Current trends in the management of urinary stones

Transcription

1 Acta Radiologica ISSN: (Print) (Online) Journal homepage: Current trends in the management of urinary stones T. P. Smith, W. R. Castaneda-Zuniga, M. D. Darcy, A. H. Cragg, D. W. Hunter & K. Amplatz To cite this article: T. P. Smith, W. R. Castaneda-Zuniga, M. D. Darcy, A. H. Cragg, D. W. Hunter & K. Amplatz (1988) Current trends in the management of urinary stones, Acta Radiologica, 29:2, To link to this article: Published online: 07 Jan Submit your article to this journal Article views: 138 Full Terms & Conditions of access and use can be found at

2 A C T A R A D I O L O G I C A Vol. 29 Fasc March-April REVIEW ARTICLE CURRENT TRENDS IN THE MANAGEMENT OF URINARY STONES T. P. SMITH, W. R. CASTANEDA-ZUNIGA, M. D. DARCY, A. H. CRAGG, D. W. HUNTER and K. AMPLATZ Abstract The treatment of renal and ureteral stones has undergone rapid and major changes over the past ten years. Extracorporeal shockwave lithotripsy has become the most commonly used modality for the treatment of renal and upper ureteral stones. Lower ureteral stones are more commonly being approached by retrograde techniques. Percutaneous nephrolithotomy, medical therapy, and open surgical nephrolithotomy offer viable alternatives in given situations. Presented here is the current application of each of these techniques, both alone and in combination, for the treatment of urinary stones. Key words: Genitourinary system, calculi; management. Alternatives to open surgical nephrolithotomy have long been sought. It is well known that such open surgical procedures are often associated with high rates of morbidity. Approximately ten years prior to this writing, percutaneous nephrolithotomy (PNL) and extracorporeal shockwave lithotripsy (ESWL) began development (8, 19). Early reports of PNL were clinical and although laboratory work was performed, clinical application was almost immediate (42). Rapid advancements were made as more varied and complex urinary stones were approached. Out of PNL the concept of endourology was developed, including antegrade and retrograde ureteral techniques. The acceptance of PNL over surgery was rapid. With superior morbidity rates and lessened convalescence time, PNL became the standard for stone removal (3, 4). Open surgical nephrolithotomy became reserved for complicated and individualized cases which often required the application of corrective surgical techniques for underlying urinary abnormalities. In contrast to PNL, ESWL underwent extensive laboratory testing prior to its clinical application (7, 11). ESWL demonstrated excellent patient results and its clinical applications were obvious (12). Due to its reduced morbidity when compared with PNL, ESWL has become the accepted method of treatment for most renal and upper ureteral stones (6, 13). The role of PNL is still important, but has become necessary in decreasing amounts over the past few years (5). It is clear that there are numerous ways to approach the removal of urinary calculi, ranging from open surgery to completely non-invasive methods. Whether a stone is located in the kidney or ureter, particularly its position either in the proximal or distal ureter, as well as stone size and composition always plays an important role in the method of stone removal. In addition, the anatomy and any abnormalities in the urinary system must also be considered. Obviously the choice must be made for each patient on an individual basis and may involve a combined approach using more than one available technique. There are five currently available techniques for urinary stone removal: 1) Extracorporeal shockwave lithotripsy, 2) percutaneous nephrolithotorny, 3) retrograde ureterorenoscopy, 4) open surgical nephrolithotomy, and 5) medical management. From the Department of Radiology, University of Minnesota Hospital and Clinic, Minneapolis, Minnesota 55455, USA. Accepted for publication 8 June

