- Email: [email protected]
Geriatrics
1028
GERIATRICS
Ureteroscopy in Pregnant Women for Ureteral Stone M. Travassos, I. Amselem, N. S. Filho, M. Miguel, A. Sakai, H. Consolmagno, M. Nogueira and O. Fugita Department of Urology, Sao Paulo State University, Botucatu, Brazil J Endourol 2009; 23: 405– 407.
Introduction: The occurrence of urolithiasis in pregnancy represents a challenge in both diagnosis and treatment of this condition, because it presents risks not only to the mother but also to the fetus. Surgical treatment may be indicated for patients with infection, persistent pain, and obstruction of a solitary kidney. We present our experience on the management of pregnant patients with ureteral calculi and a review of the literature. Materials and Methods: The charts of 19 pregnant patients with obstructive ureteral calculi were retrospectively reviewed. Gestational age ranged from 13 to 33 weeks. In all patients, ureteral stone was diagnosed on abdominal ultrasound. In regard to localization, 15 calculi were in the distal ureter, 3 in the proximal ureter, and 1 in the interior of an ureterocele. Calculi size ranged from 6 to 10 mm (mean, 8 mm). The following criteria were used to indicate ureteroscopy: persistent pain with no improvement after clinical treatment, increase in renal dilation, or presence of uterine contractions. Nine patients (47.3%) were submitted to ureteroscopy. All calculi (100%) were removed with a stone basket extractor under continuous endoscopic vision. None of the calculi demanded the use of a lithotriptor. Results: Nine patients (47.3%) treated with clinical measurements presented no obstetric complications and spontaneous elimination of the calculi. Nine patients (47.3%) submitted to ureteroscopy had no surgical complications. There was remission of pain in all cases after ureteroscopy and ureteral catheter placement. Conclusion: The diagnosis and treatment of ureteral lithiasis in pregnant women present potential risks for the fetus and the mother. Conservative management is the first option, but ureteroscopy may be performed with safety and high success rates. Editorial Comment: This is another series demonstrating that ureteroscopic stone removal is an effective and safe method of treating pregnant patients with stones. While some have advocated just placing a ureteral stent in such patients, this approach is associated with stent related symptoms and rapid stent incrustation, prompting frequent stent changes. Dean Assimos, M.D.
Geriatrics Safety and Outcome of Percutaneous Nephrolithotomy in the Elderly: Retrospective Comparison to a Younger Patient Group T. Anagnostou, T. Thompson, C. F. Ng, S. Moussa, G. Smith and D. A. Tolley Scottish Lithotriptor Centre, Western General Hospital, Edinburgh, United Kingdom J Endourol 2008; 22: 2139 –2145.
Aim: To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (⬎70 years) patients might influence the decision for the procedure in the elderly. Materials and Methods: A large database was created from our patients (n ⫽ 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n ⫽ 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operationrelated adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments ⬍4 mm). Further analysis was performed for the same endpoints
GERIATRICS
1029
after stratification of the patients by (1) previous stone procedures and (2) special clinical features. Results: In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P ⫽ 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P ⫽ 0.01). Conclusion: In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population. Editorial Comment: Epidemiological studies have shown that urolithiasis occurs in elderly patients at rates similar to the general population. Optimal management of stone disease includes a variety of surgical and nonsurgical approaches. Percutaneous nephrolithotomy (PCNL) has become a standard surgical approach for managing staghorn and other larger stones in the renal collecting system and proximal ureter. Numerous studies have documented the safety and overall efficacy of this technique. However, there are few data on this treatment modality specifically analyzing outcomes in geriatric patients. Hypothetically older adults may be at higher risk for complications due to underlying comorbidities or other risk factors that could influence surgical results. This retrospective study from a large specialty center examined the outcomes of PCNL in 657 patients who underwent a total of 779 procedures. Subjects were stratified by age into groups younger than 70 years (531 patients, 644 procedures) and 70 years or older (126 patients, 135 procedures). Calculated preoperative stone burden and rates of prior attempted treatments were similar between groups (p >0.05). A variety of perioperative adverse events were seen in younger and older subjects (incidence 9.0% and 14.1%, respectively), although the difference was not statistically significant (p ⴝ 0.07). Observed stonefree and clinical success rates (defined as residual fragments smaller than 4 mm) were also equivalent between the 2 age groups. Prior attempted treatments did not appear to influence outcomes in either group. These results reiterate that chronological age is generally not a valid standard on which to base decisions for urological surgery. Older adults with larger stone burdens may benefit from PCNL, and overall rates of adverse events are not statistically higher in these patients. The authors correctly note that special consideration must be made for older adults who may have a history of cardiopulmonary disease. These procedures are performed using general anesthesia with the patient in the prone position and may take an extended time to complete. These circumstances could put older adults with limited cardiopulmonary reserve at higher risk for postoperative complications. However, careful patient selection, preoperative evaluation and intraoperative care can help reduce these potential risks. Tomas L. Griebling, M.D., M.P.H.
