Microsoft PowerPoint - 1637-1644 N\343o Guido Giusti

www.guidogiusti.it
www.etce.it
INTRODUCTION
Staghorn stones are unquestionably an indication for interventional therapy,
since conservative treatment show an increased rate of nephrectomy (up to
half) and an increase in associated morbidity (i.e. dialysis); in many cases
(up to 28%) the disease resulted in death
Open surgery has been the corner stone of treatment of urolithiasis for
more than 30 years till 80s
www.guidogiusti.it
www.etce.it
INTRODUCTION
After 1980 PCNL monotherapy first and then combined treatments have been
suggested (PCNL+ESWL+PCNL (sandwich therapy)),( PCNL+ESWL (open
sandwich therapy))
www.guidogiusti.it
www.etce.it
ENDOUROLOGY VS OPEN SURGERY
J.J. Rassweiler1, C. Renner1, F. Eisenberger2: The management of complex
renal stones. BJU International Volume 86, Issue 8, pages 919–928, November 2000
www.guidogiusti.it
www.etce.it
EVOLUTION OF PCNL
www.guidogiusti.it
www.etce.it
SUPINE PCNL
EASY RETROGRADE ACCESS
ENDOSCOPIC COMBINED INTRARENAL SURGERY
ECIRS
www.guidogiusti.it
www.etce.it
Scoffone C., Scarpa RM
www.guidogiusti.it
www.etce.it
ECIRS
www.guidogiusti.it
www.etce.it
COMPLETE STAGHORN STONE
SUPINE PCNL WITH 3 ACCESSES
RIRS 2° LOOK
www.guidogiusti.it
www.etce.it
COMPLETE STAGHORN STONE IN HORSESHOE KIDNEY
PCNL 2nd LOOK
ECIRS WITH DOUBLE ACCESS
RIRS 3rd LOOK
www.guidogiusti.it
www.etce.it
NO MORE OPEN SURGERY?
www.guidogiusti.it
www.etce.it
GUIDELINES
Advances in SWL and endourological surgery (URS and PNL) have
significantly decreased the indications for open stone surgery, which is now
often a 2°- or 3° -line treatment option needed in 1.0-5.4% of cases only .
•
2012 EAU guidelines for urolithiasis
The incidence of open stone surgery is ~1.5% of all stone removal
interventions in developed countries, and in developing countries, it has
dropped from 26% to 3.5 % in recent years (3,5).
www.guidogiusti.it
www.etce.it
GUIDELINES
5.7.1.1 Indications for open surgery
There is a consensus that most complex stones, including partial and complete
staghorn stones, should be approached primarily with PNL or combined PNL and SWL.
If a reasonable number of percutaneous approaches are not likely to be successful, or
if multiple, endourological approaches have been performed unsuccessfully, open
surgery may be a valid treatment option.
•
2012 EAU guidelines for urolithiasis
www.guidogiusti.it
www.etce.it
GUIDELINES
5.7.1.1 Indications for open surgery
There is a consensus that most complex stones, including partial and complete
staghorn stones, should be approached primarily with PNL or combined PNL and SWL.
If a reasonable number of percutaneous approaches are not likely to be successful, or
if multiple, endourological approaches have been performed unsuccessfully, open
surgery may be a valid treatment option.
•
2012 EAU guidelines for urolithiasis
www.guidogiusti.it
GUIDELINES
•
2012 EAU guidelines for urolithiasis
www.etce.it
www.guidogiusti.it
www.etce.it
CONCLUSION
However, open surgery is still needed for the most difficult stones, which supports the
importance of maintaining proficiency, skills and expertise in open renal and ureteral surgical
techniques such as extended pyelolithotomy, pyelonephrolithotomy, anatrophic
nephrolithotomy, multiple radial nephrotomy, partial nephrectomy and renal surgery under
hypothermia
PLEASE CHIEF,
TEACH ME HOW
TO DO IT!
•
2012 EAU guidelines for urolithiasis
ALMOST…
……….Modern endourologist should master FIRST all
the available ENDOUROLOGICAL solutions (rigid and
flexible nephroscopy, RIRS) to reach the stone-free
status BEFORE CONSIDER OPEN SURGERY.
www.guidogiusti.it
www.etce.it
RENAL CALCULI FEATURES
Laparoscopic urinary stone surgery: an updated evidence-based review.
Laparoscopic pyelolithotomy is feasible but rarely indicated in the present era
. Laparoscopic nephrolithotomy may be indicated to remove a stone from an
anterior diverticulum or when PNL or flexible ureteroscopy have failed
Skolarikos A et al: Urol Res. 2010 Oct;38(5):337-44.
provided that all endourological solutions are clearly
contraindicated as first treatment option!!
staghorn calculus (stag-horn) n. a
branched stone forming a cast of the
collecting system of the kidney and
therefore filling and obstructing the calyces
and pelvis. It is usually associated with
infection and can cause pyonephrosis and,
if neglected, a perinephric abscess.
www.guidogiusti.it
www.etce.it
OPEN SURGERY?
Does open stone surgery still play a role in the treatment of urolithiasis? Data
of a primary urolithiasis center.
stone-free rate after a single procedure: 69% (18/26 patients).
CONCLUSIONS:Although today most stone cases can be handled by minimally
invasive treatment, open stone surgery maintains a mandatory role in very selected
cases
Honeck P, Alken P, Michel MS.: J Endourol. 2009 Jul;23(7):1209-12
www.guidogiusti.it
www.etce.it
INTRODUCTION
www.guidogiusti.it
www.etce.it
EVOLUTION OF UROLITHIASIS
STAGHORN STONES 1990-2000: 56%
STAGHORN STONES 2000-2009: 13%