Non-staghorn Kidney Stone: - PowerPoint PPT Presentation

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Non-staghorn Kidney Stone:

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... ESWL vs PCNL or URS Lower Pole I study : PCNL vs ESWL ( Clayman et al. J Urol 2001) stone size: 14.43 mm (PCNL), 14.03 (ESWL) stone ... – PowerPoint PPT presentation

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Title: Non-staghorn Kidney Stone:


1
Non-staghorn Kidney Stone PCNL Vs Retrograde
Intrarenal Surgery
????? ? ??
2
Natural history of renal stones
  • Staghorn stone
  • renal destruction and significant morbidity and
    mortality ? active treatment
  • Asymptomatic calyceal renal stone or simple renal
    stone
  • half of stone grew during the period of
    observation
  • an episode of ureteric colic within 7 years 68
  • requiring surgery 40
  • correlated with number of stones

  • (Hubner et al, Eur Urol 1993)
  • Noninvasive and minimally invasive treatments are
    now available

3
Less invasive techniques
4
Advantages Disadvantages
  • PCNL
  • advantage higher stone-free rates, lower
    retreatment rates
  • disadvantage more invasive, complication?
  • ESWL
  • advantage less invasive, short recovery time,
    pts prefer
  • disadvantage lower stone-free rates in large or
    lower pole stone
  • URS
  • advantage less invasive, complication?,
    outpatient procedure
  • disadvantage leaves fragmented stone ,
    relatively lower stone-clearance rates, routine
    need for ureteral stenting, longer fragmentation
    time

5
Traditional concepts
? Now Future
  • advances in URS
  • miniature flexible ureterosocpy
  • bidirectional deflection up to 270
  • superior optics
  • energy sources for intracorporeal lithotripsy
  • availability of accessories

? URS?
? URS?
? URS?
6
Outcomes
7
Stone burden (size)
  • CT improve treatment decisions for many
    borderline renal stone cases
  • stone burden?, stone free rate?
  • Stone free rate of large renal stone (gt2 cm)
  • PCNL 71-95
  • ESWL 41-54

8
Stone Free Rates of URS (lt2cm)
Sofer et al (2002) Elashry et al (1996) Tawfiek et al (1999)
No. of pts 56 57 59
Mean size (mm) 13.5 8.5 6.8
Lithotriptor HoYAG, EHL 1.9 Fr EHL HoYAG, EHL
Residual lt2mm lt2mm lt3mm
Stone free rate() 84 98 79.7
9
PCNL (N15) vs URS (N12)
10
Stone Free Rates of URS (gt2cm)
Mariani (2004) Ricchiuti et al (2007) Breda et al (2008) Mariani (2008)
No. of pts 13 23 15 16
Mean size (mm) 33 31 22 65
Stages 2.4 1.5 2.3 2.4
Stone free rate() 92 73.9 93.3 88
11
Lower pole stone ESWL vs PCNL or URS
  • Lower Pole I study PCNL vs ESWL (
    Clayman et al. J Urol 2001)
  • stone size 14.43 mm (PCNL), 14.03 (ESWL)
  • stone free rate 95 vs 37 (gt1cm 21)
  • morbidity 22 vs 11, no significance
  • Lower pole II study URS vs ESWL (
    Pearle et al. J Urol 2005)
  • stone size lt1cm
  • stone free rate 50 vs 35, no significance
  • ESWL short recovery period, feel more
    positively

12
Lower pole stone URS
Grasso et al (1999) Hollenbeck et al (2001) Schuster et al (2002)
No. of pts 79 61 95
Stone free rate () 1-10mm 82 11-20mm 71 gt20mm 65 1-10mm 71 10-20mm 75 in situ 71 displacement 94
Comment Long lower pole infundibulum infundibular stricture displacement gt in situ
13
Stone composition
  • CT attenuation
  • lt1000 HU- uric acid or struvite stones
  • gt1000 HU- calcium oxalate and hydroxyapatite
    stone
  • Stone clearance rate following ESWL
    (Joseph et al, J Uol 2002)
  • gt1000 HU- 54.5
  • 500-1000 HU- 85.7
  • lt500 HU- 100
  • The range of fragility within a single
    composition
  • More fragile in cystine stone with rough surface

14
Anatomical variants
  • Calyceal diverticulum
  • Incidence of stone forming 10-50
  • Stone-free rates
  • ESWL (4-58), PCNL (85-93), URS (50-73)
  • Obliteration rates
  • PCNL (80-100), URS (18)

Auge et al (2002) Park et al (1999)
Comparison PCNL vs URS PCNL vs URS
Stone free rate 78 vs 19 92 vs 64
complication 10 vs 0 42 vs 0
conclusions PNL gtURS URS is an attractive modality
15
Patients clinical factors
  • Obesity
  • Skin-to-stone distancegt 10cm
  • Flexible ureterosocpy 70-78 stone free rates
    (lt2cm stone)
  • PCNL 83-88 stone free rates (large stone
    burden)
  • Bleeding diathesis
  • Uncorrected coagulopathy absolute CIx for ESWL
    and PCNL
  • Ureteroscopy with holmium laser lithotripsy
    effective and safe

16
Complications
  • PCNL
  • the overall major complications rates 4-8
  • transfusion 2-23 (major vascular injury
    2-3)
  • pulmonary colon injury rare
  • medical complication postoperative fever
    (22-25), urosepsis (1-2)
  • URS
  • the overall complication rates 1-10
  • mostly minor complication UTI, pain, failed
    access

17
Life of scope (durability)
  • The effect of repeated procedure (after 50
    procedure, 76h use)


  • Traxer et al. Urology 2006
  • maximal deflection ventral (270?208), dorsal
    (270?133)
  • irrigation flow 50ml/min?40ml/min
  • image broken 6/50
  • laser perforation of working channel

18
Conclusions
  • Stone free rates PCNL URS
  • Complication rates PCNL gt URS
  • The choice of treatment individual surgeons
    preference level of expertise
  • Flexible URS broadening indication (durability)
  • The randomized prospective study is needed.

19
The Algorithm of management
Symptomatic renal stone
20
Thank You!
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