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Because they are a brittle material medications rights cheap ondansetron master card, kidney stones are theorized more likely to fail under tension rather than compression (Johrde and Cocks, 1985). The second mechanism for stone breakage, squeezing-splitting or circumferential compression, occurs because of the difference in sound speed between the stone and the surrounding fluid (Eisenmenger, 1998). The shock wave inside the stone advances faster through the stone than the shock wave in the fluid outside the stone. Summary of how the various mechanical forces generated by a lithotripsy shock wave may cause a kidney stone to fracture. It has been theorized that squeezing should be enhanced when the entire stone falls within the diameter of the focal zone; thus a wider F2 or focal zone in a lithotripter may be of benefit. Shear stress will be generated by shear waves (also termed transverse waves) that develop as the shock wave passes into the stone. The shear waves propagate through the stone, which results in shifting of molecules perpendicular or transverse to the wave. Mathematical modeling has demonstrated that shear waves are a more power force in stone comminution than the spall effect (Sapozhnikov et al. However, the intensity of the shear wave is dependent on the width of F2 or focal zone with larger focal zones being more beneficial. The fourth mechanism for stone breakage, superfocusing, is the amplification of stresses inside the stone because of the geometry of that stone. The shock wave that is reflected at the distal surface of the stone can be focused by either refraction or diffraction from the corners of the stone to create areas of high stress in the interior of the stone (Gracewski et al. The regions of high stress (tensile and shear) depend on the geometry of the stone and elastic properties. The negative pressure in the trailing part of the shock pulse causes bubble formation. As these bubbles grow, they oscillate in size for about 200 microseconds and then collapse violently, giving rise to high pressures and temperatures. This release of energy is generally in the form of a positive and negative wave that can create all the comminution mechanisms described. However, in the presence of a boundary, a liquid jet, also termed a cavitation microjet, forms inside the bubble during the collapse (Crum, 1979, 1988). If the cavitation microjet is near the surface of a stone, it creates a locally compressive stress field in the stone, which propagates into the stone interior. Essential to this process are nucleation, growth, and coalescence of flaws within the stone caused by a tensile or shear stress. Because renal calculi are not homogeneous but rather have either a lamellar crystalline structure bonded by an organic matrix material or an agglomeration of crystalline and noncrystalline material there are numerous sites of preexisting flaws (microcracks).

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Chapter 82 Surgery for Benign Disorders of the Penis and Urethra 1829 Evaluation As with the repair of any stricture or stenosis symptoms diarrhea discount ondansetron 4 mg buy on line, it is important to define the precise anatomy of the pelvic fracture injury before treatment is undertaken (McCallum and Colapinto, 1979a, 1979b); this includes the depth, density, length, and location. In pelvic fracture urethral distraction defects, the depth and density of fibrosis are predictable. Although the location of the distraction injury has been shown to be an important factor in continence after reconstruction, this information should be a factor only in counseling of patients before the reconstruction and not in the treatment approach. The length of the defect is an important consideration and must be determined as precisely as possible. A cystogram outlines the bladder and provides information about rostral displacement of the proximal urethra. A lack of contrast material in the posterior urethra gives some information, albeit inconclusive, about the integrity of the bladder neck. When the patient is successful in relaxing to void and the cystogram outlines the posterior urethra, a simultaneous retrograde urethrogram outlines the length of the injury defect. However, this situation is the exception rather than the rule, and retrograde urethrography is most useful for determining whether the anterior urethra is normal. If the anterior urethra is normal, a successful anastomotic repair is ensured, from our experience and that of others. A primary anastomosis has been demonstrated possible even with some involvement of the anterior urethra. Even in cases of prior failed posterior urethral reconstruction, primary anastomotic repair is often feasible, although the failure rate is slightly higher in these cases (Chapple and Pang, 1999; Flynn et al. Primary anastomosis is unquestionably the goal in all patients until it is proven impossible to perform. When the proximal urethra is not visualized on a simultaneous cystogram with urethrogram, endoscopy through the suprapubic tract in combination with retrograde urethrography can be used to outline the defect. After the endoscopic appearance of the bladder neck is assessed, the flexible endoscope can be advanced through the bladder neck and into the posterior urethra to the level of the obstruction. The appearance of the bladder neck on contrast studies or on antegrade endoscopy does not accurately predict the ultimate function of the bladder neck after urethral reconstruction (Iselin and Webster, 1999). A simultaneous retrograde urethrogram outlines the anterior urethra, with the space not visualized representing the injury defect. This information was essential to planning of subsequent reconstruction in this case. It would seem intuitively obvious that knowing the length of distraction would be helpful in determining the precise approach and steps necessary for reconstruction. However, orthopedic injuries of the lower extremities often necessitate a delay in proceeding with urethral reconstruction (Brandes and Borrelli, 2001; Follis et al.

