ENDOUROLOGIC MANAGEMENT OF MEDULLARY SPONGE KIDNEY

Transcription

1 4/1/15 ENDOUROLOGIC MANAGEMENT OF MEDULLARY SPONGE KIDNEY Joel Teichman MD Professor, University of British Columbia St. Paul s Hospital Vancouver, BC TAKE-HOME POINTS MSK/nephrocalcinosis pain may differ from classic renal colic Metabolic parameters Pain control may require surgical intervention 1

2 4/1/15 MEDULLARY BLUSH MEDULLARY CALCIFICATIONS 2

3 4/1/15 MSK Curr Opin Nephrol Hypertens 2013;; 22: 421 Prevalence <0.5% 12-20% recurrent stone formers 50% of patients have MSK relatives Autosomal dominant, reduced penetrance, variable expressivity MSK Curr Opin Nephrol Hypertens 2013;; 22: 421, AUA 2009 (#1461) Kidney Int 1984;; 25: 453 Disruption ureteric bud (GCNF)-metanephric mesenchyme (RET) Defective urinary concentration, altered Tm glucose PAH, drta, hypocitraturia, low plasma P, renal leak Ca Hypocitraturia 52%, hypercalciuria 24%, hyperoxaluria 17%, hyperuricosuria 8% Stones, hematuria, UTI (biofilm) 3

4 4/1/15 ACUTE LEFT RENAL COLIC RENAL COLIC Acute RPP hydronephrosis capsular distension mechanoreceptors splanchnic innervation 4

5 4/1/15 UROSEPSIS UROSEPSIS 5

6 4/1/15 PAPILLARY CALCIFICATIONS PATIENT PERSPECTIVE Has it happened to you? Have you struggled to make your doctor understand? It isn t just you. It seems to be the endless plight of many symptomatic MSK patients. The doctor rolls his eyes and explains to the patient MSK doesn t cause pain unless there is a stone on the move or a blockage. I used to go to the ER nearly once a month. I was labeled a drug seeker. It didn t matter my urine was red and my scans showed extensive nephrocalcinosis the docs treated me like a junkie I was sent home to deal with the pain on my own and told stones inside the kidney don t cause pain. 6

7 4/1/15 MSK PAIN No evidence obstruction (absence of hydro) Hundreds of stones Medullary pyramids Ache > colic Pain seems outsized for the problem ESWL FOR MSK UROL 1993;; 41: patients with MSK who had ESWL 31 treatments on 24 renal units 94% renal colic 15 targeted renal calculi (5 diffuse), 5 ureteral stones Mean FU 25 months 7/17 (41%) symptom-free 2/17 (12%) stone-free 7

8 4/1/15 5 diffuse renal stones ESWL FOR MSK UROL 1993;; 41: 331 2/5 had postop infection 1/5 was symptom-free 5/17 (31%) required retreatment, 4 within 6 months 3/17 (18%) required rehospitalization for colic 3/5 ureteral stone patients were symptomfree ESWL AND MSK Urologia Internationalis 2001;; 66: patients HM patients MSK Mean stone size 18 mm 2000 shocks, 20 kv 1/16 (8%) stone-free 2/16 (12%) success 13/16 (82%) failure 8/16 retreatment 8

9 4/1/15 PROPHYLACTIC ESWL FOR MSK Brit J Urol 1993;; 71: renal units 9 patients Tomograms showed > 10 calcifications Lithostar Ureteral stones 3 x/week (1-7 SWL) 8 mm Renal stones (q 2 weeks) (1-10 SWL, 4.5) 15,930 shocks, 17.6 kv PROPHYLACTIC ESWL FOR MSK Brit J Urol 1993;; 71: 392 0/11 renal units showed significant fragmentation or evacuation (3 months) 2/3 required nephrostomy Prophylactic ESWL not recommended 9

10 4/1/15 PAPILLARY CALCIFICATIONS INDEX CASE 43 yo woman left flank pain 6 months Small bowel resection, ureteral stone UA, U C&S, lytes, PTH were normal CT and IVU: 4 left renal stones < 3 mm Hypocitraturia, hyperoxaluria Lasix renal scan and VCUG normal 10

