Surgical Management of Renal Calculi: An Update

2014%03%10'
Surgical)Management)of)Renal)Calculi:) !'
An)Update)
Henry'Tran,'PGY3,'UBC'Department'of'Urologic'Sciences'
Outline)
!  Natural'history'of'renal'calculi'
!  Treatment'OpFons''
!  ESWL'
!  PCNL'
!  Ureteroscopy'
!  Open/laparoscopic/roboFc'pyelolithotomy''
!  Unique'SituaFons'
!  Lower'pole'calculi'
!  1%2cm'calculi/>2cm'calculi'
!  Ultra'Low%Dose'CT'Imaging'
1'
2014%03%10'
Case)
! 
68'year'old'man'
! 
2'cm'leS'renal'pelvic'stone'
! 
'Diabetes'
! 
Hypertension'
! 
CAD'
! 
Treatment?'
! 
! 
! 
! 
ObservaFon?'
ESWL?'
URS?'
PCNL?'
Case)
!  Bilateral'staghorn'calculi'
!  ESWL?'
!  Ureteroscopy?'
!  PCNL?'
!  ObservaFon?'
2'
2014%03%10'
Natural)History)of)Renal)Calculi)
!  Do'kidney'stones'need'to'be'treated?'Which'ones?'
!  ObservaFon'of'kidney'stones'depends'on'their'natural'history'
!  Natural'history'of'small,'asymptomaFc,'non%obstrucFng'caliceal'
calculi'is'poorly'defined'
!  Risk'of'progression'is'unclear'
'
EAU$Urolithiasis$Guidelines$2013$
Case)!
!  A'31'yr'old'woman'complains'of'epigastric'abdominal'pain'
and'her'GP'orders'an'abdominal'ultrasound'
"  Stone'leS'kidney'
!  KUB'demonstrates''
!  4'mm'stone'in'leS'lower'pole'
!  AsymptomaFc'%'no'pain,'hematuria'or'UTIs'
!  Serum'Cr'='90''umol/L'
!  She'wishes'to'start'a'family'and'asks'
''“Should'this'stone'be'treated'before'I'become'pregnant?”''
3'
2014%03%10'
What)do)we)tell)her?!
4 mm lower pole stone
!  ProspecFve'study''
!  Inclusion'criteria:'asymptomaFc'single'or'mulFple'LP'calculi'for'at'
least'6'months'
! 
! 
! 
! 
24'paFents;'27'renal'units;'age'22%73(47);'assessed'q6months;''
regular'imaging;'CT'(even'years);'U/S'(odd'years);'plain'KUB;'
followed'for'24%72(52)months;'
IniFal'stone'size'8.8mm'(2%26mm)'
!  Progression:'pain,'stone'growth,'recurrent'UTI,'gross'hematuria'
!  Result:'9'of'27'renal'units'had'increased'stone'size;'3'of'these'
required'intervenFon'(ESWL/PCNL/URS);'18.5%'were'stone'free;''
!  Conclusion:'smaller'calculi'more'likely'to'pass;'asymptomaFc'LP'
caliceal'stones'can'be'safely'observed;'inform'pt'of'33%'progression'
rate;'
Journal$of$Urology$2007$
4'
2014%03%10'
!  228'pts;'<15mm'asymptomaFc'calyceal'stones;'
!  113'pts'ESWL;'115'pts'observaFon'only'
!  Outcome'–'stone%free'rate,'symptoms,'quality'of'life,'renal'fxn'
!  Results'''
!  SFR:'28%'(ESWL)'vs'17%'(obs)'(p=ns)'
!  Further'tx'(abx,'analgesics,'procedure):'15%'(ESWL)'vs'21%'(obs)'
!  Invasive'tx'(stenFng,'URS):'0%'(ESWL)'vs'8%'(obs)'
!  Quality'of'life,'renal'funcFon:'no'difference'
!  Conclusion'
!  ProphylacFc'ESWL'in'small,'asymptomaFc'renal'calculi'has'no'
benefit'for'SFR,'QoL,'renal'funcFon,'symptoms'or'hospital'
admissions;'observaFon'may'lead'to'more'invasive'procedures'
required;'
BJUI$2001$
Observation)of)Kidney)Stones)
EAU)Urolithiasis)2013)
5'
2014%03%10'
Case)
!  80M,'mulFple'comorbidiFes'
!  2'cm'lower'pole''
!  Observe'
!  2'cm'stone'in'renal'pelvis'
!  AcFve'treatment'
EAU$Urolithiasis$Guidelines$2013$
Options)for)Active)Stone)Removal)
!  Extracorporeal'shockwave'lithotripsy'(ESWL)'
!  How'many'lithos'before'moving'on'to'URS?'