Extracorporeal Shock Wave Lithotripsy in an Elderly Population: How to Prevent Complications and Make the Treatment Safe and Effective M. C. Sighinolfi, S. Micali, M. Grande, A. Mofferdin, S. De Stefani and G. Bianchi Department of Urology, University of Modena and Reggio Emilia, Modena, Italy J Endourol 2008; 22: 2223–2226.
Introduction: The aim of our study is to consider the feasibility and the results of shock wave lithotripsy (SWL) in an elderly cohort of patients, considering different diseases and concomitant morbidity. Materials and Methods: From January 2003 up to July 2006, a total of 1100 SWL treatments were performed in our Stone Centre with Dornier Lithotripter S device. We retrospectively analyzed all the treatments carried out in patients older than 70 years of age, collecting a total
1030
LAPAROSCOPY/NEW TECHNOLOGY
of 130 patients. The average age was 75.1 years (range: 70 – 89). Stone location was renal in 95 and ureteral in 45 patients. Information about SWL outcomes and complications were collected as well as patient’s characteristics and treatment modalities. Results: Average stone size was 10.2⫹/⫺3.4 and 8.7⫹/⫺3.1 for the renal and ureteral location, respectively. 73 out of 140 patients (52.1%) were stone free after a single treatment; 49 patients (35%) required an adjunctive session, whereas SWL was unsuccessful in 18 (12.8%) patients. We observed 64, 24, 21, 10, 31 cases of concomitant arterial hypertension, diabetes mellitus, chronic renal failure, solitary kidney condition and previous neoplastic pathologies. A total of 8 and 6 subjects had previous cardiac surgery and atrial fibrillation respectively, thus requiring a warfarin scheduled conversion to low molecular weight heparin. Five patients had a pace maker implant and three patients an abdominal aortic aneurism. No SWL-related complications were found in this series considering both urological and systemic features. Conclusion: SWL represents the treatment of choice for urolithiasis, and it has to be recommended especially to geriatric patients. In those subjects, SWL complications can be avoided with a proper and personalized preparation, together with an ECG and ultrasound continuously monitored procedure. Editorial Comment: The development extracorporeal SWL in the 1980s revolutionized the care of a large proportion of patients with renal and ureteral calculi. Extracorporeal SWL technology evolved through time with development of advanced lithotriptors that use smaller focal zones. This evolution has led to a decrease in tissue damage and other complications. However, many urologists continue to have reservations about the safety of extracorporeal SWL in the elderly population due to possible complications and the influence of underlying comorbid chronic disorders. This retrospective cohort study examined the safety and clinical outcomes of extracorporeal SWL in 130 subjects 70 to 89 years old (mean 75.1). Overall stone-free rate was 87.1%, although 40% of those achieving this outcome measure required a second treatment. This population was characteristic of the general elderly population with a sizable proportion of subjects having at least 1 chronic comorbid health condition such as hypertension, diabetes, renal insufficiency, prior cancer or a solitary kidney. Overall, no treatment related complications were observed in this series. It is noteworthy that several modifications were made in the preoperative evaluation and perioperative treatment of these patients. All patients underwent preoperative cardiological evaluation and intraoperative electrocardiographic monitoring. Subjects receiving chronic anticoagulation medication were converted to a low molecular weight heparin alternative or had anticoagulation discontinued preoperatively. SWL was performed in a nongated fashion, and ultrasound guided stone localization was used where possible. Extracorporeal SWL remains a cornerstone of minimally invasive therapy for the treatment of renal and proximal ureteral calculi. These data support the premise that SWL can be performed safely with acceptable clinical outcomes in elderly patients. However, as with all surgery in the geriatric population, the results illustrate that care may need to be tailored to accommodate other underlying comorbidities commonly associated with aging. Tomas L. Griebling, M.D., M.P.H.
