The Rational Choice Of Treatment For Renal Stones≥2cm

Background:Renal stone is one of the most common and frequently encountered disease in clinics of urology. Patients suffer from a serious characterized symptoms, including abdominal pain, hematuresis, urological or systematic infection, affecting renal function and even leading to renal failure,especially when the renal stones are≥2cm. There are a variety of therapies, among which open surgery was the main treatment in the past. However, with the development of the equipment and operation technique, the minimally invasive treatment gradually replaced the open surgery, and has become the first-line treatment of renal stones, such as extracorporeal shock wave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL), flexible ureteroscopy lithotripsy (FURL). Nevertheless, each treatment has its own advantages and disadvantages:ESWL has advantages of small trauma, short hospitalization time and low cost, but has limitation in stone free rate; PCNL have its unique advantages in treatment of stones in the lower renal calices and stones with hydronephrosis, but there are risks of puncture related bleeding,organ damage and other complications, hospitalization time and cost is relatively higher than ESWL; FURL has the characteristics of smaller trauma, less complications, faster recovery and repeatable, but requires high technology and equipment, hospitalization cost is relatively higher. Therefore, the first line of treatment for renal stones≥2cm is still controversial.This study is a retrospective analysis of clinical data with patients who received treatment for renal stones≥2cm in our center, and review the related literature, which intends to define the individual and reasonable treatment modalities for patients with renal stones≥2cm, and provide a reliable evidence for urologist to choose.Section 1:Treatment of renal stones≥2cm with extracorporeal shock wave lithotripsyAims:To evaluate the efficacy, safety of extracorporeal shock wave lithotripsy (ESWL) monotherapy for treatment of renal stones≥2cm and its clinical application values.Methods:A total of 376 patients with renal stones≥2cm were included, who underwent monotherapy with ESWL in Shandong Provincial Hospital affiliated to Shandong University from July 2007 to July 2014. The patient’s general information, stone size, location, density, number of ESWL, and postoperative complications were collected. All patients were treated with ESWL in real-time X-ray control. Patients were re-examined using ultrasonography(US) or plain abdominal X-ray (KUB) 2 weeks after the first treatment of ESWL. Based on the follow up results, whether further ESWL treatment was needed would be determined.The treatment effect was finally evaluated 3 months after the last ESWL treatment by US and KUB.A stone-free status or fragmentation of stones to 4 mm or smaller was considered efficacious.Results:Three months after the treatment, the overall stone-free rate was 64.4%, and the efficacy rate was 70.7%. The patient’s sex,age and body mass index (BMI) can’t affect ESWL outcome,while the stone features, including size,shape,number, site, stone surface area and stone density can affect ESWL outcome. The efficacy was 92.2% for stones≤400 mm2 and those with low radiodensity, as determined by a plain (KUB) film; while the efficacy rate was 55.9% for other patients.The mean ESWL sessions were 2.2 sessions(range from one to four sessions).274 patients (72.9%) underwent sencondary ESWL to treat residual stones 2 weeks after the first treatment. The efficacy rate was 89.4% for patients with a residual stone surface area≤50% of baseline after the first ESWL, while the efficacy rate was 32.4% for other patients.Conclusions:For renal stones with a surface area≤400 mm2 and a radiodensity equal to or less than that of the 12th rib as determined by a KUB film, ESWL may be considered the first line of treatment, even for stones with a diameter≥2cm. For large stones requiring repeat treatments, the surface area of the residual stones after the first ESWL is a predictor of the final treatment result.Section 2:Treatment of renal stones≥2cm with open surgeryAims:To evaluate the efficacy, safety of open surgery for treatment of renal stones ≥2cm and its clinical application values.Methods:A total of 138 patients with renal stones≥2cm were included, who underwent monotherapy with open surgery in Shandong Provincial Hospital affiliated to Shandong University from July 2007 to July 2014. The patient’s general information, stone size, location, operative time, operative blood loss, hospital stay, hospital costs, postoperative complications and stone-free rate were collected. All patients underwent open surgery under general anesthesia.Patients were re-examined using US or KUB 2 weeks after the operation. Based on the follow up results, whether further treatment was needed would be determined.The treatment effect was finally evaluated 3 months after operation。