!  StenFng?'
!  Steinstrasse'management'
!  Percutaneous'nephrolithotomy'
!  Ureteroscopy'
!  Open/laparoscopic/roboFc'pyelolithotomy'
6'
2014%03%10'
Management)of)ESWL)Failure))
Pre%Litho'CT'
Pre%Litho'KUB'
No)Change)After)Shockwave)lithotripsy:)
Next)Step?)
Pre%Litho'KUB'
Post%Litho'KUB'
7'
2014%03%10'
Treatment)of)SWL)Failure?)
!  8'mm'proximal'ureteral'stone'unchanged'at'all'by'SWL.'
!  Next'step?'
1. 
2. 
3. 
• 
• 
• 
• 
Repeat'shockwave'lithotripsy'
Ureteroscopy'
Observe''
1,593'ureteral'calculi'(1994'–'1999)'
Dornier'MFL'5000'Lithotripter'
Follow%up'at'2'weeks'and'3'months'with'KUB'
Compared'stone'free'rate'of'iniFal'treatment'vs.'re%treatment'
•  MulFvariate'analysis'looking'at'predictors'of'stone'free'status'
•  Stone'size'
•  Stone'locaFon'
•  BMI'
•  Use'of'ureteral'stent'
Pace'et'al,'J'Urol,'164:'1905%07,'2000'
'
8'
2014%03%10'
Results)
8%$
8%'
1%$1%'
1%$
1%'
Pace'et'al,'J'Urol,'164:'1905%07,'2000'
'
Conclusions)
!  Re%treatment'success'rates'of'SWL'are'lower'for'both'RENAL'
and'URETERAL'calculi'
!  PaFents'who'fail'or'have'poor'response'to'iniFal'SWL,'should'
be'referred'for'ureteroscopy$
!  STENTING$reduced'stone'free'rate'
!  Compared'to'stented'group'with'same'stone'size…'
!  NO'stent'&'stone'<10mm'%>'8%'berer'SFR''
!  NO'stent'&'stone'11%20mm'%>'21%'berer'SFR'
9'
2014%03%10'
Stenting)in)ESWL)
!  What'is'the'role'of'stenFng'pre%ESWL?'
!  What'are'the'potenFal'downfalls'of'stenFng?'
!  64'pts;'stone'burden'>'2cm;'randomized'to'ESWL'+/%'ureteric'stent'
!  3'month'postop'treatment'result'and'post%ESWL'morbidity'analyzed'
Results$
No$stent$(n=23)$
Stent$(n=41)$
Fever/pyelonephriFs'
4'(17%)'
8'(20%)'
Steinstrasse'
3'(13%)'
6'(15%)'
Stent'calcificaFon'
7'(17%)'
Stent'migraFon'
10'(24%)'
Stone'free'rate'
8'(35%)'
18'(44%)'
!  Conclusion:'ureteral'stents'NOT'RECOMMENDED'as'they'do'not'
reduce'post%ESWL'complicaFons;'have'associated'morbidity;'do'not'
markedly'improve'stone'passage;'
J$Urol$1991$
10'
2014%03%10'
! 
8'randomized'clinical'trials;'876'pts;'stented'(n=453);'stentless'(n=423);'
subgroups'(renal,'ureteral,'renal'or'ureteral)'
! 
Results:'
! 
Stone'free'rate'(all'8'trials)'
!  Stented'–'78%'(354'of'453);'stentless'–'83%'(351'of'423)'
! 
Steinstrasse'incidence'(5'of'8'trials)'
!  All'but'1'trial'had'no'significant'difference'in'incidence'
!  Al%awadi'et'al.'reported'possible'advantage'with'stenFng'
! 
LUTS'(3'of'8'trials)'
!  Significant'difference'in'incidence'(stented)'
! 