Laparoscopy/New Technology Clinical Evaluation of Efficacy of Novel Optically Activated Digital Endoscope Protection System Against Laser Energy Damage K. Xavier, G. W. Hruby, C. R. Kelly, J. Landman and M. Gupta Department of Urology, Columbia University College of Physicians and Surgeons, Columbia University Medical Center, New York, New York Urology 2009; 73: 37– 40.
Objectives: To evaluate the clinical reliability and efficacy of a novel endoscope protection system (EPS) against direct laser energy damage during ureteroscopy. Methods: We performed an in vivo
GERIATRICS
Ureteroscopy in Pregnant Women for Ureteral Stone M. Travassos, I. Amselem, N. S. Filho, M. Miguel, A. Sakai, H. Consolmagno, M. Nogueira and O. Fugita Department of Urology, Sao Paulo State University, Botucatu, Brazil J Endourol 2009; 23: 405– 407.
Introduction: The occurrence of urolithiasis in pregnancy represents a challenge in both diagnosis and treatment of this condition, because it presents risks not only to the mother but also to the fetus. Surgical treatment may be indicated for patients with infection, persistent pain, and obstruction of a solitary kidney. We present our experience on the management of pregnant patients with ureteral calculi and a review of the literature. Materials and Methods: The charts of 19 pregnant patients with obstructive ureteral calculi were retrospectively reviewed. Gestational age ranged from 13 to 33 weeks. In all patients, ureteral stone was diagnosed on abdominal ultrasound. In regard to localization, 15 calculi were in the distal ureter, 3 in the proximal ureter, and 1 in the interior of an ureterocele. Calculi size ranged from 6 to 10 mm (mean, 8 mm). The following criteria were used to indicate ureteroscopy: persistent pain with no improvement after clinical treatment, increase in renal dilation, or presence of uterine contractions. Nine patients (47.3%) were submitted to ureteroscopy. All calculi (100%) were removed with a stone basket extractor under continuous endoscopic vision. None of the calculi demanded the use of a lithotriptor. Results: Nine patients (47.3%) treated with clinical measurements presented no obstetric complications and spontaneous elimination of the calculi. Nine patients (47.3%) submitted to ureteroscopy had no surgical complications. There was remission of pain in all cases after ureteroscopy and ureteral catheter placement. Conclusion: The diagnosis and treatment of ureteral lithiasis in pregnant women present potential risks for the fetus and the mother. Conservative management is the first option, but ureteroscopy may be performed with safety and high success rates. Editorial Comment: This is another series demonstrating that ureteroscopic stone removal is an effective and safe method of treating pregnant patients with stones. While some have advocated just placing a ureteral stent in such patients, this approach is associated with stent related symptoms and rapid stent incrustation, prompting frequent stent changes. Dean Assimos, M.D.
Geriatrics Safety and Outcome of Percutaneous Nephrolithotomy in the Elderly: Retrospective Comparison to a Younger Patient Group T. Anagnostou, T. Thompson, C. F. Ng, S. Moussa, G. Smith and D. A. Tolley Scottish Lithotriptor Centre, Western General Hospital, Edinburgh, United Kingdom J Endourol 2008; 22: 2139 –2145.