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A closed suction drain is positioned in the most dependent (caudal) portion of the lymphadenectomy field medications zopiclone purchase discount ondansetron on-line, as the fluid will drain dependently toward the drain when the patient is upright. However, a "therapeutic curative window" exists, and it is mainly associated with the volume of inguinal metastases. Patients who have unilateral limited metastases without extranodal extension of cancer or pelvic metastases are potentially curable (Johnson and Lo, 1984a, 1984b; Spratt, 2000; Srinivas et al. Radical Inguinal Lymph Node Dissection the patient is positioned with the thigh abducted and externally rotated with support under the flexed knee. The dissection is limited superiorly by a line drawn from margin of the external ring to the anterior superior iliac spine, laterally, by a line drawn from the anterior superior iliac spine extending 20 cm inferiorly, and medially by a line drawn from the pubic tubercle 15 cm down the medial thigh. The most utilized incision is an oblique 2-cm section below and parallel to the inguinal ligament extending from the lateral to the medial limit of the dissection. Alternatively, in this case, the incision may be extended superiorly from the lateral border of the ellipse and inferiorly from the medial border to make a single S-shaped incision for concomitant iliac and inguinal dissections. Superior and inferior skin flaps are developed in the plane just below Scarpa fascia. The superior flap is elevated 3 cm cephalad above the inguinal ligament and the inferior flap to the limit of the dissection. The advantages reported are minimized skin devascularization, because the superior border of incision remains intact, and this permits easy access to concomitant iliac dissection if necessary. The fat and areolar tissues are dissected from the external oblique aponeurosis and the spermatic cord to the inferior border of the inguinal ligament, forming the superior boundary of the lymph node packet. The inferior angle is the apex of the femoral triangle, where the long saphenous vein is identified and divided. In patients with minimal metastatic disease, it may be feasible and beneficial to spare the saphenous vein. Dissection is deepened through the fascia lata overlying the sartorius muscle laterally and the fascia covering the adductor longus muscle medially. At the apex of the femoral triangle, the femoral artery and vein are identified, and the dissection is continued superiorly along the femoral vessels. Cutaneous perforating arteries are ligated as they are encountered on the surface of the femoral artery. The anterior aspects of the femoral vessels are dissected, but lateral surface of the femoral artery is not exposed. After the femoral triangle is dissected, the sartorius muscle is mobilized from its origin at the anterior superior iliac spine and either transposed or rolled 180 degrees medially to cover the femoral vessels (Barofsky maneuver). The muscle is sutured to the inguinal ligament superiorly, and its margins are sutured to the muscles of the thigh immediately adjacent to the femoral vessels. The femoral canal can be closed by suturing the shelving edge of the inguinal ligament to Cooper ligament, being careful not to compromise the lumen of the external iliac vein or to injure the inferior epigastric vessels in the process. Primary closure of the dissection is usually possible with minimal or no further mobilization of the excision margins. When circumstances demand a large area of skin resection, a primary closure may be performed using scrotal skin rotation flaps (Skinner, 1974), an abdominal wall advancement flap (Tabatabaei and McDougal, 2003), or a myocutaneous flap based on the rectus abdominis or tensor fascia lata (Airhart et al.