Auxillary'treatment'(6'of'8'trials)'
!  No'staFsFcal'difference'
! 
Conclusion:'
! 
! 
J$Urol$2011$
Pre%stenFng'ESWL'remains'controversial'
No'difference'in'stone%free'rate,'auxillary'treatment,'possible'advantage'for'
steinstrasse'(only'1'trial'showed'benefit)'
!  ProspecFve'analysis;'Sept'2004'–'March'2006;'pts'with'solitary,'
radiopaque,'previously'untreated'ureteric'calculi'matched'by'gender,'
side,'locaFon'in'ureter'and'size'(+/%'1%2mm)'
!  45'pts'with'ureteric'stent'paired''
!  Reasons'for'pre%stenFng:'infecFon,'obstrucFon,'pain'
!  Stone%free'rate'(plain'film'KUB'@3'month'follow'up)'
!  Stented'–'71%'
!  Unstented'–'93%'
!  Conclusion'
!  StenFng'has'LOWER'stone'free'rate'for'ESWL'in'ureteric'calculi'
!  SFll'use'in'obstrucFon,'risk'of'sepsis,'&'renal'failure'
BJUI$2008$
11'
2014%03%10'
Indications)for)stent)use)in)ESWL)
!  Stents'allow'for'urinary'drainage'
!  Absolute'
!  ObstrucFve'pyelonephriFs'
!  Renal'failure'
!  Solitary'kidney'
!  RelaFve'
!  Stone'size'>'1.5cm'%'?'
!  Pain'management'%'?'(increased'LUTS)'
!  Hydronephrosis'
!  Long'travel'distance'to'stone'centre'
!  Steroid'therapy,'diabeFc,'advanced'age'
Steinstrasse)
EAU$Urolithiasis$Guidelines$2013$
12'
2014%03%10'
Steinstrasse)Management)
!  885'pt'tx'for'renal/ureteric'calculi'via'ESWL;'Jan'1997%Feb'1999;'
!  52'(6%)'developed'steinstrasse;'5'pts'were'pre%stented'
!  ASer'iniFal'ESWL,'all'pts'followed'weekly'with'plain'KUB'+'U/S'x'1'
month,'then'monthly'x'2'
!  Tx'Algorithm'
!  AsymptomaFc'or'minimal'sx,'mild'hydronephrosis'
!  ConservaFve'–'analgesics,'abx'and'follow%up'
!  Moderate'obstrucFon'or'type'II'or'III'steinstrasse'
!  Repeat'ESWL'of'leading'fragment'
!  Severe'obstrucFon'or'infecFon'
!  Percutaneous'nephrostomy;'decreased'intrapelvic'pressures're%
establishes'ureteric'peristalsis'
!  Failure'of'resoluFon''
!  Ureteroscopy'then'if'needed,'open'ureterolithotomy'
BJUI$2001;$88(675L678)$
13'
2014%03%10'
! 
Incidence''
! 
! 
! 
! 
Stones'<1cm'–'0.3%'
Stones'1%2cm'–'7%'
Stones'>2cm'–'11.5%'
Treatment'
! 
! 
! 
