EXTRACORPOREAL SHOCK-WAVE LITHOTRIPSY FOR STONES IN SOLITARY KIDNEY EDWARD S. COHEN, M.D. JOSEPH D. SCHMIDT, M.D. From the San Diego Kidney Stone Treatment Center, and Division of Urology, University of California, San Diego Medical Center, San Diego, California
ABSTRACT--Twelve extracorporeal shock-wave lithotripsy (ESWL) treatments were performed on 10 patients with a solitary kidney. Nine patients had a ureteral stent placed pretreatment. Nine patients were available for follow-up. Seven (78 %) were stone free or had insignificant fragments at three months. Complications were seen in 4 patients, including two instances of pyelonephritis. Failures were associated with an increased stone burden. E S W L is an effective and safe treatment for upper urinary tract stones in patients with a solitary kidney. We recommend pretreatment stenting in patients with a solitary kidney.
The efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of renal calculi is well established. 1 Attempts to simplify the procedure, minimize morbidity, and improve its effectiveness are the current goals of those involved with ESWL. The etiology of a solitary kidney is manifold, including congenital and nephrectomy for tumor, infection, and stone disease. Many patients with a previous nephrectomy for urolithiasis will later present with a stone in their remaining kidney. These stones have been treated with open surgery, percutaneous removal, and more recently, ESWL. We present our experience with ESWL in the solitary kidney. Material and Methods From the opening of our ESWL unit in March, 1986, until June, 1987, 780 extracorporeal shock-wave lithotripsy treatments were performed on 728 patients for calculi in the upper urinary tracts. Of these treatments, 12 were done on 10 patients (1.4 % ) with a solitary kidney. All 10 patients were treated with Dornier HM-3 model lithotriptor. The treatment procedure has been described previously. 2 All patients were referred to our center and evaluated by one of the treating urologists. Average number of shocks given to achieve fragmentation
52
was 1,950 with a range of 1,300 to 2,400 at 1822 kV. Epidural anesthesia was used in 8 p a tients, spinal anesthesia in 1, and general anes-i thesia in 1. Antibiotics were given priorly if the'! patient had a urinalysis positive for bacteria oi:~ a history of infectious stones. All had a Double, J stent placed prior to ESWL except for 1 pad tient who had a ureteral catheter placed to hel~ localize a 4-mm stone. A plain film was ob4 tained on all patients one day post-ESWL. All patients were hospitalized a minimum of on day. Follow-up was done by the referring urol0 gist. A plain film was usually obtained at two tc three months after the procedure. Patients weri considered treatment successes if on their foI low-up plain film (KUB) at three months thei were either stone free or they had insignificani fragments defined as less than 5 m m that were not struvite. All patients with a solitary kidney treatedI with ESWL at our center were included in oui~ review (Table I). There were 12 treatments per~ formed on 10 patients, seven females (70%!1 and 3 males (30 %). Ages ranged from twenty~ five to sixty-nine years, with an average o!~ 45.2 years. Two patients had a congenital soli~ tary kidney while the other 8 patients had il nephrectomy for stones and or infection. Six pa~ tients had stone burden (defined as the sum ,o~ UROLOGY
/
JULY 1990
/
VOLUME XXXVI, NUMBEtt~
TABLEI. Review o] 10 patients with solitary kidney treated with ESWL patient Age/Sex pW BC LS PS RB BW ME KS MC
37/F 39/F 35/M 53/F 27/M 52/M
57/F 58/F 69/F 25/F
Stone Burden*
Reason for Nephrectomy
8ram, LK Urolithiasis, infection 4mm, RK Staghorn calculus, renal abscess l l m m , RK Urolithiasis 10mm, LK Urolithiasis 9mm, LK Urolithiasis, pyelonephritis 21mm, RK "Congenital" 18ram, LK Pyelonephritis 24mm, RK Urolithiasis, infection 40mm, RK Atrophic pyelonephritis 48mm, RK "Congenital"
KEY:LK = left kidney; RK = right kidney. ?Sum of largest diameters of all stones present.