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In patients with blunt trauma medicine reaction ondansetron 4 mg online, microscopic hematuria associated with shock significantly increases the incidence of severe renal injuries (Mee and McAninch, 1989; Mee et al. Later urine samples may be diluted by diuresis from resuscitation fluids, resulting in an underestimation or absence of hematuria. The dipstick method is rapid and has a sensitivity and specificity for detection of microhematuria of more than 97%, even though a poor correlation with actual urinalysis was noted in a single study (Chandhoke and McAninch, 1988). Although critical to the initial evaluation of traumatic urinary tract injury, the presence or absence of hematuria should not be the sole determinant in the assessment of a patient with suspected renal trauma. In a report by Carroll and McAninch (1985), 27 of 50 patients with penetrating renal trauma had only microscopic hematuria. A more recent study from South Africa showed a stronger correlation between degree of hematuria and severity of injury (Moolman et al. Pediatric patients (younger than 18 years) sustaining blunt renal trauma generally can be evaluated like adults (Santucci et al. Children have an up to 50% higher risk for renal trauma than adults after blunt abdominal injury, such as motor vehicle accidents (Kurtz et al. Possible explanations are the larger comparative kidney size, less perirenal fat, non-ossified bones, and less relative rib coverage over the kidneys in children (Buckley and McAninch, 2004). Importantly, children often do not become hypotensive with major blood loss, and in the absence of this sign can still have an exsanguinating renal injury. Children have a high catecholamine output after trauma, which maintains blood pressure until approximately 50% of blood volume has been lost. Children have a higher proportion of congenital renal abnormalities such as severe hydronephrosis or uretero-pelvic junction obstruction, which may result in significant renal injury from seemingly minor trauma. All patients with blunt trauma with significant acceleration/ deceleration mechanism of injury, specifically rapid deceleration as would occur in a high-speed motor vehicle accident or a fall from heights 3. All patients with blunt trauma with microhematuria and hypotension (defined as a systolic pressure of less than 90 mm Hg at any time during evaluation and resuscitation) 5. An extensive prospective study based at San Francisco General Hospital evaluating indications for radiographic imaging continued for more than 25 years. The findings have been updated in three reports (Mee and McAninch, 1989; Miller and McAninch, 1995; Nicolaisen et al. Patients with microscopic hematuria without hypotension or acceleration/deceleration injury can be observed clinically without imaging. First noted by Miller and McAninch (1995) but confirmed by several subsequent findings, these patients rarely have a significant injury (<0. It is important to remember that blunt rapid deceleration injuries, such as high-speed motor vehicle accidents or falls from great heights, pose a higher risk for vascular pedicle or ureteral pelvic junction injury. Note poor contrast uptake in right kidney compared with left and diffuse soft tissue injury medial to right kidney in the area of the renal artery. Injury to the renal collecting system may be missed if contrast material has not had time to be excreted into the parenchyma and collecting system adequately. Delayed scanning of the kidneys 10 to 15 minutes after injection of contrast identifies parenchymal lacerations and urinary extravasation accurately and reliably.

