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Highlights • FR generation and persist time should be studied to avoid its risk in clinic. • FR generation and persist time were measured by SCL with a PMT in nanoseconds. • The measured FR persist time reaches a maximum of 1000 ms. • It is recommended to set the shock wave irradiation frequency below 1 Hz., The shock wave used in extracorporeal shock wave lithotripsy (ESWL) induces strong cavitation and generates a large amount of free radicals (FR). In order to evaluate the harmfulness of FR in the ESWL, information on the incidence and persist time of FR caused by shock waves is required. FR markers can estimate the amount of FR generated, but not how long the FRs will survive. The OH* FR generated by the ESWL shock wave reacts with luminol and emits blue light, which is called sonochemical luminescence (SCL) phenomenon. In this study, FR generation and persist time were measured by recording SCL phenomenon with a sensitive photomultiplier tube (PMT) that responds in nanoseconds. As a result of measurement with the PMT, when the electromagnetic shock wave used in clinical practice was irradiated to the luminol solution, the amount of light emitted per unit time reached its maximum value within a very short time (< ∼600us) and then exponentially decreased for a long time (∼several hundred ms). The measured FR persist time reaches a maximum of 1000 ms. As the output setting of the shock wave generator increases, the minimum or average FR persist time increases, but the maximum value does not show a high correlation with the output setting. The amount of generated FR shows a very high correlation with the shock wave setting, and when the setting is changed from low to high, it increases very sensitively, rapidly and non-linearly. In order to reduce the risk of FR in patient treatment using lithotripsy, the output setting of the shock wave should be minimized, and the interval between the shock wave pulses should be sufficiently larger than the FR persist time. Therefore, it is recommended to avoid increasing the output setting and setting the shock wave irradiation frequency below 1 Hz to shorten the treatment time in clinical practice. For the purpose of formulating these recommendations, additional studies on the generation and persist time of FR depending on the shock wave generation method and set conditions in living tissue or similar environment are required in the future.

Jackstones are a rare subtype of calculi, characterised by radiating spicules. We describe a case of multiple jackstones in the urinary upper tract. A 53-year-old man was referred for evaluation of left flank pain. Imaging revealed a left pelvic-ureteric junction obstruction and several left renal calculi. A left supine percutaneous nephrolithotomy was performed and two jackstone calculi were extracted. The presence of multiple jackstones in the renal pelvis should prompt for evaluation for obstruction and complete stone clearance should be achieved to avoid recurrence.

Introduction Synthol injection for body contouring has been used by bodybuilders for some time. We report two extremely rare systemic complications; pulmonary granulomatosis and hypercalcemia, in a woman who has received Synthol injections for buttocks augmentation. Presentation of case The case discussed in this report is of a 36-year-old lady who presented for severe hypercalcemia and nephrocalcinosis. Subsequent workup revealed granulomas in the buttocks and in the lungs. Upon questioning, it was discovered that she had received Synthol injection for buttocks augmentation a few months earlier. Labs were consistent with calcitriol mediated hypercalcemia, a phenomenon observed in granulomatous diseases. A diagnosis of foreign body granulomatosis with pulmonary migration and secondary hypercalcemia was made. The patient was started on prednisone and showed an initial positive response. Discussion Reported complications of Synthol include pain, muscle deformity, and ulceration at the injection site. Hypercalcemia secondary to foreign body granulomatosis after Synthol injection has been reported only once previously, and here we report a second case. The hypercalcemia is thought to be calcitriol mediated, where overexpression of CYP27B1 in the macrophages forming the granulomas leads to pathological extrarenal calcitriol production. Pulmonary granulomatosis, theorized to be secondary to hematologic migration of the injected material, has never been reported previously with Synthol use. Conclusion Synthol injection for body contouring may be a cause of extensive local and pulmonary foreign body granulomatosis leading to calcitriol mediated hypercalcemia. History of cosmetic injections should not be disregarded during history taking., Highlights • Synthol injections for site enhancement can lead to systemic complications • Pulmonary granulomatosis can be secondary to hematogenic spread of Synthol • Hypercalcemia can be secondary to severe foreign body granulomatosis • Hypercalcemia is due to overexpression of CYP27B1 in macrophages • Site enhancement injections should not be dismissed during history taking

