Urinary Lithiasis (Urinary Stone Disease)

Urinary Lithiasis (Urinary Stone Disease) Dr WONG Tak Hing Bill Specialist in Urology, Pedder Clinic Hon Consultant Urologist, Queen Elizabeth Hospital Hon Director, Urology Centre, St Paul s Hospital Hong Kong Urinary Stone Which Stone Needs Tx? Stone size Stone location Obstruction Pelvicalyceal anatomy Urinary Stone Diagnosis & Assessment of Size Intravenous urography (IVU) Sensitivity 64 % Specificity 92 % Advantages: Radiation dose averages half that of NCCT Accurate in assessing stone size Disadvantages: Time consuming Potential contrast toxicity Non-contrast helical CT Sensitivity ~ 1 % Specificity ~ 98 % Advantages: Fast Demonstrates pathology outside urinary tract Disadvantages: Correctly measures stone transverse diameter, but tends to overestimate cranio-caudal length * Differentiation between calyceal & parenchymal calcification more difficult Ureteric Stone Spontaneous Passage Ueno, et al Urol 1:544, 1977 Size (mm) 1 2 3 4 5 6 7-9 1-12 Overall Ureteric Stone Spontaneous Passage Proximal 1 % 42 % 2 % 6 % 22 % % Stones Passed Middle 1 % 83 % 55 % 62 % 57 % 46 % Morse, et al J Urol 145:263, 1991 Distal 85 % 93 % 69 % 55 % 45 % 25 % 71 % Renal Stone Medical Expulsive Therapy (MET) Ureteral smooth muscle relaxants: α-1 receptor blocker Tamsulosine, Alfuzosin, Doxazosin, Terazosin Calcium-channel blocker Nifedipine Duration 3 days Grade of Recommendation: A EAU Guidelines, 211 1

Renal Stone Medical Expulsive Therapy (MET) Renal Stone Factors affecting success of MET: Stone size & location Stone <5 mm need for analgesic Proximal ureteral stone 5-1 mm encourage migration After for ureteral & renal stone Expedite expulsion, stone-free rate, analgesic requirement After URSL (lithotripsy) stone-free rate, colic episodes Renal Stone Management Expectant treatment Extracorporeal shockwave lithotripsy () Percutaneous nephro-lithotripsy (PCNL) Flexible uretero-renoscopic lithotripsy (URSL) Retrograde intra-renal surgery (RIRS) Open nephro-lithotomy Nephrectomy Lithotriptors Four Main Parts 1. Shock wave generator 2. Shock wave focusing 3. Shock wave coupling 4. Stone localisation Lithotriptors Dornier HM3 Shockwave Generation Electrohydraulic Electromagnetic Piezoelectric Electrohydraulic Piezoelectric Electromagnetic Spark gap electrode 2

Lithotriptors Dornier Gemini Renal Stone Management Pelvic / PUJ stone Size < 2 cm URSL Size > 2 cm PCNL Calyceal Size < 1 cm Expectant tx Size > 1 cm URS PCNL Renal Stone Management Ureteric Stone Management Pelvic / PUJ stone Size < 2 cm URSL Size > 2 cm PCNL Calyceal Size < 1 cm Expectant tx Size > 1 cm URS PCNL Size </= 4 mm Expectant tx Size > 4 mm Non obstructed Expectant tx Obstructed URS Stent Urinary Stone Diagnosis of Obstruction General Indications Isotope renography Functional study Best method NCCT / IVU / USG Signs: Uretero-hydronephrosis Periureteric stranding (on NCCT) or urinoma Only infer obstruction; unreliable Doppler Resistive index / colour doppler to observe ureteric jets Useful in pregnancy Renal calculi Ureteral calculi </= 2 cm </= 1 cm 3

Complications Steinstrasse Stone street Complications Perinephric Hematoma Presenting features: Significant Post- pain, requiring narcotic analgesics Drop in Hgb > 2 g/dl Risk factors: Pre-existing hypertension 2.5 % Unsatisfactorily controlled HT 3.8 % Overall.66 % UTI Simultaneous bilateral treatment [ No correlation with stone or shock wave parameters ] Knapp, et al J Urol 139:7, 1988 Risk Factors / Contraindications Complex Renal Stone (Staghorn) Pregnancy Uncontrolled coagulopathy Uncontrolled hypertension Vascular disorder Diabetes mellitus Coronary artery disease Obesity Distal obstruction Febrile UTI The Case for a More Aggressive Approach Conservative N = 6 2/3 nephrectomy 2 cold 16 pyonephrosis 4 carcinoma 28 % overall mortality (in 2 yrs) Blandy et al J Urol 115:55, 1976 Extended pyelolithotomy N = 125 % operative mortality 16.8 % recurrent stone 7.2 % overall mortality (in 1 yrs) N = 177 Solitary kidney Previous history of stone Complete staghorn Hypertension Urinary diversion Neurogenic bladder Refused treatment Renal Deterioration 77 % 39 % 34 % 5 % 58 % 47 % 1 % Overall rate of renal deterioration = 28 % Rate of Renal Deterioration + 21 % 14 % 13 % 22 % 19 % 21 % 28 % Teichman, et al J Urol 153:143, 1995 P <.1.3.2.6 <.1.6 <.1 4

