Preparation and sterilization by filtration of Renacidin irrigation.
Newton D W,Pollock G R,Narducci W A,Augustine S C
American journal of hospital pharmacy
A method for the sterilizing filtration of Renacidin, a urologic irrigating solution, was evaluated. Renacidin irrigation was prepared and sterilized by microporous membrane filtration. A sterilizing membrane filtration apparatus was challenged by inoculating a batch of irrigation solution with Escherichia coli. The sterility of both intentionally contaminated and routinely prepared batches was evaluated. The stability of the solution was monitored by pH measurement, visual examination, maintenance of a vacuum, and absorbance spectrum of a 1:100 dilution in deionized water over a wavelength range from 400 to 200 nm. The time required to prepare three one-liter units was about two hours. No microbial growth was detected in any of the samples. The predicted minimum shelf-life at 10 degrees C was six months. Because the prepared solution contains some unreacted citric acid and bicarbonates, storage at room temperature could produce excessive pressure inside the container from carbon dioxide gas evolution. Refrigerated storage is recommended. This method for the preparation and sterilization of Renacidin irrigation is reasonably expedient, economical, and reliable.
Urothelial injury to the rabbit bladder from various alkaline and acidic solutions used to dissolve kidney stones.
Reckler J,Rodman J S,Jacobs D,Rotterdam H,Marion D,Vaughan E D
The Journal of urology
Different irrigating solutions are used clinically to dissolve uric acid, cystine and struvite stones. These studies were undertaken to assess the toxicity to the rabbit bladder epithelium of several commonly used formulations. Test solutions were infused antegrade through a left ureterotomy overnight. Bladders were removed and routine histological sections made. A pH 7.6 solution of NaHCO3 appeared harmless. The same solution with two per cent acetylcysteine produced slight injury. All pH 4 solutions caused significant damage to the urothelium. Hemiacidrin, which contains magnesium, produced less damage than did other pH 4 solutions without that cation. Our data tend to support Suby's conclusions that addition of magnesium reduces urothelial injury even though the presence of magnesium will slow dissolution of struvite.
Urothelial injury to the rabbit bladder caused by calcium dissolving agents including two new citrate solutions.
Zhang Xiang-bo,Wang Zhi-ping,Duan Jian-min,Duan Guo-lan,Shi Ting-kai,Lu Jian-zhong,Ma Bao-liang
We compared the urothelial injury to the bladder caused by four agents capable of dissolving calcium salts. The solutions were administrated in an antegrade way through left ureterostomies in 54 rabbits for periods of 24, 48 and 72 h. The bladders were then removed and three routine histological sections were made for each. The following six solutions were used: physiological sodium chloride solution (Phys), artificial urine (Art), 0.03 M disodium EDTA buffered to pH 8.5 with triethanolamine (EDTA), 10% Renacidin (R), test solution 2 (S2, using D-gluconic acid-lactone and other compounds that differ from R in terms of ingredients or quantity), and test solution 1 (S1, using D-gluconic-acid instead of D-gluconic acid-lactone in S2 but keeping the other ingredients the same) for irrigation. At 24 h there was no observable urothelial damage caused by perfusion with Phys or Art; solutions R, S1 and S2 caused approximately the same level of injury to the rabbit bladder mucosa; however, irrigation with disodium-EDTA caused more serious urothelial injury than R, S1 and S2 (P<0.05, chi2-test) and may be unacceptable. The damage to bladder tissues treated with S1 and S2 was less than that caused by R, but this was not significant (P>0.05, chi2-test). Following a prolonged irrigation time, all of these solutions cause further urothelial damage, but EDTA caused the most, followed by R, S1, S2, Phys or Art, respectively, at 48 and 72 h. In view of the better solubility effect of solutions S1 and S2 compared with R, it might be justified in accepting the more pronounced urothelial irritation caused these solutions, but in order to enhance their effectiveness and reduce urothelial injury further study will be needed.
Primary dissolution therapy of struvite calculi.
Dretler S P,Pfister R C
The Journal of urology
Percutaneous nephrostomy and hemiacidrin were used as primary treatment of magnesium ammonium phosphate calculi in 32 surgical candidates. Of 28 patients who actually received hemiacidrin 24 (85 per cent) had successful treatment (no surgery necessary), including 19 (68 per cent) who had total stone dissolution. There were no significant complications. Patients have been followed for 3 months to 7 years. Percutaneous nephrostomy with hemiacidrin infusion is another possible treatment in the growing alternatives available for patients with urinary struvite calculi.