th~i:iargest diameters of all stones present) g~afer than 1 cm, and 4 of these 6 had a stone b~rden greater than 2 cm. Eight patients had a ~i~f6ry of stone disease, and 3 of these had had previous open surgical removal of stone from SSIitary kidney. Follow-up is complete in 9 of th~10 patients. Results iPl'~tin radiographs done at twenty-four hours re~ealed good fragmentation in 11 of the 12 tment complications occurred atients (Table II). There were f acute pyelonephritis within ~rs following the treatment. :l a history of recurrent urinary but pretreatment antibiotics nly one. The latter patient, a -old woman, became anuric vith an elevated temperature. TABLEII. Complications • ~A ~ lJC ~S I:~P ;:~B BW
Pyelonephritis None None None None None Obstruction 7 weeks after treatment
~ kS
None Urethral obstruction
~=~ MC
Pyelonephritis Obstruction post-ESWL
Her ureteral stent was replaced with a ureteral catheter, and she became afebrile. Of interest was the development of urethral obstruction, requiring endoscopic removal, in a female patient who had a significant stone burden. In a fourth patient anuria developed seven weeks post-treatment, four weeks after her stent had been removed. She had significant retained fragments at that time; another stent was placed without difficulty. One patient was lost to follow-up at three months. Of the remaining 9 patients, 7 were stone free or had insignificant fragments at three months. In one treatment failure, the patient had good fragmentation of her struvite stones at her first treatment; however, the stones did not pass and, in fact, increased in size over the next five months. Her stent was removed at three weeks. One month later anuria developed, and a stent was placed. After failure of her second ESWL treatment, she had a percutaneous nephroscopic debulking and irrigation. She is stone free nine months after her first ESWL treatment. The other patient failing treatment had a significant stone burden that required two ESWL treatments. Nonobstructing steinstrasse developed, and she still had significant upper tract stone burden four months after her procedure. She underwent percutaneous stone manipulation, and at eight months after her initial procedure she had only insignificant calcium apatite fragments left. Ureteral stents were placed in all but 1 patient. The stents were removed at the discretion of the referring urologist, usually at one to two weeks post-procedure. The average hospital stay was 1.7 days.
Complications, secondary procedures, and results in i0 patients with stones in solitary kidneys Success at 3 Mos.
Secondary Procedures None None None None None None Repeat ESWL Pereutaneous stone removal and irrigation None Repeat ESWL Percutaneous and endoscopic stone removal Immediate stent change
, ,R~LOCy / JULY1990 / VOLUME XXXVI, NUMBER 1
Lost to follow-up Yes Yes Yes Yes Yes No (yes at 9 months)
Evidence of Current Infection
? .9 No No No No Yes (chronic indwelling Foley catheter)
Yes No (yes at 8 months)
No Yes
Yes
No
53
Comment E S W L is a safe and effective treatment for upper urinary tract calculi. Since introduction into the U.S., experience with E S W L t r e a t m e n t has grown. Efficacy of E S W L in solitary kidney has been established with success rates and complications nearly equivalent to t r e a t m e n t of patients with two kidneys. Ureteral obstruction following E S W L has been reported in up to 20 percent of patients, a In a review by Kulb e t a l . ~ on E S W L in a solitary kidney, 6 of 68 patients had partial or complete ureteral obstruction requiring posttreatment manipulation. In our study, all patients except 1 had preoperative stenting. Ureteral obstruction was seen in 2 patients in our study. In 1 patient the stent became obstructed post-ESWL. We hypothesized this was secondary to her infection stone matrix. Ureteral obstruction secondary to stone matrix following E S W L has been r e p o r t e d previously. 