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Therapy of Large Kidney Stones with ESWL and Ureteral Stenting
Calculi 700
701
TREATMENT OF STAGHORN CALCULUS BY PERCUTANEOUS LITHOTRIPSY FOLLOWED BY ESWL. Rene Gilhuis*, Paul J. Carpentier, Rotterdam, The Netherlands (Presentation to be made by Dr. Gilhuis).
LASER-INDUCED SHCCK WAVE LITHOI'RIPSY (LISL) 'R.Hofrnann,R.Hartung~J.Braun and~H.Schmidt-Kloiber,Munich, Fffi and'"Graz,Austria (Presentation to be made by Dr.Hofmann) A new methcxi for laser stone fragmentation-the intracorporeal laser induced shock wave lithotripsy-is intra:luced. Teclmical develoµnent: A Q-switched Neodymium-YAG laser (il=1064nrn) generates a short, high-energy pulse. In a liquid surrounding a urinary stone,a laser-induced breakdown (LIB) is created;the resultirB shock-wave of high amplitude disintegrates the stone. Cavitation only can be generated in fluids around the stone. No thennic effects are involved. With an electrical field-strength of 6CMV/m all urinary stones, regardless of canposition and hardness can be destroyed. LIB can be generate:'! with a minor electrical field strength in higher concentrated solutions (dest. water( glycin sol.( o,9%NaCl< 2MNaC1). With a high repetition rate (10/20/SOHz) stone parts created are extranely small. Concentration of light by means of cone channels (energy loss 10%) allo,,ed guidance of the laser light to flexible fibres (200µm diameter), which allo,,s application of laser p::,,,er within the urinary tract. The tip of the laser fibre has a slightly convex surface, thus focussing the anitted light. Biological effects: ~ kidney cell cultures: focussed laser pulses (50Hz, 6nsec, 18ar\J) only destroyed directly hit cells, while the surroundirB cells of the monolayer were viable. b. hemolysis: no hemolysis could be generated by irradiation up to 3Qnin (2Qnl whole blood). l.: live tissue: direct irradiation (kidney J?8lvis, ureter in minipigs) only caused a small rupture cone within the tissue (max. 40µm depth). No necrosis or thennic effects could be observed. No late effects (30d) were found. 4. sister chranatid exchange: no mutagenic effects of the pulsed Nd-YAG laser irradiation. LISL is a fast procedure, suitable for all kinds of urinary stones,generating stone powder or very tiny fragments.With a flexible laser-guide stones everywhere in the urinary tract can be reached.Patient treatment is started.
Treatment of staghorn calculus by extracorporeal shock-
wave lithotripsy (ESWL) would lead to a large stone mass in the upper urinary system. Spontaneous passage of this stone
mass is unlikely. Percutaneous stone debulking followed by ESWL,therefore, was applied to 120 patients from March 1985 to September 1986. 89 patients with a follow-up of at least 3 months were evaluated.
The mean stone size ranged from 34 to 54 mm. All the percutaneous operations have been done through the rigid
nephroscope with the use of the ultrasound probe. Evaluation of the first 41 patients after a 3 months follow-up revealed a stone free percentage of 66%. This figure prompted to change our therapeutic approach. Especially in dilated systems, when there was no spontaneous passage, residual stone fragments are removed percutaneously af-
ter 6 weeks. Also the interval time between PCL and ESWL was shortened. Thus the second group of patients (n = 48), evaluated 3 months after combined treatment, showed a stone
free percentage of 87.5%. There was no significant differce between the 2 groups in age distribution, stone size, hospital stay and complication rates. The overall percentage of stone free patients is now 83%. Time to freedom of
stones averaged 65 days. As complications in 2 cases a severe bleeding and in 2 a chronic fistula occurred. Both of these problems were managed conservatively. No additional complication was noted
after ESWL. Important items of concern are: What to do on small retained stone fragments? Is the described approach compatible with cure or palliation?