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They found that the stone formers consuming the low-sodium diet had a reduction in urinary calcium (271 vs symptoms stomach cancer purchase ondansetron 4 mg overnight delivery. In addition, a low-sodium diet corrected the idiopathic hypercalciuria in approximately 30% of patients. These findings are supported by an earlier randomized controlled trial performed by Borghi et al. In addition, when combined with animal protein restriction and moderate calcium ingestion, a reduced-sodium diet decreased stone episodes by roughly 50%. A recommended target for patients with calcium stones is sodium consumption of less than or equal to 100 mEq (2300 mg) per day (Pearle et al. Conservative Strategies for Hypercalciuria Sodium and Hypercalciuria Dietary sodium increases urinary calcium levels because sodium and calcium share a common transport mechanism in the renal tubule. High sodium intake will result in decreased proximal sodium reabsorption and reduced distal renal tubular calcium reabsorption. The end result is hypernatriuria and hypercalciuria, which are risk factors that contribute to calcium nephrolithiasis. The degree of hypercalciuria has been shown to increase proportionally with the amount of sodium excreted in the urine (Sakhaee et al. Earlier studies reported that for every 100 mEq increase in dietary sodium, there was a 25- to 40-mg increase in urinary calcium excretion in normal subjects and an 80- to 120-mg increase in hypercalciuric stone formers (Bleich et al. A more recent study suggests that the effect of sodium on urinary calcium excretion may be slightly overestimated as the investigators found in a short-term randomized controlled trial of hypercalciuric calcium oxalate stone formers a reduction of urinary calcium of approximately 64 mg/day for every 100-mmol reduction in urinary sodium (Nouvenne et al. Epidemiologic studies have shown an independent association of dietary sodium consumption with kidney stone formation, Medical Therapy for Hypercalciuria Thiazides and Thiazide-Like Diuretics Thiazide diuretics are the preferred medical agent for hypercalciuria. They are among the best- studied medications for stone prevention, with evidence supporting their use both in disease-specific and nonspecific subgroups of stone formers (Borghi et al. Thiazides directly stimulate calcium resorption in the distal nephron while promoting excretion of sodium. A list of available thiazides and other medications used in stone prevention can be found in Table 92. Two double-blind randomized controlled trials have tested the treatment effect of hypercalciuria. Laerum and Larsen (1984) found that patients administered hydrochlorathiazide 25 mg two times a day had a 75% likelihood of not forming a stone at a median of 3 years follow-up compared with 45% among patients administered a placebo. Among 316 patients included from five separate studies, patients on thiazide therapy had a 60% reduction in new stone recurrences relative to those on placebo (Escribano et al. Long-term thiazide therapy results in volume depletion, extracellular volume contraction, and proximal tubular resorption of sodium and calcium.

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The fascia lata medial to the saphenous arch is opened to expose the saphenofemoral junction medications you can take while breastfeeding order ondansetron canada. This should be continued to the level of the femoral canal until the pectineus muscle is seen to ensure complete nodal retrieval. It is of great importance that meticulous control of lymphatics and excellent hemostasis be established to reduce the risk for lymphocele and hematoma formation, which could potentially become infected. During closure, the skin flaps are sutured to the surface of the exposed musculature to decrease dead space. In contemporary series, early minor complications have been reported in about 50% of radical dissections (Bevan-Thomas et al. These consist primarily of lymphocele, wound infection or necrosis, and lymphedema. Major complications, such as debilitating lymphedema, flap necrosis, and lymphocele requiring intervention, occur in 5% to 20% of patients (Bevan-Thomas et al. Efforts to minimize lowerextremity lymphedema include early use of compression stockings and saphenous vein preservation when feasible. Adjuvant Chemotherapy A study of more than 200 patients with penile cancer reported a relapse rate of 45% in patients treated with surgery versus 16% in those who received adjuvant chemotherapy after surgery (Pizzocaro et al. The authors concluded that adjuvant chemotherapy can improve the results of radical surgery significantly. However, most of the patients in need of adjuvant treatment, such as patients with bilateral metastases or pelvic involvement, had poorer outcomes. In a study of 13 patients with radically resected node metastases treated with adjuvant chemotherapy, 3 of 8 patients were cured, 4 progressed, and 1 died from chemotherapy-related pulmonary toxicity. The authors concluded that adjuvant chemotherapy can increase survival compared with surgery alone but that the risk for toxicity is high (Hakenberg et al. Graphic representation of an inguinal lymph node dissection plus resection of an inguinal metastasis. It has been suggested that adjuvant therapy is advisable when there are two or more positive nodes, extranodal extension of cancer, or pelvic node metastasis (Solsona et al. Surgery for Palliative Purposes Infiltrative or coalescent inguinal disease left untreated can result in significant local complications such as infection, abscess, foul-smelling drainage, and life-threatening vascular hemorrhage (Koifman et al. Palliative surgery can offer a better short-term quality of life by removing infected and painful disease, however, cure is rarely achieved. One study included 24 patients who underwent a palliative dissection, of whom 21%, 8%, and 4% survived 1, 2, and 3 years, respectively (Srinivas et al. In very select cases, an extra-anatomical arterial bypass can be performed to prevent femoral hemorrhage or death (Ferreira et al. Considering surgery as monotherapy for this disease stage is inadequate because it only addresses the genital and inguinal area, thereby, distant metastases are not being treated.