Introduction Extracorporeal shock wave lithotripsy has been confirmed as the least invasive and the most widely used treatment for kidney and ureteral stones. However, as with any other type of therapy, potential complications do exist. Case presentation Herein, we describe a 55-year-old male patient who developed symptoms of acute pancreatitis one day after extracorporeal shock wave lithotripsy for left renal stones. The patient used to manage himself with NSAIDs till he presented to the emergency department with severe epigastric pain and tenderness due to giant pancreatic pseudocyst formation. The pseudocyst was treated by endoscopic cystogastrostomy using metallic stent with uneventful recovery. In addition, we extensively reviewed all available literature studies of pancreatitis and pancreatic pseudocyst occurring after extracorporeal shock wave lithotripsy. We summarized all reported cases and presented them in a comprehensive table. Discussion Post ESWL acute pancreatitis is a rare clinical entity with only 11 reported cases. In all cases, abdominal pain was the most common symptom that occurs in less than 24h following ESWL treatment. So it should be considered in the differential diagnosis of acute abdominal pain after ESWL. Conclusion Although ESWL is generally considered safe and effective treatment; however, major complications have been reported to occur in less than 1% of patients. One of the extremely rare complications is the development of pancreatitis and pancreatic pseudocyst., Highlights • ESWL is a safe and effective treatment modality. • Serious complications have been reported in 1% of patients. • Post-ESWL acute pancreatitis is extremely rare. • Only 5 cases of pancreatic pseudocyst after ESWL have been reported. • Endoscopic cystogastrostomy approach is cost-saving, can avoid surgical complications, and offer an early hospital discharge.

Background and Aims Lithotripsy is a procedure for fragmentation or destruction of stones to facilitate their removal or passage from the biliary or pancreatic ducts. Although most stones may be removed endoscopically using conventional techniques such as endoscopic sphincterotomy in combination with balloon or basket extraction, lithotripsy may be required for clearance of large, impacted, or irregularly shaped stones. Several modalities have been described, including intracorporeal techniques such as mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy, as well as extracorporeal shock-wave lithotripsy (ESWL). Methods In this document, we review devices and methods for biliary and pancreatic lithotripsy and the evidence regarding efficacy, safety, and financial considerations. Results Although many difficult stones can be safely removed using ML, endoscopic papillary balloon dilation (EPBD) has emerged as an alternative that may lessen the need for ML and also reduce the rate of adverse events. EHL and laser lithotripsy are effective at ductal clearance when conventional techniques are unsuccessful, although they usually require direct visualization of the stone by the use of cholangiopancreatoscopy and are often limited to referral centers. ESWL is effective but often requires coordination with urologists and the placement of stents or drains with subsequent procedures for extracting stone fragments and, thus, may be associated with increased costs. Conclusions Several lithotripsy techniques have been described that vary with respect to ease of use, generalizability, and cost. Overall, lithotripsy is a safe and effective treatment for difficult biliary and pancreatic duct stones.

Urinary calculi are a frequent complication of urinary diversion following radical cystectomy, including in ileal conduit systems. We report the case of a 38-year-old man with ileal conduit urinary diversion, following radical cystectomy for transitional cell cancer, who presented with symptomatic bilateral kidney stones. By reporting the medical record and management procedure for this patient, we aim to demonstrate the successful management of kidney stones via supine percutaneous nephrolithotomy, using an Alken telescopic metal dilator, under spinal anesthesia. Consistent with most literature, percutaneous nephrolithotomy was the best management procedure in this case.

Objectives To evaluate the efficacy of solifenacin, tamsulosin oral-controlled absorption system (OCAS), and the combination of both drugs on JJ stent-related symptoms using the validated Arabic version of the ureteric stent symptom questionnaire (USSQ). Patients and methods In all, 260 patients who had undergone JJ stenting of the ureter for different endoscopic urological procedures were postoperatively randomly assigned into four equal groups. Patients in Group I received no treatment and served as the control group, Group II patients received tamsulosin OCAS 0.4 mg daily, Group III patients received solifenacin 5 mg daily, and Group IV patients received a combination of both drugs. Before stent removal, all patients completed the Arabic version of the USSQ. Results In all, 234 patients completed the study, comprised of 56 in Group I, 59 in Group II, 58 in Group III, and 61 in Group IV. Baseline characteristics and indications for JJ stenting were comparable in the four groups. There were highly significant differences in all items of the USSQ between the treatment groups and the controls, while Group II and III were comparable. The USSQ score was significantly lower in Group IV vs Groups II and III. Crossing of the distal curl of the stent to the midline had a significant positive correlation with the severity of the urinary symptoms, body pain, general health, and work performance in the medicated groups. Conclusions Combined therapy with tamsulosin OCAS 0.4 mg daily and solifenacin 5 mg daily is a safe and well-tolerated management for stent-related symptoms. However, stent position remains a significant factor affecting response to medical therapy and patients’ health-related quality of life.