N
702
703
A CATHETER FOR SAFE TREATMENT OF LARGE RENAL STONES BY EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY. T Philp & J Wickham, London UK, D Wilbert, Mainz, West Germany (Presentation to be made by Dr Philp/ We report an irrigating catheter designed to be passed up the ureter prior to extracorporeal shockwave lithotripsy (ESWL) to extract stone fragments during treatment. This may achieve both better disintegration of large (>2 cm) renal calculi and reduce residual stone mass. Initial experiments showed that for efficient removal of fragments, turbulent flow around the outflow of the catheter to keep fragments in suspension, active suction to extract maximum stone mass, and thus a balanced flow of irrigant to ensure no rapid pressure or volume changes within the renal pelvis, were required. These criteria were ful fi 11 ed by a two channel catheter of 12 FG external diameter. Both channels are connected to a roller pump to irrigate at volumes up to 100 ml/min. The tip of the smaller inflow channel is directed backward down the outflow channel into which side holes of O.12 cm are cut. Several experimental models were used. The catheter extracted+ 35 ml (87.5 gm) of sand per hour with negligible volume changes within the reservoir, and without blockage of the outflow channel. In the isolated, sand filled kidney, the catheter efficiently cleared the pelvis with pressure changes of 2 cm diameter have been treated. The catheter is passed to the pelvis over a guide wire and irrigation commenced during ESWL. Results to date confirm the ability of the catheter to irrigate out stone fragments and haematuria and efficient disintegration of residual stones has occurred. These early results suggest that this device offers an advance in the treatment of large renal stones by ESWL.
'IBERAPY CF LI\RGE KITNEY SICNES wrIH ESWL l\ND UREl'EW,L Sl'ENI'IN3.
*Daniel K. Acke:t:mann, *M3=l Gmst, *Otrist.op:i Zetmtner, Berne, SWitzerlan::l (Presentatim to be made by Dr. l\cke:r:mann) 'll1e o::nhlnatim of p,rcutaneoos nep,rolitootarr,, an::l extrarorp:,re,l shock "'3.ve litrotripsy (ESWL) for the treabrent of kidney stooes larger than 2.5 an is generally acx::epte:i. Difficulties in disintegratim of the stmes an::l in passage of the strne rraterial are p.,t f<=.atd as reascns against the ESWL =therapy. Percutaneous nep,rolitootarr,, has soo,.n significant o:npl.icatims. 'll1e aim of this prospactive study """ to determine the effectiveness of ESWL ooly o::nbinei with ureteral stenting in the treabrent of la,:ge kidney stmes. 34 renal units (RU) in 33 patients have been treate:l, 17 RU with
struvite/apatite stales (10 total stagh::n:n, 7 partial stagoom) an::l 17 with calciun oxalate stmes larger than 2.5 an. 'll1e ext.raoorp::,real shock "'3.ve litrotripay""" parfome'l with the D::irnier a!'P3X"tus HM--3, the ntnbar of shock "'3.ves did not excee:I 2500 par sessim, the rraxinun electrical discharge never rrore than 24 kv. In the case of failed disinl:83ration dur:in;J the first treabrent sessim, a sean:'l ESWL follo...e:l 2-10 days later. Before ESWL treabrent a ureteral stent v.as placed: D:Juble-J or Pigtail, 7 or 8 F. 'll1e stents were left until m:st stooe rraterial had passed. With an average of 3400 shock "'3.ves (SD:1100) in 1.5 ESWL sessims (min. 1, rrax. 3) disintegratim of the strne lli3SS ""5 adti.eve:l in 29/34 (85 %). '!he patients raraina1 hospitalized 5-18 days (m: 8.5 days), the stents were taken oot after 1-44 days (m: 17 days) • Post-ESWL auxiliary neasures a:osiste:l of 7 replacarents of dislocate:l stents an::l 1 Zeiss loop extractim of a prevesical strne fragment. 2 patients suffered fran fever>38.5°C dur:in;J 1-2 days, 1 patient fran severe oolics. Fever an::l oolics resµn:led to rre:J.ical rranagatent. At the follo..,-up 3 m:nths after EBIII., 9/14 (64 %) were free of stmes, 4/14 (29 %) sln,e:i disintegrate:l stooe rraterial ..W.ch will prd:>,bly be discharged sp::ntanaJusly. With ESWL alcne a sufficient disintegratim even of total stagh::n:n calculi= possible. '!he insertioo of a ureteral stent in m:st cases prevente:l urinary obstructim due to stooe rraterial an::l kept the rate of CXIIJ?].icatim la.. '!he cx:nbinatim of ESWL an:1 ureteral stenting is proven to be an effective therapy for large kidney sl:a1es provided that there are ro strictures almg the urinary tract. RU
=
279A
701
TREATMENT OF STAGHORN CALCULUS BY PERCUTANEOUS LITHOTRIPSY FOLLOWED BY ESWL. Rene Gilhuis*, Paul J. Carpentier, Rotterdam, The Netherlands (Presentation to be made by Dr. Gilhuis).
