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RISK OF DIABETES MELLITUS AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY OR URETEROSCOPY FOR URINARY STONE DISEASE
Vol. 179, No. 4, Supplement, Tuesday, May 20, 2008
has been proposed that patients undergoing SWL have a higher risk of developing diabetes. We determined the prevalence of diabetes in patients who underwent SWL 20 years ago at our institution and compared it to the provincial prevalence (BC Ministry of Health Services: Responding to Diabetes, 2002). 0(7+2'6 7KUHHKXQGUHGDQG¿IW\VHYHQ SDWLHQWVZKR underwent SWL using a Dornier HM-3 lithotriptor between 1985 to 1987 ZHUH LGHQWL¿HG IURP RXU GDWDEDVH DW 9DQFRXYHU *HQHUDO +RVSLWDO$ telephone survey was conducted with consent. Information was gathered regarding onset of diabetes, body-mass-index, hypertension, smoking, recurrent stone disease, and family history of diabetes. RESULTS: Of the 357 contact letters mailed, a total of 130 patients completed the telephone questionnaire, giving an overall response rate of 36.4%. Of the 357 patients, 247 were excluded from study due to: deceased (18), incorrect address (104), unable to reach (82), refused/unable to consent (11), other (12). Four were excluded from analysis due to diagnosis of diabetes prior to SWL. The median age at time of survey was 67.4 years, and the median BMI at time of survey was 26.7 kg/m2. Background BMI and smoking characteristics for this age group in BC were comparable to the study group. The provincial prevalence of diabetes for this age group is 12-18% for men and 9-15% for women. The overall prevalence of diabetes in the study group was 25.4%. With respect to gender, males in the study had a prevalence of diabetes of 28.7% (25/87) and females 17.9% (7/39). CONCLUSIONS: There is an elevated prevalence of diabetes in the group of male patients who had undergone SWL 20 years previously compared to the provincial prevalence. The shortcomings of this study are that proper controls were not possible to identify. It would be premature to conclude that SWL alone results in a higher prevalence of diabetes. This association may be attributed to factors such as: 1) people with undiagnosed diabetes have a higher risk of stone disease, IRUZKLFKWKH\ZLOOOLNHO\UHFHLYH6:/ DQG SHRSOHZLWKVWRQHGLVHDVH have an inherently higher risk of diabetes possibly due to an underlying metabolic derangement. Source of Funding: Vancouver Coastal Health Research Institute, Michael Smith Foundation for Health Research.
1352 RISK OF DIABETES MELLITUS AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY OR URETEROSCOPY FOR URINARY STONE DISEASE Matthew C Kincade*, David Vance, Jessica Hammett, Sisir Botta, Kevin Walls, Bighnesh Satpathy, Ithaar H Derweesh. Memphis, TN. INTRODUCTION AND OBJECTIVE: To evaluate whether the treatment of urinary stone disease with extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy (URS) is associated with an increased risk of Diabetes Mellitus (DM). METHODS: In this retrospective case-control study of 713 consecutive patients treated with ESWL and 146 consecutive SDWLHQWVWUHDWHGZLWK856DWRXULQVWLWXWLRQZHDQDO\]HGWKHVXEMHFWV¶ demographic information (including age, race, and gender), laterality of stone burden and treatment modality, and presence of preoperative and SRVWRSHUDWLYH'0WRGHWHUPLQHZKHWKHUWKHUHZHUHVWDWLVWLFDOO\VLJQL¿FDQW UHODWLRQVKLSV'0GLDJQRVHVZHUHEDVHGRQDFRPSXWHUL]HGGLDJQRVLV list and/or the presence of medical therapy for either disease. The data ZHUHWKHQDQDO\]HGE\VWXGHQW¶VWWHVWDQGE\$129$DQDO\VLV RESULTS: Of the 713 ESWL patients, 137 patients had preexisting DM. Of the remaining patients, 57 (9.9%) developed de novo DM,. Average follow-up was 44.7 months. Of the 146 URS patients, 24 patients had pre-existing DM. Of the remaining patients, 9 (7.3%) developed de novo DM. Average follow-up was 39.4 months. Upon data analysis of the ESWL cohort, no epidemiological or clinical variables were found to be associated with the development of DM. Laterality of stone burden was not predictive of DM onset. The average length of follow-up was 44.7 months. After URS, only the total number of treatments was IRXQGWREHVLJQL¿FDQWO\DVVRFLDWHGZLWKWKHGHYHORSPHQWRIGHQRYR DM (p<0.001 on ANOVA analysis). Again, laterality of stone burden or WUHDWPHQWZDVQRWIRXQGWREHVLJQL¿FDQW:KHQFRPSDULQJGHQRYR'0 after ESWL and URS, only the total number of treatments (1.7 ESWL vs. 856WUHDWPHQWVS VLJQL¿FDQWO\SUHGLFWHGWKHRQVHWRI'0
