Open Stone Surgery: Is it Still a Preferable Procedure in the Management of Staghom Calculi?*

Transcription

1 International Urolog-v and Nephrology 26 (3). pp (199) Open Stone Surgery: Is it Still a Preferable Procedure in the Management of Staghom Calculi?* A. A. ESEN, Z. KIRKALI, C. GOLER Department of Urology, Dokuz Eyltd University, School of Medicine, Inciralti, Izmir, Turkey (Accepted October 28, 1993) We reviewed 3 patients with staghorn calculi to determine the effectiveness of various treatment modalit:es such as extracorporeal shock wave lithotripsy (ESWL) monotherapy, FSWL and percutaneous nephrolithotomy (PCNL) combined therapy, and open stone surge~'. While ESWL monotherapy and ESWL + PCNL were perforrncd in 25 and 8 patients, respectively, 10 patients tmderwent open stone surgery. Of the 25 patients treated with ESWL, 8 were stone-free, whereas out of 8 patients treated with ESWL + PCNI, and 8 out of 10 patients treated with open surger 3' were stone-tree. The complications of ESWL monotherapy consisted of pyelonephritis in one patient, and stone street formation in three. In the group of ESWL + PCNL, one patient developed pyonephrosis, and another perinephritic abbess. No serious complication was noted in patients who ttnderwent open surgery,, but an average of 525 ml of blood trtmsfusion was required. We conclude that open stone surgery, although invasive, is still beneficial in the treatment of staghorn calculi. Extracorporeal shock wave litholxip~, (ESWL) and endoscopic procedures such as percutaneous nephrolithotomy (PCNL) have dramatically changed the management of upper urinau, tract calculi [1, 2]. Open surge~' is now performed in less than 5% of patients requiring treatment [3]. Although the indications and effectiveness of PCNL and ESWL are well established for patients with stones smaller than 2 cm, the management of complex stones, particularly staghom calculi, remains somewhat controversial Several modalities such as open surge~', percutaneous nephrolithotom}' with ESWL, and ESWL monotherapy have been suggested for the treatment of staghom calculi [1-6]. However, none of the methods have proved to give the best results. Therefore we have reviewed our experience with the management of staghorn calculi using ESWL monotherapy, ESWL + PCNL and open surger}. * Presented at the 10th Congress of the European Association of Urology, July 1992, Genoa. VSP, Utrecht Akadermat Ktadr, Budapest

2 28 Esen et al.: Open stone sur,geo, Materials and methods We have retrospectively evaluated 3 patients with renal staghorn calculi who were treated at the Department of Urology, Dokuz Eyltil University, from June 1989 to December During the same period 2095 patients were treated at our institution with upper urinary.' tract stones. Patients were divided into three groups according to the methods of treatment applied: ESWL monotherapy, PCNL (with or w-ithout ESWL) and open surgew. All patients in this study had staghom calculi which were classified as complete or partial on the basis of intravenous urography (IVU) findings. Complete staghom stone was defined as a calculus that totally filled all the calyces and the renal pelvis. Partial staghorn stone was defined as one that filled the renal pelvis plus one or more calyces. Pelvicalyceal anatomy was classified according to the degree of hydronephrosis. In addition to IVU, urinalysis, urine culture, renal and liver function and blood coagulation tests were performed in all patients before treatment. All patients with positive urine cultures received antibiotics according to the sensitivity results. ESWL monothera:~v There were 9 females: and 16 males (mean age 38 years). Significant loss of renal function and congenital obstructive abnormalities were excluded with 1VU and radioisotope studies. Characteristics of patients and stones are summarized in Table 1. While four patients underwent ESWL Table I General characteristics of patients and stones treated with open surge~-, PCNL + ESWL and ESWL monotherapy Open PCNL ~- ESWL ESWL surge~' monothcrapy,'~ex female male Symptoms pre sen t absent Staghorn partial complete Dilatation present absent 9 I lnterna#onal Urology and Nephrology 26, I99

