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Percutaneous Nephrostolithotomy—Is it Time to Abandon Extracorporeal Shock Wave Lithotripsy?
Percutaneous Nephrostolithotomy—Is it Time to Abandon Extracorporeal Shock Wave Lithotripsy? THIS issue of The Journal features 2 reports on the current status of percutaneous nephrostolithotomy (PCNL). Bagrodia et al (page 149) demonstrated that simultaneous bilateral PCNL saves an average of $4,374 to $5,126 in direct hospital costs compared to staged bilateral PCNL with comparable complication rates. Unfortunately there are financial disincentives for urologists performing simultaneous bilateral PCNL in that they receive $275 to $1,069 less in reimbursement compared to staged PCNL. In this important article the authors argue that the urologist who performs simultaneous bilateral PCNL and, thereby, decreases costs to third party payers should appropriately and in turn receive increased reimbursement from said payers. Kefer et al (page 144) demonstrated that PCNL can be safely performed in patients on chronic anticoagulation therapy using enoxaparin bridging. PCNL monotherapy resulted in a 93% stone-free rate in patients with an average stone size of 7.43 cm2, with only 1 of 27 requiring a transfusion and angioablation to achieve hemostasis for tract site bleeding. Only 1 other patient in the series had significant delayed bleeding with postoperative resumption of anticoagulation. These articles further demonstrate the efficacy, efficiency and safety of contemporary PCNL as a treatment modality for renal calculi even in those patients with bilateral disease and significant comorbidities. Estimates of surgical trends in the Medicare population undergoing surgery for upper tract calculi demonstrate relative stability from 1992 to 1998 with approximately 54%, 41% and 4% receiving extracorporeal shock wave lithotripsy (SWL), ureteroscopy or PCNL, respectively.1 With an estimated annual cost of $2 billion in the United States and a suspected increasing incidence, the treatment of urolithiasis should focus on effectiveness to limit the need for re-treatment to achieve cost containment. PCNL is superior to extracorporeal SWL in the treatment of staghorn calculi as reflected by American Urological Association clinical guidelines from 2005 promoting PCNL based therapy. Meta-analytic 0022-5347/09/1811-0011/0 THE JOURNAL OF UROLOGY® Copyright © 2009 by AMERICAN UROLOGICAL ASSOCIATION
data show stone-free rates of 78% compared to series of extracorporeal SWL with stone-free rates of 54%. Single access PCNL combined with flexible nephroscopy, holmium laser lithotripsy and advanced endourological graspers achieves 95% stone-free rates in patients with staghorn calculi requiring a mean of only 1.6 procedures.2 A prospective randomized trial of PCNL vs extracorporeal SWL has been reported that clearly demonstrates the superiority of PCNL in treating lower pole calculi 10 mm or larger with a stone-free rate of 95% for PCNL compared to only 37% for extracorporeal SWL.3 Concerns have been raised with respect to the long-term sequelae of extracorporeal SWL. A case control study of patients with stones treated with the Dornier HM3 lithotriptor with 19 years of followup reported an increased risk of diabetes mellitus in those receiving extracorporeal SWL vs those treated conservatively.4 Patients treated with bilateral extracorporeal SWL were at increased risk for hypertension in the same study. Although attractive for the treatment of nonobstructing renal calculi 10 mm or smaller, extensive data show acceptable efficacy for ureteroscopy and laser lithotripsy in the treatment of stones this size.5 So why has extracorporeal SWL not yet been abandoned? Extracorporeal SWL remains the most commonly used surgical modality for stone treatment because patients like it, and it is relatively easy and inexpensive for urologists to perform. In addition, 50% to 60% of all solitary renal calculi are 10 mm or smaller, an acceptable size which meets relatively good stone-free rates ranging between 63% and 90% in reported extracorporeal SWL series.6 However, caution must be exercised in the interpretation of stone-free rates in extracorporeal SWL series because the definition among series is variable, and can range from stone-free status based on plain x-ray of the kidneys, ureters and bladder to the acceptable presence of asymptomatic residual fragments 4 mm or smaller. This range in definition is important in counseling patients on outcomes since a recent survey of patients in the United Kingdom undergoing extracorporeal SWL revealed that Vol. 181, 11-12, January 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.10.071
www.jurology.com
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PERCUTANEOUS NEPHROSTOLITHOTOMY VERSUS EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
achieving a stone-free status was the most important patient expectation involving the overall surgical experience for elective stone treatment.7 Nevertheless, patients still seem relatively pleased with extracorporeal SWL. There is relatively low morbidity and, when experienced, complications usually involve retained ureteral fragments. The reported incidence of Steinstrasse is acceptable for stones smaller than 10 mm at 0.3%.8 This rate increases to 4% to 7% in stones between 10 and 20 mm.9 Additionally, keeping in mind that approximately 50% of patients with stones will have another stone within 5 years, there is a large subset of patients that requires multiple surgeries over the years. Not surprisingly this group is interested in minimizing morbidity. In a study of treatment preferences among patients with recurrent stone disease PCNL was less desirable in those who already underwent the procedure vs surgically naïve patients.