THE JOURNAL OF UROLOGY®
463
$JHJHQGHUHWKQLFLW\DQGODWHUDOLW\RIVWRQHGLVHDVHZHUHQRWVLJQL¿FDQW risk factors for de novo DM. CONCLUSIONS: An increased number of URS treatments VLJQL¿FDQWO\SUHGLFWHGWKHRQVHWRI'0FRPSDUHGWR(6:/7KLVLVLQ contrast to previously published data that suggests an increased risk of DM after ESWL. Further prospective studies that include a more detailed history including BMI and other risk factors are in order, but ESWL continues to be a safe modality for the treatment of urinary stone disease. Source of Funding: None
1353 PROSPECTIVE EVALUATION OF PANCREATIC ENZYME LEVELS FOLLOWING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Theodore E Brisson*, Alexander S Parker, Michelle Arnold, Mike Wehle. Jacksonville, FL. INTRODUCTION AND OBJECTIVE: Investigators from our institution recently demonstrated evidence of a positive association between extracorporeal shock wave lithotripsy (SWL) for renal and proximal ureteral stones and the development of diabetes mellitus at 19 years follow-up. To date, the underlying mechanism for this risk is unclear. Animal studies have indicated an increase in pancreatic HQ]\PHVSRVW6:/ KRZHYHUGDWDIURPDKXPDQPRGHODUHH[WUHPHO\ limited. In addition, individual case reports of acute pancreatitis post 6:/ KDYH EHHQ UHSRUWHG :H WKHRUL]H WKDW VKHDU IRUFHV FUHDWHG E\ the shock waves cause sub-clinical damage to surrounding tissues. If the pancreas is damaged by these forces, this may decrease insulin secreting beta cell reserves and contribute to the development of DM over time. Motivated by this, we designed a prospective clinical study to evaluate acute sub-clinical pancreatic damage in patients treated for kidney stones. METHODS: The four treatment arms for our investigation included patients undergoing ESWL, ureteroscopic stone manipulation, percutaneous nephrostolithotomy (PNL) and a control group who had urologic surgeries unrelated to kidney stones. We aim to enroll 20 patients in each arm and to collect a baseline, 1 month and 3 month serum sample in order to measure circulating levels of amylase and lipase. RESULTS: To date, we have enrolled a total of 30 patients to this study: 16 patients undergoing PNL, 9 patients undergoing ESWL, and 5 patients undergoing ureteroscopic stone manipulation. There were 19 men and 11 women with an average age 62 years. In our interim DQDO\VLVZHQRWHGQRGLIIHUHQFHLQWKHVWRQHVL]HRUORFDWLRQEHWZHHQ the groups. More importantly, a paired t-test on these preliminary data suggest no statistical difference between the pre and post procedure amylase and lipase levels in any of the treatment groups. CONCLUSIONS: While we anticipate complete enrollment of this study to be achieved by January 2008, the preliminary results do not support the hypothesis that ESWL associated shear forces cause VXEFOLQLFDOGDPDJHWRWKHSDQFUHDVUHÀHFWHGE\DULVHLQDP\ODVHRU lipase levels. Completion of our full complement of 3 month follow-up visits on all patients enrolled in this study will provide vital information regarding this putative underlying mechanism. Moreover, further studies with more extended follow-up and examination of additional biomarkers of pancreatic damage are needed to clarify the potential relationship between ESWL and the development of DM. Source of Funding: CR Award from Mayo Clinic Research Program.