LASER-INDUCED SHCCK WAVE LITHOI'RIPSY (LISL) 'R.Hofrnann,R.Hartung~J.Braun and~H.Schmidt-Kloiber,Munich, Fffi and'"Graz,Austria (Presentation to be made by Dr.Hofmann) A new methcxi for laser stone fragmentation-the intracorporeal laser induced shock wave lithotripsy-is intra:luced. Teclmical develoµnent: A Q-switched Neodymium-YAG laser (il=1064nrn) generates a short, high-energy pulse. In a liquid surrounding a urinary stone,a laser-induced breakdown (LIB) is created;the resultirB shock-wave of high amplitude disintegrates the stone. Cavitation only can be generated in fluids around the stone. No thennic effects are involved. With an electrical field-strength of 6CMV/m all urinary stones, regardless of canposition and hardness can be destroyed. LIB can be generate:'! with a minor electrical field strength in higher concentrated solutions (dest. water( glycin sol.( o,9%NaCl< 2MNaC1). With a high repetition rate (10/20/SOHz) stone parts created are extranely small. Concentration of light by means of cone channels (energy loss 10%) allo,,ed guidance of the laser light to flexible fibres (200µm diameter), which allo,,s application of laser p::,,,er within the urinary tract. The tip of the laser fibre has a slightly convex surface, thus focussing the anitted light. Biological effects: ~ kidney cell cultures: focussed laser pulses (50Hz, 6nsec, 18ar\J) only destroyed directly hit cells, while the surroundirB cells of the monolayer were viable. b. hemolysis: no hemolysis could be generated by irradiation up to 3Qnin (2Qnl whole blood). l.: live tissue: direct irradiation (kidney J?8lvis, ureter in minipigs) only caused a small rupture cone within the tissue (max. 40µm depth). No necrosis or thennic effects could be observed. No late effects (30d) were found. 4. sister chranatid exchange: no mutagenic effects of the pulsed Nd-YAG laser irradiation. LISL is a fast procedure, suitable for all kinds of urinary stones,generating stone powder or very tiny fragments.With a flexible laser-guide stones everywhere in the urinary tract can be reached.Patient treatment is started.
Treatment of staghorn calculus by extracorporeal shock-
wave lithotripsy (ESWL) would lead to a large stone mass in the upper urinary system. Spontaneous passage of this stone
mass is unlikely. Percutaneous stone debulking followed by ESWL,therefore, was applied to 120 patients from March 1985 to September 1986. 89 patients with a follow-up of at least 3 months were evaluated.
The mean stone size ranged from 34 to 54 mm. All the percutaneous operations have been done through the rigid
nephroscope with the use of the ultrasound probe. Evaluation of the first 41 patients after a 3 months follow-up revealed a stone free percentage of 66%. This figure prompted to change our therapeutic approach. Especially in dilated systems, when there was no spontaneous passage, residual stone fragments are removed percutaneously af-
ter 6 weeks. Also the interval time between PCL and ESWL was shortened. Thus the second group of patients (n = 48), evaluated 3 months after combined treatment, showed a stone
free percentage of 87.5%. There was no significant differce between the 2 groups in age distribution, stone size, hospital stay and complication rates. The overall percentage of stone free patients is now 83%. Time to freedom of
stones averaged 65 days. As complications in 2 cases a severe bleeding and in 2 a chronic fistula occurred. Both of these problems were managed conservatively. No additional complication was noted
after ESWL. Important items of concern are: What to do on small retained stone fragments? Is the described approach compatible with cure or palliation?
