34 Special article

Recent technological developments in the management of urinary tract stones

SIMON CHOONG In the 1980s, the advent of non-invasive techniques, such as lithotripsy, ureteroscopy and percutaneous nephrolithotomy, revolutionised the treatment of urinary tract stones. Since then, technological advances have been at the forefront of improvements in stone management.
Mr S. Choong, MS, FRCS(Urol), Director of Stone Unit, Institute of Urology, University College London Hospitals. Box 1. Developments in stone disease.

ntil the 1980s, urinary tract stones were managed largely U by extensive open operations, which were often multiple because of the recurrent nature of the disease; these resulted in renal impairment and loss of kidneys in some cases. The advent of extracorporeal shock-wave lithotripsy (ESWL), ureteroscopy and percutaneous nephrolithotomy in the 1980s ushered in a new era of minimally invasive treatment of urinary tract stones. Since then, technological advances have been at the forefront of improvements in stone management. Developments in stone disease are summarised in Box 1. Epidemiology and causes of stone disease The rate of stone occurrence has been rising progressively over recent decades.13 Stone incidence was noted to have risen from 0.54 per cent in 1979 to 0.88 per cent in 1984.4 In addition, over the past 30 years, the age at onset of stones in the UK has been steadily falling, with more individuals forming their first stone during their late teens and early twenties. In boys and young men, this has been attributed to increases in the consumption of animal protein, salt and refined sugars. In girls and young women, it appears to be more a result of changes in lifestyle, though diet may also have played a role, perhaps caused by the current fad for high-protein, low-carbohydrate, weight-reducing diets. The average lifetime risk of a renal stone has been reported to be in the range of 521 per cent.5 The lifetime risk is approximately 10 per cent in the UK, 15 per cent in the USA and 20 per cent in Saudi Arabia. Most patients have recurrent stones, and the recurrence rate is about 10 per cent at one year, 35 per cent at five years, and 50 per cent at ten years.6 More men than women are affected by stone disease, but the difference is narrowing (the maleto-female ratio is now 1.6:1, compared with 3:1 in 1975). The peak incidence is between the fourth and fifth decades, and therefore generally affects active and working adults.
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The incidence of stones is rising The male-to-female ratio is

narrowing (1.6:1, compared with 3.0:1 in 1975) An increased risk of stone formation may be linked to reduced colonisation with Oxalobacter formigenes There is increasing use of low-dose, non-contrast computed tomography scans to diagnose stones (compared with intravenous urography) Extracorporeal shock-wave Figure 1. New nitinol tipless baskets lithotripsy has become enable capture and extraction of stones easier to use and requires even in the lower pole of the kidney. less analgesia, but treatment results have not improved significantly Technological advances in ureteroscopes (rigid and flexible), lasers, baskets (Figure 1) and guidewires have resulted in higher success rates of stone treatment and higher costs of treating stones There is increasing use of smaller ureteroscopes and the holmium laser to treat ureteric stones (compared with lithotripsy) Flexible ureterorenoscopy is used to treat kidney stones resistant to lithotripsy Percutaneous nephrolithotomy has replaced open surgery to remove large renal stones. Use of balloon dilators to achieve access to the renal collecting system for percutaneous nephrolithotomy enables urologists to do their own tracts and results in less bleeding Paediatric stones can be managed by minimally invasive treatments instead of open operations Open surgery in adults and children has become extremely rare The availability of minimally invasive treatments has resulted in less renal impairment in recurrent stone formers, who required multiple extensive open surgical procedures before the 1980s With current techniques, the advantages of treating asymptomatic stones outweigh the disadvantages There is no evidence base to guide follow-up care

