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ROMANCING THE STONE
THIRTY YEARS OF PROGRESS IN THE DIAGNOSIS, PREVENTION AND
MANAGEMENT OF URINARY CALCULI
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WHY STONES?
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• Lifetime prevalence 13%• Stone belt phenomenon• Global warming• American diet• Sedentary lifestyles
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DIAGNOSIS
• Symptoms – flank pain• Physical exam• Urinalysis • Radiographic
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RADIOLOGY - 1982
• KUB• IVP
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PROBLEMS WITH IVP
• Some stones are radiolucent• Contrast allergy• Contrast nephropathy• Radiation exposure
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RADIOLOGY - 2012
• Rarely contrast studies (CT, IVP) • Non-contrast CT scanning
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ADVANTAGES
• No contrast• Fast• Only indinavir stones and some matrix stones
are “radiolucent” for the CT• ? Other pathology found
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DISADVANTAGES
• Radiation exposure• Expense
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MEDICAL MANAGEMENT - 1982
• Taught no need to investigate first stone• Water• Thiazides
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WHAT HAVE WE LEARNED?
• If you have first stone, you are going to have another
• Medical management works• Oxalate restriction• Importance of uric acid in calcium stone
formation (protein restriction)• Importance of citrate as inhibitor• Importance of limiting salt intake
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INTERVENTION - 1982
• If stone is < 5 mm, let it pass• Still good advice but can be morbid and
patient may be unproductive during that time (shouldn’t drive if taking pain meds)
• Can we predict better who will pass their stone?
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PREDICTION OF SPONTANEOUS URETERAL CALCULUS PASSAGE WITH AN ARTIFICIAL NEURAL NETWORK
James M. CummingsSeth D. IzenbergDavid Kitchens
Rupa KothandapaniUniversity of South Alabama
Mobile, Alabama
AUA 1999, JUrol 2000
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Results
• 125 patients used to train neural network• 55 patients in test set (25 with spontaneous
passage, 30 required intervention)• Network prediction was correct in 42
patients (76%)• Network prediction was 100% correct in the
subgroup passing their stones
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Influences on network predictions
Symptom duration*Hydronephrosis grade
PositionNausea/vomitingObstruction grade
*Most influential in neural network by far
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INTERVENTION - 1982
• Blind stone basketing• Open surgery
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INTERVENTION - 2012
• Ureteroscopy (URS)• Percutaneous nephrostolithotomy (PCNL)• Extracorporeal shock wave lithotripsy (ESWL)
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Ureteroscopy
• Performed transurethrally• Good for ureteral stones• Stone free rate 95% for distal ureteral stones• Flexible and rigid scopes• Variety of baskets, small lithotriptors and
lasers
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PCNL
• Scope passed into kidney through small incision in flank
• Stone visualized and broken up and extracted• Used mainly for very large staghorn type
stones
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EXTRACORPOREAL SHOCKWAVE LITHOTRIPSY
(ESWL)
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ESWL
• Discovered as a result of research into stress on airplane wings passing through air
• Thousands of shock waves passed through body to strike stone
• Stone breaks into small pieces and pass• Best used with renal and upper ureteral
stones < 2.5 cm in size
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Complications / Morbidity
• Hematuria (gross or microscopic): 100%• Pain: 60-70%• Renal colic in 5-10%• Hematoma / perirenal hemorrhage
(clinically significant): <1%• Sepsis <1%• Steinstrasse
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Complications / Morbidity
• Renal trauma (hemorrhage, endothelial cell damage, glomerular atrophy & sclerosis, & interstitial fibrosis)– 22% decrease in GFR after ESWL in solitary kidneys;
29% decrease after PCNL• Hypertension (inconclusive)• Bowel perforation: 3 reports.
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Efficacy
Opell & Pahira. Contemp Urol; 12-27, October 2000
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Efficacy
• Stone-free rate using HM-3 for stones < 2 cm is 91.3% at 3 months
• Only 50-70% stone-free rate with 2-3 cm stones
• In general, stone-free rate is inversely related to stone size
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CONCLUSIONS – IN 30 YEARS
• Diagnosis has moved from contrast studies to noncontrast CT
• Prevention is used over a broader range of sufferers
• Intervention is minimally invasive with scopes and shockwaves – no longer open surgery or blind efforts