3 146 T. P. SMITH ET COLL. a b C d Fig. 1. PNL and ESWL in a patient with urinary stones. a) Nephrotomogram demonstrating a calculus in the inferior portion of the right renal pelvis. b) Nephrostogram following percutaneous stone removal demonstrating no residual stones. A balloon catheter filled with contrast medium is present in the renal pelvis. c) Radiograph three years later demonstrating a stone (+) in the collecting system of the inferior pole. d) Patient three days after ESWL with no stone fragments demonstrated. Extracorporeal shockwave lithotripsy ESWL is currently the most accepted mode of treatment for most renal and upper ureteral calculi. ESWL has replaced PNL for renal calculi in at least ninety per cent of the patients (5) (Fig. 1). CHAUSSY & FUCHS (9) reported their world experience as greater than a ninety per cent success rate of stone removal using ESWL. DRACH et coll. (14) in a United States cooperative study reported successful removal rates for renal stones under one cm in size to be approximately eighty-two per cent. However, this figure rapidly decreased as stone size increased. Staghorn calculi treated by ESWL alone demonstrated success rates of less than seventy per cent. Upper ureteral stones can be subjected to ESWL either in situ or following endoscopic manipulation. Endoscopic manipulation consists of either relocating the calculus more superiorly (into upper ureter or renal pelvis) or placing a catheter alongside the existing calculus for a modified in situ treatment. Upper ureteral stones are most successfully treated by being pushed into the renal pelvis or at least higher in the ureter and subsequently subjected to ESWL. By this combined approach, successful stone removal rates have been shown to significantly improve (37). When the stone cannot be dislodged from the ureter, in situ ESWL is the initial mode of therapy. The in situ ureteral stone success rates have been reported to improve significantly with the small catheter alongside and beyond the stone (29). These data clearly demonstrate the continued need for endourology skills. Recent reports proclaim good success rates for distal ureteral stones using ESWL (34). However, the major anatomic limitation to ESWL for distal ureteral stone remains; the bony pelvis and distal ureteral stones are still most often removed via an alternative method. ESWL has proved to be a safe technique which has been shown to be relatively free of serious damage to the kidney itself (27, 38). One of the most common complications remains obstruction to urine outflow by stone fragments, CHAUSSY & SCHMIEDT (10) reporting three per cent needing auxiliary interventional procedures for stone debris. Such auxiliary procedures most often involve PNL or retrograde ureteral techniques. Percutaneous nephrolithotomy PNL has proven to be an effective method of stone removal. Large series demonstrate success levels of near ninety-nine per cent for renal stones (35, 41). Ureteral stone removal has also approached one hundred per cent success rates when combined with retrograde techniques (23). Therefore, when successful stone removal alone is the prime consideration, PNL in experienced hands is overall superior to ESWL. However, the attractiveness of ESWL is obvious in its non-invasiveness and lower complication rates. LANC (25) in a large series comprised of multiple institutions noted a serious complication rate of 1.46 per cent for PNL even in experienced hands, the most common complications being perirenal abscess formation and hemorrhage requiring transfusion. This is in contrast to large ESWL studies demonstrating severe complication rates of only 0.2 per cent (1). However, nearly twenty-five per cent of stones are not amendable to ESWL therapy alone and require percutaneous techniques (17). PNL is most useful for: 1) Large stone vol-