4 T h e other obstruction occurred four weeks after ureteral stent removal in a patient w h o had persistent large fragments after her first E S W L treatment. The obstruction was thought to be at the ureteropelvie junction and was treated successfully with stent placement. Deeisions on w h e n to remove the stent should be dictated by the stone burden. If sizable stone fragments or stone burden are present after treatment, the stent should be left in until the fragments have cleared significantly to prevent delayed obstruction. Pyelonephritis was seen in 2 patients, 1 of w h o m had an obstructed stent. Pye!onephritis in an obstructed solitary kidney is a potentially disastrous c o m p l i c a t i o n r e q u i r i n g e m e r g e n t drainage. Passing a ureteral stent through steinstrasse can at times be difficult, and often these patients need to have a pereutaneous nephrostomy tube placed on an emergent basis. 5 Our success rate at three months was 78 percent. Our two failures included 1 patient with significant stone burden (multiple stones with stone burden = 4 em) that required a combination of pereutaneous lithotripsy and ESWL. She had insignificant fragments eight months after ESWL. The other failure was in a paraplegic patient with struvite stones. Her first treatment fragmented the stones; however, they did not pass, possibly related to her immobility and the dependent position of the calculi. A second E S W L treatment, done after it was noted that her fragmented stones were increasing in
54
size, was not effective. She required pereuta{ neous ultrasonic lithotripsy and irrigation to:i render her stone free. The morbidity of E S W L and the rate of re, sidual fragments increase significantly as the size and n u m b e r of stones increase. 6 The use o: a combined approach of pereutaneous debull ing and ESWL for a large stone b u r d e n is wel: documented. 7,s The use of a combined proee dure should be considered in patients with large stone b u r d e n (>__ 2.5 em) in a solitary kid ney. Finally, although the three-month interva f o l l o w i n g E S W L has b e e n c o n s i d e r e d tht b e n e h m a r k of success in this series and by man others, it is clear that at least some of these p~ tients can be rendered stone free after a m u d longer interval. Conclusion E S W L is a safe and effective t r e a t m e n t f0 patients with upper tract stones in a solitar! kidney. We believe preoperative stenting is ind cated in all patients with a solitary kidney uI dergoing E S W L to prevent ureteral obstruetio and associated complications. Placing a ste~ before E S W L ean often be easier than a t t e m p ing this post-ESWL in an obstructed systea Patients with stone b u r d e n greater t h a n 2.5 ci . a sohtary . . .should be considered fo r ~ in kidney combined procedure to decrease morbidity ar/I improve the stone-free success rate. Division of Urology (H-897~ n 2 2 5 Dickinson S t r ~ Sa Diego, California 9210~
(DR. COHEN~ References 1. Kulb TB, et ah Extracorporeal shock-wave lithotripsy in Pffm tients with a solitary kidney, J Urol 136:786 (1986). 2. Riehle RA Jr, Naslund EB, Fair W, and Vaughan ED J ~ Impact of shock-wave lithotripsy on upper urinary tract calc~i~ Urology 28:261 (1986). ~1 3. Steinboek GS Bezirdjian L Newman RC and Finlaysorl~ , , , Extracorporeal shock-wave lithotripsy, Sur Rounds, July, 1986~ 4. LaBerge JM, and 8heff CD: Renal obstruction from p e r s i ~ ent struvite stone matrix, a complication of extracorporeal shoeg~ wave lithotripsy, Radiology 163:535 (1987). 5. Riehle RA, Fair WR, and Vaughan ED: E x t r a c o r p o r ~ shock-wave lithotripsy for upper urinary tract calculi: one year~l experience at a single center, JAMA 255:2043 (1986). ~.._ 6. Lingeman JE, et ah Extraeorporeal shock-wave lithotripi~ the Methodist Hospital of Indiana experience, J Urol 135: 1 l ~ (1986). =~ 7. Kahnoski RJ, et ah Combined pereutaneous and extrac°r~4~ real shock-wave lithotripsy for staghorn calculi J Urol 135: 6"¢¢~ (1986) . . . . ~ 8. Schultz H, et ah Combined treatment of branched calC bv percutaneous nephrotithotomy and extracorporeal shock-Wa lithotripsy, J Urol 135:1138 (1986).