ConservaFve'%'48%;''
Repeat'ESWL'%'23%;'
'Perc'NT'–'19%'
!  Conclusions'
!  Large'stone'burden,'impaired'urinary'drainage'(stricture'etc)'
predispose'to'steinstrasse'
!  Ureteroscopy''for'tx'steinstrasse'is'difficult'and'tedious;'can'be'difficult'
even'to'pass'guidewire'and'ureter'may'easily'perforate'
!  Ureteric'stenFng'before'ESWL'does$not$prevent$steinstrasse'but'does'
allow'urinary'drainage'(**consider'PCNL'as'first'therapy**)'
BJUI$2001;$88(675L678)$
!  RetrospecFve'analysis'395'renal'units'in'381'children;'March'
1992%Feb'2008'
!  3'groups'according'to'stone'burden;'<1cm,'1%2cm,'>2cm'
!  Steinstrasse'in'26'renal'units'(7.6%);'2%(group'1);'15%(group'2);'
20%'(group'3)'
!  Tx'
!  ConservaFve'15%;'repeat'ESWL'65%;'ureteroscopy'post'repeat'ESWL'
(15%);'ureteroscopy'as'primary'treatment'(3.4%)'
!  Conclusion'
!  Stone'burden'staFsFcally'correlated'with'formaFon'steinstrasse'
!  Repeat'ESWL'safe'and'effecFve'in'most'pediatric'paFents'
!  *Children'have'wider'ureters'with'more'stretch'
Urology$2012;$80(5)$
14'
2014%03%10'
Steinstrasse)Conclusion)
!  Stone'burden'correlates'directly'with'risk'of'steinstrasse'
!  Other'factors'causing'impaired'urinary'drainage'(e.g.'strictures)'
can'also'increase'this'risk'
!  Pre%stenFng'does'not'prevent'steinstrasse'but'does'allow'
urinary'drainage'
!  ESWL'of'lead'fragment'is'treatment'opFon'
!  Ureteroscopy'can'be'difficult.'Consider'antegrade'ureteroscopy'
through'PNL'tract'
!  Consider'doing'PNL'in'first'place'for'larger'stones'
Options)for)Active)Stone)Removal)
!  Extracorporeal'shockwave'lithotripsy'(ESWL)'
!  Percutaneous'nephrolithotomy ''
!  What'is'ideal'drainage'post%operaFvely?'
!  OutpaFent'tubeless'PCNL,'is'this'a'possibility?'
!  Ureteroscopy'
!  Open/laparoscopic/roboFc'pyelolithotomy'
15'
2014%03%10'
PCNL)Treatment)
Unfavorable$Factors$for$SWL:$
1.  SWL'resistant'stones'
2.  Steep'infundibular%pelvic'angle'
3.  Long'lower'pole'calyx'(>10mm)'
4.  Narrow'infundibulum'(<5mm)'
EAU$Urolithiasis$Guidelines$2013$
PCNL)Post)Procedure:)
Tube)Management)
!  EAU'Urolithiasis'Guidelines'2013'
!  Several'factors'to'consider'when'deciding'about'postop'nephrostomy'
tube'need'and'type:'
!  Residual'stones'
!  Likelihood'of'second%look'procedure'
!  Degree'of'blood'loss'or'bleeding'diathesis'
!  Urine'extravasaFon'
!  Ureteral'obstrucFon'
!  Persistent'bacteriuria'from'infected'stones'
!  Solitary'kidney'
!  Percutaneous'chemolitholysis'
16'
2014%03%10'
!  121'pts;'mean'stone'size'31mm'%'(18%70mm);'age'4%80;'punctures'
–'114'single,'8'double,'1'triple;'
!  Excluded'–'OR'Fme'>'2'hrs,'or'presence'of'significant'collecFng'
system'injury,'bleeding'or'residual'stones'
!  6'Fr'external'retrograde'stent;'All'had'plain'KUB'and'U/S'POD#1;''
!  Results:''
!  Mean'OR'Fme'–'46mins'
!  External'ureteral'catheter'6Fr'x'7%72h'(mean'45h)'
!  Stone%free:'86%;''
!  Success'rate:'96.75%'(post'ESWL'for'significant'residual'fragments)'
Int$Urol$Nephrol$2008$
ß)
!  ComplicaFons'
!  Only'1'required'double'J'
!  5'paFents'required'blood'
transfusion'(4%)'
!  18%'of'pts'required'analgesic'
(Ketorolac),'avg'23mg;'
!  Conclusion:'
!  Tubeless'PNL'good'opFon'
for'lowering'postop'pain,'
analgesic'use,'and'hospital'
stay'in'UNCOMPLICATED'
cases'
Int$Urol$Nephrol$2008$
17'
2014%03%10'
PCNL)Post)Procedure:)
Tube)Management)
!  Despite'tubeless'approach'being'proven'as'an'effecFve'and'
safe'alternaFve'to'NT'placement,'PCNL'Global'study'showed'
tubeless'approach'adopted'in'only'1.7%'of'5803'paFents''
!  What'happens'if'you'have'a'complicated'PCNL?'
!  What'kind'of'nephrostomy'drainage'is'opFmal?'
!  Does'nephrostomy'size'marer?'