3 Esen et al.: Open stone surge~. 29 without prophylactic ureteral stenting, double-j stents were placed in the remaining 21. All patients were treated with an electromagnetic lithotriptor Siemens Lithostar Plus on an outpatient basis. Treatments were performed in stages in order to avoid obstructive steinstrasse. Initially the pelvic component was disintegrated, and later the upper, middle and lower calyceal components were treated consecutively. The energy of the generator was set at 13.0 to 19.0 kv and a maximum of 6000 shocks were delivered during each treatment session. All patients were observed carefully for fever and progression of hydronephrosis. In the presence of these complications percutaneous nephrostomy or ureteroscopy was performed. Patients were followed up for to 22 months (mean 10.6) with plain abdominal X-rays to document the stone clearance. Open surgery This group consisted of 8 males and 2 females 12 to 63 years old (mcan age 3). Characteristics are summarized in Table 1. The procedure was performed as described elsewhere [71. PCNL with or without ESWL This group consisted of 5 males and 3 females. Mean age was 3 years (range 3 to 66). None of the patients had infundibular stenosis or coagulation defects. The procedure was performed under general anaesthesia. Treatment was achieved by one-stage procedure in which fluoroscopy, antegrade puncture of the kidney and calculus removal by ultrasonic, mechanical and/or electrohydraulic lithotripsy were performed. A 2 F nephrostomy tube was left in place for drainage and irrigation or for re-entry as needed. Residual fragments were destroyed with ESWL after PCNL. The mean follow-up of patients in this group was 11.6 months (3 to 22 months). The outcome of different forms of treatment was determined by plain abdominal X- rays and IVU. Success of treatment in patients undergoing open surgery was defined,as complete removal of stones by the time the patient was discharged from the hospital. Success of treatment with ESWL monotherapy and PCNL + ESWL was defined as being free of stones 3 months after therapy. Results ESWL. Comparative results of ESWL to other methods are shown in Table 2. While patients with partial staghom calculi required an average of 21,220 shocks for adequate pulverization of the stones, complete staghom stones required an average of 30,100 shocks for disintegration. Stone-free status varied with stone burden and collecting system anatomy. Six out of 1 patients International Urology and Nephrolog2; 26, 199

4 250 Esen et al.: Open stone surgery Table 2 Treatment results of patients in relation to preoperative stone burden Open surgery PCNL + ESWL ESWL monotherapy C P C P C P No. of shocks - - 5,550 28,600 30, ~220 Stone-flee 5/7 3/3 2/ 2/ 2/11 6/1 Rate (%) Hospitalization (day) Mean follow-up (month) l Total operation time (h) Average blood transfusion (ml) C ~ complete P = partial (2.8%) with partial staghorn calculi became stone-free, and 2 out of 11 patients (18.1%) with complete staghorn calculi reached stone-free status. Six out of 13 patients (6.1%) with no dilatation became stone-free, as compared to 2 out of 12 patients (16%) treated similarly with grossly dilated collecting systems. Complications are summarized in Table 3. PCNL + ESWL. Patients in this group required an average of 1.12 session of PCNL for the removal of their calculi. Mean operative time notably differed among complete (2.5 h) and partial (2 h) staghorn stones. Patients undergoing open surgery, required no further procedure. In this group mean operative time for partial stones was 3.2 h, as compared to. h for complete staghorn stones. The average blood transfusion in the open surgery group was 525 ml, and in the PCNL + ESWL group 360 ml. Stone-free status in the PCNL + ESWL group did not vary according to the stone burden. In both the partial and the complete staghorn stone groups, 2 out of patients each (50%) became stone-free. Table 3 Perioperative complications in relation to treatment modality PCNL + F.,SWL No. ESWLmono~e~py No, Pyoncphrosis Pcrinephric abscess I I Pyelonephritis Stone street 1 3 Double-J stent + incrustation I Double-J stent + migration 1 International Urology and Nephrolo~e 26, 199

5 Esen et al.: Open stone surge~ 251 Overall stone-free rate in the PCNL + ESWL group was 50"%, as compared to 80% in the open surge~" group. Minor complications were similar in both groups as shown in Table 3. However, major complications were common in the PCNL + ESWL group. Pyonephrosis developed in 1 patient treated with PCNL, who required nephrectomy, and perinephric abscess developed in another who was treated by pereutaneous drainage. Discussion Staghom calculi pose a threat to the viability of the kidney and to the patients' survival [8]. In order to decrease the loss of renal function, morbidity and mortality rates, most authors agree on the need for the interventional therapy of these stones [8, 9]. Although several modalities such as ESWL, PCNL with or without ESWL and open surgery" have been suggested by different authors, there is still controversy_ on this subject [10, 11]. Since its introduction, ESWL has become the treatment of choice for most of the renal and ureteral stones, However, ESWL monotherapy for staghorn calculi has generally resulted in poor stone-free results ranging from 30 to 63% [3, ]. While Eisenberger [12] stated that % of their patients with staghorn calculi became stone-free, Sohn [13] reported 30% stone-free rate with ESWL monotherapy which compares favourably with our results. Stone burden and collecting system anatomy have been claimed for this poor outcome after ESWL monotherapy [8, 9]. Lingemann et al. [9] reported that 67% of their patients with partial staghorn calculi had become stone-free while in those with complete staghorn calculi the rate was 31%. These investigators also demonstrated that collecting system anatomy had a major impact on stone-free results [3, 9]. In their series 86% of patients with non-dilated collecting systems became stone-free compared to only 3% with dilated calyces [ 1]. This study also has shown that the presence of a dilated collecting system adversely affects stone-free results. High incidence of complications such as stone-street, pyelonephritis, pyonephrosis, sepsis, etc. and auxiliary procedure requirement have led most centres to limit ESWL monotherapy and move to other treatment modalities [2, 3, 7]. PCNL with ESWL appeared to be a more effective method than ESWL monotherapy in staghorn calculi. However, it is not always possible to get satisfactory results, because several factors limit the outcome of this modality. It has been demonstrated that collecting system anatomy like dilatation of calyces or infundibular stenosis and patient's habitus such as obesity may influence the outcome of therapy [3]. Fuchs et al. [1] reported that 86% of their patients with non-dilated collecting system became stone-flee, while complete clearance rate of patients with a dilated system was 3%. We think that the high incidence of dilated collecting systems produced lower success rates in International Urology and Nephrology 26, 199