11 4/1/ flex ureteroscope 6 stones visualized CASE REPORT UROL 2000: 56: 508 stones attached to the papillae;; some had overlying intact urothelium Ho:YAG and EHL All papillae stone free 16 months later pain-free and stone-free CASE REPORT UROL 2000: 56: 508 Our case is unique in published reports that flex ureteroscopy combined with laser and EH lithotripsy was successfully used to render a patient with early nephrocalcinosis stone-free with resultant resolution of her flank discomfort. Further experience is needed to determine whether this approach to symptomatic nephrocalcinosis should become more widespread. 11

12 4/1/15 ACUTE LEFT RENAL COLIC Patient Demographics Patient Age Gender Side Treated Treatment Date JF 24 M Bilateral 5/01 YL 42 F Right Left BC 28 F Right 4/01 5/01 10/01 12

13 4/1/15 Results Patient Preop stones Postop stones Preop pain Postop pain Preop Meds (daily) Postop meds JF 8 (0.5-5 mm) 1 (2mm) 9 (8-10) 0 Vioxx Percocet 25mg none YL >20 ( mm) significantly decreased 7 (5-9) 0 Oxycontin 100mg none BC >10 (0.5-5 mm) CT pending 7 (4-10) 0 Vicodin 60mg none Preoperative Postoperative 13

14 4/1/15 Preoperative Quality of life (0 pain does not interfere, 10 pain totally interferes) Parameters JF YL BC General activity 6 7 8/9 Mood 2 9 8/9 Walking ability 0 1 8/9 Normal work 6 8 8/9 Relations with other people 6 7 8/9 Enjoyment of life 6 8 8/9 Sexual activity Sleep 8 9 6/7 Results All patients Pain free Follow-up ( months) Pain medication free Normal quality of life No complications 14

15 4/1/15 Conclusions Parenchymal stones may cause collecting duct obstruction and pain Ureteroscopy is a safe and effective treatment for these patients Pain relief Elimination of narcotic usage Dramatic improvement in QOL LASER PAPILLOTOMY J Urol 2011;; 185: institutions MSK and papillary calcifications 65 patients (176 procedures, 29 bilateral) 39 patients repeat (2-12) FU mean 38 months Mean age 42 years 15

16 4/1/15 MEDULLARY STONES PRE AND POST 16

17 4/1/15 LASER PAPILLOTOMY Significantly less pain > 3 months 83% Mean response 26 months > 1 year 60% 0/65 patients reported increased pain No difference MSK vs nonmsk LASER PAPILLOTOMY Hospitalization 8% Overall, mean GFR decreased 2.2 ml/min 3 years 11% hypertension pre, 6% new onset hypertension 17

18 4/1/15 PERSPECTIVES In March 2012, I met my MSK savior in the form of Dr. Stuart Wolf. MC: I have treated patients. I have been impressed with the dramatic relief of pain patients can have after unroofing these stones. These patients have a constant achy pain in the kidney(s), not colicky. I think of it as a prostatitis of the kidney. RVC: I think papillotomy makes a lot of sense if I am not mistaken this goes back even to Bill Boyce. I believe it is a reasonable option and have used it in MSK patients. URETERONEPHROSCOPY J Urol 2002;; 167: 31 N=598 ureteral/renal stones (9.4% kidney) Semirigid Fr Flexible Fr No sheaths Stent x 7 days IVU or US at 6-12 weeks 18

19 4/1/15 URETERONEPHROSCOPY J Urol 2002;; 167: 31 94% stone-free one sitting Repeat ureteroscopy 27 (5%) Intraop complications 13 1 ureteral perforation 3 Laser fiber breakage within the scope 6 Ureteral injury (wire, EHL) 1 ureteral stricture (no impaction) 6 ureteral stricture (impaction) REPEAT URETEROSCOPY AUA patients > 2 ureteroscopies (n=210) 8/83 repeat URS for ureteral stone vs. 1/127 for renal stone had a stricture, p<0.01 6/8 (75%) had impacted ureteral stone, 2/8 perforation 1 renal stone stricture (UPJO and perforation) No access sheath patient developed stricture 19

20 4/1/15 URETEROSCOPY J Endourol 2013;; 27: 710 n=292 (163 obese, 76 overweight, 53 normal) 80% flexible ureteroscopy (obese) Trend in obese towards access sheath p= strictures in the obese (1.2%) SUMMARY MSK/nephrocalcinosis pain may differ from classic renal colic Metabolic parameters Laser papillotomy 20

21

22

23

24

25

26

27

28

29

30

31

32

33

34

35

36

37

38

39

40