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Stone Management
absorption of oxalate. Differences in dietary oxalate intake and in statistically significant difference in stone-free rates between SWL
renal oxalate excretion are other potential parameters, but more and URS (35 and 50%; p=NS) for the treatment of small lower-pole
extensive examinations of intestinal oxalate absorption should help renal calculi. However, SWL was associated with greater patient
clarify the role of dietary oxalate in stone formation. Babowski et acceptance and shorter convalescence. This is actually not in
al.
16
presented their expertise for current therapy of hyperoxaluria. accordance with our own experience, since patient preference is
Primarily accurate diagnosis leads to the use of therapies, including strongly related to immediate and less morbid treatment, usually
pyridoxine supplementation, urinary crystallisation inhibitors and only achieved with endourology.
hydration with enteral fluids. In the near future, probiotic
supplementation or other innovative therapies may even be able to There is an increasing prevalence of obesity and new studies have
correct the underlying genetic defect. confirmed the link to urolithiasis. A study presented by Calvert et
al.
21
demonstrated that flexible ureterorenoscopy and adapted
Micali et al.
17
provided an update on the medical treatment of stone percutaneous nephrolithotomy techniques can result in similar
disease. They highlighted recent findings of an interesting role stone clearance rates and morbidity in non-obese patients, but SWL
for Phillantus niruri, a phytotherapeutic agent, and its inhibitory failure is higher in this patient cohort. For caliceal anatomy for
action on calcium oxalate crystallisation related to the higher
incorporation of glycosamin–glycanes into the calculi. This may be
of clinical importance in the future. In addition, expulsive therapy
Due to technical enhancement of
with nifedipine and alpha-blockers in association with anti-oedema
drugs demonstrates high efficacy in expelling ureteral stones.
endourological methods, surgical therapy
According to our experience, this is successful only when sufficient
of renal and ureteral stones has become
pain relieve is achieved, otherwise expulsive therapy unnecessarily
prolong time to potential successful treatment.
a very uncommon intervention in
developed countries.
Shock-wave Lithotripsy
The future of SWL was questioned by Köhmann et al.,
18
since the
development of newer lithotripters has not been able to improve stone clearance following SWL, Juan et al.
22
clearly demonstrated
clinical efficacy because the shock-wave parameters specifically that only infundibular length, stone size and stone burden were of
responsible for stone disintegration or tissue trauma and pain clinical importance in stones ≤10mm, showing lower complication
induction have not yet been identified. Economic aspects, the and acceptable stone-free rates. Keeley et al.
23
found that in lower-
surgeon’s expertise and patient preference are still of greater pole stones between 11 and 20mm in size, the angle of the lower-
importance when a procedure is chosen. Undoubtly, SWL will be an pole infundibulum as it relates to the pelvis plays a role in eventual
inherent part of future treatment modalities for urinary stones. stone clearance and should be taken into account before choosing
However, the optimal treatment of lower-pole renal calculi is a mode of treatment.
controversial. In a fundamental review, Raman et al.
19
concluded
that SWL and ureteroscopy have similar stone-free rates in small Endourology and Laparoscopy
stones, although SWL may be preferable due to more favourable Use of flexible ureteroscopes is limited by the need to dilatate the
secondary outcomes. Lower-pole stones that are 1–2cm in diameter ureteric orifice and that the deflection of the uretroscope may be
are best managed with percutaneous nephrostolithotomy, although highly influenced by a lithotripsy probe inside the working channel.
ureteroscopy is an option in select patients. Finally, patients with Michel et al.
24
investigated flexible ureteroscopes (9.0F Wolf, 7.5F
lower-pole stones larger than 2cm are best served with Olympus, 7.5F Storz) for the treatment of lower-pole calyx stones.
percutaneous nephrostolithotomy, as the morbidity in experienced The flexible Lithoclast, the non-nitinol baskets and the 365-micron
laser probes were found to significantly inhibit the deflection of all
scopes. The greatest deflection with inserted working tool was
possible using the Wolf and Storz scopes. Both nitinol tools as well
Use of flexible ureteroscopes is limited by
as the 200-micron laser probe had only a minimal influence on the
the need to dilatate the ureteric orifice
deflection. However, even the 200-micron laser probe reduced the
irrigation flow from 50 to 28ml/minute. In conclusion, there are
and that the deflection of the uretroscope
significant differences in active and passive flexion depending on
may be highly influenced by a lithotripsy
the ureterorenoscopes itself and the different tools.
probe inside the working channel.
The same experience was noted by Preminger,
25
where lower-pole
renal calculi were managed with a 7.5F ureteroscope and a
hands is low and stone-free rates are unequivocally higher than 200mum holmium laser fragmentation either in situ or by first
those of other treatment modalities. Similar to the study mentioned displacing the stone with the aid of a nitinol stone retrieval device.
above, they conclude that a variety of contributing factors, including He concluded that lower-pole stones less than 20mm can be
patient body habitus, local renal anatomy, cost and patient primarily treated by flexible ureteroscopic as an alternative to SWL
preference, must be taken into consideration for optimal patient or percutaneous nephrolithotomy (PCNL), even in patients who are
counselling and treatment. This is underlined by their prospective, obese or who have a bleeding diathesis or stones resistant to SWL.
randomised trial comparing SWL and ureteroscopy for lower-pole However, Lahme et al.
26
demonstrated minimally invasive 12F PCNL
caliceal calculi ≤1cm.
20
This study failed to demonstrate a in patients with renal pelvic and calyceal stones, representing an
80 EUROPEAN UROLOGICAL REVIEW
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