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The Role of Percutaneous Surgery in Renal and Ureteral Stone Removal
0022-5347 /89/1413-0780$02.00/0 Vol. 141, March Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1989 by The Williams & Wilkins Co.
THE ROLE OF PERCUTANEOUS SURGERY IN RENAL AND URETERAL STONE REMOVAL JOSEPH W. SEGURA From the Department of Urology, Mayo Clinic, Rochester, Minnesota
ABSTRACT
Percutaneous procedures are appropriate for a wide variety of renal and ureteral stones. In the era of shock wave lithotripsy percutaneous procedures usually are indicated in stones for which extracorporeal shock wave lithotripsy is not appropriate. Many of these situations occur in patients with large stones, and stones associated with obstruction and other problems. Indications for percutaneous stone removal and indications for open surgery are discussed. (J. Urol., part 2, 141: 780-781, 1989) In 1976 the first percutaneous tract specifically for the removal of a stone was established.' By the early 1980s development of instruments designed to work through such tracts had permitted percutaneous techniques to mature to the point that, at least theoretically, any stone could be removed from the urinary tract with reasonable economy and morbidity. 2 - 5 Today, despite the pervasiveness of shock wave lithotripsy, percutaneous stone removal remains the procedure of choice in many clinical situations and a viable alternative to others. When used in a broad spectrum of clinical applications percutaneous lithotripsy is strikingly effective. Successful removal of the targeted renal stone may be expected in up to 98 per cent of the patients. Residual stone rates vary but in the best selected series they have been 3 to 0.6 per cent. Ureteral stones, most of which are upper and mid ureteral stones, are removable by percutaneous procedures, with success rates of about 90 per cent. Hospitalization of 4 to 5 days is typical with 10 to 14 days of total disability. 6 Percutaneous lithotripsy is an invasive procedure and complications may occur. The most significant of these probably is arteriovenous fistula formation resulting from trauma to a peripheral artery. Such trauma may proceed from nephrostomy tube placement and/or it may be related to trauma at the time of stone removal. The incidence of this complication in our practice is about 0.5 per cent. 7 Treatment consists of arteriographic embolization of the peripheral vessel and it is effective in all cases. A variety of other problems may occur (table 1). It was interesting that in our practice 75 per cent of the major complications occurred in 2 groups of patients: those with struvite stones and those with cystine staghorn calculi. Since these usually were the most technically demanding groups of patients, it seems a fair conclusion that the rate of complications is a function of technical factors that become more apparent in the more difficult cases, much as in other areas of medicine. ROLE OF PERCUTANEOUS LITHOTRIPSY TODAY
There are few areas in the United States where extracorporeal shock wave lithotripsy (ESWL *) is not available. Because of its ubiquity and because of its "noninvasive" appeal, the usual question is whether the stone is treatable by ESWL. As a result, those patients who receive percutaneous lithotripsy today usually are not candidates for ESWL for whatever reason. We recently studied the patients who underwent percutaneous lithotripsy in the first 12 months that ESWL was available at the Mayo Clinic (table 2). 8 Of the group 15 per cent were treated by percutaneous lithotripsy and 85 per cent by
* Dornier Medical Systems, Inc., Marietta, Georgia.
ESWL (this does not include those patients managed by ureteroscopy). While there are a wide variety of indications for percutaneous lithotripsy, one of the more common is a large stone volume, either in a metabolic stone or in a struvite staghorn calculus. Percutaneous lithotripsy also was used in a combined fashion with ESWL in the treatment of struvite staghorns. When ESWL is used to treat large volume stones, multiple ESWL treatments often are necessary to achieve complete break-up. A steinstrasse may obstruct the ureter (or require placement of an indwelling stent to prevent it) but the most troublesome problem has been the high rate of residual stones. This is of particular concern in the treatment of struvite calculi. The unpredictability of passage of fragments after ESWL has affected our opinion concerning the management of infected stones, especially staghorn stones. The residual stone rate in patients with infected stones who were treated by percutaneous lithotripsy in our practice was 16 per cent at the time they were discharged from the hospital. 6 The viability of this technique is revealed in the long-term followup. Of 74 patients followed from 2 to 4 years (mean 34 months) new stone was noted in only 10 per cent of those rendered stonefree. 9 In other words, if the passage is stone-free after percutaneous lithotripsy, there is a 90 per cent chance that the patient will be free of stone 3 years later. Combined ESWL and percutaneous lithotripsy treatment of such struvite stones would seem to be advantageous. Such treatment would take advantage of the ability of percutaneous lithotripsy to remove rapidly large volumes of readily accessible stone and the ability of ESWL to treat stones in locations difficult to access. In our hands and in the hands of others this has proved to be less useful than one might suspect, with high residual stone rates (50 to 75 per cent) at 3 to 6 months. The problem would appear to be that the stones break up but they do not pass. The best results of combined therapy in the literature are reported by Schulze and associates, who noted a residual stone rate of 20 per cent, 10 slightly worse than that obtained by percutaneous lithotripsy alone in our practice. Some of the poorer results that have been obtained by combined methods may be obviated by restricting the use of ESWL to the treatment of only those cases when the residual fragments after percutaneous lithotripsy are difficult or dangerous to access and by making every effort to achieve a maximal result with percutaneous lithotripsy. Obstructive uropathies may coexist with a stone and ESWL may be contraindicated owing to the obstruction. Such situations lend themselves to percutaneous removal of the stone and endourological treatment of the obstruction. Obese individuals present difficulties no matter how they are managed but large people are often not candidates for ESWL because of their
780
ROLE OF PERCUTANEOUS SURGERY IN RENAL AND URETERAL STONE REMOVAL Causes of failure in 15 of 805 patients with renal stones who underwent percutaneous removal (reprinted with permission6)
TABLE 1.
