e734
THE JOURNAL OF UROLOGY姞
Vol. 183, No. 4, Supplement, Wednesday, June 2, 2010
Stone Disease: SWL, Ureteroscopic or
Percutaneous Stone Removal IV
Podium 56
Wednesday, June 2, 2010
8:00 AM-10:00 AM
1888
CHANGING STONE COMPOSITION IN RECURRENT STONE
FORMERS
Kashif Alvi*, Mohummad Siddiqui, Ahmad Sharif-Tabrizi, Stephen
Dretler, Dianne Sacco, Boston, MA
INTRODUCTION AND OBJECTIVES: Nephrolithiasis is a recurrent condition in which approximately 50-70% of all stone formers
have a risk of subsequent stone formation. Preventative treatment is
based on the stone type as well as serum and urinary metabolic factors.
The possibility that a recurrent stone former can make more than one
stone type over time was evaluated.
METHODS: A medical record review was performed on 302
patients who had repeat stone analysis between 1988 and 2008. Stone
analyses were performed on stones retrieved either after ureteroscopy/
laser lithotripsy, percutaneous ultrasonic lithotripsy or from voided
specimens. The same stone laboratory analyzed all these stones by
x-ray crystallography. The stones were noted to be of following types:
Calcium phosphate- Carbonate, Calcium oxalate monohydrate, Calcium oxalate dihydrate, Ammonium Urate, Brushite (Calcium hydrogen
phosphate dihydrate), Struvite, Uric Acid, Cystine, Ammonium Urate,
and Xanthine stones.
RESULTS: A total of 302 patients and 736 stone analyses were
reviewed. Out of the 302 patients, 173 patients had change in their
stone analyses over a certain period of time. A total of 193 stone
analyses had changed from one mixed type to a different mixed type,
41 stone analyses changed from a pure stone type to a mixed stone
type, 40 analyses changed from a mixed stone type to a pure stone
type and 10 stone analyses had changed from one pure stone type to
another pure stone type. Among 10 pure stone type changes, 5 stone
analyses had a change from uric acid stone into calcium oxalate
monohydrate & 2 analysis had changed from uric acid stone to calcium
oxalate monohydrate stone. Hence, stone composition changed in 173
(57%) patients in this study upon repeat stone analysis. The most
common stone composition change was calcium oxalate monohydrate.
CONCLUSIONS: Stone composition may change in recurrent
stone formers with subsequent stone analysis. It is especillay important
when one pure stone type is completely replaced by a totally different
stone. These findings suggest that a solitary stone analysis may not be
reliable in long term management of recurrent stone formers.
1889
CALCIUM PHOSPHATE CONTENT DOES NOT EFFECT STONE
FREE RATES FOLLOWING PERCUTANEOUS
NEPROLITHOTOMY (PCNL)
Chad Tracy*, Iowa City, IA; Amit Gupta, Richard Ho, Margaret
Pearle, Yair Lotan, Dallas, TX
INTRODUCTION AND OBJECTIVES: Work by others has suggested that stone free rates with percutaneous nephrostolithotomy
(PCNL) are lower in patients with calcium phosphate stones compared
with stones of other composition. Although stone composition may be
important in non-extirpative stone surgery, it is unclear why stone
composition should influence stone clearance in procedures that rely
on stone fragmentation and retrieval under endoscopic visualization.
We reviewed our PCNL experience in patients with calcium phosphate
stones.
METHODS: 200 consecutive patients underwent PCNL between September 2005 and May 2007. A total of 212 procedures were
performed in these 200 patients and, after excluding patients with
simultaneous bilateral PCNL, the study group consisted of 188 patients
who underwent unilateral PCNL. Initial stone size prior to PCNL was
determined, and patients were assigned into 4 groups based on stone
burden: ⬍ 2cm, ⬎ 2cm, partial staghorn calculus, and complete staghorn calculus. Stone analysis was available for all patients and stones
were classified by calcium phosphate content (0 %, 1-10%, 11-60%,
and ⬎60%). Unenhanced computerized tomography (CT) was obtained on post-operative day 1, and, in order to stay consistent with the
previous paper, cases were considered to be failures if stone fragments
were ⬎ 2 mm.