Expedited struvite-stone dissolution using a high-flow low-pressure irrigation system.
Collins Sean,Ortiz Jorge,Maruffo Franzo,Hruby Gregory W,Pierorazio Phillip M,Gupta Mantu,Monga Manoj,Landman Jaime
Journal of endourology
BACKGROUND AND PURPOSE:The clinical application of chemolysis for struvite stones is limited because of the need for a nephrostomy tube and the potential risk of elevated intrarenal pressures, which may be associated with sepsis and metabolic derangements. We evaluated the utility of a high-flow low-pressure irrigation system, designed to minimize the disadvantages of chemolysis, for struvite-stone dissolution. MATERIALS AND METHODS:An in-vitro urinary-tract model was used to compare a novel dual-lumen ureteral catheter with a standard nephrostomy tube for struvite stone chemolysis. A laboratory-proved large human struvite stone was divided into 3.5-g fragments, which were placed in the model. In the experimental group, Renacidin (citric acid, glucono-Delta-lactone, and magnesium carbonate; Guardian Laboratories, Lake Forest, IL) irrigation was performed through the high-flow low-pressure irrigation system. In the control group, Renacidin solution was infused at 120 mL/hour through a nephrostomy tube. Three stones were tested in each group. Intrarenal pressures, irrigant-flow rates, chemolysis rates at each time interval, overall chemolysis rates, and changes in chemolysis rates over time were compared using ANOVA. RESULTS:The mean intrarenal pressure with the high-flow low-pressure irrigation system and the nephrostomy tube were 5.3 and 7.5 cm H(2)O, respectively (P < 0.001). The overall chemolysis rates with the high-flow low-pressure irrigation and control systems were 0.12 g/hr and 0.06 g/hr, respectively (P = 0.025). The chemolysis rates in the experimental and control groups did not differ significantly with time (P = 0.75 and 0.21, respectively). CONCLUSIONS:In this in-vitro model, the high-flow low-pressure irrigation system facilitated struvite-stone chemolysis by achieving significantly higher flow rates than a traditional percutaneous system. Additionally, the system yielded lower intrarenal pressures than standard nephrostomy-tube irrigation.
The use of chemical treatments for improved comminution of artificial stones.
Heimbach D,Kourambas J,Zhong P,Jacobs J,Hesse A,Mueller S C,Delvecchio F C,Cocks F H,Preminger G M
The Journal of urology
PURPOSE:The acoustic and mechanical properties of various stone compositions are significantly different and thus result in varying degrees of fragility. Consequently, results to shock wave lithotripsy (SWL) are influenced accordingly. We report the results of a study of fragility of various stone compositions, and the influence on each stone's baseline physical properties and fragility when exposed to various chemolytic solutions. MATERIALS AND METHODS:Before SWL artificial stones of differing compositions were irrigated with various chemolytic solutions. Calcium oxalate monohydrate (COM) stones were treated with ethylenediaminetetraacetic acid (EDTA), stones composed of magnesium ammonium phosphate hydrogen were treated with hemiacidrin, and stones made of uric acid (UA) were treated with tromethamine. Synthetic urine served as a control for all stone groups. Using an ultrasound transmission technique, longitudinal wave propagation speed was measured in all groups of artificial stones. Stone density was also measured by using a pycnometer (based on Archimedes' principle). Based on these measurements transverse (shear) wave speed (assuming a constant Poisson's ratio), wave impedance and dynamic mechanical properties of the artificial stones were calculated. Moreover, the microhardness of these artificial stones was measured, and fragility testing using SWL with and without pretreatment with the previously mentioned chemolytic solutions, was performed. RESULTS:Wave speed, wave impedance, dynamic mechanical properties and microhardness of EDTA treated COM stones and tromethamine treated UA stones were found to decrease compared to untreated (synthetic urine) control groups. The suggestion that chemolytic pretreatment increases stone fragility was verified by the finding of increased stone comminution after SWL testing. Combining this medical pretreatment and SWL, the findings demonstrate a significant impact of various solvents on stone comminution, in particular EDTA treated COM stones, tromethamine treated UA stones and hemiacidrin treated magnesium ammonium phosphate hydrogen stones. These data suggest that by altering the chemical environment of the fluid surrounding the stones it is possible to increase the fragility of renal calculi in vitro. CONCLUSIONS:These results indicate that appropriate chemical treatments may provide a useful adjunctive modality for improving the efficacy of stone comminution during shock wave lithotripsy.