UROLOGY
/ JULY 1990 /
VOLUME XXXVI, N U M B t ~
ABSTRACT--Twelve extracorporeal shock-wave lithotripsy (ESWL) treatments were performed on 10 patients with a solitary kidney. Nine patients had a ureteral stent placed pretreatment. Nine patients were available for follow-up. Seven (78 %) were stone free or had insignificant fragments at three months. Complications were seen in 4 patients, including two instances of pyelonephritis. Failures were associated with an increased stone burden. E S W L is an effective and safe treatment for upper urinary tract stones in patients with a solitary kidney. We recommend pretreatment stenting in patients with a solitary kidney.
The efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of renal calculi is well established. 1 Attempts to simplify the procedure, minimize morbidity, and improve its effectiveness are the current goals of those involved with ESWL. The etiology of a solitary kidney is manifold, including congenital and nephrectomy for tumor, infection, and stone disease. Many patients with a previous nephrectomy for urolithiasis will later present with a stone in their remaining kidney. These stones have been treated with open surgery, percutaneous removal, and more recently, ESWL. We present our experience with ESWL in the solitary kidney. Material and Methods From the opening of our ESWL unit in March, 1986, until June, 1987, 780 extracorporeal shock-wave lithotripsy treatments were performed on 728 patients for calculi in the upper urinary tracts. Of these treatments, 12 were done on 10 patients (1.4 % ) with a solitary kidney. All 10 patients were treated with Dornier HM-3 model lithotriptor. The treatment procedure has been described previously. 2 All patients were referred to our center and evaluated by one of the treating urologists. Average number of shocks given to achieve fragmentation
52
was 1,950 with a range of 1,300 to 2,400 at 1822 kV. Epidural anesthesia was used in 8 p a tients, spinal anesthesia in 1, and general anes-i thesia in 1. Antibiotics were given priorly if the'! patient had a urinalysis positive for bacteria oi:~ a history of infectious stones. All had a Double, J stent placed prior to ESWL except for 1 pad tient who had a ureteral catheter placed to hel~ localize a 4-mm stone. A plain film was ob4 tained on all patients one day post-ESWL. All patients were hospitalized a minimum of on day. Follow-up was done by the referring urol0 gist. A plain film was usually obtained at two tc three months after the procedure. Patients weri considered treatment successes if on their foI low-up plain film (KUB) at three months thei were either stone free or they had insignificani fragments defined as less than 5 m m that were not struvite. All patients with a solitary kidney treatedI with ESWL at our center were included in oui~ review (Table I). There were 12 treatments per~ formed on 10 patients, seven females (70%!1 and 3 males (30 %). Ages ranged from twenty~ five to sixty-nine years, with an average o!~ 45.2 years. Two patients had a congenital soli~ tary kidney while the other 8 patients had il nephrectomy for stones and or infection. Six pa~ tients had stone burden (defined as the sum ,o~ UROLOGY
/
JULY 1990
/
VOLUME XXXVI, NUMBEtt~
TABLEI. Review o] 10 patients with solitary kidney treated with ESWL patient Age/Sex pW BC LS PS RB BW ME KS MC
37/F 39/F 35/M 53/F 27/M 52/M
57/F 58/F 69/F 25/F
Stone Burden*
Reason for Nephrectomy
8ram, LK Urolithiasis, infection 4mm, RK Staghorn calculus, renal abscess l l m m , RK Urolithiasis 10mm, LK Urolithiasis 9mm, LK Urolithiasis, pyelonephritis 21mm, RK "Congenital" 18ram, LK Pyelonephritis 24mm, RK Urolithiasis, infection 40mm, RK Atrophic pyelonephritis 48mm, RK "Congenital"
KEY:LK = left kidney; RK = right kidney. ?Sum of largest diameters of all stones present.