4 CURRENT TRENDS IN THE MANAGEMENT OF URINARY STONES 147 Fig. 2. Large stone volumes are probably best approached in a combination of percutaneous nephrolithotomy (PNL) and extracorporeal shockwave lithotripsy (ESWL). a) Large stone volume in a patient treated initially only with ESWL. Abdominal film demonstrating large stone volume in the right kidney. b) Following ESWL, multiple fragments are noted filling the distal ureter, resulting in complete obstruction. These subsequently had to be removed via percutaneous and retrograde methods. c) Abdominal film in a patient with a large left staghorn calculus. d) A percutaneous nephrostomy was performed with stone debulking. Note the large nephrostomy catheter as well as the smaller catheter which has been placed down the ureter. The patient was subsequently subjected to ESWL. A follow-up film is shown here and the patient is stone-free radiographically. umes (greater than 2.5 cm), 2) anatomically obstructed urinary systems, 3) cystine calculi, and 4) ESWL failures. It is generally accepted that larger stone volumes, including staghorn calculi do poorly with extracorporeal methods (45). Alternatively, it has been well shown that a combined approach using PNL and ESWL insures better overall success rates for removal of large calculi (24) (Fig. 2). PNL is initially carried out with as much stone debulking as possible. The nephrostomy tube then remains in place following the subsequent ESWL to facilitate drainage of stone fragments. If stone fragments fail to drain adequately they can be removed via the percutaneous access. TEGTMEYER et coll. (43) report that stones of less than 2.5 cm in diameter, only 1.8 per cent required inter- ventional procedures. Whereas for stones 2.5 cm or greater, twenty-nine per cent needed interventional procedures to relieve obstruction. Anatomic obstruction to urine outflow is used here to denote a narrowing in the urinary system. When considering stone disease, this occurs in three main areas: the ureter including the ureteropelvic junction, a caliceal infundibulum, and the neck of a caliceal diverticulum (Fig. 3). Stone fragments from ESWL cannot drain from such obstructed areas and thus necessitate an alternative form of removal. PNL allows the calculi to be removed effectively in all of these situations provided the proper access can be achieved, and excellent success rates have been reported (22, 36). In addition the anatomic areas of narrowing can be effectively treated percutaneously by dilatation, electrocautery, or a combination of these techniques (26). Cystine stones have been shown to respond less well to ESWL (44). Currently, the best approach to cystine calculi is unanswered. Probably a combined approach using ESWL and PNL is best. Such an approach even allows additional techniques of chemolysis. However, a trial of ESWL alone may be warranted so long as endourologic and open surgical alternatives are available. Finally, PNL offers an alternative to open surgery in the event of ESWL failure for whatever reason. However, following such failure, any alternative attempt at stone removal must be well planned and individualized to the particular patient to ensure the safest, most successful outcome possible. Retrograde ureterorenoscopy As PNL developed, the associated instrumentation improved. This improved instrumentation allowed quite intricate bladder, ureteral, and renal work using rigid and flexible endoscopes in a retrograde manner (20). Retrograde work can be an adjunct to ESWL or for direct stone removal. As discussed earlier, retrograde techniques before undergoing ESWL have greatly enhanced the success rates of ESWL upon ureteral stones, at the same time limiting the degree of necessary stone manipulation. In addition, placement of catheters pre-eswl for injections of contrast medium allows adequate focusing for nonopaque renal calculi. Retrograde ureteroscopy following ESWL is most often for distal ureteral stone fragment removal. Following all successful stone fragmentations with ESWL, there is a degree of accumulation of calculi along the course of the ureter ( Steinstrasse ). In most instances these fragments pass without difficulty. However, in six per cent these become symptomatic and removal becomes necessary and is best achieved through retrograde ureteroscopy (28). Not only can stones be removed, retrograde techniques, like PNL, have the added advantage of being able to stent ureters to allow easy passage of additional stone debris.

