Urolithiasis: Therapy · Prevention

Edited by

Hans-Joachim Schneider

Contributions by

P.Alken D. Bach Ch. Chaussy R. Hautmann F. Hering W Lutzeyer M. Marberger E. Schmiedt H. -J. Schneider W. Stackl

Springer-Verlag Berlin Heidelberg New York Tokyo

Handbook of Urology . Volume 17/11 Continuation of Handbuch der Urologie . Encyclopedia of Urology

With 127 Figures

ISBN-13 :978-3-642-70714-8 e-ISBN-13: 978-3-642-70712-4 DOl: 10.1007/978-3-642-70712-4

Library of Congress Cataloging in Publication Data. Main entry under title: Urolithiasis : therapy, prevention. (Handbook of urology ; v. 17/11) Includes bibliographies and index. 1. Calculi, Urinary-Treatment. 2. Calculi, Urinary-Surgery. I. Schneider, Hans-Joachim, 1931- . II. AIken, P. III. Series. [DNLM: I. Urinary Calculi. WJ 39 U78 v. 17 no. 2) RC916.U77 1985 616.6'22 85-26162 ISBN-13:978-3-642-70714-8 (U.S.)

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Under § 54 of the German Copyright Law where copies are made for other than private use, a fee is payable to "Verwertungsgesellschaft Wort", Munich.

® Springer-Verlag Berlin Heidelberg 1986 Softcover reprint of the hardcover 1st edition 1986

The use of registered names, trademarks, etc. in this publication does not imply, even in the ab­sence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

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2122/3130-543210

List of Contributors

SCHNEIDER, H.-J., Professor Dr. Ludwigsplatz 11, D-6300 Giessen

ALKEN, P., Professor Dr. Urologische Klinik und Poliklinik, Klinikum der Johannes Gutenberg-Universitat Mainz, Langenbeckstr. 1, D-6500 Mainz

BACH, D., Professor Dr. St. Agnes-Hospital Bocholt, Barloer Weg 125, D-4290 Bocholt

CHAUSSY, CH., Professor Dr. Urologische Klinik und Poliklinik der Universitat Munchen, Klinikum GroBhadern, Marchioninistr. 15, D-8000 Munchen

HAUTMANN, R., Professor Dr. Arztlicher Direktor der Urologischen Klinik, Klinikum der UniversiHit Ulm, Prittwitzstr. 43, D-7900 VIm

HERING, F., Priv.-Doz. Dr. Urologische Klinik und Poliklinik, Kantonsspital Basel, Universitatskliniken, Spitalstr. 21, CH-4031 Basel

LUTZEYER, W., Professor Dr. Vorstand der Abteilung Urologie der medizinischen FakuWit, an der Rhein.-Westf. Techn. Hochschule Aachen, GoethestraBe 27 - 29, D-51 00 Aachen

MARBERGER, M., Professor Dr. Vorstand der Vrologischen Abteilung der Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Wien

SCHMIEDT, E., Professor Dr. Direktor der Urologischen Klinik und Poliklinik der Vniversitat Munchen, Klinikum GroBhadern, Marchioninistr. 15, D-8000 Munchen 70

STACKL, W., Dr. Urologische Abteilung der Krankenanstalt Rudolfstiftung, Juchgasse 25, A-1030 Wien

Preface

Since the early days of medicine one concern of doctors has been the removal of kidney stones and prevention of recurrence. Owing to the hesitancy of progress in the prevention of initial stone formation and of relapse, however, removal of stones from the kidney and ureter were developed to highly refined techniques and they formerly accounted for a major proportion of the urological operations performed.

In the last few years developments in the treatment of kidney stones have taken a completely different turn. In the majority of cases suit­able methods are available to bring about spontaneous passage of the stones, while in a smaller proportion drug-induced litholysis is pos­sible. Stones that cannot be passed are now treated mainly with extra­corporeal shockwave lithotripsy, percutaneous litholapaxy or uretero­renoscopy. These methods are often used in combination and comple­ment each other. Nonetheless, despite the accumulating experience with the new methods there will still be situations in which stones can­not be removed except by open surgery. "Our skill as surgeons and the management of the brilliantly designed equipment would amount to nothing more than highly skilled mechanical work if they did not go hand in hand with enhanced insight into the cause of lithiasis and thus into ways of preventing it - or at least of preventing the relapse that is the lot of most patients. Otherwise, stone and machine would be keep­ing each other going, a symbiosis that would be thoroughly unsatis­factory for all concerned" (A. Sigel). Purposeful and controlled pre­ventive measures after an initial episode can bring about a striking re­duction in the high primary relapse rate, while attempts at general prophylaxis to prevent stones from forming at all unfortunately still have little success.

Heartfelt thanks are due to all the authors who have worked on this volume. Some of them are among the pioneers of this revolution in the treatment of urinary tract stones, and their chapters reflect the fact that they embody the greatest cumulated experience in these techniques to date. The first volume of this work has already been published. It deals with the morphology and composition of urinary tract concretions, in­cluding stone analysis, together with epidemiology, aetiology, patho­genesis, and diagnosis.

The object of this volume is to inform doctors of the present status of our knowledge relating to the treatment of urolithiasis and the pre-

VIII Preface

vention of relapse, so that all patients everywhere who have such stones can benefit from the options available.

I am grateful to my colleagues and friends for their stimulating ideas and critical comments, and to Mr. W. Bergstedt of Springer-Ver­lag for his support and patience in the preparation of the book.