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The net effect is elevated serum and urine calcium levels and reduced serum phosphorus levels treatment impetigo purchase ondansetron overnight delivery. Primary hyperparathyroidism is associated with nephrolithiasis in less than 5% of affected individuals (Heath et al. However, the diagnosis should be suspected in patients with nephrolithiasis and serum calcium levels greater than 10. Serum calcium levels can vary by up to 5%, and patients with mild hyperparathyroidism may exhibit relatively small increases of serum calcium (Yendt and Gagne, 1968). Measurement of serum ionized calcium may help in equivocal cases because ionized calcium may be elevated in the setting of normal serum calcium (Yendt and Gagne, 1968). Additional, rare causes of hypercalciuria include hypercalcemia of malignancy, sarcoidosis, thyrotoxicosis, and vitamin D toxicity. Many granulomatous diseases, including tuberculosis, sarcoidosis, histoplasmosis, leprosy, and silicosis, have been reported to produce hypercalcemia. Pulmonary alveolar cells and lymph node homogenates in patients with sarcoidosis are capable of synthesizing vitamin D, a function usually limited to the kidney. Most patients with sarcoidosis Hyperoxaluria Hyperoxaluria, defined as urinary oxalate greater than 40 mg/day, leads to increased urinary saturation of calcium oxalate and subsequent promotion of calcium oxalate stones. In addition, oxalate has been implicated in crystal growth and retention by means of renal tubular cell injury mediated by lipid peroxidation and the generation of oxygen free radicals (Ravichandran and Selvam, 1990). Membrane injury facilitates the fixation of calcium oxalate crystals and subsequent crystal growth. Antioxidant therapy has been shown to prevent calcium oxalate precipitation in the rat kidney and to reduce oxalate excretion in stone patients (Selvam, 2002). Human studies, however, failed to demonstrate increases in markers of oxidative stress or renal injury in normal subjects and stone formers ingesting large doses of oxalate (up to 8 mmol), thus calling into question the importance of oxalateinduced cell membrane damage in calcium oxalate stone formation (Knight et al. Causes of hyperoxaluria include disorders in biosynthetic pathways (primary hyperoxaluria); intestinal malabsorptive states associated with inflammatory bowel disease, celiac sprue, or intestinal resection (enteric hyperoxaluria); and excessive dietary intake or high substrate levels (vitamin C) (dietary hyperoxaluria). The markedly high levels of urinary oxalate that ensue (>100 mg/day) lead to increased saturation of calcium oxalate and formation of calcium oxalate complexes and crystals in the renal tubular lumen. Some crystals attach to the surface of renal tubular epithelial cells and further aggregate into stones, whereas others are internalized into tubular cells and then extruded into the renal interstitium, leading to marked nephrocalcinosis (Hoppe et al. Renal injury may be a consequence of direct cell toxicity from either high oxalate concentration or calcium oxalate crystals, mediated through reactive oxygen species. Renal impairment occurs from recurrent obstructing calcium oxalate stones and as a result of renal parenchymal inflammation and interstitial fibrosis from severe nephrocalcinosis (Mulay et al.