5 148 T. P. SMITH ET COLL. Since ESWL is limited by the bony pelvis, distal ureteral stones must be removed by an alternative method. Direct stone removal using retrograde techniques and a variety of baskets, snares, and graspers presents an excellent alternative method to extracorporeal therapy. In addition, retrograde ureteroscopic lithotripsy allows successful fragmentation of stones in the ureter (21). The overall success rate of distal ureteral stone removal has been shown to be as high as ninety-two per cent with very low associated complication rates (39). Finally, retrograde ureteral stone removal has the advantage of appearing less invasive to the patient when compared with PNL. With low complication and morbidity rates, retrograde ureterorenoscopy is assured a future in urinary stone removal, both as a primary and as an adjunctive agent. Open surgical nephrolithotomy Open surgery remains the most effective means to completely remove renal calculi. However, even if costs are somewhat contained, open surgery has associated with it greater convalescence time and perioperative pain (4). Given the previously described success rates for ESWL and PNL, either alone or in combination, open surgical stone removal has become indicated in less than one per cent of the cases (14). Certain selected cases of large impacted stones, anatomic considerations that would necessitate open repair, and extreme obesity contraindicating ESWL or PNL are indications. Extracorporeal surgery and autotransplantation offers the advantage of repairing abnormalities such as extensive ureteral or vascular damage and treating renal calculi concomitantly (2). In addition, any cases which would require partial nephrectomy or the possibility of total nephrectomy probably should initially be undertaken as open surgical cases. Finally, and certainly not least importantly, the existence of a viable alternative to the less invasive procedures including the rare need for the treatment of severe complications of these lesser invasive procedures remains of utmost importance. Medical management Medical therapy for urinary stones can be basically divided into systemic and local administration. Systemic therapy is mostly aimed at decreasing the formation of new stones and has been shown to be effective in reducing stone formation (18) and the subsequent need for surgery (33). PAK & FULLER (31) demonstrated a reduction in the rate of new oxalate stone formation by nearly ninety per cent using potassium citrate therapy. However, actual stone dissolution can be achieved by systemic therapy. Uric acid calculi treated by oral alkalinization and cystine calculi treated by alkalinization and penicillamine have been successful (30). Local therapy is placed through a percutaneous neph- Fig. 3. Stone in a caliceal diverticulum removed by percutaneous methods. a) Abdominal film demonstrating a calcification overlying the kidney. b) Intravenous pyelogram demonstrating a caliceal diverticulum with a filling defect representing the stone. Stones in such a caliceal diverticulum with a narrowed neck are best removed via percutaneous methods. c) Chest radiograph on the patient following percutaneous removal. The nephrostomy tube is present in the left upper abdomen. No residual stones were noted. The tube has been placed across the neck of the diverticulum which was dilated. A complication of percutaneous nephrolithotomy can be involvement of the pleural space with an intercostal puncture as was necessary in this case. Note the near complete opacification of the left hemithorax. A chest tube was placed for drainage of pleural fluid. This, however, cleared cornpletely.

6 CURRENT TRENDS IN THE MANAGEMENT OF URINARY STONES 149 rostomy and involves the dissolution of existing calculi (32). This has proven to be most successful with struvite and cystine calculi. Tromethamine-E currently appears to be the most effective local treatment for cystine calculi, and hemiacidrin for struvite calculi (15, 16). When coupled with ESWL, the success of dissolution techniques increases even further (40). Although calcium oxalate stones are the most common urinary calculi, they remain at present the most resistant to dissolution techniques. With continued progressive development, medical stone therapy certainly holds promise for the future, possibly becoming the least invasive method of stone removal. The treatment of urolithiasis had changed greatly over the past ten years from open surgery to percutaneous nephrolithotomy to extracorporeal shockwave lithotripsy. The trend obviously is toward more non-invasive techniques with their associated decreased morbidity. Certainly strides will be made to continue this existing trend. Newer modalities such as laser treatment and catheters fitted with rotating, cutting blades may have a place. At present, there is certainly not one technique that can be applied in