Desirability of extracorporeal SWL did not differ between the groups indicating that extracorporeal SWL was preferred to PCNL in patients with a history of treatment with PCNL.10 In conclusion, extracorporeal SWL probably should not be abandoned due to the heterogeneous spectrum of stone disease. Decisions always should be made on a case by case basis, taking into consideration stone size, number, location and composition. Although we continue to refine and improve PCNL, as evidenced by these articles in this issue of The Journal, we must remember to rely on unique patient characteristics, physician expertise and available modalities for treating the patient with stones. Leonard G. Gomella Department of Urology Thomas Jefferson University Philadelphia, Pennsylvania
REFERENCES 1. Pearle MS, Calhoun EA, Curhan GC and the Urologic Diseases of America Project: Urologic Diseases in America Project: urolithiasis. J Urol 2005; 173: 848. 2. Wong C and Leveillee RJ: Single upper-pole percutaneous access for treatment of ⬎ or ⫽ 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary? J Endourol 2002; 16: 477. 3. Albala DM, Assimos DG, Clayman RV, Denstedt JD, Grasso M, Gutierrez-Aceves J et al: Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis–initial results. J Urol 2001; 166: 2072.
4. Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE and Segura JW: Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup. J Urol 2006; 175: 1742. 5. Fabrizio MD, Behari A and Bagley DH: Ureteroscopic management of intrarenal calculi. J Urol 1998; 159: 1139. 6. Cass AS: Comparison of first generation (Dornier HM3) and second generation (Medstone STS) lithotriptors: treatment results with 13,864 renal and ureteral calculi. J Urol 1995; 153: 588. 7. Kouriefs C, Quatan N, Larking A, Watkin NA and Boyd PJ: What is important to patients receiving
extracorporeal shock-wave lithotripsy for urinary tract calculi? Ann R Coll Surg Engl 2004; 86: 432. 8. Sayed MA, el-Taher AM, Aboul-Ella HA and Shaker SE: Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJU Int 2001; 88: 675. 9. Sulaiman MN, Buchholz NP and Clark PB: The role of ureteral stent placement in the prevention of Steinstrasse. J Endourol 1999; 13: 151. 10. Kuo RL, Aslan P, Abrahamse PH, Matchar DB and Preminger GM: Incorporation of patient preferences in the treatment of upper urinary tract calculi: a decision analytical view. J Urol 1999; 162: 1913.