No. Pts. Problems of access: Inadequate tract placement Could not access Instrument not in kidney Laceration from dilatation Could not dilate (obesity) Could not dilate (obesity and scar) Problems of lithotripsy: Stone too hard 1 cm. pelvic tear Could not move endoscope (retroperitoneal fibrosis) Could not visualize stone (extravasation) Extravasation
TABLE 2.
3 2 2 1 1 1 1 1 1 1 1
Indications for percutaneous techniques in 143 patients (reprinted with permission8)
0 bstruction: Ureteral, 4 Ureteropelvic junction, 14 Infundibular, ·5 Stone vol.: Large pelvic stone vol., 18 Staghorn, 18 Combined ESWL and percutaneous, 31 Body habitus: Pt. too large, 7 Pt. too small, 1 Scoliosis, 2 Other modality failures: Ureteroscopic failures: Ureteral stones, 4 ESWL failures: Stone did not break, 3 Retained significant fragments, 12 Hemorrhage after ESWL, 1 Hypotension in bath, 1 Miscellaneous: Cystine, 11 Cardiac pacemaker, 4 Calcified renal artery aneurysm, 1 Indwelling nephrostomy tube, 3 Pt. requested percutaneous removal, 4
781
treat them in situ with ESWL. In this latter circumstance the failure rate often is high so that repeat ESWL treatment often is necessary. Because of this, we attempt ureteroscopic removal of the stone if it is practical. We rarely treat these stones via percutaneous lithotripsy anymore. SURGERY
Few patients are candidates for surgery, and those who are usually have giant staghorns, may be candidates for nephrectomy, or may have other special circumstances precluding ESWL or percutaneous lithotripsy. There have been a few patients with marginal renal function in whom we.have thought that surgery was safer than either percutaneous lithotripsy or ESWL. Double-J* insertion is the procedure of choice in those who are pregnant and have symptomatic stones. If this is not possible, surgery is probably safer for the fetus than either ESWL or percutaneous lithotripsy.
No.(%)
CONCLUSION
23 (16)
Percutaneous lithotripsy is preferred in those patients who are not candidates for ESWL. In trying to decide the optimal therapy, the surgeon should remember that the idea is not to use the machine; the idea is to remove the stone safely, expeditiously and economically. In our practice percutaneous lithotripsy has been preferred in 15 to 20 per cent of our nonureteroscopy patients. · General indications for percutaneous lithotripsy include large stone volume (greater than 2.5 to 3.0 cm.), infected stone, cystine stone, obstructive uropathy, massive obesity, children, ESWL failures, miscellaneous and certainty of final result.
66 (46)
10 (7)
21 (15)
* Medical Engineering Corp., New York, New York. REFERENCES 23 (16)
dimensions. Obese patients and those with other anatomical abnormalities may be candidates for a percutaneous technique. It is certainly possible to treat children with ESWL with safety, at least in the short term. However, ESWL has been demonstrated to have an antimitotic effect in certain tumor systems. It is at least theoretically possible that there could be some long-term effect on growth after treatment in children. In the absence of any applicable animal studies or followup reports on those who have been treated, I am reluctant to use ESWL in children. We use percutaneous lithotripsy in children with stones, changing the technique only in that we work through a mature tract in the young or small patient. URETERAL STONES
Stones in the lower third of the ureter (below the iliac vessels) are managed ureteroscopically. The high success rate (98 per cent), low level of complications and certainty of the result seem overwhelming reasons for this choice.'11 Stones in the mid or upper ureter usually are managed by attempting to push them back to the renal pelvis where they may then be treated with ESWL. Failing that, we usually will
1. Fernstrom, I. and Johansson, B.: Percutaneous pyelolithotomy: a
2. 3. 4. 5. 6.