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Approximately 25 per cent of stone formers had a family history of urinary tract stones in an American study.7 In this longitudinal follow-up study of 37 999 men, a family history of stones was three times higher in stone formers than in non-stone formers. The relative risk of forming stones remained high even when risk factors such as calcium consumption and urinary metabolite excretion were adjusted for. Genetic studies suggest that stone formation may be the result of a polygenic defect with partial penetrance.8 Most stones are calcium oxalate (approximately 80 per cent), the oxalate component being more influential than the calcium component in calcium oxalate stone formation. The reason is that urinary oxalate concentration is one-tenth that of calcium, and small rises in urinary oxalate concentration have far more profound effects than equivalent rises in calcium concentration. Two intestinal bacteria, Oxalobacter formigenes and Pseudomonas oxalaticus, secrete enzymes that break down oxalate within the physiological pH range.9,10 Antimicrobial administration may affect bacterial colonisation of these oxalate-degrading bacteria in the gut, with a consequent rise in urinary oxalate concentration. Patients with cystic fibrosis on long-term antibiotics frequently lack O. formigenes in the intestine and have hyperoxaluria. Diagnosis of stone disease The first investigation in the diagnosis of stone disease is usually a plain kidney-ureter-bladder (KUB) X-ray. When a patient presents acutely with ureteric colic and has haematuria, a positive KUB X-ray diagnoses the presence of ureteric calculus with 96 per cent accuracy.11 However, bowel gas may obscure the view and pelvic phleboliths may mimic a distal ureteric stone and make the diagnosis uncertain. Ultrasonography of renal stones is operator-dependent and cannot detect ureteric stones.

Figure 2. Low-dose, non-contrast computerised tomography scan showing a stone in the right proximal ureter and right hydronephrosis.

Spiral CT is much faster than conventional CT and provides a three-dimensional image. The amount of radiation for spiral CT can be programmed to be less than or similar to that of the average IVU. In addition, CT scanning can detect non-urological abnormalities such as acute appendicitis or ovarian cysts that could mimic ureteric colic. A CT scan has a sensitivity of 97 per cent and a specificity of 96 per cent when reported by a radiologist specialising in the urinary tract.12 The debate of IVU versus CT in the diagnosis of ureteric colic is ongoing (Box 2). The choice and decision depend on the local availability and expertise, particularly out of hours. An IVU is easily interpreted by an attending physician, whereas a CT often requires a radiologist specialising in the urinary tract to differentiate a phlebolith from a ureteric stone. The investigation that is most appropriate to the local setting should be chosen. Asymptomatic renal stones Most renal stones in the collecting system, when untreated, are likely to increase in size, resulting in pain and/or infection, and may cause ureteric colic and renal obstruction. In the past, the risks of open surgical treatment were unacceptably high, but with current minimally invasive treatments, the benefits of treating asymptomatic stones outweigh the risks of leaving a stone untreated. Lithotripsy of renal stones The modern management of stone disease has become minimally invasive as a result of technological advances. Suitable stones can be treated by lithotripsy with minimal or no analgesia, and the lithotripters have become more user- and patient-friendly. However, because current lithotripters are less powerful than the Dornier HM3, the first-generation lithotripter used in 1980, success rates have not improved significantly. The three-month stone-free rates of renal stones range from 59 to 76 per cent, with stones in the lower pole
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Intravenous urography An intravenous urogram (IVU) is often used to confirm a ureteric stone and assess the degree of obstruction. However, it carries a risk of allergy to contrast agents, lactic acidosis in diabetic patients on metformin and potential nephrotoxicity. In addition, plain X-rays, including IVUs, cannot detect the 10 per cent of stones that are radiolucent (Box 2). Computed tomography Computed tomography (CT) scanning can be performed in less than five minutes without the need for contrast agents (Figure 2). However, use of a CT scanner in diagnosing acute renal colic depends on accessibility, especially out of normal working hours, and expertise in interpreting the findings. Thus, the use of CT scanning for diagnosing renal colic varies between hospitals and depends on local hospital policies.
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Box 2. Advantages and disadvantages of IVU and CT.

Advantage of IVU Easy interpretation by attending physician

Disadvantages of IVU Risk of allergy to contrast agent Diabetic patients need to stop metformin to prevent the small risk of lactic acidosis Increased risk of nephrotoxicity in patients with renal impairment, dehydration or the elderly Takes longer to perform than CT Cannot detect radiolucent stones (uric acid, xanthine, indinavir, triamterene and matrix stones) Advantages of CT Quick No need for contrast agent No risk of nephrotoxicity Ability to diagnose non-urological abdominal abnormalities Similar dose of radiation to IVU Disadvantages of CT Difficult to interpret by physician Dependent on interpretation by radiologist with specialised skills