1354 LONG-TERM OUTCOMES OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY ON THE DEVELOPMENT OF CHRONIC MEDICAL CONDITIONS Kirsten L Greene*, Olivia Lee, Hsueh-Fu Lu, Marshall L Stoller. San Francisco, CA, and Cincinnati, OH. INTRODUCTION AND OBJECTIVE: Extracorporeal shock wave lithotripsy(ESWL) for the treatment of renal stones was introduced in the United States in 1984 and is the treatment modality of choice for most patients presenting with nephrolithiasis. Recent studies have LGHQWL¿HG DQ LQFUHDVHG ULVN RI K\SHUWHQVLRQ DQG GLDEHWHV GHYHORSLQJ
has been proposed that patients undergoing SWL have a higher risk of developing diabetes. We determined the prevalence of diabetes in patients who underwent SWL 20 years ago at our institution and compared it to the provincial prevalence (BC Ministry of Health Services: Responding to Diabetes, 2002). 0(7+2'6 7KUHHKXQGUHGDQG¿IW\VHYHQ SDWLHQWVZKR underwent SWL using a Dornier HM-3 lithotriptor between 1985 to 1987 ZHUH LGHQWL¿HG IURP RXU GDWDEDVH DW 9DQFRXYHU *HQHUDO +RVSLWDO$ telephone survey was conducted with consent. Information was gathered regarding onset of diabetes, body-mass-index, hypertension, smoking, recurrent stone disease, and family history of diabetes. RESULTS: Of the 357 contact letters mailed, a total of 130 patients completed the telephone questionnaire, giving an overall response rate of 36.4%. Of the 357 patients, 247 were excluded from study due to: deceased (18), incorrect address (104), unable to reach (82), refused/unable to consent (11), other (12). Four were excluded from analysis due to diagnosis of diabetes prior to SWL. The median age at time of survey was 67.4 years, and the median BMI at time of survey was 26.7 kg/m2. Background BMI and smoking characteristics for this age group in BC were comparable to the study group. The provincial prevalence of diabetes for this age group is 12-18% for men and 9-15% for women. The overall prevalence of diabetes in the study group was 25.4%. With respect to gender, males in the study had a prevalence of diabetes of 28.7% (25/87) and females 17.9% (7/39). CONCLUSIONS: There is an elevated prevalence of diabetes in the group of male patients who had undergone SWL 20 years previously compared to the provincial prevalence. The shortcomings of this study are that proper controls were not possible to identify. It would be premature to conclude that SWL alone results in a higher prevalence of diabetes. This association may be attributed to factors such as: 1) people with undiagnosed diabetes have a higher risk of stone disease, IRUZKLFKWKH\ZLOOOLNHO\UHFHLYH6:/ DQG SHRSOHZLWKVWRQHGLVHDVH have an inherently higher risk of diabetes possibly due to an underlying metabolic derangement. Source of Funding: Vancouver Coastal Health Research Institute, Michael Smith Foundation for Health Research.
1352 RISK OF DIABETES MELLITUS AFTER EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY OR URETEROSCOPY FOR URINARY STONE DISEASE Matthew C Kincade*, David Vance, Jessica Hammett, Sisir Botta, Kevin Walls, Bighnesh Satpathy, Ithaar H Derweesh. Memphis, TN. INTRODUCTION AND OBJECTIVE: To evaluate whether the treatment of urinary stone disease with extracorporeal shock wave lithotripsy (ESWL) or ureteroscopy (URS) is associated with an increased risk of Diabetes Mellitus (DM). METHODS: In this retrospective case-control study of 713 consecutive patients treated with ESWL and 146 consecutive SDWLHQWVWUHDWHGZLWK856DWRXULQVWLWXWLRQZHDQDO\]HGWKHVXEMHFWV¶ demographic information (including age, race, and gender), laterality of stone burden and treatment modality, and presence of preoperative and SRVWRSHUDWLYH'0WRGHWHUPLQHZKHWKHUWKHUHZHUHVWDWLVWLFDOO\VLJQL¿FDQW UHODWLRQVKLSV'0GLDJQRVHVZHUHEDVHGRQDFRPSXWHUL]HGGLDJQRVLV list and/or the presence of medical therapy for either disease. The data ZHUHWKHQDQDO\]HGE\VWXGHQW¶VWWHVWDQGE\$129$DQDO\VLV RESULTS: Of the 713 ESWL patients, 137 patients had preexisting DM. Of the remaining patients, 57 (9.9%) developed de novo DM,. Average follow-up was 44.7 months. Of the 146 URS patients, 24 patients had pre-existing DM. Of the remaining patients, 9 (7.3%) developed de novo DM. Average follow-up was 39.4 months. Upon data analysis of the ESWL cohort, no epidemiological or clinical variables were found to be associated with the development of DM. Laterality of stone burden was not predictive of DM onset. The average length of follow-up was 44.7 months. After URS, only the total number of treatments was IRXQGWREHVLJQL¿FDQWO\DVVRFLDWHGZLWKWKHGHYHORSPHQWRIGHQRYR DM (p<0.001 on ANOVA analysis). Again, laterality of stone burden or WUHDWPHQWZDVQRWIRXQGWREHVLJQL¿FDQW:KHQFRPSDULQJGHQRYR'0 after ESWL and URS, only the total number of treatments (1.7 ESWL vs. 856WUHDWPHQWVS VLJQL¿FDQWO\SUHGLFWHGWKHRQVHWRI'0