Standard: A newly diagnosed patient should be actively treated. Left untreated Recurrent UTI, sepsis, & pain Destruction of kidney Mortality Priestly et al, 1949 Blandy et al, 1976 Rous et al, 1977 Vargas et al, 1982 Koga et al, 1991 Teichman et al, 1995 Treatment Options +/- indwelling stent PCNL Debulking PCNL + Open surgery Retrograde URSL Optimal Treatment Indications for Tx Approaches Stone characteristics: Overall stone burden Location of stone burden Stone composition Anatomy of collecting system Renal function Associated UTI monotherapy Minor stone burden Peripheral stone load Narrow renal collecting system High risk patients Difficult percutaneous technique - Children - Urinary diversion PCNL monotherapy Major stone burden Central (pelvic) stone load Dilated renal collecting system Less radiopaque Shockwave resistant (cystine) calculi Complete Monotherapy vs PCNL + Prospective, randomized, single centre study Stone-free rate Complication rate Unplanned ancillary procedure Overall treatment length Monotherapy (n = 27) 22 % 15 episodes (in 1 patients) 8 procedures (in 7 patients) 6 months PCNL + (n = 23) 72 % 2 episodes 1 procedure 1 month Meretyk, et al J Urol 157:78, 1997 P.5.7.3.6 Recommendation: SWL monotherapy should not be used for most patients. If undertaken, adequate drainage should be established before treatment. 5

Treatment Options Indications for Tx Approaches +/- indwelling stent PCNL Debulking PCNL + Open surgery Retrograde URSL Combined PCNL & Major stone burden Central & peripheral stone load Open surgery Massive stone burden - that requires a considerable no. of treatment sessions Concomitant reconstructive surgery AUA Guideline 1994 As a guideline, percutaneous stone removal, followed by SWL &/or repeat percutaneous procedures as warranted, should be utilized for most standard patients with struvite staghorn calculi, with percutaneous lithotripsy being the first part of the combination therapy. Recommendation: Percutaneous nephrolithotomy should be the 1st treatment for most patients. AUA Nephrolithiasis Clinical Guidelines Panel J Urol 151:1648, 1994 : Criteria of Success Clinically insignificant residual fragments (CIRF) Residual fragments </= 4 mm Ca oxalate/phosphate calculi Normal anatomy of upper urinary tract No UTI No symptoms after No adjuvant therapy required Prone oblique Prone Lateral Supine PCNL Positioning 6

PCNL Positioning : Criteria of Success Clinically insignificant residual fragments (CIRF) Residual fragments </= 4 mm Ca oxalate/phosphate calculi Normal anatomy of upper urinary tract No UTI No symptoms after No adjuvant therapy required Treatment Outcome Stone-free Status Plain AXR Percutaneous nephroscopy Non-contrast CT (NCCT) Recommendation: In combination therapy, percutaneous nephroscopy should be the last procedure for most patients. may be utilised where remaining stones cannot be reached with flexible nephroscopy cannot be safely approached via another access tract * Treatment Outcome Efficiency Quotient % Stone-free 1 + % Retreatment + % Ancillary procedures 1 Standard: Patient must be informed about relative benefits & risks associated with active treatment modalities. Denstedt, Clayman, Preminger J Endourol 4(Suppl):S1, 199 7

Morbidity of Tx (1) Open Surgery PCNL + Blood transfusion 14-7 % 5-53 % Fever 26-29 % 12-64 % Septicaemia 1 % 2-4 % Pneumothorax 5 % 2 % Arteriovenous malformation 1 % Recurrent bleeding 4 % Colonic perforation 1 % Embolism 2 % Rassweiler et al BJU 86:919, 2 Morbidity of Tx (2) Open Surgery PCNL + Urinoma / fistula 1 % Flank abscess 2 % 1 % Wound infections 4 % Flank pain 16 % Flank bulge 5 % Incisional hernia 2 % Rassweiler et al BJU 86:919, 2 Recommendation: Open surgery (nephrolithotomy) should not be used for most patients. Option: Open surgery can be considered.. when the stone is not expected to be removed by a reasonable number of less invasive procedures. Especially when Staghorn calculi extremely large Anatomy of collecting system unfavourable Abnormalities of body habitus, like extreme morbid obesity Recommendation: Nephrectomy should be considered when the involved kidney has negligible function. Lower Pole Calyceal Stone Lower Pole Calyceal Stone Post Outcome Stone Regrowth Stone Clearance (Tolley et al) (Ramsden et al) Acute infundibulo- + pelvic angle Calyceal dilatation / + morphology Infundibular width + Infundibular length Calyx pelvis height + Infundibulo-vertical angle Original stone size Original stone-free status BJU Int 83,Suppl 4:27, abstracts P51 & P52, 1999 8