RESULTS: The study group comprised 101 women (54%), and
132 patients (71%) were recurrent stone formers. Partial or complete
staghorn calculi occurred in 47% of patients and an additional 13% had
a maximal stone diameter ⬎ 2 cm. Among the group, 87% of patients
had no anatomic abnormalities. Overall, 57% (n ⫽ 107) of patients had
calcium phosphate as a component of their stone and of these patients,
20% (n ⫽ 37) had a stone composition consisting of ⬎60% calcium
phosphate. After PCNL, 38% of the patients were found on CT to have
⬎2 mm residual fragments (treatment failures). Increasing stone size
was associated with reduced stone free rates and the failure rates were
23%, 36%, 38% and 59% for patients with stone size ⬍ 2cm, ⬎ 2 cm,
partial and complete staghorn respectively (p⫽0.001). There was no
association between calcium phosphate content and failure. The failure
rates were 37%, 46.4%, 38.1% and 32.4% for patients with 0%, 1-10%,
11-60%, and ⬎60% calcium phosphate stone content (p⫽0.68). On
multivariable logistic regression analyses, after controlling for stone
size there was no association between calcium phosphate content and
⬎2 mm residual stones (p ⫽ 0.67).
CONCLUSIONS: Calcium phosphate stone composition does
not predict poor stone free rates after PCNL.
Source of Funding: None
1890
THE “ALL-SEEING NEEDLE“ – AN OPTICAL PUNCTURE
SYSTEM CONFIRMING PERCUTANEOUS ACCESS IN PCNL
Markus Bader*, München, Germany; Christian Gratzke, Boris
Schlenker, Munich, Germany; Derya Tilki, München, Germany;
Oliver Reich, Christian Gozzi, Munich, Germany; Rudolf Pfab,
Fürstenfeldbruck, Germany; Christian Stief, Munich, Germany
Source of Funding: None
INTRODUCTION AND OBJECTIVES: In PCNL, real time fluoroscopy and ultrasound have made the percutaneous access substantially safer and have reduced access related complications. However,
there is no final confirmation of the quality of the access until the tract
has been dilated and the nephroscope has been inserted. After the full
size access has been established, there is hardly a way to correct a
suboptimal or wrong access.
METHODS: We describe our initial experience of using a microoptical system through a particular puncture needle in order to confirm
Vol. 183, No. 4, Supplement, Wednesday, June 2, 2010
the quality of the chosen access prior to dilating the operating tract to
standard nephroscope sizes of 24-28F. We used micro-optics of
0.9mm (angle of view: 120°) and 0.6 mm (angle of view: 70°) diameter,
with resolutions of up to 10k Pixels suitable for exploration of renal
calyces and pelvis. The micro-optics with integrated light lead are
inserted in the working sheath of the puncture needle. The special
needle has an outer diameter of 1.6mm (4.85F), slightly larger than the
diameter of a standard needle of 1.3mm. The needle comprises a
Y-piece for connection of irrigation. The optics are length adjusted so
that the distal end is flush with the tip of the needle. The optics are
connected via a zoom ocular and light adapters to standard endoscopic
camera systems and to Xenon light sources of at least 100W power.
RESULTS: The optical puncture needle was used in 15 patients
during PCNL procedures. In all cases, we were able to visualize the
punctured kidney calyces and to confirm presence of calculi prior to
dilating up the tract for insertion of the operating nephroscope. The
0.9mm optic was found to be superior in terms of field of view,
brightness and sharpness. Sufficient irrigation was confirmed for both
optical systems. The puncture with the 1.6mm needle was smooth and
no differences compared to standard 1.3mm needles were perceived.