7. 8. 9. 10.
11.
new extraction technique. Scand. J. Urol. Nephrol., 10: 257, 1977. Smith, A. D.: Forward: symposium on endourology. Urol. Clin. N. Amer., 9: 1, 1982. Alken, P., Hutschenreiter, G., Gunther, R. and Marberger, M.: Percutaneous stone manipulation. J. Urol., 125: 463, 1981. Segura, J. W., Patterson, D. E., LeRoy, A. J., McGough, P. F. and Barrett, D. M.: Percutaneous removal of kidney stones: preliminary report. Mayo Clin. Proc., 57: 615, 1982. Segura, J. W., Patterson, D. E., LeRoy, A. J., May, G. R. and Smith, L. H.: Percutaneous lithotripsy. J. Urol., 130: 1051, 1983. Segura, J. W., Patterson, D. E., LeRoy, A. J., Williams, H. J., Jr., Barrett, D. M., Benson, R. C., Jr., May, G. R. and Bender, C. E.: Percutaneous removal of kidney stones: review of 1,000 cases. J. Urol., 134: 1077, 1985. Patterson, D. E., Segura, J. W., LeRoy, A. J., Benson, R. C., Jr., and May, G. R.: The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J. Urol., 133: 447, 1985. LeRoy, A. J., Segura, J. W., Williams, H. J., Jr. and Patterson, D. E.: Percutaneous renal calculus removal in an extracorporeal shock wave lithotripsy practice. J. Urol., 138: 703, 1987. Patterson, D. E., Segura, J. W. and LeRoy, A. J.: Long-term followup of patients treated by percutaneous ultrasonic lithotripsy for struvite staghorn calculi. J. Endourol., 1: 177, 1987. Schulze, H., Hertle, L., Graff, J., Funke, P.-J. and Senge, T.: Combined treatment of branched calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J. Urol., 135: 1138, 1986. Blute, M. L., Segura, J. W. and Patterson, D. E.: Ureteroscopy. J. Urol., 139: 510, 1988.
THE JOURNAL OF UROLOGY
Copyright © 1989 by The Williams & Wilkins Co.
THE ROLE OF PERCUTANEOUS SURGERY IN RENAL AND URETERAL STONE REMOVAL JOSEPH W. SEGURA From the Department of Urology, Mayo Clinic, Rochester, Minnesota
ABSTRACT
Percutaneous procedures are appropriate for a wide variety of renal and ureteral stones. In the era of shock wave lithotripsy percutaneous procedures usually are indicated in stones for which extracorporeal shock wave lithotripsy is not appropriate. Many of these situations occur in patients with large stones, and stones associated with obstruction and other problems. Indications for percutaneous stone removal and indications for open surgery are discussed. (J. Urol., part 2, 141: 780-781, 1989) In 1976 the first percutaneous tract specifically for the removal of a stone was established.' By the early 1980s development of instruments designed to work through such tracts had permitted percutaneous techniques to mature to the point that, at least theoretically, any stone could be removed from the urinary tract with reasonable economy and morbidity. 2 - 5 Today, despite the pervasiveness of shock wave lithotripsy, percutaneous stone removal remains the procedure of choice in many clinical situations and a viable alternative to others. When used in a broad spectrum of clinical applications percutaneous lithotripsy is strikingly effective. Successful removal of the targeted renal stone may be expected in up to 98 per cent of the patients. Residual stone rates vary but in the best selected series they have been 3 to 0.6 per cent. Ureteral stones, most of which are upper and mid ureteral stones, are removable by percutaneous procedures, with success rates of about 90 per cent. Hospitalization of 4 to 5 days is typical with 10 to 14 days of total disability. 6 Percutaneous lithotripsy is an invasive procedure and complications may occur. The most significant of these probably is arteriovenous fistula formation resulting from trauma to a peripheral artery. Such trauma may proceed from nephrostomy tube placement and/or it may be related to trauma at the time of stone removal. The incidence of this complication in our practice is about 0.5 per cent. 7 Treatment consists of arteriographic embolization of the peripheral vessel and it is effective in all cases. A variety of other problems may occur (table 1). It was interesting that in our practice 75 per cent of the major complications occurred in 2 groups of patients: those with struvite stones and those with cystine staghorn calculi. Since these usually were the most technically demanding groups of patients, it seems a fair conclusion that the rate of complications is a function of technical factors that become more apparent in the more difficult cases, much as in other areas of medicine. ROLE OF PERCUTANEOUS LITHOTRIPSY TODAY
There are few areas in the United States where extracorporeal shock wave lithotripsy (ESWL *) is not available. Because of its ubiquity and because of its "noninvasive" appeal, the usual question is whether the stone is treatable by ESWL. As a result, those patients who receive percutaneous lithotripsy today usually are not candidates for ESWL for whatever reason. We recently studied the patients who underwent percutaneous lithotripsy in the first 12 months that ESWL was available at the Mayo Clinic (table 2). 8 Of the group 15 per cent were treated by percutaneous lithotripsy and 85 per cent by
* Dornier Medical Systems, Inc., Marietta, Georgia.