Simplified infusion method for 10% hemiacidrin irrigation of renal pelvis.
Angermeier K,Streem S B,Yost A
A variable pressure volumetric pump was used for 10% hemiacidrin irrigation of the renal pelvis in 7 renal units (6 patients) with struvite calculi after initial percutaneous debulking and extracorporeal shock-wave lithotripsy (ESWL). The pump provided a constant display of intrapelvic infusion pressure, and an alarm which signaled if a preset maximum infusion pressure was exceeded. Compared with standard open manometer monitoring of intrapelvic pressure, this closed system of irrigation eliminates the problems associated with time-consuming assembly and maintenance, irrigant spillage, and system contamination. At the completion of therapy, 5 renal units were completely stone-free while 2 had only minimal residual caliceal "dust." Complications were minor and few in number. We conclude that a variable pressure volumetric pump provides excellent clinical results and safely simplifies irrigation for percutaneous chemolysis of struvite calculi.
Unresectable calcified bladder tumor: hemiacidrin irrigation as an adjunct to resection.
Bundrick W S,Culkin D J,Mata J A,Venable D D
The Journal of urology
Radiographic calcification of urothelial malignancies is an uncommon finding. To our knowledge, calcification of transitional cell carcinoma of the bladder preventing transurethral resection has not been reported previously. We report a case of an initially unresectable radiopaque bladder tumor and discuss the successful, conservative management with continuous bladder irrigation with hemiacidrin followed by complete transurethral resection.
Hemiacidrin irrigations to dissolve stone remnants after nephrolithotomy. Problems with solution flow.
Rodman J S,Reckler J M,Israel A R
Following surgery for branched renal calculi, hemiacidrin irrigation may be useful to dissolve any residual stones. Struvite, the mineral in these stones, is itself an alkaline buffer and can raise the pH of the irrigating solution rendering it ineffective. Large volumes of hemiacidrin must reach the stone remnants or they are unlikely to dissolve. Two cases are described in which creative positioning of the patient or the irrigation catheters was necessary to permit adequate amounts of hemiacidrin to reach and dissolve stone remnants.
Hemiacidrin renal irrigation: complications and successful management.
Klein R S,Cattolica E V,Rankin K N
The Journal of urology
The complications of hemiacidrin irrigation of the kidneys for postoperative residual struvite calculi can test the ingenuity and perseverance of the clinician. The complications encountered during the irrigation of 9 kidneys in 8 patients included Candida urinary tract infection, irrigant extravasation, ureteral obstruction and chemical cystitis. Some causes and the management of these problems are discussed. Although the period of irrigation and the hospitalization are prolonged by these complications hemiacidrin irrigation remains a safe procedure when used meticulously.
Complex struvite calculi treated by primary extracorporeal shock wave lithotripsy and chemolysis with hemiacidrin irrigation.
Spirnak J P,DeBaz B P,Green H Y,Resnick M I
The Journal of urology
Ten patients with complex struvite stones were treated successfully with primary extracorporeal shock wave lithotripsy followed by chemolysis with 10 per cent hemiacidrin renal irrigation. The average number of treatments per renal unit was 1.2 and an average of 2,688 shocks was administered per treatment. No patient required a blood transfusion. Ureteral obstruction did not occur in those patients receiving planned hemiacidrin irrigation immediately after extracorporeal shock wave lithotripsy. At 6-week followup 9 patients were free of residual fragments. The combination of extracorporeal shock wave lithotripsy and hemiacidrin chemolysis represents a satisfactory alternative to the traditional surgical management of complex struvite calculi.
Use of hemiacidrin in management of infection stones.
Nemoy N J,Stamey T A
The Journal of urology
Unless all fragments are removed at the time of surgery for struvite stones a high incidence of recurrent infection and stone formation is likely. To reduce the recurrence rate of such stones the renal pelvis is irrigated postoperatively with 10 per cent hemiacidrin solution for at least 48 hours or until all fragments have been dissolved. We have managed successfully 35 patients (36 kidneys) without enxountering any complications. Included in our most recent series are 2 patients with solitary kidneys who had successful dissolution of stone fragments. Absolute contraindications to the use of hemiacidrin are infected urine, fever or flank discomfort. Although we have found hemiacidrin dissolution of renal stones to be safe and effective it is essential that the clinician be aware of the proper technique and its possible complications.