CONCLUSIONS: The optical puncture needle for PCNL appears to be extremely helpful for confirming the percutaneous access to
the kidney prior to dilation of the operating tract, thus making PCNL, a
surgery where access is the key, inherently safer. In our opinion, this
system can substantially assist the learning curve for puncturing of the
kidney. The space inside the working sheath of the needle is even
sufficient to introduce a laser fiber (365 micrometer with the 0.9mm
optics, up to 600 micrometer with the 0.6mm optics) for lithotripsy of
small fragments into spontaneously passable fragments. This therapeutic extension will be investigated in future treatment series.
THE JOURNAL OF UROLOGY姞
e735
CONCLUSIONS: Nephrostomy tract closure with Floseal, deep
fascial stitch and 10F Cope loop nephrostomy tube following PCNL
result in similar peri-op bleeding, changes in serum creatinine and
post-op discomfort. Patients had similar post-op hospital stays and
analgesic use with no statistical difference in SF-36 and analog pain
scale scores on the first post-op day, 1 month post-op, and 3 months
post-op. In this preliminary study, the post PCNL placement of a fascial
suture appears to be a reasonable way of managing PCNL patients,
especially if a nephrostomy free approach is reasonable.
Table 1
Hospital stay (days)
Floseal
Fascial stitch
1.7 ⫾ 1.16
1.5 ⫾ 0.71
Test of
Cope loop significance
2 ⫾ 0.77 P ⫽ 0.4
Parenteral analgesics
(Morphine
equivalents)
28.42 ⫾ 41.3
19.5 ⫾ 15.2
24.3 ⫾ 26.9
P ⫽ 0.8
Change in serum Cr
0.08 ⫾ 1.16
0.19 ⫾ 0.21
0.08 ⫾ 0.17
P ⫽ 0.3
Change in hemoglobin -2.56 ⫾ 1.06 -2.49 ⫾ 1.16 -2.88 ⫾ 1.25
P ⫽ 0.7
SF-36 total scores
Pre-op
69.2 ⫾ 20.6
55.3 ⫾ 24.7
56 ⫾ 17.6
Post-op day #1
58.7 ⫾ 22.9
45.4 ⫾ 22.5
55 ⫾ 15.0
P ⫽ 0.5
55 ⫾ 14.7
52.3 ⫾ 22.2
51.2 ⫾ 12.0
P ⫽ 0.9
1 month
68.8 ⫾ 23.5
70.3 ⫾ 29.8
69.5 ⫾ 18.7
P ⫽ 1.0
3 months
72.2 ⫾ 18.2
65 ⫾ 31.3
67 ⫾ 16.7
P ⫽ 0.8
1 week
P ⫽ 0.4
Analog pain scale
8 ⫾ 12.6
14.4 ⫾ 19.0
16.1 ⫾ 14.5
P ⫽ 0.7
Post-op day #1
16.2 ⫾ 14.9
23.8 ⫾ 17.0
25.1 ⫾ 14.9
P ⫽ 0.6
1 week
22.6 ⫾ 11.3
15.6 ⫾ 13.3
4.6 ⫾ 4.5
P ⬍ 0.05
1 month
15.8 ⫾ 11.3
16.7 ⫾ 23.0
9.4 ⫾ 11.6
P ⫽ 0.7
3 months
9.8 ⫾ 11.4
12 ⫾ 19.1
8.6 ⫾ 12.0
P ⫽ 0.9
Pre-op
Source of Funding: None
Source of Funding: None
1891
1892
PRELIMINARY RESULTS OF A PROSPECTIVE RANDOMIZED
TRIAL OF TUBELESS FLOSEAL VS TUBELESS FASCIAL
STITCH VS COPE LOOP NEPHROSTOMY PERCUTANEOUS
NEPHROLITHOTOMY (PCNL)
UPDATED RESULTS ON LOWER POLE STONE MANAGEMENT:
URETERORENOSCOPY VS TUBELESS PCNL VS. SHOCKWAVE
LITHOTRIPSY FOR 0.5MM TO 1.5CM STONES
Roger Li, Jason Lee*, Hak J Lee, Donald Pick, Michael Louie,
Rosanne T Santos, Denise Wong, Elspeth M McDougall,
Orange, CA
INTRODUCTION AND OBJECTIVES: We present the preliminary results of a prospective randomized trial evaluating the safety and
efficacy of various “tubeless” PCNL techniques in reducing post-operative (post-op) morbidity. We compared post-op hospital stay, analgesics use, changes in serum creatinine, changes in hemoglobin, SF-36
scores, as well as post-op pain analog scores among patients randomized to undergo nephrostomy tract closure with Floseal (hemostatic
gelatin matrix), a deep fascial stitch, or a 10F Cope loop nephrostomy
tube.