!  CROES'database;'all'paFents'
receiving'nephrostomy'tube'
of'known'size;''
!  3968'pts;''
!  2'groups'–'large'bore'(>18Fr)'
vs'small'bore'(≤18Fr);''
!  Assess:'Impact'of'NT'&'
sheath'size'on'Hgb'drop;'
stone'free'based'on'U/S,'
plain'KUB'or'CT'
'
'
World$J$Urol$2013$
18'
2014%03%10'
!  Results:'
!  Small'Bore'1983'pts;'Large'Bore'1985'pts;''
!  Majority'were'ASA'I'or'II'
!  Large'Bore'group'significantly'older'&'more'stone'burden;''
!  **Small'Bore'group'more'likely'anFcoagulated'(112'vs'79);'
World$J$Urol$2013$
World$J$Urol$2013$
19'
2014%03%10'
!  Conclusion'
!  PaFents'with'large'bore'nephrostomy'tubes'had'less'
postoperaFve'blood'loss'
!  No'comparison'of'postoperaFve'pain'done'
!  If'inserFng'a'nephrostomy'tube'for'bleeding,'larger'is'berer'
(>18Fr)'
!  LimitaFon:'
!  CROES'data'quality'concerns'
!  Small'bore'group'was'more'likely'anFcoagulated''
World$J$Urol$2013$
So)what)do)we)do)at)VGH?)
5'Fr'DAV'Catheter'
!  Tubeless'PCNL'+'5'Fr'safety'DAV'catheter'
20'
2014%03%10'
!  Tubeless'surgery'allowing'for'second%look'nephroscopy'
!  Inclusion'criteria:'
!  Absence'of'UTI;'single'puncture;'OR'Fme'<'2h;''
!  Ureteral'catheter'leS'in'situ'at'end'of'PCNL'via'iniFal'perc'site'
!  Imaging'POD#1'
!  No'stone'–'ureteral'catheter'removed'
!  Stones'–'uFlize'ureteral'catheter'for'second'look'nephroscopy'
!  13'pts;'2'pts'required'2nd'PCNL'for'residual'calculi;'no'
complicaFons'
!  Conclusion:'safe,'simple'modificaFon'of'tubeless'PCNL;'
Actas$Urol$Esp$2013$
!  Hypothesis:'OutpaFent'tubeless'PCNL'can'be'performed'safely'
in'select'group'of'paFents'
!  3'paFents;'mean'stone'size:'1.4cm;''
!  OR'Fme:'87'mins;'
!  Mean'Fme'to'd/c'home'aSer'leaving'recovery'room:'175mins;'
!  JJ'internal'ureteral'stent'leS'in'situ;''
CUAJ$2010$
21'
2014%03%10'
!  PotenFal'cost'reducFon,'avoiding'
inpaFent'stay'
!  LimitaFons:'
! 
! 
Very'small'case'series'
Small'diameter'stones'
!  Supracostal'puncture'not'official'
exclusion'criteria,'but'should'be'
!  Conclusions:'
Possible'in'properly'selected'
paFents'
!  Findings'warrant'further'
invesFgaFon'in'larger'
populaFon'
! 
22'
2014%03%10'
Options)for)Active)Stone)Removal)
!  Extracorporeal'shockwave'lithotripsy'(ESWL)'
!  Percutaneous'nephrolithotomy'
!  Ureteroscopy'
!  Open/laparoscopic/roboFc'pyelolithotomy'
Other)Treatment)Options)
!  Ureteroscopy'
!  EAU'Nephrolithiasis'Guidelines'2013'Updates'
!  Short%term'abx'prophylaxis'should'be'administered'
!  Placement'of'safety'wire'is'recommended'
!  Do'not'perform'blind'baskeFng'
!  Can'perform'even'in'paFents'fully'anFcoagulated'
!  Open,'laparoscopic'pyelolithotomy'
!  Has'very'limited'role'in'developed'countries'
!  Khaled'A.'et'al'2005'(J'Urol)'
!  PCNL'vs'open'pyelolithotomy'for'complete'staghorn'stones'
!  88'pts'randomized'to'either'tx'(43'PCNL,'45'open'sx)'
!  PCNL'–'shorter'operaFve'Fme'(127'vs'204'mins),'shorter'hospital'stay'
(6.4'vs'10'days),'earlier'return'to'work'(2.5'vs'4)'
!  Similar'stone'free'rates'
!  RoboFc'pyelolithotomy'
23'
2014%03%10'
Treatment)modality)based)on)stone)size)
and)location))
!  Management'of'Lower'pole'calculi'
!  Treatment'of'1%2cm'stones?'