Results:Three months after the treatment, the stone-free rate was 84.8%.The mean operative time was 92.46±14.25 min and mean operative blood loss was 218.00±80.20 ml.The mean hospital stay was 11.04±2.36 days and mean hospital cost was 15480.80±1604.54 yuan. The postoperative complications were listed as follows: blood transfusion in 10 cases,3 cases were treated by superselective embolization of renal artery,1 case underwent nephrectomy; infection after operation was seen in 12 patients,including 4 cases incision infection; 3 patients had leakage of urine; 7 cases need analgesic drugs because of pain after operation. The main reason of open surgery for renal stones patients is renal anatomical abnormalities. Other reasons including stone treatment failure by ESWL and endoscopic treatment, complete deerhorn shaped stones and the patient’s choice.Conclusions:Open surgery plays a critical role in the treatment of renal stones≥2cm, especially for complex stone burden and renal anatomical abnormalities patients.Section 3:Treatment of renal stones≥2cm with percutaneous nephrolithotomyAims:To evaluate the efficacy, safety of percutaneous nephrolithotomy (PCNL) monotherapy for treatment of renal stones≥2cm and its clinical application values.Methods:A total of 289 patients with renal stones≥2cm were included, who underwent monotherapy with PCNL in Shandong Provincial Hospital affiliated to Shandong University from July 2007 to July 2014. The patient’s general information, stone size, location, operative time, operative blood loss, hospital stay, hospital costs, postoperative complications and stone-free rate were collected. All patients underwent PCNL under general anesthesia, and operated with standard PCNL procedure including puncturing into the renal collection system under the guidance of ultrasonography, expanding percutaneous renal access,using single F24 channel, then putting nephroscope into renal collection system to break and remove stone. Patients were re-examined using US or KUB 2 weeks after the operation. Based on the follow up results, whether further treatment was needed would be determined.The treatment effect was finally evaluated 3 months after operation。Results:Three months after the treatment, the stone-free rate was 86.9%.54 cases of stones with a diameter between 2.0 to 3.0cm,and the stone-free rate was 88.9%; 137 cases of stones with a diameter between 3.0 to 4.0cm,and the stone-free rate was 87.6%;98 cases of stones with a diameter larger than 4.0cm,and the stone-free rate was 84.5%.72 cases of renal pelvis stones.and the stone-free rate was 91.7%; 38 cases of upper renal calyceal stones, and the stone-free rate was 92.1%; 22 cases of middle renal calyceal stones, and the stone-free rate was 90.9%;93 cases of lower renal calyceal stones, and the stone-free rate was 94.6%; 64 cases of renal staghorn stones and multiple renal calyceal stones (stones located in more than two renal calyxes), and the stone-free rate was 65.6%.The mean operative time was 95.28±12.63 min,mean operative blood loss was 210.56±58.27 ml,mean hospital stay was 10.82±3.25 days,mean hospital cost was 22634.52±2064.38 yuan. Two cases had pleura injury and causing pneumothorax when puncturing the percutaneous renal access;blood transfusion was used in 12 cases,8 cases were treated by superselective embolization of renal artery,1 case underwent nephrectomy; infection after operation was observed in 16 patients,among which 5 cases were deteriorated into urosepsis and septic shock,while 4 cases were improved after positive treatment,only 1 case were treated actively but still die; urinoma around kidney was seen in 5 cases and treated by puncturing under the guidance of ultrasound.Conclusions:Percutaneous nephrolithotomy (PCNL) could be considered as the first line of treatment for renal stones≥2cm, especially for lower renal calyceal stones, but as a minimally invasive surgery with high