We investigated 117 patients undergoing percutaneous nephrolithotomy, percutaneous nephrostomy, ureterorenoscopy, the push-back or push-bang procedure for ureteral stones, Double-J* ureteral stenting plus extracorporeal shock wave lithotripsy (ESWL), ESWL alone or cystoscopy. Blood samples obtained before, during and 1 hour after the procedure were cultured and assayed for endotoxin and tumor necrosis factor. Also, culture was done of the urine preoperatively and postoperatively, and the stones when they could be retrieved. There was a temporal relationship among bacteremia, endotoxemia and elevation of tumor necrosis factor. An unexpected finding was peroperative endotoxemia in a significant number of patients with stones. Risk factors noted for postoperative bacteremia, endotoxemia and/or elevation of tumor necrosis factor included preoperative endotoxin level, type of procedure, presence of preoperative bacteriuria and pyuria. With respect to the procedure the risk was greatest after the push-back method and least after cystoscopy (push-back method greater than percutaneous nephrolithotomy/percutaneous nephrostomy greater than Double-J stenting plus ESWL greater than ureterorenoscopy greater than ESWL greater than cystoscopy). If the risk factors are measured preoperatively it may be possible to identify the risk of postoperative bacteremia/endotoxemia and, therefore, septic shock postoperatively. Our patients appear to be a good clinical model to investigate the problems related to septicemia.

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Nine cases of severe sepsis following percutaneous or endoscopic procedures for upper urinary tract stones are reported. The mortality rate was 66%. Despite the fact that approximately 700 procedures were carried out in males and females in roughly equal proportions, a striking but inexplicable feature was that all 9 patients in the study group were female. Severe systemic sepsis has a high mortality rate and any procedure that may put patients at risk of this complication should not be undertaken lightly (and certainly not as an out-patient procedure). Recovery is possible with a high index of suspicion, early intervention and intensive treatment.

Citrate inhibited stone growth in this laboratory model. This was true both in defined media and with addition of UMM. This adds to evidence justifying the use of alkaline citrate in calcium oxalate nephrolithiasis.

Objectives To determine the optimal method of treatpreference or the availability of urgent ESWL. The success rate was measured by the disintegration of ment for ureteric stones causing complete obstruction, treated by insertion of a JJ stent or a nephrostomy the stone and spontaneous passage after ESWL; failure was defined as the need for additional procedure(s) for tube, followed by extracorporeal shock wave lithotripsy (ESWL) or by urgent in situ ESWL if readily stone extraction. Results Urgent in situ ESWL (group 3) had a median available.Patients and methods The study comprised a retrospec-(95% confidence interval) success rate of 81 (54-96)%, compared with 70 (53-83)% in group 2 tive analysis of 82 consecutive patients who presented with ureteric stones causing complete obstruction.and 54 (33-73)% in group 1. Conclusion If facilities are available, urgent in situ ESWL Twenty-six had a percutaneous nephrostomy (PCN, group 1) and 40 had a JJ stent (group 2) placed to appears to be the choice of treatment for obstructing ureteric stones. If such facilities are not available, a relieve the obstruction, and the stones were subsequently treated by ESWL. Sixteen patients under-JJ stent may oCer better success than a PCN. A prospective controlled trial is necessary to confirm went urgent in situ ESWL without recourse to either a JJ stent or a PCN (group 3). The choice of the these findings.

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Objective To determine, in a randomized controlled clinical trial, the effect of extracorporeal shock wave lithotripsy (ESWL) on blood pressure.

Inhibition of crystallization by phytate does not depend on decreasing the effective ionized calcium concentration and inhibition of in vitro stone growth does not depend on inhibiting crystallization of the suspended crystals. To our knowledge this is the first demonstration of a quantitative distinction between the inhibition of crystallization and stone growth. Inhibition of in vitro stone growth in the presence of macromolecules occurred at concentrations consistent with urinary phytate excretion.