THE JOURNAL OF UROLOGY®
463
$JHJHQGHUHWKQLFLW\DQGODWHUDOLW\RIVWRQHGLVHDVHZHUHQRWVLJQL¿FDQW risk factors for de novo DM. CONCLUSIONS: An increased number of URS treatments VLJQL¿FDQWO\SUHGLFWHGWKHRQVHWRI'0FRPSDUHGWR(6:/7KLVLVLQ contrast to previously published data that suggests an increased risk of DM after ESWL. Further prospective studies that include a more detailed history including BMI and other risk factors are in order, but ESWL continues to be a safe modality for the treatment of urinary stone disease. Source of Funding: None
1353 PROSPECTIVE EVALUATION OF PANCREATIC ENZYME LEVELS FOLLOWING EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY Theodore E Brisson*, Alexander S Parker, Michelle Arnold, Mike Wehle. Jacksonville, FL. INTRODUCTION AND OBJECTIVE: Investigators from our institution recently demonstrated evidence of a positive association between extracorporeal shock wave lithotripsy (SWL) for renal and proximal ureteral stones and the development of diabetes mellitus at 19 years follow-up. To date, the underlying mechanism for this risk is unclear. Animal studies have indicated an increase in pancreatic HQ]\PHVSRVW6:/ KRZHYHUGDWDIURPDKXPDQPRGHODUHH[WUHPHO\ limited. In addition, individual case reports of acute pancreatitis post 6:/ KDYH EHHQ UHSRUWHG :H WKHRUL]H WKDW VKHDU IRUFHV FUHDWHG E\ the shock waves cause sub-clinical damage to surrounding tissues. If the pancreas is damaged by these forces, this may decrease insulin secreting beta cell reserves and contribute to the development of DM over time. Motivated by this, we designed a prospective clinical study to evaluate acute sub-clinical pancreatic damage in patients treated for kidney stones. METHODS: The four treatment arms for our investigation included patients undergoing ESWL, ureteroscopic stone manipulation, percutaneous nephrostolithotomy (PNL) and a control group who had urologic surgeries unrelated to kidney stones. We aim to enroll 20 patients in each arm and to collect a baseline, 1 month and 3 month serum sample in order to measure circulating levels of amylase and lipase. RESULTS: To date, we have enrolled a total of 30 patients to this study: 16 patients undergoing PNL, 9 patients undergoing ESWL, and 5 patients undergoing ureteroscopic stone manipulation. There were 19 men and 11 women with an average age 62 years. In our interim DQDO\VLVZHQRWHGQRGLIIHUHQFHLQWKHVWRQHVL]HRUORFDWLRQEHWZHHQ the groups. More importantly, a paired t-test on these preliminary data suggest no statistical difference between the pre and post procedure amylase and lipase levels in any of the treatment groups. CONCLUSIONS: While we anticipate complete enrollment of this study to be achieved by January 2008, the preliminary results do not support the hypothesis that ESWL associated shear forces cause VXEFOLQLFDOGDPDJHWRWKHSDQFUHDVUHÀHFWHGE\DULVHLQDP\ODVHRU lipase levels. Completion of our full complement of 3 month follow-up visits on all patients enrolled in this study will provide vital information regarding this putative underlying mechanism. Moreover, further studies with more extended follow-up and examination of additional biomarkers of pancreatic damage are needed to clarify the potential relationship between ESWL and the development of DM. Source of Funding: CR Award from Mayo Clinic Research Program.
1354 LONG-TERM OUTCOMES OF EXTRACORPOREAL SHOCK WAVE LITHOTRIPSY ON THE DEVELOPMENT OF CHRONIC MEDICAL CONDITIONS Kirsten L Greene*, Olivia Lee, Hsueh-Fu Lu, Marshall L Stoller. San Francisco, CA, and Cincinnati, OH. INTRODUCTION AND OBJECTIVE: Extracorporeal shock wave lithotripsy(ESWL) for the treatment of renal stones was introduced in the United States in 1984 and is the treatment modality of choice for most patients presenting with nephrolithiasis. Recent studies have LGHQWL¿HG DQ LQFUHDVHG ULVN RI K\SHUWHQVLRQ DQG GLDEHWHV GHYHORSLQJ