devices to prevent stone migration during ureteroscopy have resulted in a treatment success rate of 95 per cent for ureteric stones.13 When compared to lithotripsy, endoscopic ureterolithotomy unblocks the kidney and achieves stone clearance simultaneously and immediately. The complication rate is extremely uncommon in the right hands and may be more suitable than ESWL in patients who need definitive treatment quickly. Flexible ureterorenoscopy for ESWL-resistant renal stones Small, flexible ureterorenoscopes of 23mm in diameter enable treatment of impacted ureteric stones and renal stones resistant to ESWL. Holmium laser fibres of 0.2mm can be passed through these scopes to disintegrate any type of stones. New tipless baskets made of nitinol material with a diameter of 0.6mm can capture and retrieve stones, even in the lower pole of the kidney (see Figure 1). The flexible ureterorenoscope is also useful to diagnose and treat renal transitional cell tumours, vascular malformation within the renal collecting system and difficult ureteric stones. Percutaneous nephrolithotomy Percutaneous nephrolithotomy has replaced open surgery to remove large stones of greater than 2.02.5cm in diameter from the kidney. The procedure is performed through a keyhole of 1cm or less in diameter from the skin to the renal collecting system. New balloon dilators make it easier to establish a tract into the kidney and are associated with less bleeding. A nephroscope is inserted through the tract and stone-breaking ballistic or ultrasound lithoclast is passed through the nephroscope to disintegrate and remove the stone fragments. New devices that combine ballistic and ultrasound lithoclast and powerful suction can remove large stone bulk in less than half the time when compared to ultrasound lithoclast and suction only. The procedure carries the risk of haemorrhage (blood transfusion rates of 110 per cent), infection and sepsis (in 0.32.5 per cent), but does not significantly impair renal function.1921 Paediatric stones Studies in the 1970s revealed that urinary tract stones are much less common in children, accounting for 23 per cent of all stones.22,23 The incidence of stones is twice as high in boys as in girls. Infected urolithiasis occurs more commonly in children younger than four years, and metabolic causes occur more commonly in older children and adolescents. Cystinuria and hyperoxaluria each account for 515 per cent of paediatric stones.24 Until recently, multiple open operations were performed to remove recurrent stones in children. In select centres, stones in children are treated in the same way as in adults, with lithotripsy for renal stones, ureteroscopy
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calyx carrying the lowest success rates because of poor stone clearance from the most dependent part of the kidney.13 Lithotripsy of ureteric stones The success rates of ESWL for ureteric stones range from 50 to 85 per cent.1418 Ureteric stones are localised by X-ray, whereas renal stones can be localised by ultrasound or X-ray. Stones in the mid-ureter overlying the sacroiliac joint cannot be localised for treatment. Patients with uncontrolled pain or renal obstruction are unsuitable for ESWL. Various factors influence the success rate, including operator skill, type of machine, ease of stone localisation, stone size and location, stone type and hardness. The availability of lithotripters and advanced ureteroscopic instruments and accessories such as holmium lasers and lithoclasts determines the best treatment option. Patients circumstances need to be taken into consideration, as ESWL requires a longer time (two to four weeks) to assess treatment outcome than does ureteroscopic removal of stones. When neither a lithotripter nor endoscopic ureterolithotomy is immediately available, it may be necessary to insert a temporary JJ stent to unblock the kidney; treatment of the stone is deferred. A JJ stent is associated with urinary frequency, haematuria, painful micturition and loin discomfort (Figure 3). Ureteroscopy for ureteric stones Significant advances in fibreoptics, smaller rigid ureteroscopes (2mm in diameter), holmium laser and accessory
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for ureteric stones and percutaneous nephrolithotomy for large renal stones, with excellent results.25 Follow-up care I am unaware of any good recent studies to guide best practice in follow-up care. Dietary restrictions are controversial, with compliance problems and difficulty in proving a reduction in stone recurrence rate. It is not routine to monitor blood pressure and renal function, as studies have produced conflicting results. The future The future of minimally invasive management of urinary tract stones will be technologically driven. Digitalised telescope systems for nephroscopes, rigid and flexible ureterorenoscopes will significantly improve optical resolution. Rigid and flexible ureterorenoscopes will continue to become smaller and more robust to help access and negotiate a tight ureter. Accessory instruments such as devices to prevent stone migration during ureteroscopy, tipless stone retrieval baskets and guidewires will continue to evolve and improve. These technologically advanced instruments are expensive and will increase the cost of stone management. However, they will greatly increase the success rate of stone treatment and reduce the number of operations and hospital admissions required. Patients will benefit from these day-case minimally invasive procedures, with less discomfort, reduced complications and fewer days off work. References
1. Norlin A, Lindell B, Granberg PO, Lindvall N. Urolithiasis: a study of its frequency. Scand J Urol Nephrol 1976; 10: 150-3. 2. Ljunghall S. Incidence of upper urinary tract stones. Mineral Electrolyte Metab 1987; 13: 220-7. 3. Robertson WG, Peacock M. The pattern of urinary stone disease in Leeds and in the United Kingdom in relation to animal protein intake during the period 1960-1980. Urol Int 1982; 30: 394-9. 4. Vahlensieck W, Hesse A, Schaefer RM. Epidemiologische Studien zur Inzidenz, Pravalenz and Mortalitat des Harnsteinleidens in der Bundesrepublik Deutschland 1979 und 1984. In: Vahlensieck W, Gasser G, eds. Pathogenese und Klinik der Harnsteine XII. Darmstadt: Steinkopff, 1986; 1-4. 5. Amiel J, Choong S. Renal stone disease: the urological perspective. Nephron Clin Pract 2004; 98(2): C54-8. 6. Uribarri J, Oh MS, Carrol HJ. The first kidney stone. Ann Intern Med 1989; 111: 1006-9. 7. Curhan GC, Willett WC, Rimm EB, Stampfer MJ. Family history and risk of kidney stone. J Am Soc Nephrol 1997; 8: 1568-73. 8. Resnick M, Pridgen DB, Goodman HO. Genetic predisposition to formation of calcium oxalate renal calculi. N Eng J Med 1968; 278: 1313-18. 9. Allison MG, Cook HM, Milne DB, et al. Oxalate degradation by gastrointestinal bacteria from humans. J Nutr 1986; 116: 455-60. 10. Dawson KA, Allison MJ, Hartman PA. Isolation and some characteristics of anaerobic oxalate degrading bacteria from the rumen. Appl Environ Microbiol 1988; 40: 833-9.