Therapy for renal calculi via percutaneous nephrostomy: dissolution and extraction.
Newhouse J H,Pfister R C
Nephrostomy catheters offer nonsurgical modes of therapy for some renal stones. Continuous lavage of the stones using hemiacidrin (Renacidin) for struvite stones, THAM-E or acetylcysteine for cystine stones, and bicarbonate solution for uric acid stones may dissolve either entire stones or stone fragments remaining after surgery. Although irrigation is not without potential complications, recent developments in technique have minimized these. Nephrostomy tubes can also be used to transmit stone baskets through steerable catheters to snare stones from the upper collecting system or from the ureter; any stone that can be engaged and withdrawn through the tube tract can be removed; stones larger than those which can be safely extracted through the ureterovesical junction can be so treated. Neither of these procedures requires general anesthesia, the rate of serious morbidity is low, and the required hospital stay is often less than that for surgery; these modes of therapy are therefore valuable for certain patients.
Combined oral and local therapy for the dissolution of urinary calculi.
Götz F,Frang D,Hübler J,Nagy Z
International urology and nephrology
The factors underlying the formation of Ca-phosphate and struvite calculi, as well as the present possibilities for oral and local therapy, their advantages and drawbacks are discussed in the light of published evidence. In this context a clinical case of multiple injuries is reported in which practically complete chemolitholysis has been achieved by combined oral and local therapy. The rapid growth of the calculi and their alarming tendency to recurrence in case of inadequate treatment is emphasized. The therapeutic method used in this case is regarded as suitable for practical purposes.
Experimental investigations on dissolution of incrustations on the surface of catheters.
Hesse A,Schreyger F,Tuschewitzki G J,Classen A,Bach D
On the basis of a standardized in vitro irrigation model, the incrustation behavior of catheters was investigated using collected urine with controlled contamination (Proteus, mirabilis). Irrigation treatment with a NaCl solution did not effectively reduce incrustation compared to the control experiment. On the other hand, incrustations were definitively prevented or existing crystal deposits were largely dissolved with a citrate solution of pH 4.0 (Suby G). Analytical investigations (infrared spectroscopy, scanning electron microscopy) of the deposits on the catheter revealed the presence of struvite (MgNH4PO4 x 6H2O), brushite (CaHPO4 x 2H2O) and carbonate apatite (Ca10[PO4] [CO3OH]6[OH]2).
Medical dissolution and prevention of canine and feline uroliths: diagnostic and therapeutic caveats.
Osborne C A,Lulich J P,Bartges J W,Felice L J
The Veterinary record
Medical protocols designed to promote the dissolution of canine and feline struvite uroliths, the dissolution of canine ammonium urate and cystine uroliths and the prevention of all major types of canine and feline uroliths have been developed. However, because the causes of different types of uroliths vary, the medical protocols for their dissolution and prevention also vary. When the diagnosis of the underlying causes of uroliths becomes the rule rather than the exception, therapeutic failures should become the exception rather than the rule.
Percutaneous dissolution of renal calculi.
Dretler S P,Pfister R C
Annual review of medicine
The use of percutaneous nephrostomy catheters has allowed access to intrarenal urinary calculi for dissolution. Renacidin is the successful agent for dissolving struvite stones. THAM-E is the most effective agent for the intrarenal dissolution of cystine stone. Calcium oxalate stones are still resistant to dissolution techniques.
Chemolitholysis and lithotripsy of infectious urinary stones - an in vitro study.