technology, high skills and high risks, the operative indications must be under the strict control and standardized operation.Section 4:Treatment of renal stones≥2cm with flexible ureteroscopy lithotripsyAims:To evaluate the efficacy, safety of flexible ureteroscopy lithotripsy (FURL) monotherapy for treatment of renal stones≥2cm and its clinical application values.Methods:A total of 118 patients with renal stones≥2cm were included, who underwent monotherapy with FURL in Shandong Provincial Hospital affiliated to Shandong University from July 2007 to July 2014. The patient’s general information, stone size, location, operative time, operative blood loss, hospital stay, hospital costs, postoperative complications and stone-free rate were collected. Double J stent were placed in all patients 2 weeks before operation.All patients underwent FURL under general anesthesia, and operated with standard FURL procedure including lithotomy position,first use ureteroscope to check the ureter and insert the guide wire into the ureter, then put Ureteric Access Sheath(UAS) into the ureter through the guide wire,place flexible ureteroscope into renal pelvis and calyxes to search the stones.After found the stones,using the holmium laser to break the stones. Patients were re-examined using US or KUB 2 weeks after the operation. Based on the follow up results, whether further treatment was needed would be determined.The treatment effect was finally evaluated 3 months after operation。Results:We succeed in inserting the ureteroscope in 110 cases(93.2%) and found the stones successfully in 105 cases. Three months after the treatment, the stone-free rate was 81.4%. The mean number of procedures was 1.25 (range from 1 to 3).The stone-free rate after 1st FURL was 66.1%,and the stone-free rate after 2nd FURL was 76.3%,and the stone-free rate after 3rd FURL was 81.4%.The stones located in renal pelvis and upper middle renal calyxes were 84 cases,and the stone-free rate was 89.3%;while stones located in lower renal calyx were 34 cases,and the stone-free rate was 61.8%. The stone-free rate for renal stones in diameter between 2cm to 3cm after FURL was 91.5%(65/71),64 cases(90.1%) were succeed after 1st FURL.The stones located in renal pelvis and upper middle renal calyxes with a diameter between 2cm to 3cm were 58 cases,55 cases(94.8%) were succeed after 1st FURL.The mean operative time was 88.12±12.47 min and mean operative blood loss was 30.40±16.35 ml.The mean hospital stay was 4.88±0.89 days and mean hospital cost was 25947.58±1663.57 yuan. Infection after operation was seen in 10 patients,among which 2 cases were deteriorated into urosepsis and septic shock and were improved after positive treatment; 2 cases need analgesic drugs because of pain after operation.Conclusions:Flexible ureteroscopy lithotripsy (FURL) is a safe and effective treatment for renal stones≥2cm, with the characteristics of smaller trauma, less complications, faster recovery and repeatable, especially for renal stones located in renal pelvis and upper middle renal calyxes with a diameter between 2cm to 3 cm, but requires high surgical skills and professional equipment, with the development of flexible ureteroscope and laser technology, FURL has a broad development prospects.Summary:In the selecting of treatment modalities for patients with renal stones≥2cm, combining the patient’s characteristics with the urologist’s technique and the medical equipment in hospital should be recommended, making individual and reasonable treatment modalities, in order to protect renal functions and reduce the patient’s suffering. We maintain that below suggestions based on our data should be recommended:1、Open surgery could be considered as the treatment choice for renal stones >2cm with complex stone burden and renal anatomical abnormalities.2、Extracorporeal shock wave lithotripsy could be considered as the first-line treatment for renal stones≥2cm with a surface area≤400 mm2 and a radiodensity equal to or less than that of the 12th rib as determined by a KUB film.3、Percutaneous nephrolithotomy could be considered as the first-line treatment for renal stones≥3cm which located in renal pelvis and upper middle renal calyxes and renal stones≥2cm which located in lower renal calyceal.4、Flexible ureteroscopy lithotripsy may be considered as the first-line treatment for renal stones located in renal pelvis and upper middle renal calyxes with a diameter between 2cm to 3cm.