Download 53 Strategies for Nonmedical Management of Upper Urinary Tract

SURGICAL
MANAGEMENT OF UPPER
URINARY TRACT CALCULI
M.H.IZADPANAHI, MD, FEBU
FELLOWSHIP OF UROLOGIC ONCOLOGY
IUMS, ISFAHAN, IRAN
BACKGROUND
• Kidney stones are common and costly
• Affect 10% of population
• Prevalence rates are increasing
• Cost> US $2 billion per year
RATIONALE FOR TX
NONSTAGHORN RENAL CALCULI
• First, stone-related symptoms or stone growth,
with
a calculated risk of approximately 50% at 5 years.
• Second, spontaneous stone passage occurs about
15% of the time and is more likely in stones 5 mm in
size or smaller.
STAGHORN STONES
• Untreated staghorn stones are associated with
1- recurrent UTIs
2- urosepsis events
3- renal functional deterioration, and a higher likelihood of
death
• Complete renal function loss in 50% of affected kidneys
can occur after 2 years without treatment
MODALITIES
• ESWL
• URS or RIRS
• PCNL
• laparoscopic or robotic assisted stone surgery
ESWL(MECHANISM OF ACTION)
• All shock waves, despite their source, are capable of
fragmenting stones when focused
• Fragmentation is achieved by several mechanisms
• forces result in erosion at the entry and exit sites of the
shock wave
ESWL
POSTOPERATIVE CARE
• active ambulatory status to facilitate stone passage
• Gross hematuria should resolve during the first
•
postoperative week
Fluid intake should be encouraged
• Follow-up in approximately 2 weeks for discussion and
evaluation of a KUB and renal ultrasonography
ESWL(COMPLICATIONS)
• perirenal hematomas:Severe pain unresponsive to routine
intravenous or oral medications(Dx=CT)
• Steinstrasse (stone street)
• Stone residue(depends on the size and location of stone)
URS OR TUL
TUL
LITHOCLAST
PNL
PNL
PNL
PNL
PNL
PNL
ESWL AND PCNL OUTCOMES
STAGHORN STONES.
• PCNL is the method of choice for treating partial and
complete staghorn kidney stones
• Observation and nonoperative management should
be discouraged, because eventually cause complete
loss of function in the affected kidney, can be the
cause of recurrent UTIs and sepsis episodes, and are
associated with an increased overall mortality
URETERAL CALCULI
the chief determinant of stone passage:
1- is the diameter of the stone in its transverse orientation .
2- the location of the stone within the ureter at
presentation with a review of the literature demonstrating
a 71% chance of passage of a distal ureteral stone versus
22% for proximal stones
For stones that do not move in a reasonable time
frame, or in the setting of recurring severe pain, or if
the patient prefers, surgical therapy is indicated.
Primary options include SWL and URS, although PCNL
and antegrade nephroscopy may be indicated for
select cases
Distal Ureter. As discussed earlier, distal stones are most
likely to pass with observation or MET . The most
typical site for impaction in this region of the ureter is at the
UVJ; stones reaching this location often cause significant
irritative symptoms owing to stimulation of the bladder, a
clinical sign that helps localize them. When stones fail to pass,
once again surgical therapy
is indicated.
A UTI associated with an obstructing upper tract stone
(ureteral or renal) represents a true urologic
emergency and requires emergent
urinary tract drainage. This is accomplished by either
ureteral stenting or percutaneous nephrostomy.
Attempts to definitively treat the obstructing stone
should be postponed until the patient is stabilized and
the infection is completely treated.78
RENAL FUNCTION
The general consensus is that symptomatic upper
tract stones located in renal units with
approximately 15% or less split function
should be considered for nephrectomy, and
stone-specific, nephron-sparing treatments
should not be pursued.
MORBID OBESITY
A BMI above 40 kg/m2 is considered morbid obesity
by the World Health Organization. Ureterorenoscopy
and PCNL outcomes appear to be relatively
independent of obesity status, whereas those after
SWL are drastically worse.
OLD AGE AND FRAILTY
A number of groups have looked at PCNL
outcomes in elderly populations and have found
essentially unchanged surgical success, albeit
with a higher rate of complications.Shock wave
lithotripsy in the elderly is feasible as well, but
it may be associated with an increased risk of
perinephric hematoma.
UNCORRECTED COAGULOPATHY
Uncorrected coagulopathy is a contraindication to SWL and
PCNL; however, URS can be successfully undertaken in
such circumstances with little to no increase in surgical
morbidity.
PRIOR RENAL SURGERY
Prior renal surgery is not a contraindication
to any form of renal stone surgery and presents no new
specific concerns.
Thus, all treatment modalities may be employed as
necessary, given appropriate indications (SWL, URS, PCNL).
RENAL TRANSPLANTS
• because of the lack of innervation in renal transplants,
obstructing stones do not manifest with typical renal colic.
•
vague graft site discomfort, fevers, oliguria, hematuria, or
rising creatinine may be the only presenting signs
SWL has been described for stones in transplant
kidneys and is an option for stones smaller than 1.5
cm; however, high re-treatment rates and auxiliary
procedure rates should be expected
PCNL remains the preferred treatment choice for
large-burden stones (>1.5 cm) or if less invasive
methods have failed. Stone-free rates ranging from
77% to 100%, similar to rates in the general
population, have been reported
EVALUATION OF OUTCOME
ASSESSMENT AND FATE OF RESIDUAL FRAGMENTS
•
In the modern era with the rise of endourology and the
frequent use of SWL, URS, and PCNL, postoperative
residual fragments are relatively common.
• The definition and optimal management of residual
fragments continue to generate controversy.