Heimbach D,Jacobs D,Müller S C,Hesse A
OBJECTIVES:This study was performed to look for an improvement of therapeutic strategies with regard to the treatment of infectious urinary stones using artificial stones made of struvite and apatite ('Bon(n) stones') which are comparable to their natural counterparts. MATERIALS AND METHODS:Using an experimental arrangement simulating the physiological conditions in the upper urinary tract, the efficacy of artificial urine (pH 5.7), Suby G solution (pH 3.6), mixtures of artificial urine with Suby G (pH 3.9 and pH 4.1) in dissolving artificial struvite and apatite stones (Bon(n) stones) was investigated. The dissolution of natural infectious urinary stones was also measured. Additionally, investigations on shock-wave lithotripsy (SWL) combined with initial chemolytic treatment of the stones were performed. RESULTS:The efficacy of Suby G solution in dissolving artificial stones was demonstrated. Direct comparison of chemolysis of natural and artificial stones showed no statistical difference between infectious urinary stones and Bon(n) stones of the same material. The investigations on SWL showed a significant improvement on stone comminution, especially of artificial apatite stones after initial chemolytic treatment with Suby G. CONCLUSION:New basics to improve dissolution of infectious urinary stones have been developed by performing standardized in vitro investigations. Local chemolysis with Suby G is an effective tool in the treatment of infectious stone disease. SWL can be improved by varying the physical properties of infectious stones through initial treatment with Suby G solution.
Hemiacidrin irrigation in the management of struvite calculi: long-term results.
Sant G R,Blaivas J G,Meares E M
The Journal of urology
Renacidin (10 per cent hemiacidrin) irrigation has been used in the management of renal struvite calculi in 25 patients. Of these patients 22 were free of stone after irrigation: 16 after dissolution of residual stone fragments postoperatively, 4 after prophylactic postoperative irrigation and 2 after primary, nonsurgical percutaneous dissolution. Recurrent urinary tract infections owing to the original urease-producing bacteria occurred in 14 per cent of these patients and recurrent nephrolithiasis occurred in 9 per cent during an average followup period of 66 months.
Dissolution of struvite calculi by hemiacidrin solution.
Massaro F J,Weiner B,Sant G R,Meares E M
Struvite calculi result from urinary tract infections secondary to urease-producing bacteria. To prevent recurrent infection and stone formation complete removal of struvite calculi is recommended. Two illustrative reports of patients with renal struvite calculi are presented in which 10% hemiacidrin (Renacidin) irrigation was instituted for stone dissolution. After surgical removal of the calculi a nephrostomy tube was placed in the renal pelvis. With confirmation of residual struvite calculi, 10% hemiacidrin irrigation was initiated. Urine cultures, electrolytes and nephrotomograms were performed and adverse effects monitored. Using strict aseptic technique and appropriate precautions, hemiacidrin irrigation safely dissolves struvite calculi.
Partial dissolution of struvite calculus with oral acetohydroxamic acid.
Rodman J S,Williams J J,Peterson C M
Most staghorn calculi occur in patients who have chronic urinary tract infections with urea-splitting organisms. Acetohydroxamic acid, an inhibitor of the bacterial urease enzyme, is currently undergoing clinical trials to determine whether or not it can prevent stone growth in patients at risk. We report on a patient whose stones grew while she was taking placebo and then decreased in size when she took the active drug.
[Dissolution therapy of struvite calculi with solution G].
Hosomi M,Maeda O,Matsumiya K,Koide T,Takaha M,Oka T,Sonoda T
Hinyokika kiyo. Acta urologica Japonica
In 6 patients (9 kidneys) irrigation with Solution G in the renal pelvis was performed for the dissolution of their infectious stones. Staghorn calculi larger than 30 mm in diameter were observed in all patients. In two kidneys all stones were dissolved and the rest were dissolved into small fragments that constituted no problem in those kidneys. Irrigation was done with no major side effects or complications. The dissolution of infectious stones with Solution G is another possible treatment that could be first chosen among percutaneous nephrolithotripsy, extracorporeal shock wave lithotripsy and other treatments.
Effect of acetohydroxamic acid on dissolution of canine struvite uroliths.
Krawiec D R,Osborne C A,Leininger J R,Griffith D P
American journal of veterinary research
Long-term administration of acetohydroxamic acid to dogs with experimentally induced urease-positive staphylococcal urinary tract infections and struvite urolithiasis resulted in dose-dependent inhibition of urolith growth or urolith dissolution. Inhibition of urolith growth was associated with drug dose-dependent reduction of urine urease activity, urine pH, crystalluria, pyuria, hematuria, and proteinuria. Lesions of the urinary tract of dogs treated with acetohydroxamic acid were less severe than those of control dogs. Dose-dependent adverse drug reactions included reversible hemolytic anemia, abnormal red cell morphology, and abnormalities of bilirubin metabolism.