ESWL (this does not include those patients managed by ureteroscopy). While there are a wide variety of indications for percutaneous lithotripsy, one of the more common is a large stone volume, either in a metabolic stone or in a struvite staghorn calculus. Percutaneous lithotripsy also was used in a combined fashion with ESWL in the treatment of struvite staghorns. When ESWL is used to treat large volume stones, multiple ESWL treatments often are necessary to achieve complete break-up. A steinstrasse may obstruct the ureter (or require placement of an indwelling stent to prevent it) but the most troublesome problem has been the high rate of residual stones. This is of particular concern in the treatment of struvite calculi. The unpredictability of passage of fragments after ESWL has affected our opinion concerning the management of infected stones, especially staghorn stones. The residual stone rate in patients with infected stones who were treated by percutaneous lithotripsy in our practice was 16 per cent at the time they were discharged from the hospital. 6 The viability of this technique is revealed in the long-term followup. Of 74 patients followed from 2 to 4 years (mean 34 months) new stone was noted in only 10 per cent of those rendered stonefree. 9 In other words, if the passage is stone-free after percutaneous lithotripsy, there is a 90 per cent chance that the patient will be free of stone 3 years later. Combined ESWL and percutaneous lithotripsy treatment of such struvite stones would seem to be advantageous. Such treatment would take advantage of the ability of percutaneous lithotripsy to remove rapidly large volumes of readily accessible stone and the ability of ESWL to treat stones in locations difficult to access. In our hands and in the hands of others this has proved to be less useful than one might suspect, with high residual stone rates (50 to 75 per cent) at 3 to 6 months. The problem would appear to be that the stones break up but they do not pass. The best results of combined therapy in the literature are reported by Schulze and associates, who noted a residual stone rate of 20 per cent, 10 slightly worse than that obtained by percutaneous lithotripsy alone in our practice. Some of the poorer results that have been obtained by combined methods may be obviated by restricting the use of ESWL to the treatment of only those cases when the residual fragments after percutaneous lithotripsy are difficult or dangerous to access and by making every effort to achieve a maximal result with percutaneous lithotripsy. Obstructive uropathies may coexist with a stone and ESWL may be contraindicated owing to the obstruction. Such situations lend themselves to percutaneous removal of the stone and endourological treatment of the obstruction. Obese individuals present difficulties no matter how they are managed but large people are often not candidates for ESWL because of their
780
ROLE OF PERCUTANEOUS SURGERY IN RENAL AND URETERAL STONE REMOVAL Causes of failure in 15 of 805 patients with renal stones who underwent percutaneous removal (reprinted with permission6)
TABLE 1.
No. Pts. Problems of access: Inadequate tract placement Could not access Instrument not in kidney Laceration from dilatation Could not dilate (obesity) Could not dilate (obesity and scar) Problems of lithotripsy: Stone too hard 1 cm. pelvic tear Could not move endoscope (retroperitoneal fibrosis) Could not visualize stone (extravasation) Extravasation
TABLE 2.
3 2 2 1 1 1 1 1 1 1 1
Indications for percutaneous techniques in 143 patients (reprinted with permission8)
0 bstruction: Ureteral, 4 Ureteropelvic junction, 14 Infundibular, ·5 Stone vol.: Large pelvic stone vol., 18 Staghorn, 18 Combined ESWL and percutaneous, 31 Body habitus: Pt. too large, 7 Pt. too small, 1 Scoliosis, 2 Other modality failures: Ureteroscopic failures: Ureteral stones, 4 ESWL failures: Stone did not break, 3 Retained significant fragments, 12 Hemorrhage after ESWL, 1 Hypotension in bath, 1 Miscellaneous: Cystine, 11 Cardiac pacemaker, 4 Calcified renal artery aneurysm, 1 Indwelling nephrostomy tube, 3 Pt. requested percutaneous removal, 4
781
treat them in situ with ESWL. In this latter circumstance the failure rate often is high so that repeat ESWL treatment often is necessary. Because of this, we attempt ureteroscopic removal of the stone if it is practical. We rarely treat these stones via percutaneous lithotripsy anymore. SURGERY
Few patients are candidates for surgery, and those who are usually have giant staghorns, may be candidates for nephrectomy, or may have other special circumstances precluding ESWL or percutaneous lithotripsy. There have been a few patients with marginal renal function in whom we.have thought that surgery was safer than either percutaneous lithotripsy or ESWL. Double-J* insertion is the procedure of choice in those who are pregnant and have symptomatic stones. If this is not possible, surgery is probably safer for the fetus than either ESWL or percutaneous lithotripsy.
