percutaneous nephrolithotomy procedures done in 50 children (32 boys and 18 girls) between 2000 and 2007. Mean patient age was 7 +/- 4 years (range 9 months to 14 years). Noncontrast computerized tomography was the primary radiological investigation for most of the cases. The subcostal approach was used in 40 procedures, and the supracostal approach (above the 12th rib) was required in 20. We compared both approaches regarding preoperative characteristics, stone-free and complication rates, and the need for auxiliary procedures. RESULTS: The preoperative characteristics of the patients, urinary tracts and stones were comparable for both treatment groups. There were no major complications. Significant bleeding requiring blood transfusion was observed in 3 patients (5%), transient fever in 3 (5%) and urinary leakage through the nephrostomy site in 3 (5%). The distribution of complications among subcostal and supracostal approaches was comparable. Of the 60 renal units 46 (77%) were stone-free after percutaneous nephrolithotomy at discharge from the hospital. Of the remaining 14 units 9 (15%) were stone-free after shock wave lithotripsy and 5 (8%) had insignificant residual stones. Therefore, the overall stone-free rate at 3 months was 92.5%. Comparing the subcostal and supracostal approaches, there were no significant differences between hospital stays, complication rates, unplanned auxiliary procedures, and stone-free rates at discharge home and at 3-month followup. CONCLUSIONS: Percutaneous nephrolithotomy for treating renal stones in children provides a high degree of safety and efficacy whether a supracostal or subcostal approach is used.

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OBJECTIVE: To asses the efficacy and safety of bidirectional synchronous twin-pulse extracorporeal shock wave lithotripsy (ESWL) compared with standard ESWL. PATIENTS AND METHODS: Between March 2003 and December 2006, 240 patients with a radio-opaque single renal stone of 10 mm the rate for the failure of disintegration was 13.3% for the DLS vs 1.4% for the TH (P = 0.009). For stones of 10 mm it was 78.1% and 66.7%, respectively (P = 0.14). The median (range) number of sessions in both groups was 2 (1-5). After ESWL urinary NAG levels were increased significantly in both groups; in the TH group it declined below the level before ESWL after 2 days, while in the DLS group it remained high after 7 days. In the DLS group four patients developed subcapsular or parenchymal haematoma after ESWL, vs none in the TH group. There was loss of corticomedullary differentiation after ESWL in three patients in the DLS group and only one in the TH group. In the DLS group there was a statistically significantly decrease in bilateral renal perfusion after ESWL, but no changes in the TH group. CONCLUSIONS: Synchronous twin-pulse ESWL has clinical advantages over standard ESWL in terms of safety and efficacy.

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PURPOSE: We addressed the impact of stone density and size on the role of computerized tomography for diagnosing residual stones after percutaneous nephrolithotomy. MATERIALS AND METHODS: We prospectively evaluated 100 renal units that underwent percutaneous nephrolithotomy. The study included 55 opaque and 45 lucent or faint stones. Patients were examined after the procedure by plain x-ray of the kidneys, ureters and bladder, linear tomography, ultrasound and spiral computerized tomography. Minute residual stones were defined as 1 or 2 caliceal stones less than 5 mm, as measured by computerized tomography. RESULTS: Stone-free status was achieved in 38 renal units. Minute and significant residual stones were detected in 26 and 36 renal units, respectively. For faint and lucent stones sensitivity for overall stone detection was 100% for computerized tomography, 11.1% for plain x-ray, 22.2% for linear tomography and 22.2% for ultrasound (p <0.05). Sensitivity for detecting significant residual stones was 100% for computerized tomography, 20% for plain x-ray, 33.3% for linear tomography and 20% for ultrasound (p <0.05). For opaque stones sensitivity for overall stone detection was 100% for computerized tomography, 62.9% for plain x-ray, 74.3% linear tomography and 48.6% for ultrasound (p <0.05). Sensitivity for detecting significant residual stones was 100% for computerized tomography, 85.7% for plain x-ray (p not significant), 95.2% for linear tomography (p not significant) and 57.1% for ultrasound (p <0.05). CONCLUSIONS: Computerized tomography provides the most sensitive tool for detecting residual stones after percutaneous nephrolithotomy. Nevertheless, it should not be routinely performed in patients with opaque stones because it yields no statistically valuable increase in the diagnosis of significant residual stones compared with that of plain x-ray and linear tomography.

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