all cases. Each case must be approached on an individual basis and the proper mode of therapy or combination of therapies applied to ensure the greatest possible success. Requestfor reprints: Dr Wilfrido R. Castaneda-Zuniga, Department of Radiology, Box 292 UMHC, University of Minnesota Hospital and Clinic, Harvard Street at East River Road, Minneapolis, MN 55455, USA. REFERENCES 1. ALKEN P., HARDEMAN S., WILBERT D., THUROFF J. and JACOBI G. H.: Extracorporeal shock wave lithotripsy (ESWL). Alternatives and adjuvant procedures. World J. Urol. 3 (19851, ANDERSEN 0. S., CLARK S. S., MARLETT M. M. and JONASSON 0.: Treatment of extensive renal calculi with extracorporeal surgery and autotransplantation. Urology 7 (1976), BRANNEN G. E. and BUSH W. H.: Percutaneous ultrasonic versus surgical removal of kidney stones. Surg. Gynecol. Obstet. 161 (1985), BROWN M. W., CARSON C. C., DUNNICK N. R. and WEINERTH J. L.: Comparison of the costs and morbidity of percutaneous and open flank procedures. J. Urol. 135 (1986), BUSH W. H., GIBBONS R. P., LEWIS G. P. and BRANNEN G. E.: Impact of extracorporeal shock waves lithotripsy on percutaneous stone procedures. Amer. J. Roentgenol. 147 (1986), CHAIUG C. R., WEBB D. R., PAYNE S. R. and WICKHAM J. E. A.: Comparison of treatment of renal calculi by open surgery, percutaneous nephrolithotomy, and extracorporeal shockwave lithotripsy. Brit. Med. J. 292 (1986), CHAUSSY C., BRENDEL W. and SCHMIEDT E.: Extracorporeally induced destruction of renal stones by shockwaves. Lancet I (1980), EISENBERGER F., WANNER K. et coll.: The use of shockwaves for the destruction of renal calculi without direct contact. Urol. Res. 4 (1976) and FUCHS G. J.: World experience with extracorporeal shock-wave lithotripsy (ESWL) for the treatment of urinary stones. An assessment of its role after five years of clinical use. Endourology 1 (1986), and SCHMIEDT E.: Extracorporeal shock wave lithotripsy (ESWL) for kidney stones. An alternative to surgery? Urol. Radiol. 6 (1984), FORSSMANN B. and BRENDEL W.: Contact-free renal stone destruction by means of shockwaves. Eur. Surg. Res. 2 (1979), JOCHAM D., BRENDEL W., FORSSMANN B. and WALTHER V.: First clinical experience with extracorporeally induced destruction of kidney stones by shockwaves. J. Urol. 127 (1982), SCHULLER J., BRANDL H. and LIEDL B.: Extracorporeal shock-wave lithotripsy (ESWL) for treatment of urolithiasis. Urology 23 (1984), DRACH G. W., DRETLER S., FAIR W. et coll.: Report of the United States cooperative study of extracorporeal shock wave lithotripsy. J. Urol. 135 (1986) DRETLER S. P. and PFISTE R. C.: Primary dissolution therapy of struvite calculi. Urology 131 (1984), NEWHOUSE J. H. and PRIEN E. L.: Percutaneous catheter dissolution of cystine calculi. Urology 131 (1984), EISENBERGER F., FUCHS G., MILLER K., BUB P. and RASS- WEILER J.: Extracorporeal shockwave lithotripsy (ESWL) and endourology. An ideal combination for the treatment of kidney stones. World J. Urol. 3 (1985), ELOMAA I., ALA-OPAS M. and PORKKA L.: Five years of experience with selective therapy in recurrent calcium nephrolithiasis. Urology 132 (1984), FERNSTROM I. and JOHANSSON B.: Percutaneous pyelolithotomy. A new extraction technique. Scand. J. Urol. Nephrol. 10 (1976), HUFFMAN J. L., BAGLEY D. H. and LYON E. S.: Extending cystoscopic techniques into the ureter and renal pelvis. Experience with ureteroscopy and pyeloscopy. J. Amer. Med. Ass. 250 (1983), SCHOENBERG H. W. and LYON E. S.: Transurethral removal of large ureteral and renal pelvic calculi using ureteroscopic ultrasonic lithotripsy. J. Urol. 130 (1983), HULBERT J. C., REDDY P. K., HUNTER D. W., CASTANEDA- ZUNIGA W. R., AMPLATZ K. and LANCE P. H.: Percutaneous techniques for the management of caliceal diverticula containing calculi. J. Urol. 135 (1986), HUNTER D. W., CASTANEDA-ZUNIGA W. R., YOUNG A. T. et coll.: Percutaneous removal of ureteral calculi. Clinical and experimental results. Radiology 156 (1983, KAHNOSKI R. J. LINGEMAN J. E., COURY T. A., STEELE R. E. and MOSBAUGH P. G.: Combined percutaneous and extracorporeal shock wave lithotripsy for staghorn calculi. An alternative to anatrophic nephrolithotomy. J. Urol. 135 (19861, LANG E. K.: Percutaneous nephrostolithotomy and lithotripsy. A multi-institutional survey of complications. Radiology 162 (1987), LEE W. J., BADLANI G. H. and SMITH A. D.: Percutaneous nephrostomy for endopyelotomy. Amer. J. Roentgenol. 148 (1987), MARCELLAN F. J. R. and SERVIO L. I.: Evaluation of renal damage in extracorporeal lithotripsy by shock waves. Eur. Urol. 12 (1986), MILLER K., FUCHS G., RASSWEILER J. and EISENBERGER F.: Treatment of ureteral stone disease. The role of ESWL and endourology. World J. Urol. 3 (19851, MUELLER S. C., WILBERT D., THUEROFF J. W. and ALKEN P.: Extracorporeal shock wave lithotripsy of ureteral stones. Clinical experience and experimental findings. J. Urol. 135 (1986), 831.