METHODS: A total of 31 patients undergoing PCNL met the
inclusion criteria for the study and were randomized into one of the 3
aforementioned groups; 10 Floseal, 10 fascial stitch, 11 Cope loop. All
patients underwent an uncomplicated endoscopic-guided PCNL, standard technique at our institution. A study questionnaire consisting of a
SF-36 questionnaire and analog pain scales were given pre-operatively, on post-op day #1, and at 1 week, 1 month and 3 months after
the procedure. Statistical analysis was performed using the ANOVA
test.
RESULTS: The mean age, BMI, stone burden, pre-op labs, and
complication rates were not significantly different among the three
groups. The post-op hospital stay (p ⫽ 0.45), amount of opioid analgesia used in morphine equivalents (p ⫽ 0.79), changes in serum
creatinine (p ⫽ 0.28) and hemoglobin (p ⫽ 0.09) were also not
significantly different among the groups. The SF-36 total scores and
pain analog scores were all comparable at each time-point, except at 1
week post-op, when there was a significantly higher pain analog score
in the Floseal group compared to the Cope loop group (p ⫽ 0.02).
Michael Lasser*, Sutchin Patel, George Haleblian, Gyan Pareek,
Providence, RI
INTRODUCTION AND OBJECTIVES: Lower pole stone data
suggest that tubeless percutaneous nephrolithotomy (PNL), ureterorenoscopy (URS) and shockwave lithotripsy (SWL) are available treatment modalities for stones ⬍1.5 cm. Previously, we reported that
tubeless PNL may be more efficacious than the other modalities. As
more experience has been gained, an updated analysis was performed
to evaluate the efficacy of front line URS, SWL, or tubeless PNL for
treatment of lower pole stones.
METHODS: 60 patients from the Stone Therapy Center of New
England (STONE) undergoing treatment of 0.5 to 1.5 cm lower pole
calculi were reviewed (2007-2009). Of these, 15 underwent tubeless
PNL, 25 URS and 20 SWL. Demographic data, stone size, Hounsfield
units (HU), and skin to stone distance (SSD) were measured in each
cohort. The stone free status (no residual calculi) of patients was
determined by post-treatment imaging (CT scan or KUB) at 6 weeks. In
addition the number of auxiliary procedures to clear calculi and the
number of complications in each group were tabulated. Statistical
analysis was performed to evaluate for significant difference in SF rates
and the number of auxiliary procedures.
RESULTS: Between the three cohorts, there was no statistically significant difference in demographics, HU and SSD. The mean
stone size was 0.9 cm, 0.9 cm, 1.2 cm for the SWL, URS and tubeless
PNL groups respectively (p⬎0.05). There was a significant difference
between the stone free rates in the tubeless PNL group (100%) and
SWL Group (33%) (p⬍0.05). There was no significant difference in
stone free rates between the tubeless PNL group and URS group. The
number of auxiliary procedures in the SWL cohort (n ⫽ 9) was significantly greater than in the URS (n ⫽ 2) and tubeless PNL (n ⫽ 0)
groups. Mean hospital stay for tubeless PNL patients was 1.2 days