Aim: To evaluate whether the overall safety and efficacy profile of percutaneous surgery for urinary stone disease in older (⬎70 years) patients might influence the decision for the procedure in the elderly. Materials and Methods: A large database was created from our patients (n ⫽ 1058) who underwent percutaneous surgery for stone disease between 1991 and 2003 in the Scottish Lithotriptor Centre, including clinical and operation details for each case. Only percutaneous nephrolithotomy cases with full details were studied (n ⫽ 779) and were grouped into two age groups: (1) between 17 and 69 years and (2) over 70 years. Statistical analysis evaluated differences in terms of operationrelated adverse events, stone-free success rates, and clinical success rates (including stone-free cases and cases with residual fragments ⬍4 mm). Further analysis was performed for the same endpoints
GERIATRICS
1029
after stratification of the patients by (1) previous stone procedures and (2) special clinical features. Results: In the overall database, no statistically important differences were found between the two groups in terms of stone burden before surgery, adverse events rates, complete stone-free rates, and clinical success rates. However, a statistical trend toward higher clinical success rates in favor of the younger group was seen (P ⫽ 0.051). Stratification of our database according to previous stone disease procedures or special clinical or anatomic characteristics has only shown a statistically important difference for clinical success rates in favor of the older group without special features (P ⫽ 0.01). Conclusion: In experienced hands, age-related morbidity or age itself should not be a discouraging consideration when deciding on performing percutaneous nephrolithotomy, as the procedure is as equally feasible and safe in the elderly as in the younger patient population. Editorial Comment: Epidemiological studies have shown that urolithiasis occurs in elderly patients at rates similar to the general population. Optimal management of stone disease includes a variety of surgical and nonsurgical approaches. Percutaneous nephrolithotomy (PCNL) has become a standard surgical approach for managing staghorn and other larger stones in the renal collecting system and proximal ureter. Numerous studies have documented the safety and overall efficacy of this technique. However, there are few data on this treatment modality specifically analyzing outcomes in geriatric patients. Hypothetically older adults may be at higher risk for complications due to underlying comorbidities or other risk factors that could influence surgical results. This retrospective study from a large specialty center examined the outcomes of PCNL in 657 patients who underwent a total of 779 procedures. Subjects were stratified by age into groups younger than 70 years (531 patients, 644 procedures) and 70 years or older (126 patients, 135 procedures). Calculated preoperative stone burden and rates of prior attempted treatments were similar between groups (p >0.05). A variety of perioperative adverse events were seen in younger and older subjects (incidence 9.0% and 14.1%, respectively), although the difference was not statistically significant (p ⴝ 0.07). Observed stonefree and clinical success rates (defined as residual fragments smaller than 4 mm) were also equivalent between the 2 age groups. Prior attempted treatments did not appear to influence outcomes in either group. These results reiterate that chronological age is generally not a valid standard on which to base decisions for urological surgery. Older adults with larger stone burdens may benefit from PCNL, and overall rates of adverse events are not statistically higher in these patients. The authors correctly note that special consideration must be made for older adults who may have a history of cardiopulmonary disease. These procedures are performed using general anesthesia with the patient in the prone position and may take an extended time to complete. These circumstances could put older adults with limited cardiopulmonary reserve at higher risk for postoperative complications. However, careful patient selection, preoperative evaluation and intraoperative care can help reduce these potential risks. Tomas L. Griebling, M.D., M.P.H.
Extracorporeal Shock Wave Lithotripsy in an Elderly Population: How to Prevent Complications and Make the Treatment Safe and Effective M. C. Sighinolfi, S. Micali, M. Grande, A. Mofferdin, S. De Stefani and G. Bianchi Department of Urology, University of Modena and Reggio Emilia, Modena, Italy J Endourol 2008; 22: 2223–2226.