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Bladder Calculi After Renal Transplantation Urolithiasis after renal transplantation is not uncommon and has an incidence of 1% to 1 treatment 3rd degree av block generic ondansetron 8 mg on-line. Even though renal calculi are more common after transplantation, bladder calculi are common. There are many causative factors for bladder calculi in a post-transplant setting, especially persistent infection with Proteus sp. Immunosuppressive drugs such as calcineurin inhibitors and steroids can also be a contributory factor. The incidence of bladder stones has decreased after the use of absorbable suture (Klein and Goldman,1997; Lipke et al. The first investigation in case of a bladder stone is ultrasonography to rule out the presence of concomitant renal or ureteric calculi. The ideal modality of treatment of bladder calculi in a posttransplantation scenario does not differ much from routine situations. Primary Urethral Calculi Primary urethral calculi are considered primary because they originate at the same site as they are found ultimately. In reality, they form secondary to obstruction of urethra at any level of urinary stasis in urethral diverticula. Presence of a foreign body and urinary infection provide a conducive milieu for stone formation (Rivilla et al. In the presence of infection stones, the commonly isolated organisms are Escherichia coli, Proteus spp. Most of these stones are small, round, without a core or nucleus, and composed primarily of struvite (magnesium ammonium phosphate), although other types such as calcium phosphate and uric acid have been reported (Verit et al. Urethral stricture is the leading cause for the formation of urethral stones as discussed earlier. On the other hand, placement of hairbearing grafts for the management of urethral stricture or hypospadias has resulted in urethral stones as well. The hair acts as a nidus for precipitation and inspissation of lithogenic salts and results in primary calculi in the urethra (Singh and Hemal, 2001). These stones remain adherent to the hair ball and the urethral mucosa, causing partial obstruction and further stone formation. Attempts at epilation before engraftment have reduced but not eliminated the risk: the follicles persist and lead to hair growth in 3% to 6% of patients (Singh and Hemal, 2001). The advent of brachytherapy as a treatment modality for carcinoma prostate over the last two decades requires the placement of radioactive seeds into the prostate. These seeds can migrate or intrude into the prostatic urethra and may form a nidus for stone formation. Cryoablation causes ischemic necrosis of the gland, and necrosis with persistent inflammation may give rise to stones (Aus et al.

Dolok, 23 years: Moreover, the addition of potassium citrate not only prevents a decrease in urinary citrate during thiazide therapy, but may increase citrate excretion (Pak et al.

Kayor, 37 years: In percutaneous technique either the Amplatz sheath or laparoscopic trocars can be used (Franzoni et al.

Saturas, 28 years: Several factors must be considered with laparoscopic nephroureterectomy, including the risk of tumor seeding from the ureter and the bladder.

Hauke, 56 years: The incision from the apex of the flap (the stem of the Y) is then performed along the lateral aspect of the proximal ureter.

Thorald, 61 years: Some patients (particularly young patients) complain of perineal pain, often with vigorous activity, even after implantation of the stent in the deep bulbous urethra.

Hector, 25 years: The greatest amount of clinical evidence exists for lemonade therapy, and this is most widely prescribed.

Jose, 64 years: Serni S, Vittori G, Masieri L, et al: Robotic vs open simple enucleation for the treatment of T1a-T1b renal cell carcinoma: a single center matched-pair comparison, Urology 83(2):331­337, 2014.

Gunock, 62 years: Dinckan A, Tekin A, Turkyilmaz S, et al: Early and late urological complications corrected surgically following renal transplantation, Transpl Int 20(8):702­ 707, 2007.

Raid, 26 years: Takahashi T, Kakehi Y, Mitsumori K, et al: Distinct microsatellite alterations in upper urinary tract tumors and subsequent bladder tumors, J Urol 165(2):672­677, 2001.

Nafalem, 51 years: For this reason, a fasting serum calcium level is preferred (Siyam and Klachko, 2013).

Gamal, 44 years: The cricket bat modification has been useful in trauma patients, particularly in patients who have a significant stump of erectile bodies and urethra left after the injury.

Bernado, 65 years: Radical Nephroureterectomy Indications Radical nephroureterectomy with excision of a bladder cuff is the gold standard for large, high-grade, suspected invasive tumors of the renal pelvis and proximal ureter (Babaian and Johnson, 1980; Batata and Grabstald, 1976; Cummings, 1980; McCarron et al.

Tarok, 54 years: This prevents activation of the contractile apparatus, because the myosin light chain cannot be phosphorylated, a process that must precede tension development.

Umul, 34 years: Despite the histologic similarity of these lesions to the urothelial bladder cancer, the thinner muscle layers of the renal pelvis and ureter allow for an earlier involvement of the muscle layer in comparison with the bladder.

Joey, 48 years: In summary, although several beverages have been shown to increase urinary citrate levels, none has demonstrated superiority.

Ateras, 58 years: The term "Chinese herb nephropathy" was eventually proposed for this clinical entity.

Roy, 33 years: Small nuclei are unstable; below a critical size threshold, dissolution of the crystal is favored over crystal growth.

Hengley, 35 years: Excessive body size may also be associated with rhabdomyolysis secondary to crush injuries from placement in the lateral approach; if this technique is used, care must be taken to minimize muscle crush injury.