1. ADVANCES IN THE MANAGEMENT OF NEPHROLITHIASIS Glenn M. Preminger, M.D. • Comprehensive Kidney Stone Center • at Duke University Medical Center • Durham, North Carolina

2. NEPHROLITHIASIS EPIDEMIOLOGY • Affects 1 - 3 % of adult population • Annual incidence 1% in white males • Life - time risk in adult males - 20% • Recurrent stones in 63% after 8 years

3. NEPHROLITHIASIS ANATOMY

4. NEPHROLITHIASIS NATURAL HISTORY & RISK FACTORS Peak incidence age 30 - 60 Gender (Male : Female) 3 : 1 Family history 3 - fold  risk Body size  risk with  weight Recurrence after first stone: Year 1 10 - 15% Year 5 50 - 60% Year 10 70 - 80%

5. STONE BELT

6. NEPHROLITHIASIS ECONOMIC IMPLICATIONS - 1993 DATA • Inpatient • Evaluation $155 million • Hospitalization $848 million • Professional $762 million • Wages $140 million • Outpatient • Evaluation $358 million • Wages $128 million • Total $2.39 Billion Thompson, et al, 1995

7. ASYMPTOMATIC CALCULI TREATMENT • Solitary kidney • Occupation (pilot, business traveler • Simultaneous contralateral treatment • It’s difficult to make an asymptomatic patient feel any better !

8. SURGICAL STONE DEFINITION • Intractable pain • Significant obstruction • Recurrent infection • Severe bleeding • Imminent threat

9. STONE MANAGEMENT OPTIONS • Open surgery • Percutaneous nephrolithotomy • Ureteroscopy • Shock wave lithotripsy • Medical therapy

10. STONE MANAGEMENT OPEN NEPHROLITHOTOMY

11. SURGICAL STONE MANAGEMENT CONSIDERATIONS • Residual stone rate • Recurrence rate • Number of procedures • Hospitalization • Convalescence • Cost

12. SHOCK WAVE LITHOTRIPSY HISTORY • 1972 - 1980 Preliminary research • Feb, 1980 First human treated • May, 1984 Clinical trials begin in USA • Dec, 1984 FDA approval (Dornier)

13. SHOCK WAVE LITHOTRIPSY ORIGINAL DORNIER HM3

14. SHOCK WAVE LITHOTRIPSY SECOND GENERATION MACHINES

15. SHOCK WAVE LITHOTRIPSY STONE FRAGMENTATION

16. SHOCK WAVE LITHOTRIPSY STONE FRAGMENTATION

17. SHOCK WAVE LITHOTRIPSY INDICATIONS • Surgical stone • No obstruction • Reasonable chanceof expeditious removal

18. SHOCK WAVE LITHOTRIPSY RELATIVE CONTAINDICATIONS • Large stones Calcium oxalate > 20 mm Struvite > 30 mm • Cystine stones • Distal obstruction • Poorly informed patients

19. SHOCK WAVE LITHOTRIPSY CLINICAL SIDE-EFFECTS • Hematuria • Pain • Obstruction (Steinstrasse)

20. SHOCK WAVE LITHOTRIPSY CLINICAL RENAL INJURY • Mild contusion - Large hematoma • Renal injury in 63 - 85% by MRI • Little data on chronic injury • Hypertension probably not a problem

21. SHOCK WAVE LITHOTRIPSY APPROPRIATE FOLLOW-UP • Plain radiographs (KUB + tomograms) • Renal scan • Intravenous pyelogram • Spiral CT

22. SHOCK WAVE LITHOTRIPSY REALITY • <15mm15-29mm>30mm • Multiple SWL 5% 10% 15-30% • Stone-free rate >80% 60% 50% • Auxiliary procedures 2% 5-7% 15% • Repeat procedures 1-2% 10-15% 15-20%

23. SHOCK WAVE LITHOTRIPSY REALITY • Ideal for some • Marginal in some • Contraindicated in few • THE KEY IS PROPER PATIENTSELECTION AND EDUCATION

24. SHOCK WAVE LITHOTRIPSY IDEAL CANDIDATES • Small stone (< 1.5 cm) • Mid or upper pole location • Normal renal anatomy • No distal obstruction

25. SURGICAL STONE MANAGEMENT Stone size Stone location Stone composition MODIFIERS OF STONE-FREE RATE

26. SHOCK WAVE LITHOTRIPSY Completeness of stone fragmentation Completeness of fragment elimination LIMITATIONS

27. SHOCK WAVE LITHOTRIPSY STONE FREE RATES % Stone Free Lingeman and Newman, 1990

28. STONE MANAGEMENT PERCUTANEOUS NEPHROLITHOTOMY

29. STONE MANAGEMENT PERCUTANEOUS NEPHROLITHOTOMY

30. STONE MANAGEMENT Large stone mass Obstruction Anatomic abnormality SWL failure Horseshoe, divertic Certainty of results Cystine stones Obesity PNL IN THE AGE OF SWL

31. SURGICAL STONE MANAGEMENT Stone volume 46% Obstruction 16% Cystine stones 16% Body habitus 12% SWL failures 10% CURRENT ROLE OFPERCUTANEOUS STONE REMOVAL

32. SURGICAL STONE MANAGEMENT CURRENT ROLE OF PNL

33. SURGICAL STONE MANAGEMENT CURRENT ROLE OFPERCUTANEOUS STONE REMOVAL Pre-op KUB Post-SWL KUB

34. SURGICAL STONE MANAGEMENT CURRENT ROLE OFPERCUTANEOUS STONE REMOVAL Post-PNL KUB Post-PNL IVP

35. SURGICAL STONE MANAGEMENT STAY OUT OF TROUBLE Pre-op KUB Pre-op IVP

36. SURGICAL STONE MANAGEMENT STAY OUT OF TROUBLE Post-op tomogram Post-op IVP

37. STAGHORN CALCULI CRITERIA FOR EVALUATION Stone-free rates Primary procedures Secondary procedures Unexplained secondary procedures Hospital days AUA Guidelines Panel, 1994

38. STAGHORN CALCULI STONE FREE RATE % Stone Free AUA Guidelines Panel, 1994

39. STAGHORN CALCULI PROCEDURES PER PATIENT (20) % 20 Procedures AUA Guidelines Panel, 1994

40. STAGHORN CALCULI SANDWICH THERAPY PNL SWL FLEX NEPHROCOPY

41. STAGHORN CALCULI Allows debulking of large stones (Should push PNL "to the limit") SWL reserved for inaccessible fragments Flexible nephroscopy to insure stone-free status SANDWICH THERAPY

42. STAGHORN CALCULI SANDWICH THERAPY

43. STAGHORN CALCULI AGGRESSIVE PNL - SINGLE PROCEDURE Pre-op KUB Pre-op KUB

44. STAGHORN CALCULI AGGRESSIVE PNL - SINGLE PROCEDURE Pre-op IVP Pre-op IVP

45. STAGHORN CALCULI AGGRESSIVE PNL - SINGLE PROCEDURE 3 N-tracts Upper pole access

46. STAGHORN CALCULI AGGRESSIVE PNL - SINGLE PROCEDURE 3 access sheaths Post-op N-tubes

47. URETERAL CALCULI

48. URETERAL CALCULI TREATMENT CONSIDERATIONS Location Size Chronicity Equipment Expertise

49. URETERAL CALCULI TREATMENT OPTIONS Observation Shock wave lithotripsy Ureteroscopy Blind basket extraction Percutaneous approach Open surgery

50. URETERAL CALCULI SPONTANEOUS PASSAGE