6 252 Esen et al.: Open stone surge~ our patients. Assimos et al. [3] also reported similar results with a 60% stonefree rate in a group of patients with staghom calculi treated with combination therapy. Although stone volume does not affect the results of this modality, multiple procedures with anaesthesia are mandatory for satisfacto~' stone clearance. Complication rate mav also be increased with procedures as we observed in one of our patients who underwent nephrectomy [3,, 7]. According to our experience we believe that percutaneous nephrolithotomy with or without ESWL is not less invasive than open surgeb,; it may be even more invasive when multiple procedures are required. Several authors also suggest that complication rates of the two methods are not different from each other [3]. Hospitalization periods of patients treated with either of the methods were similar. Open surgery is a well-known procedure in the management of staghorn calculi. A stone-free rate of 75% has been reported with this procedure which compares favourably with our results [1 I]. Patients with staghorn calculi are a heterogeneous group: most individuals with partial staghorn calculi can be treated with PCNL + ESWL combination therapy. However, a group of patients with complex anatomical and physiological problems such as complete staghorn calculi and dilated collecting system will have the best results with an open operation. In conclusion, we recommend that open stone surger3' should be presented as a treatment option to patients with complete staghorn calculi and dilated collecting system References 1. Bossche, M. V., Simon, J., Schulman, C. C.: Shock wave monotherapy of staghom calculi. Eur. Urol., 17, 1 (1990). 2. Schulze, H., Hertle, L., Kutta, A., Graff, J., Senge, T.: Critical evaluation of treatment of staghom calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J. Urol., 11, 822 (1989). 3. Assimos, D. G., Wrenn, J. J., Harrison, L. t-t., McCullough, D. L., Boyce, W. H., Taylor, C. L., Zagoria, R. L, Dyer, R. B.: A comparison of anatrophic nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghorn calculi. J. Urol., (1991).. Gleeson, M., Lerner, S. P., Griffith, D. P.: Treatment of staghom calculi with extracorporeal shock wave and percutaneous nephrolithotomy. Urology, 38, 15 (1991). 5. Vandeursen, H., Baert, L.: Extracorporeal shock wave lithotripsy monotherapy for staghorn stones with the second generation lith0triptors. J. Urol., 13, 252 (1990). 6. WmlMd, H. N., Clayman, R. V., Chaussy, C. G., Weyman, P. J., Fucks, G. J., Lupu, A. N.: Monotherapy of staghom renal calculi: A comparative study between percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J. Urol., 139, 895 (1988). 7. Assimos, D. G., Boyce, W. H., Harrison, L. H., McCullough, D. L., Ka-oovand, R. L., Sweat, K. R.: The role of open stone surgery since extracorporeal shock wave lithotripsy. J. Urol., 12, 263 (1989). 8. Koga, S., Arakaki, Y., Matsuoka, M., Ohyama, C.: Staghom calculi - Long-term results ofmanagement. Br. J. Urol., 68, 122 (1991). 9. Lingemann, J. E., Smith, L., Woods, J. R., Newman, D. M.: Urinary Calculi: ESWL, Endourology and Medical Therapy. Lea & Febiger, Philadelphia 1989, pp International Urology and Nephrology 26, 199

7 Esen et at.: ()pen stone surgery Constantinides, C., Recker, F., Jaeger, P., Hauri, D: Extracorporeal shock wave lithotripsy as monotherapy of staghorn renal calculi: 3 )'ears of experience. J. Urot.. 12, 115 (1989). 11. Rao, P N., Holden, D: Management of staghom stones using a combination of lithotripsy, percu "taneous nephrolithotomy and solution R imgation. Br, J. Urol., 167, 13 (1991). ~2. Eisenberger, F.: Differentiated approach to staghom calculi using extracorporeal shock wave lithotripsy and percutancous nephrolithotomy. An analysis of I51 consecutive cases. WorhtJ. Urol.. 5, 28 (I 987). 13. Sohn, M.: Anesthesia-free ESWL monotherapy with double J stents versus PCNL/ESWL combined approach in staghorn disease. A retrospective randomized study. In: Lingemann, J. E., Newman, D. M. (eds): Shock Wave Lithotripsy: State of lhe Art. Plenum Press, New York 1988, Chapter 18, pp Fuchs, G. J., Fuchs, A. M., Royce, P. L.. Stenzl, A., Chaussy, C. G.: Sm~orn stone treatment with extracorpc~real shock wave lithotripsy: The fate of residual stones. In: Lmgemann. 3. E., Newman, D. M. (eds): Shock Wave Lithotrip~': State of the Art. Plenum Press, New" York 1988, Chapter 19, pp International Urology and.~lephrology 26, 199