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The Future of Stone Management
H Christoph Klingler
Vice Chairman, Department of Urology, Medical University of Vienna
In the developed world over the last few decades, the composition and size of renal and ureteric stones has dramatically changed.
Extracorporeal shock-wave lithotripsy (SWL) has revolutionised urological stone therapy; however, in contrast to endourological
techniques, SWL only disintegrates, it does not remove the calculus. Not surprisingly, endourological techniques have become the
treatment method of choice, because the clinical aim is complete and primary stone removal. There has been a renaissance of
endourological procedures due to technical refinements and high success rates, and because immediate stone removal is preferred by
both patients and urologists. As stone disease is associated with a high recurrence rate, there is much interest and research on stone
pathophysiology and stone metaphylaxis. Unfortunately, little has changed in terms of stone metaphylaxis and urological surgery will
remain mandatory for stone treatment for the foreseeable future.
Stones, teaching, treatment, endourology, shock-wave lithotripsy
Disclosure: The author has no conflicts of interest to declare.
Received: 16 November 2008 Accepted: 10 July 2009
Correspondence: H Christoph Klinger, Department of Urology, Medical University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.
Due to the continuous use of renal ultrasonography for diagnostic in a small distal stone, and is a typical training procedure for ongoing
purposes and early surgical stone interventions, stone composition endourologists. Conversely, handling and orientation with flexible
and size have changed dramatically over the last decades within instruments is more advanced and requires some training; in
developed communities. For treatment, extracorporeal shock-wave addition, gaining access to the ureter is more elaborate even
lithotripsy (SWL) has revolutionised urological stone therapy and has with ultra-thin flexible ureteroscopes (see Figure 2). Furthermore,
become established as the therapy of choice for stones in the upper according to D Bagley: “Even in the hands of experts and regardless
urinary tract. Numerous studies reporting success rates of up to 90% of manufacturer, there is the need for major repair for the flexible
following primary SWL therapy have been published.
However, in ureteroscope after 10 procedures.” Therefore, proper handling is
contrast to endourological techniques, SWL only disintegrates but mandatory. However, excellent training models and computed
does not remove the calculus, thus requiring spontaneous passage ‘virtual reality’ ureteroscope training programs are readily available
of residual fragments. In addition, the high ‘success rates’ reported on the market, thus facilitating training for junior urologists.
for SWL commonly also include patients with persisting small,
asymptomatic residual fragments (RFs).
However, these RFs are However, this is not the case for percutaneous stone treatment.
associated with a high recurrence and re-treatment rate.
Gaining access to the kidney and the stone is still an elaborate and
Unsurprisingly, endourological techniques have taken more ground cumbersome part of the procedure, with various pitfalls. In addition,
since their aim is complete primary stone removal. Since stone achieving a high stone-free rate requires continuous training to
disease is associated with a high recurrence rate, there is a great improve technical skills. This experience fits well with results
deal of interest and research on stone pathophysiology and presented by de la Rosette,
where obtaining renal access was
metaphylaxis. This article attempts to give an overview of the defined as the most important factor in training for percutaneous
literature about these topics in the most recent publications, nephrolithotripsy (PCNL). They concluded that competence at
combined with personal experience and institutional concepts. performing PCNL is reached after 60 cases and excellence is
obtained after >100 cases. However, these numbers are a matter of
Training in Stone Treatment concern. Even in a high-volume western stone centre with 100 PCNL
Technically, the learning curve for SWL is moderate, since focusing interventions per year, this would require teaching for a single
on the stone is the most crucial part of the procedure. Thereafter, it trainee for two to five years. Therefore, virtual reality simulators
is more related to the surgeon’s patients to keep the stone within the seem to be mandatory for sufficient PCNL training. However,
focus. Likewise, ureteroscopy is a straightforward procedure with validated virtual simulators are not in sight on the horizon. In
modern ultra-thin semi-rigid instruments (see Figure 1), particularly addition, the need for continuous education in endoscopic
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