At the International Kidney Stone Institute, our goal is nothing less than the cure.
In an active urology department, 30 percent of the surgical workload is related to the treatment of urinary stones. This past April in Chicago at the American Urological Association (AUA), the various factors that influence the worldwide treatment of stone disease and management of renal calculi was a hot topic.
“In the so-called “stone belt” countries, including India, Turkey, and Brazil, the incidence of urinary stones is in the range of 10 to 15 percent compared to 5 percent in the rest of the world,” said Dr. de la Rosette, Professor and Chair of the Urology Department at Urology Academic Medical Centrum University, University of Amsterdam, the Netherlands. “Secondly the availability of treatment technologies may differ significantly between countries.”
For decades, treatment of renal stone disease was dominated by open surgical stone removal. This is still performed in countries where limited availability of endoscopic equipment is combined with an excellent experience in open surgery, or because of a high number of staghorn calculi. But new modalities and approaches have seen global development and utilization.
“Since its first presentation in West Germany in the early 1980s, extracorporeal shock wave lithotripsy (ESWL) has revolutioned the treatment of urinary lithiasis,” Dr. de la Rosette said. ESWL gained rapid acceptance worldwide because of its ease of use, noninvasive nature, and high efficacy in treating kidney and ureteral stones. The wide availability of lithotriptors also was a factor. However, the current lithotriptors have not reached the potential of the original electrohydraulic device and provide inferior fragmentation rates compared with the original generation.
“The industry, in an attempt to minimize morbidity, compressed energy and reduced the size of the lithotriptor focal zone,” Dr. de la Rosette said. This fact, combined with the advent of advanced endoscopic techniques, has resulted in a renaissance of the endourological treatments of percutaneous nephrolithotomy (PCNL) and ureterorenoscopy (URS).
Among all urinary stone treatments, PCNL is the most challenging. “Training in PCNL has a steep learning curve that is mainly related to obtaining renal access,” Dr. de la Rosette said. “The quality of training during residency is likely related to the recruitment of patients at the training center and availability of complete up-to-date equipment.” “With increased understanding of renal anatomy and related viscera, urologists have altered patient positioning,” Dr. de la Rosette explained. “These alterations include the reverse lithotomy, lateral decubitus, and supine positions.”
Advances in ureteroscope design and newer methods of intracorporeal stone fragmentation have also resulted in treatment changes for the management of renal stones. Glenn M. Preminger, M.D., from Duke University Medical Center in Durham, North Carolina, is a pioneer and expert in the field of flexible ureteroscopy.