N
702
703
A CATHETER FOR SAFE TREATMENT OF LARGE RENAL STONES BY EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY. T Philp & J Wickham, London UK, D Wilbert, Mainz, West Germany (Presentation to be made by Dr Philp/ We report an irrigating catheter designed to be passed up the ureter prior to extracorporeal shockwave lithotripsy (ESWL) to extract stone fragments during treatment. This may achieve both better disintegration of large (>2 cm) renal calculi and reduce residual stone mass. Initial experiments showed that for efficient removal of fragments, turbulent flow around the outflow of the catheter to keep fragments in suspension, active suction to extract maximum stone mass, and thus a balanced flow of irrigant to ensure no rapid pressure or volume changes within the renal pelvis, were required. These criteria were ful fi 11 ed by a two channel catheter of 12 FG external diameter. Both channels are connected to a roller pump to irrigate at volumes up to 100 ml/min. The tip of the smaller inflow channel is directed backward down the outflow channel into which side holes of O.12 cm are cut. Several experimental models were used. The catheter extracted+ 35 ml (87.5 gm) of sand per hour with negligible volume changes within the reservoir, and without blockage of the outflow channel. In the isolated, sand filled kidney, the catheter efficiently cleared the pelvis with pressure changes of
'IBERAPY CF LI\RGE KITNEY SICNES wrIH ESWL l\ND UREl'EW,L Sl'ENI'IN3.
*Daniel K. Acke:t:mann, *M3=l Gmst, *Otrist.op:i Zetmtner, Berne, SWitzerlan::l (Presentatim to be made by Dr. l\cke:r:mann) 'll1e o::nhlnatim of p,rcutaneoos nep,rolitootarr,, an::l extrarorp:,re,l shock "'3.ve litrotripsy (ESWL) for the treabrent of kidney stooes larger than 2.5 an is generally acx::epte:i. Difficulties in disintegratim of the stmes an::l in passage of the strne rraterial are p.,t f<=.atd as reascns against the ESWL =therapy. Percutaneous nep,rolitootarr,, has soo,.n significant o:npl.icatims. 'll1e aim of this prospactive study """ to determine the effectiveness of ESWL ooly o::nbinei with ureteral stenting in the treabrent of la,:ge kidney stmes. 34 renal units (RU) in 33 patients have been treate:l, 17 RU with
struvite/apatite stales (10 total stagh::n:n, 7 partial stagoom) an::l 17 with calciun oxalate stmes larger than 2.5 an. 'll1e ext.raoorp::,real shock "'3.ve litrotripay""" parfome'l with the D::irnier a!'P3X"tus HM--3, the ntnbar of shock "'3.ves did not excee:I 2500 par sessim, the rraxinun electrical discharge never rrore than 24 kv. In the case of failed disinl:83ration dur:in;J the first treabrent sessim, a sean:'l ESWL follo...e:l 2-10 days later. Before ESWL treabrent a ureteral stent v.as placed: D:Juble-J or Pigtail, 7 or 8 F. 'll1e stents were left until m:st stooe rraterial had passed. With an average of 3400 shock "'3.ves (SD:1100) in 1.5 ESWL sessims (min. 1, rrax. 3) disintegratim of the strne lli3SS ""5 adti.eve:l in 29/34 (85 %). '!he patients raraina1 hospitalized 5-18 days (m: 8.5 days), the stents were taken oot after 1-44 days (m: 17 days) • Post-ESWL auxiliary neasures a:osiste:l of 7 replacarents of dislocate:l stents an::l 1 Zeiss loop extractim of a prevesical strne fragment. 2 patients suffered fran fever>38.5°C dur:in;J 1-2 days, 1 patient fran severe oolics. Fever an::l oolics resµn:led to rre:J.ical rranagatent. At the follo..,-up 3 m:nths after EBIII., 9/14 (64 %) were free of stmes, 4/14 (29 %) sln,e:i disintegrate:l stooe rraterial ..W.ch will prd:>,bly be discharged sp::ntanaJusly. With ESWL alcne a sufficient disintegratim even of total stagh::n:n calculi= possible. '!he insertioo of a ureteral stent in m:st cases prevente:l urinary obstructim due to stooe rraterial an::l kept the rate of CXIIJ?].icatim la.. '!he cx:nbinatim of ESWL an:1 ureteral stenting is proven to be an effective therapy for large kidney sl:a1es provided that there are ro strictures almg the urinary tract. RU
=
279A