Introduction: The aim of our study is to consider the feasibility and the results of shock wave lithotripsy (SWL) in an elderly cohort of patients, considering different diseases and concomitant morbidity. Materials and Methods: From January 2003 up to July 2006, a total of 1100 SWL treatments were performed in our Stone Centre with Dornier Lithotripter S device. We retrospectively analyzed all the treatments carried out in patients older than 70 years of age, collecting a total
1030
LAPAROSCOPY/NEW TECHNOLOGY
of 130 patients. The average age was 75.1 years (range: 70 – 89). Stone location was renal in 95 and ureteral in 45 patients. Information about SWL outcomes and complications were collected as well as patient’s characteristics and treatment modalities. Results: Average stone size was 10.2⫹/⫺3.4 and 8.7⫹/⫺3.1 for the renal and ureteral location, respectively. 73 out of 140 patients (52.1%) were stone free after a single treatment; 49 patients (35%) required an adjunctive session, whereas SWL was unsuccessful in 18 (12.8%) patients. We observed 64, 24, 21, 10, 31 cases of concomitant arterial hypertension, diabetes mellitus, chronic renal failure, solitary kidney condition and previous neoplastic pathologies. A total of 8 and 6 subjects had previous cardiac surgery and atrial fibrillation respectively, thus requiring a warfarin scheduled conversion to low molecular weight heparin. Five patients had a pace maker implant and three patients an abdominal aortic aneurism. No SWL-related complications were found in this series considering both urological and systemic features. Conclusion: SWL represents the treatment of choice for urolithiasis, and it has to be recommended especially to geriatric patients. In those subjects, SWL complications can be avoided with a proper and personalized preparation, together with an ECG and ultrasound continuously monitored procedure. Editorial Comment: The development extracorporeal SWL in the 1980s revolutionized the care of a large proportion of patients with renal and ureteral calculi. Extracorporeal SWL technology evolved through time with development of advanced lithotriptors that use smaller focal zones. This evolution has led to a decrease in tissue damage and other complications. However, many urologists continue to have reservations about the safety of extracorporeal SWL in the elderly population due to possible complications and the influence of underlying comorbid chronic disorders. This retrospective cohort study examined the safety and clinical outcomes of extracorporeal SWL in 130 subjects 70 to 89 years old (mean 75.1). Overall stone-free rate was 87.1%, although 40% of those achieving this outcome measure required a second treatment. This population was characteristic of the general elderly population with a sizable proportion of subjects having at least 1 chronic comorbid health condition such as hypertension, diabetes, renal insufficiency, prior cancer or a solitary kidney. Overall, no treatment related complications were observed in this series. It is noteworthy that several modifications were made in the preoperative evaluation and perioperative treatment of these patients. All patients underwent preoperative cardiological evaluation and intraoperative electrocardiographic monitoring. Subjects receiving chronic anticoagulation medication were converted to a low molecular weight heparin alternative or had anticoagulation discontinued preoperatively. SWL was performed in a nongated fashion, and ultrasound guided stone localization was used where possible. Extracorporeal SWL remains a cornerstone of minimally invasive therapy for the treatment of renal and proximal ureteral calculi. These data support the premise that SWL can be performed safely with acceptable clinical outcomes in elderly patients. However, as with all surgery in the geriatric population, the results illustrate that care may need to be tailored to accommodate other underlying comorbidities commonly associated with aging. Tomas L. Griebling, M.D., M.P.H.
Laparoscopy/New Technology Clinical Evaluation of Efficacy of Novel Optically Activated Digital Endoscope Protection System Against Laser Energy Damage K. Xavier, G. W. Hruby, C. R. Kelly, J. Landman and M. Gupta Department of Urology, Columbia University College of Physicians and Surgeons, Columbia University Medical Center, New York, New York Urology 2009; 73: 37– 40.
Objectives: To evaluate the clinical reliability and efficacy of a novel endoscope protection system (EPS) against direct laser energy damage during ureteroscopy. Methods: We performed an in vivo