th~i:iargest diameters of all stones present) g~afer than 1 cm, and 4 of these 6 had a stone b~rden greater than 2 cm. Eight patients had a ~i~f6ry of stone disease, and 3 of these had had previous open surgical removal of stone from SSIitary kidney. Follow-up is complete in 9 of th~10 patients. Results iPl'~tin radiographs done at twenty-four hours re~ealed good fragmentation in 11 of the 12 tment complications occurred atients (Table II). There were f acute pyelonephritis within ~rs following the treatment. :l a history of recurrent urinary but pretreatment antibiotics nly one. The latter patient, a -old woman, became anuric vith an elevated temperature. TABLEII. Complications • ~A ~ lJC ~S I:~P ;:~B BW
Pyelonephritis None None None None None Obstruction 7 weeks after treatment
~ kS
None Urethral obstruction
~=~ MC
Pyelonephritis Obstruction post-ESWL
Her ureteral stent was replaced with a ureteral catheter, and she became afebrile. Of interest was the development of urethral obstruction, requiring endoscopic removal, in a female patient who had a significant stone burden. In a fourth patient anuria developed seven weeks post-treatment, four weeks after her stent had been removed. She had significant retained fragments at that time; another stent was placed without difficulty. One patient was lost to follow-up at three months. Of the remaining 9 patients, 7 were stone free or had insignificant fragments at three months. In one treatment failure, the patient had good fragmentation of her struvite stones at her first treatment; however, the stones did not pass and, in fact, increased in size over the next five months. Her stent was removed at three weeks. One month later anuria developed, and a stent was placed. After failure of her second ESWL treatment, she had a percutaneous nephroscopic debulking and irrigation. She is stone free nine months after her first ESWL treatment. The other patient failing treatment had a significant stone burden that required two ESWL treatments. Nonobstructing steinstrasse developed, and she still had significant upper tract stone burden four months after her procedure. She underwent percutaneous stone manipulation, and at eight months after her initial procedure she had only insignificant calcium apatite fragments left. Ureteral stents were placed in all but 1 patient. The stents were removed at the discretion of the referring urologist, usually at one to two weeks post-procedure. The average hospital stay was 1.7 days.
Complications, secondary procedures, and results in i0 patients with stones in solitary kidneys Success at 3 Mos.
Secondary Procedures None None None None None None Repeat ESWL Pereutaneous stone removal and irrigation None Repeat ESWL Percutaneous and endoscopic stone removal Immediate stent change
, ,R~LOCy / JULY1990 / VOLUME XXXVI, NUMBER 1
Lost to follow-up Yes Yes Yes Yes Yes No (yes at 9 months)
Evidence of Current Infection
? .9 No No No No Yes (chronic indwelling Foley catheter)
Yes No (yes at 8 months)
No Yes
Yes
No
53
Comment E S W L is a safe and effective treatment for upper urinary tract calculi. Since introduction into the U.S., experience with E S W L t r e a t m e n t has grown. Efficacy of E S W L in solitary kidney has been established with success rates and complications nearly equivalent to t r e a t m e n t of patients with two kidneys. Ureteral obstruction following E S W L has been reported in up to 20 percent of patients, a In a review by Kulb e t a l . ~ on E S W L in a solitary kidney, 6 of 68 patients had partial or complete ureteral obstruction requiring posttreatment manipulation. In our study, all patients except 1 had preoperative stenting. Ureteral obstruction was seen in 2 patients in our study. In 1 patient the stent became obstructed post-ESWL. We hypothesized this was secondary to her infection stone matrix. Ureteral obstruction secondary to stone matrix following E S W L has been r e p o r t e d previously. 