Figure 3. Kidney-ureter-bladder X-ray showing a right JJ stent, inserted to unblock a kidney when treatment of the stone needs to be deferred. 11. Elton TJ, Roth CS, Berquist TH, Silverstein MD. A clinical prediction rule for the diagnosis of ureteral calculi in emergency departments. J Gen Intern Med 1993; 8: 57-62. 12. Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of non-contrast-enhanced CT and intravenous urography. Radiology 1995; 194: 789-94. 13. Lingeman JE, Lifshitz DA, Evan AP. Surgical management of urinary lithiasis. In: Walsh PC, ed. Campbells urology. Philadelphia: WB Saunders, 2002; 3382, 3405. 14. Segura JW, Preminger GM, Assimos DG, et al. Ureteral stones clinical guidelines panel summary report on the management of ureteral calculi. J Urol 1997; 158: 1915-21. 15. Bierkens AF, Hendrikx AJ, De La Rosette JJM. Treatment of mid- and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs. laser ureteroscopy. A comparison of costs, morbidity and effectiveness. Br J Urol 1998; 81: 31-5. 16. Kupeli B, Biri H, Isen K, et al. Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives. Eur Urol 1998; 34: 474-9. 17. Pardalidis NP, Kosmaoglou EV, Kapotis CG. Endoscopy vs. extracorporeal shockwave lithotripsy in the treatment of distal ureteral stones: ten years experience. J Endourol 1999; 13: 161-4. 18. Peschel R, Janetschek G, Bartsch G. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study. J Urol 1999; 162: 1909-12. 19. Lange EK. Percutaneous nephrolithotomy and lithotripsy: a multiinstitutional survey of complications. Radiology 1987; 162: 25. 20. Segura JW. Percutaneous nephrolithotomy: technique, indication and complications. AUA Update Series 1993; 12. 21. Dyer RB, Assimos DG, Regan JD. Update on interventional uroradiology. Urol Clin North Am 1997; 24: 623-8. 22. Bennett AH, Colodny AH. Urinary tract calculi in children. J Urol 1973; 109: 318-20. 23. Malek RS, Kelalis PP. Pediatric nephrolithiasis. J Urol 1975; 113: 545-51. 24. Coward RJ, Peters CJ, Duffy PG, et al. Epidemiology of paediatric renal stone disease in the UK. Arch Dis Child 2004; 89(8): 797. 25. Choong SKS, Whitfield HN, Duffy P, et al. The management of paediatric urolithiasis. BJU Int 2000; 86(7): 857-60.

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