!  Treatment'of'>2cm'stones?'
Lower)Pole)Stones)
•  ESWL?'
•  Ureteroscopy?'
'
•  Percutaneous'
Nephrolithotomy?'
24'
2014%03%10'
Lower)Pole)Stones)
!  Purpose:'determine'efficacy'of'SWL'and'PCNL'for'tx'of'
symptomaFc'lower'pole'calculi'
!  ProspecFve,'randomized,'mulFcenter'trial,'symptomaFc'LP'
calculi'<30mm'
!  Results:'
!  128'pts'(60'PCNL,'68'ESWL);''
!  3'month'f/u'available'for'88%'of'pts'
!  SFR'%'95%'PCNL'vs'37%'ESWL'
!  SFR'for'ESWL'especially'bad'for'calculi'>'10mm'(21%'SFR)'
!  Comparable'complicaFon'rates'and'stone'composiFon'types'
J$Urol$2001$
120
100%
93%
100
80
86%
SWL
63%
PCNL
60
40
23%
20
14%
0
1-10 mm
11-20 mm
21-30 mm
J'Urol,'Dec.'2001'
!  Conclusion'
!  ESWL'poor'for'LP'calculi,'especially'>10mm'size'
25'
2014%03%10'
!  Purpose:'SWL'vs'URS'for'LP'stones'<1cm'
!  67'pts'with'LP'calculi'<1cm;'1°%'SFR'@'3'months;'2°'%'length'of'stay,'
complicaFons,'need'for'ancillary'procedures,'paFent'derived'QoL'
!  Results:'
!  32'SWL;'35'URS;'similar'age,'sex,'BMI,'stone'surface'area'
!  SFR:'35%%SWL;'50%%URS;'
!  Pt'derived'QoL'–'favored'SWL'
!  Conclusion''
!  No'staFsFcally'significant'diff'in'SFR'but'SWL'pts'perceived'berer'QoL'
(less'analgesics,'more'rapid'recovery)'
!  90%'of'pts'receiving'SWL'would'repeat'the'procedure'vs'63%'for'URS'
J$Urol$2005$
Treatment)modality)based)on)stone)size)
and)location))
!  Management'of'Lower'pole'calculi'
!  Treatment'of'1%2cm'stones?'
!  Treatment'of'>2cm'stones?'
26'
2014%03%10'
Treatment)of)1T2cm)stones)
!  Based'on'EAU'Guidelines,'endourology'or''SWL'are'reasonable'
opFons'
!  Which'endourology'opFons'are'feasible?'URS?'PCNL?'Any'
superior'modality?'
!  Purpose:'Compare'PCNL'vs'URS'for'1%2cm'calculi,'specifically'
stone'clearance'rate'and'morbidity'
!  27'pts'(15%PCNL,'12%URS);'retrospecFve'review;'PCNL'group'
slightly'higher'median'stone'burden'(1.8cm'vs'1.25cm);''
!  PCNL'and'URS'–'similar'OR'Fme,'complicaFon'rate'
!  SFR:'87%'PCNL'and'65%'URS'–'not'staFsFcally'different'
!  Conclusions:'
!  Both'opFons'effecFve'for'1%2cm'calculi'
!  Treatment'choice'depends'on'surgeon'preference,'level'of'
experFse'
J$Endourology$2008$
27'
2014%03%10'
!  Purpose:'compare'PCNL'vs'ESWL'for'1%2cm'upper/mid'calculi,'
wrt'stone'clearance'rate,'morbidity,'QoL'
!  Nov'2008%Mar'2010;'pts'with'1%2cm'renal'calculi'
!  Exclusion'criteria:'pregnancy,'bleeding'diathesis,'
anFcoagulated,'HU>1000,'skin%stone'distance'>'12cm,'UPJO,'
solitary'kidney'
!  Randomized'to'PCNL'vs'ESWL'
!  Stone'Free'status'determined'by'CT'KUB'@'3'months'
J$Urology$2011$
AXR'
CT'scan'
!  Conclusion:'
!  PNL:'
!  More'likely'stone%free'
status'
!  Similar'complicaFon'profile'
!  QoL'similar'to'ESWL'@'3'
months'
!  More'adjuvant'procedures'
with'ESWL'
J$Urology$2011$
28'
2014%03%10'
Treatment)modality)based)on)stone)size)
and)location))
!  Management'of'Lower'pole'calculi'
!  Treatment'of'1%2cm'stones?'