Lower Pole Calyceal Stone PCNL vs Prospective randomized trial 3-month post-op stone-free rate : PCNL (n = 34) (n = 35) Overall 93 % 44 % - 1 mm 1 % 69 % 11-2 mm 86 % 29 % 21-3 mm 1 % 2 % Stone clearance after problematic, especially for calculi > 1 mm failures can be managed successfully with PCNL Lingeman JUrol 157:43, abstract 159, 1997 Lower Pole Calyceal Stone PCNL vs Prospective, randomized, multicentre trial Stone-free rate at 3 mth overall 1 1 mm 11 2 mm 21 3 mm Re-treatment Treatment failures Ancillary treatment Morbidity PCNL (n = 55) 95 % 2 / 2 26 / 28 6 / 7 9 % 2 % 22 % (n = 52) 37 % 12 / 19 6 / 26 1 / 7 16 % 13 % 11 % Lower Pole Study Group J Urol 166:272, 21 9 P <.1.87 * Lower Pole Calyceal Stone Retrograde Flexible URSL N = 9 Overall success rate = 91 % Complete fragmentation Post 2nd treatment 3-month stone-free rate Flexible Ureterorenoscope 12 F 9 F 7.5 F </= 1 mm 94 % 82 % 11-2 mm > 2 mm 95 % 45 % 82 % 71 % 65 % Full deflection With 3.2 FG nitinol basket With 2 μ holmium laser fibre Grasso JUrol 162:194, 1999 Kourambas, et al Urol 56:935, 2 * Schuster, et al J Urol 168:43, 22 Lower Pole Calyceal Stone Flexible URSL Indications: Bleeding diathesis Obesity Failed SWL Complicated intrarenal anatomy Lithotripsy in-situ vs after displacement Use nitinol basket or grasper to displace stone from lower pole calyx to a more favourable position to allow easier fragmentation Lower Pole Calyceal Stone (</=1cm) Flexible URSL vs Prospective, randomized, multicentre trial Stone-free rate at 3 mth Intraop complications Postop complications URSL (n = 35) 5 % 7 21 % (n = 32) 35 % 1 23 % P.92.6.84 associated with greater patient acceptance & shorter convalescence Kourambas, et al Urol 56:935, 2 Schuster, et al J Urol 168:43, 22 Lower Pole Study Group JUrol173:25, 25 9

Calyceal Diverticular Stone Calyceal Diverticular Stone PCNL vs Percutaneous nephrolithomy Hulbert, et al J Urol 135:225,1986 Shock Wave Lithotripsy Psihramis & Dretler J Urol 138:77, 1987 Streem& Yost J Urol 148:143, 1992 Calyceal Diverticular Stone PCNL vs Stone in Transplanted Kidney Jones, Lingeman, et al (1991) Symptom-free Stone-free Hendrikx, Debruyne, et al (1992) Symptom-free Stone-free PCNL 24 / 24 (1 %) 21 / 24 (88 %) 1 / 13 (8 %) 1 / 13 (8 %) 9 / 26 (36 %) 1 / 26 (4 %) 9 / 15 (6 %) 2 / 15 (13 %) Jones, et al J Urol 146:724, 1991 Hendrikx, et al BJU 7:478, 1992 Stone with Distal Obstruction PUJ Obstruction Treatment Options Percutaneous endopyelotomy Balloon dilatation Acucise endopyelotomy URS endopyelotomy Laparoscopic pyeloplasty antegrade ante / retro retrograde retrograde 1

Renal Stone + PUJ Obstruction Concomitant Lithotomy + Stricturoplasty PUJ Obstruction Percutaneous Endopyelotomy Percutaneous endopyelotomy Balloon dilatation Acucise endopyelotomy URS endopyelotomy Laparoscopic pyeloplasty antegrade ante / retro retrograde retrograde J Wickham, 1984 Percutaneous Endopyelotomy Davis Intubated Ureterotomy PUJ Obstruction Percutaneous Endopyelotomy N = 212 (1983-1991) Success rate: - Overall 86 % - Primary (11) 85 % Secondary (12) 86 % Motola, Badlani & Smith JUrol 149:453,1993 Percutaneous Endopyelotomy Contraindications Laparoscopic Reconstruction Long segment of obstruction (> 2 cm) Crossing vessel (?) Contraindications to endourological approach: Active infection Bleeding diathesis 11

Ureteral Stone Ureteral Stone Management Expectant treatment Medical expulsion therapy Extracorporeal shockwave lithotripsy () Flexible uretero-renoscopic lithotripsy (URSL) Laparoscopic uretero-lithotomy Rigid Ureterorenoscopy Day surgery Managed anaesthetic care (MAC) Intravenous Propofol Ureteral Stone Intracorporeal Lithotripsy Electrohydraulic Ultrasonic Pneumatic Alexandrite laser Dye laser Holmium laser Lower Ureteral Stone URSL vs Earlier stone-free status Lower re-treatment rate Less exposure to radiation Less time-consuming Peschel, et al J Urol 162:199, 1999 Ureteral Calculi AUA Clinical Practice Guidelines Options: PCNL URSL Proximal ureter Stones </= 1cm + Stones > 1cm + + + Distal ureter Stones </= 1cm + + Stones > 1cm + + 12

Flexible Ureterorenoscopy 13