data show stone-free rates of 78% compared to series of extracorporeal SWL with stone-free rates of 54%. Single access PCNL combined with flexible nephroscopy, holmium laser lithotripsy and advanced endourological graspers achieves 95% stone-free rates in patients with staghorn calculi requiring a mean of only 1.6 procedures.2 A prospective randomized trial of PCNL vs extracorporeal SWL has been reported that clearly demonstrates the superiority of PCNL in treating lower pole calculi 10 mm or larger with a stone-free rate of 95% for PCNL compared to only 37% for extracorporeal SWL.3 Concerns have been raised with respect to the long-term sequelae of extracorporeal SWL. A case control study of patients with stones treated with the Dornier HM3 lithotriptor with 19 years of followup reported an increased risk of diabetes mellitus in those receiving extracorporeal SWL vs those treated conservatively.4 Patients treated with bilateral extracorporeal SWL were at increased risk for hypertension in the same study. Although attractive for the treatment of nonobstructing renal calculi 10 mm or smaller, extensive data show acceptable efficacy for ureteroscopy and laser lithotripsy in the treatment of stones this size.5 So why has extracorporeal SWL not yet been abandoned? Extracorporeal SWL remains the most commonly used surgical modality for stone treatment because patients like it, and it is relatively easy and inexpensive for urologists to perform. In addition, 50% to 60% of all solitary renal calculi are 10 mm or smaller, an acceptable size which meets relatively good stone-free rates ranging between 63% and 90% in reported extracorporeal SWL series.6 However, caution must be exercised in the interpretation of stone-free rates in extracorporeal SWL series because the definition among series is variable, and can range from stone-free status based on plain x-ray of the kidneys, ureters and bladder to the acceptable presence of asymptomatic residual fragments 4 mm or smaller. This range in definition is important in counseling patients on outcomes since a recent survey of patients in the United Kingdom undergoing extracorporeal SWL revealed that Vol. 181, 11-12, January 2009 Printed in U.S.A. DOI:10.1016/j.juro.2008.10.071
www.jurology.com
11
12
PERCUTANEOUS NEPHROSTOLITHOTOMY VERSUS EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY
achieving a stone-free status was the most important patient expectation involving the overall surgical experience for elective stone treatment.7 Nevertheless, patients still seem relatively pleased with extracorporeal SWL. There is relatively low morbidity and, when experienced, complications usually involve retained ureteral fragments. The reported incidence of Steinstrasse is acceptable for stones smaller than 10 mm at 0.3%.8 This rate increases to 4% to 7% in stones between 10 and 20 mm.9 Additionally, keeping in mind that approximately 50% of patients with stones will have another stone within 5 years, there is a large subset of patients that requires multiple surgeries over the years. Not surprisingly this group is interested in minimizing morbidity. In a study of treatment preferences among patients with recurrent stone disease PCNL was less desirable in those who already underwent the procedure vs surgically naïve patients.
Desirability of extracorporeal SWL did not differ between the groups indicating that extracorporeal SWL was preferred to PCNL in patients with a history of treatment with PCNL.10 In conclusion, extracorporeal SWL probably should not be abandoned due to the heterogeneous spectrum of stone disease. Decisions always should be made on a case by case basis, taking into consideration stone size, number, location and composition. Although we continue to refine and improve PCNL, as evidenced by these articles in this issue of The Journal, we must remember to rely on unique patient characteristics, physician expertise and available modalities for treating the patient with stones. Leonard G. Gomella Department of Urology Thomas Jefferson University Philadelphia, Pennsylvania
REFERENCES 1. Pearle MS, Calhoun EA, Curhan GC and the Urologic Diseases of America Project: Urologic Diseases in America Project: urolithiasis. J Urol 2005; 173: 848. 2. Wong C and Leveillee RJ: Single upper-pole percutaneous access for treatment of ⬎ or ⫽ 5-cm complex branched staghorn calculi: is shockwave lithotripsy necessary? J Endourol 2002; 16: 477. 3. Albala DM, Assimos DG, Clayman RV, Denstedt JD, Grasso M, Gutierrez-Aceves J et al: Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis–initial results. J Urol 2001; 166: 2072.
4. Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE and Segura JW: Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup. J Urol 2006; 175: 1742. 5. Fabrizio MD, Behari A and Bagley DH: Ureteroscopic management of intrarenal calculi. J Urol 1998; 159: 1139. 6. Cass AS: Comparison of first generation (Dornier HM3) and second generation (Medstone STS) lithotriptors: treatment results with 13,864 renal and ureteral calculi. J Urol 1995; 153: 588. 7. Kouriefs C, Quatan N, Larking A, Watkin NA and Boyd PJ: What is important to patients receiving
extracorporeal shock-wave lithotripsy for urinary tract calculi? Ann R Coll Surg Engl 2004; 86: 432. 8. Sayed MA, el-Taher AM, Aboul-Ella HA and Shaker SE: Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management. BJU Int 2001; 88: 675. 9. Sulaiman MN, Buchholz NP and Clark PB: The role of ureteral stent placement in the prevention of Steinstrasse. J Endourol 1999; 13: 151. 10. Kuo RL, Aslan P, Abrahamse PH, Matchar DB and Preminger GM: Incorporation of patient preferences in the treatment of upper urinary tract calculi: a decision analytical view. J Urol 1999; 162: 1913.