!  Treatment'of'>2cm'stones?'
What)about)>2cm)stones?)
29'
2014%03%10'
Ureteroscopy)for)>2cm)stones)
!  PCNL'is'widely'regarded'gold'standard'for'treatment'of'large'
renal'calculi'(>2cm)'
!  How'do'RIRS'(retrograde'intrarenal'surgery)'and'ESWL'
compare?''
))
!  RetrospecFve'review'2003%2006;'15'pts'w/'renal'calculi'2%2.5cm;''
!  All'pts'underwent'primary'URS'+'second%look'URS'
!  10'(66%)'required'only'1'treatment'procedure''
!  4'(26.6%)'required'2'treatments'
!  1'(6.6%)'required'3'treatments'
!  Overall'SFR'–'93.3%'
!  Conclusions:'
!  PCNL'–'berer'SFR'
per'procedure'
!  URS'–'less'
morbidity'and'
hospital'stay'
J$Urol$2008$
30'
2014%03%10'
Absolute)Indications)for)Ureteroscopy)
!  Irreversible'coagulopathy'
!  URS'can'be'safely'performed'on'paFents'taking'Warfarin,'anF%
platelet'agents,'or'with'bleeding'diathesis1,2'
!  No'difference'in'stone'free'rate,'intraoperaFve'or'post%operaFve'
complicaFons1'
!  *Concomitant'use'of'EHL'for'lithotripsy'–'may'increase'risk'of'
bleeding'and'should'be'avoided'
!  1.'Turna'et'al.'J'Urol'2008'
!  2.'Warerson'et'al.'J'Urol'2002'
!  RelaFve'indicaFon:'Consider'for'morbid'obesity'(rather'than'
PNL)'
e)
!  RetrospecFve'analysis,'137'pts,'tx'with'1'of'3'modaliFes'
!  When'allowing'for'two'SWL'treatments,'staFsFcally'equivalent'
success'rates'
!  Conclusion:'SWL'is'reasonable'in'pts'who'prefer'SWL'and'willing'to'
accept'higher'number'of'treatments'or'poor'surgical'candidates'
PCNL$
URS$
SWL$
Number'
53'
41'
43'
Stone'Size'
211.1'mm2'
172.6'mm2'
162.9'mm2'
P<0.01'
Success'
95.3%'
87.8%'
60.4%'
P<0.001'
79.2%'
P=0.66'
23'
P<0.01'
2nd'SWL'
Aux'Tx'
3'
4'
PLvalue$
J$Endourol$2011$
31'
2014%03%10'
Treatment)Conclusions)
!  Lower'pole'calculi'
!  ESWL'can'be'first'line'if'<20mm;'SFR'worse'as'stone'size'
increases'
!  1%2'cm:''
!  Shockwave'lithotripsy:''
!  slower'rate'helps,'alpha'blockers,'SSD,'HU'
!  Ureteral'stent?%'controversial'
!  Residual'fragments?'
!  Ureteroscopy:'viable'alternaFve'
!  DusFng'using'Ho:YAG'laser'
!  Ureteral'Stent,'+/%'UAS'
!  PCNL:'best'stone'free'rate,'but'highest'potenFal'complicaFons'
!  >2'cm'stones:'PCNL'best'stone'free'rate;'URS'is'alternaFve'
opFon'with'less'morbidity'
Lower)Pole)Stones)10T20mm?)
Unfavorable$Factors$for$SWL:$
1.  SWL'resistant'stones'
2.  Steep'infundibular%pelvic'angle'
3.  Long'lower'pole'calyx'(>10mm)'
4.  Narrow'infundibulum'(<5mm)'
EAU$Urolithiasis$Guidelines$2013$
32'
2014%03%10'
What)is)best)treatment)modality?)
EAU$Urolithiasis$Guidelines$2013$
Emergence)of)Ultra)LowTDose)CT)
!  “Stellar'Detector”..transmits'analog'
data'with'minimal'wiring,'making'it'
possible'to'digiFze'the'measured'
signals'with'virtually'no'interference.''