7 150 T. P. SMITH ET COLL. 30. PAHIRA J. J.: Nephrolithiasis. Current concepts in medical management. Urol. Radiol. 6 (1984), PAK C. Y. C. and FULLER C.: Idiopathic hypocitraturic calciumoxalate nephrolithiasis successfully treated with potassium citrate. Ann. Intern. Med. 104 (1986), PFISTER. C. and DRETLER S. P.: Percutaneous chemolysis of renal calculi. Urol. Radiol. 6 (1984), PREMINCER G. M., PETERSON R., PETERS P. C. and PAK C. Y. C.: The current role of medical treatment of nephrolithiasis. The impact of improved techniques of stone removal. J. Urol. 134 (1985), RASSWEILER J., HATH U., BUB P. and EISENBERGER F.: Extracorporeal shock-wave lithotripsy (ESWL) for distal ureteral calculi. Endourology I (1986), REDDY P. K., HULBERT J. C., LANCE P. H. et coll.: Percutaneous removal of renal and ureteral calculi. Experience with 400 cases. J. Urol. 134 (1985), LANCE P. H., HULBERT J. C. et coll.: Percutaneous removal of caliceal and other inaccessible stones. Results. J. Urol. 132 (1984), RIEHLERA: An approach to upper ureteral stones with extracorporeal shock-wave lithotripsy (ESWL). Endourology 1 (1986), RUBIN J. I., ARCER P. H., POLLACK H. M. et coll.: Kidney changes after extracorporeal shock wave lithotripsy. CT evaluation. Radiology 162 (1987), Rutner A. B.: Ureteral balloon dilatation and stone basketing. Urology 23 (1984), SCHMELLER N. T., KERSTINC H., SCHULLER J., CHAUSSY C. and SCHMIEDT E.: Combination of chemolysis and shock wave lithotripsy in the treatment of cystine renal calculi. J. Urol. 131 (1984), SECURA J. W., PATTERSON D. E., LEROY A. J. et coll.: Percutaneous removal of kidney stones. Review of 1000 cases. J. Urol. 134 (1985), SMITH A. D., REINKE D. B., MILLE R. P. and LANCE P. H.: Percutaneous nephrostomy in the management of ureteral and renal calculi. Radiology 133 (1979), TEGTMEYER C. J., KELLUM C. D., JENKINS A. et coll.: Extracorporeal shock wave lithotripsy. Interventional radiologic solutions to associated problems. Radiology 161 (1986), WEBB D. R., MCNICHOLAS T. A., WHITFIELD H. N. and WICKHAM J. E. A.: Extracorporeal shockwave lithotripsy, endourology and open surgery. The management and followup of 200 patients with urinary calculi. Ann. Roy. Coll. Surg. Engl. 67 (1985), PAYNE S. R. and WICKHAM J. E. A.: Extracorporeal shockwave lithotripsy and percutaneous renal surgery. Cornparisons, combinations and conclusions. Brit. J. Urol. 58 (1986), 1.