4 T h e other obstruction occurred four weeks after ureteral stent removal in a patient w h o had persistent large fragments after her first E S W L treatment. The obstruction was thought to be at the ureteropelvie junction and was treated successfully with stent placement. Deeisions on w h e n to remove the stent should be dictated by the stone burden. If sizable stone fragments or stone burden are present after treatment, the stent should be left in until the fragments have cleared significantly to prevent delayed obstruction. Pyelonephritis was seen in 2 patients, 1 of w h o m had an obstructed stent. Pye!onephritis in an obstructed solitary kidney is a potentially disastrous c o m p l i c a t i o n r e q u i r i n g e m e r g e n t drainage. Passing a ureteral stent through steinstrasse can at times be difficult, and often these patients need to have a pereutaneous nephrostomy tube placed on an emergent basis. 5 Our success rate at three months was 78 percent. Our two failures included 1 patient with significant stone burden (multiple stones with stone burden = 4 em) that required a combination of pereutaneous lithotripsy and ESWL. She had insignificant fragments eight months after ESWL. The other failure was in a paraplegic patient with struvite stones. Her first treatment fragmented the stones; however, they did not pass, possibly related to her immobility and the dependent position of the calculi. A second E S W L treatment, done after it was noted that her fragmented stones were increasing in
54
size, was not effective. She required pereuta{ neous ultrasonic lithotripsy and irrigation to:i render her stone free. The morbidity of E S W L and the rate of re, sidual fragments increase significantly as the size and n u m b e r of stones increase. 6 The use o: a combined approach of pereutaneous debull ing and ESWL for a large stone b u r d e n is wel: documented. 7,s The use of a combined proee dure should be considered in patients with large stone b u r d e n (>__ 2.5 em) in a solitary kid ney. Finally, although the three-month interva f o l l o w i n g E S W L has b e e n c o n s i d e r e d tht b e n e h m a r k of success in this series and by man others, it is clear that at least some of these p~ tients can be rendered stone free after a m u d longer interval. Conclusion E S W L is a safe and effective t r e a t m e n t f0 patients with upper tract stones in a solitar! kidney. We believe preoperative stenting is ind cated in all patients with a solitary kidney uI dergoing E S W L to prevent ureteral obstruetio and associated complications. Placing a ste~ before E S W L ean often be easier than a t t e m p ing this post-ESWL in an obstructed systea Patients with stone b u r d e n greater t h a n 2.5 ci . a sohtary . . .should be considered fo r ~ in kidney combined procedure to decrease morbidity ar/I improve the stone-free success rate. Division of Urology (H-897~ n 2 2 5 Dickinson S t r ~ Sa Diego, California 9210~
(DR. COHEN~ References 1. Kulb TB, et ah Extracorporeal shock-wave lithotripsy in Pffm tients with a solitary kidney, J Urol 136:786 (1986). 2. Riehle RA Jr, Naslund EB, Fair W, and Vaughan ED J ~ Impact of shock-wave lithotripsy on upper urinary tract calc~i~ Urology 28:261 (1986). ~1 3. Steinboek GS Bezirdjian L Newman RC and Finlaysorl~ , , , Extracorporeal shock-wave lithotripsy, Sur Rounds, July, 1986~ 4. LaBerge JM, and 8heff CD: Renal obstruction from p e r s i ~ ent struvite stone matrix, a complication of extracorporeal shoeg~ wave lithotripsy, Radiology 163:535 (1987). 5. Riehle RA, Fair WR, and Vaughan ED: E x t r a c o r p o r ~ shock-wave lithotripsy for upper urinary tract calculi: one year~l experience at a single center, JAMA 255:2043 (1986). ~.._ 6. Lingeman JE, et ah Extraeorporeal shock-wave lithotripi~ the Methodist Hospital of Indiana experience, J Urol 135: 1 l ~ (1986). =~ 7. Kahnoski RJ, et ah Combined pereutaneous and extrac°r~4~ real shock-wave lithotripsy for staghorn calculi J Urol 135: 6"¢¢~ (1986) . . . . ~ 8. Schultz H, et ah Combined treatment of branched calC bv percutaneous nephrotithotomy and extracorporeal shock-Wa lithotripsy, J Urol 135:1138 (1986).
UROLOGY
/ JULY 1990 /
VOLUME XXXVI, N U M B t ~