!  “IMPROVED'PATIENT'CARE'EQUALS'
COST'SAVINGS”'
!  “…ge}ng'a'CT'scan'rather'than'an'x%
ray'increases'confidence'to'either'
send'someone'to'the'OR'or'home'
appropriately…Our'new'technology'
will'improve'diagnosFc'accuracy'and'
move'paFents'through'the'system'
faster,'resulFng'in'substanFal'
savings.”'
33'
2014%03%10'
Plain)Radiograph)Doses)at)VGH)
!  Plain'radiograph'radiaFon'doses'variable'
!  CXR'–'lowest'0.1%0.2mSv'
!  AXR'–'0.7mSv'
!  Pelvic'XR'–'0.6mSv'
!  Thoracic/lumbar'spine'XR'–'1.0'&'1.5'mSv'
!  Abdominal'films'have'highly'variable'
radiaFon'doses'
!  Factors'affecFng'dose:'
!  BMI'
!  Metal'hardware'
!  X%rays'are'not'necessarily'as'low'radiaFon'
dose'as'we'think'
Emergence)of)Ultra)LowTDose)CT)
!  Technological'advances'in'CT'imaging'
!  Automated'exposure'control'
!  IteraFve'image'reconstrucFon'algorithms'for'noise'reducFon'
!  Integrated'circuit'boards'with'reduced'electronic'noise,'and'
improved'quantum'efficiency'
!  Ultra'low%dose'CT'actually'has'less'radiaFon'than'plain'
radiographs''
!  For'evaluaFon'of'renal'calculi,'ultra'low'dose'CT'can'detect'
calculi'unseen'in'plain'film'KUB'
34'
2014%03%10'
!  ObjecFve:'assess'performance'of'low%dose'non%contrast'CT'of'
urinary'tract'using'adapFve'staFsFcal'iteraFve'reconstrucFon'
(ASiR)'
!  LD%CT'–'0.48±0.07mSv;'normal'CT'–'4.43±3.14mSv;'plain'abdo'
x%ray'–'0.7mSv'
!  Methods:'33pts;'renal'colic;'each'underwent'convenFonal'CT'+'
LD%CT;'
!  Results:'27'calculi'detected'using'70%'ASiR'–'sens/spec:
87/100%'for'calculi'>3mm'
!  Conclusion:'reconstrucFon'using'70%'ASiR'superior'image'
quality'and'good'detecFon'for'calculi'>3mm'
Insights$Imaging$2014$
RIGHT)8mm)ureteral)calculus)&)2mm)
renal)calculus)
ConvenFonal'dose'CT'%'5.1mSv'
Ultra'low%dose'CT'–'0.56mSv'
35'
2014%03%10'
Case))
!  17F,'hx'right'renal'calculi'
tx'with'ESWL'
Case)
!  3'month'post%ESWL'follow%up'
visit'
!  SFll'symptomaFc'BUT'now'leS'
flank'pain'intermirently'
!  Plain'KUB'prior'to'ESWL'–'
unable'to'idenFfy'any'stone'in'
leS'kidney'
!  Instead'of'sending'home….'
36'
2014%03%10'
Case)
!  Ultra'low%dose'CT'
performed'
!  Revealed'leS'renal'calculi'
!  Underwent'leS'ESWL'
Ultra)lowTdose)CT)at)VGH)
!  Currently'sFll'invesFgaFonal'BUT'can'be'ordered'for'
OUTPATIENTS'
!  SFll'unable'to'order'for'ER'paFents'because:'
!  Not'all'radiologists'can'read'ultra'low%dose'CT'
!  Lack'of'awareness'amongst'ER'physicians'
!  Lower'radiaFon'='poorer'quality'image'–'can'miss'other'
diagnoses'(e.g.'appendiciFs)'
!  Ultra'low%dose'CT'has'advantage'of'lower'or'equal'radiaFon'
dose'to'abdominal'x%ray'but'may'idenFfy'small'renal'calculi'
berer'
37'
2014%03%10'
Questions?)
!  Acknowledgements'
!  Dr.'Ben'Chew'
!  Dr.'Patrick'McLaughlin'
38'