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가톨릭의대 고 준성

Non-staghorn Kidney Stone: PCNL Vs Retrograde Intrarenal Surgery. 가톨릭의대 고 준성. Natural history of renal stones. Staghorn stone renal destruction and significant morbidity and mortality → active treatment

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가톨릭의대 고 준성

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  1. Non-staghorn Kidney Stone: PCNL Vs Retrograde Intrarenal Surgery 가톨릭의대 고 준성

  2. Natural history of renal stones • Staghorn stone • renal destruction and significant morbidity and mortality → active treatment • Asymptomatic calyceal renal stone or simplerenal stone • half of stone grew during the period of observation • an episode of ureteric colic within 7 years: 68% • requiring surgery: 40% • correlated with number of stones • (Hubner et al, Eur Urol 1993) • Noninvasive and minimally invasive treatments are now available

  3. Less invasive techniques PCNL Less invasive technique ESWL Flexible URS Combined

  4. Advantages & Disadvantages • PCNL • advantage: higher stone-free rates, lower retreatment rates • disadvantage: more invasive, complication↑ • ESWL • advantage: less invasive, short recovery time, pts prefer • disadvantage: lower stone-free rates in large or lower pole stone • URS • advantage: less invasive, complication↓, outpatient procedure • disadvantage: leaves fragmented stone , relatively lower stone-clearance rates, routine need for ureteral stenting, longer fragmentation time

  5. Traditional concepts → Now & Future • advances in URS • miniature flexible ureterosocpy • bidirectional deflection up to 270° • superior optics • energy sources for intracorporeal lithotripsy • availability of accessories ▶ PCNL ▶ URS? >2cm, staghorn size <1cm 1-2 cm ▶ ESWL ▶ PCNL? ▶ ESWL? ▶ URS? ▶ URS?

  6. 1 Stone burden (size) 2 Stone location 3 Stone composition 4 Anatomical variants 5 Patients clinical factors Outcomes

  7. Stone burden (size) • CT improve treatment decisions for many borderline renal stone cases • stone burden↑, stone free rate↓ • Stone free rate of large renal stone (>2 cm): • PCNL: 71-95% • ESWL: 41-54%

  8. Stone Free Rates of URS (<2cm)

  9. PCNL (N=15) vs URS (N=12)

  10. Stone Free Rates of URS (>2cm)

  11. Lower pole stone: ESWL vs PCNL or URS • Lower Pole I study : PCNL vs ESWL ( Clayman et al. J Urol 2001) • stone size: 14.43 mm (PCNL), 14.03 (ESWL) • stone free rate: 95% vs 37% (>1cm 21%) • morbidity: 22% vs 11%, no significance • Lower pole II study: URS vs ESWL ( Pearle et al. J Urol 2005) • stone size: <1cm • stone free rate: 50% vs 35%, no significance • ESWL: short recovery period, feel more positively

  12. Lower pole stone: URS

  13. Stone composition • CT attenuation: • <1000 HU- uric acid or struvite stones • >1000 HU- calcium oxalate and hydroxyapatite stone • Stone clearance rate following ESWL (Joseph et al, J Uol 2002) • >1000 HU- 54.5% • 500-1000 HU- 85.7% • <500 HU- 100% • The range of fragility within a single composition • More fragile in cystine stone with rough surface

  14. Anatomical variants • Calyceal diverticulum • Incidence of stone forming: 10-50% • Stone-free rates • ESWL (4-58%), PCNL (85-93%), URS (50-73%) • Obliteration rates • PCNL (80-100%), URS (18%)

  15. Patients clinical factors • Obesity • Skin-to-stone distance> 10cm • Flexible ureterosocpy: 70%-78% stone free rates (<2cm stone) • PCNL: 83%-88% stone free rates (large stone burden) • Bleeding diathesis • Uncorrected coagulopathy: absolute CIx for ESWL and PCNL • Ureteroscopy with holmium laser lithotripsy: effective and safe

  16. Complications • PCNL • the overall major complications rates: 4-8% • transfusion: 2-23% (major vascular injury: 2-3%) • pulmonary & colon injury: rare • medical complication: postoperative fever (22-25%), urosepsis (1-2%) • URS • the overall complication rates: 1-10% • mostly minor complication: UTI, pain, failed access

  17. Life of scope (durability) • The effect of repeated procedure (after 50 procedure, 76h use) • Traxer et al. Urology 2006 • maximal deflection: ventral (270°→208°), dorsal (270°→133°) • irrigation flow: 50ml/min→40ml/min • image broken : 6/50 • laser perforation of working channel

  18. Conclusions • Stone free rates: PCNL ≥ URS • Complication rates: PCNL > URS • The choice of treatment: individual surgeon’s preference & level of expertise • Flexible URS: broadening indication (durability) • The randomized prospective study is needed.

  19. The Algorithm of management Symptomatic renal stone <2cm >2cm >1cm <1cm Non-LP LP LP Non-LP HU>1000, Cystine, known Co-morbidity, skin to stone distance>10cm HU<1000, Pediatric PCNL Flexible URS SWL

  20. Thank You!

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