No.(%)
CONCLUSION
23 (16)
Percutaneous lithotripsy is preferred in those patients who are not candidates for ESWL. In trying to decide the optimal therapy, the surgeon should remember that the idea is not to use the machine; the idea is to remove the stone safely, expeditiously and economically. In our practice percutaneous lithotripsy has been preferred in 15 to 20 per cent of our nonureteroscopy patients. · General indications for percutaneous lithotripsy include large stone volume (greater than 2.5 to 3.0 cm.), infected stone, cystine stone, obstructive uropathy, massive obesity, children, ESWL failures, miscellaneous and certainty of final result.
66 (46)
10 (7)
21 (15)
* Medical Engineering Corp., New York, New York. REFERENCES 23 (16)
dimensions. Obese patients and those with other anatomical abnormalities may be candidates for a percutaneous technique. It is certainly possible to treat children with ESWL with safety, at least in the short term. However, ESWL has been demonstrated to have an antimitotic effect in certain tumor systems. It is at least theoretically possible that there could be some long-term effect on growth after treatment in children. In the absence of any applicable animal studies or followup reports on those who have been treated, I am reluctant to use ESWL in children. We use percutaneous lithotripsy in children with stones, changing the technique only in that we work through a mature tract in the young or small patient. URETERAL STONES
Stones in the lower third of the ureter (below the iliac vessels) are managed ureteroscopically. The high success rate (98 per cent), low level of complications and certainty of the result seem overwhelming reasons for this choice.'11 Stones in the mid or upper ureter usually are managed by attempting to push them back to the renal pelvis where they may then be treated with ESWL. Failing that, we usually will
1. Fernstrom, I. and Johansson, B.: Percutaneous pyelolithotomy: a
2. 3. 4. 5. 6.
7. 8. 9. 10.
11.
new extraction technique. Scand. J. Urol. Nephrol., 10: 257, 1977. Smith, A. D.: Forward: symposium on endourology. Urol. Clin. N. Amer., 9: 1, 1982. Alken, P., Hutschenreiter, G., Gunther, R. and Marberger, M.: Percutaneous stone manipulation. J. Urol., 125: 463, 1981. Segura, J. W., Patterson, D. E., LeRoy, A. J., McGough, P. F. and Barrett, D. M.: Percutaneous removal of kidney stones: preliminary report. Mayo Clin. Proc., 57: 615, 1982. Segura, J. W., Patterson, D. E., LeRoy, A. J., May, G. R. and Smith, L. H.: Percutaneous lithotripsy. J. Urol., 130: 1051, 1983. Segura, J. W., Patterson, D. E., LeRoy, A. J., Williams, H. J., Jr., Barrett, D. M., Benson, R. C., Jr., May, G. R. and Bender, C. E.: Percutaneous removal of kidney stones: review of 1,000 cases. J. Urol., 134: 1077, 1985. Patterson, D. E., Segura, J. W., LeRoy, A. J., Benson, R. C., Jr., and May, G. R.: The etiology and treatment of delayed bleeding following percutaneous lithotripsy. J. Urol., 133: 447, 1985. LeRoy, A. J., Segura, J. W., Williams, H. J., Jr. and Patterson, D. E.: Percutaneous renal calculus removal in an extracorporeal shock wave lithotripsy practice. J. Urol., 138: 703, 1987. Patterson, D. E., Segura, J. W. and LeRoy, A. J.: Long-term followup of patients treated by percutaneous ultrasonic lithotripsy for struvite staghorn calculi. J. Endourol., 1: 177, 1987. Schulze, H., Hertle, L., Graff, J., Funke, P.-J. and Senge, T.: Combined treatment of branched calculi by percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J. Urol., 135: 1138, 1986. Blute, M. L., Segura, J. W. and Patterson, D. E.: Ureteroscopy. J. Urol., 139: 510, 1988.