Giessen HANS-JOACHIM SCHNEIDER

Contents

Drug Therapy of Urinary Calculi and Prevention of Recurrence. W. LUTZEYER and F. HERING. With 10 Figures

I. Introduction 1 II. General Preventive Measures 2 III. Special Preventive and Therapeutic Measures 3

1. Calcium Oxalate Calculi (Mono- and Dihydrates) 3 a) Diet and Fluid Intake: Quantity and Choice

of Drinks 3 b) Drug Therapy of Calcium Oxalate Lithiasis 6 c) Calcium Oxalate Stones: Drug Therapy and

Recurrence Prevention 12 2. Infective Calculi 34 3. Uric Acid Stones: Treatment, Recurrence Prevention,

Oral Chemolysis 41 a) Diet, Fluid Intake and Choice of Drinks

in Uric Acid Lithiasis 42 b) Preventive Drug Treatment of Uric Acid Lithiasis 42

4. Urate Calculi 46 a) Sodium Hydrogenurate Monohydrate 46 b) Ammonium Hydrogenurate 46

5. The Treatment of Cystine Calculi 47 a) Cystinuria Diets and Associated Problems 49 b) Fluid Intake, Volume, and Composition 49 c) Drug Treatment of Cystine Stones 49 d) Chemical Conversion of Cystine to Cysteine 50

6. The Treatment of Rare Stones 53 a) Xanthine Lithiasis 53

IV. Childhood Urolithiasis 54 1. Dietary and Medical Treatment of Oxalosis

and Hyperoxaluria 55 2. Dietary and Medical Treatment of Cystinuria 55

a) Disorders of Purine Metabolism 56 b) Renal Tubular Acidosis 56

3. General Comments on the Drug Treatment of Juvenile Urolithiasis 58

V. Conclusion 58 References 60

X Contents

The Treatment of Ureteric Colic and Promotion of Spontaneous Passage. D. BACH. With 1 Figure

I. Introduction 75 II. Pathophysiology 75

1. Innervation of the Ureter 75 2. Urodynamics of Obstruction 76

III. The Treatment of Colic (Initial Analgesia) 77 1. Metamizole (Novaminsulfone) 77 2. Pentazocine 78 3. Morphine 78

IV. Passage of the Stone 78 1. Spasmoanalgesia 78 2. Extended Spasmoanalgesia 80 3. Herbal Remedies 80 4. Adjuvant Therapy 81

a) Anti-Edematous Drugs 81 b) Increased Diuresis 81 c) Physical Activity 81

V. Complications of Conservative Treatment 82 1. Urinary Obstruction 82 2. Infection 82

References 82

Surgical Treatment of Renal Calculi. M. MARBERGER and W. STACKL. With 16 Figures

I. Introduction ......... 85 II. The Classification of Kidney Stones 85 III. The Indication for Surgery 87 IV. Preoperative Investigations and Patient Preparation 93 V. Surgical Access to the Kidney ....... 103

1. The Modified Posterior Lumbotomy Incision 103 2. The Supracostal Approach 105 3. The Anterior Approach 109 4. Access for Recurrent Disease 110

VI. Pyelolithotomy ..... 112 1. Simple Pyelolithotomy 112 2. Coagulum Pyelolithotomy 114 3. Extended Pyelolithotomy (Intrasinusal

Pyeloinfundibulotomy) 117 References .............. 123

Ischemia and Regional Hypothermia in Renal Stone Surgery. H.-J. SCHNEIDER With 5 Figures

I. Introduction II. Renal Ischemia

133 134

Contents XI

III. Drug-Mediated Prolongation of Renal Ischemia Tolerance 134 IV. Increasing Ischemia Tolerance by Hypothermia 135 References ...................... 139

Radial Nephrolithotomy Under Ultrasound and Doppler Probe Control. P. ALKEN. With 8 Figures

I. Introduction II. Preoperative Investigation III. Apparatus

1. Doppler Probe 2. The B-Scanner

IV. Practical Application 1. Sterilization 2. Exposing the Kidney 3. Intraoperative Ultrasonography 4. Limitations of B-Scanning

a) Stone Surface and Density b) Air .... c) Scars d) Urine, Clots e) Vasculature

5. Doppler Ultrasonography a) Limitations of Doppler Ultrasonography

6. Siting the Nephrotomy . 7. Making the Nephrotomy

V. Results References

Intraoperative Pyeloscopy. P. ALKEN. With 8 Figures

I. Introduction .... II. Rigid Nephroscopes III. Flexible Nephroscopes

1. Equipment 2. Technique ....

a) Inspection . . . b) Stone Extraction c) Indication of a Nephrotomy Site

IV. Results V. Complications References

Intraoperative Radiology. P. ALKEN. With 9 Figures

I. Introduction II. X-Ray Equipment ........... .

141 142 143 143 144 144 144 145 145 146 146 147 147 147 148 149 149 149 150 151 154

157 157 157 160 161 164 164 165 165 167 167

169 169

XII

1. Stationary or Mobile X-Ray Sets 2. Renodor ......... . 3. The C-Arm Image Intensifier 4. Film Stock and Intensifying Screens 5. Polaroid Film ....... .

a) Packing and Sterilizing Film Material III. Aids to Intraoperative Radiology IV. Alternative Techniques References .......... .

Percutaneous Manipulation of Renal Calculi. M. MARBERGER.

With 18 Figures

I. II. III.

IV.

V. VI.

VII. VIII. IX.

Introd ucti on Anatomical Considerations Percutaneous Access 1. Patient Preparation 2. Patient Positioning 3. Imaging Guidance 4. Puncturing the Kidney 5. Tract Dilatation . . 6. Nephrostomy Tubes N ephroscopy .... 1. Rigid Nephroscopes 2. Flexible Nephroscopes Mechanical Stone Extraction Intrarenal Stone Disintegration 1. Mechanical Disintegration 2. Ultrasonic Lithotripsy 3. Electrohydraulic Lithotripsy 4. Microexplosion Lithotripsy 5. Stone Disintegration by Laser Irradiation Percutaneous Chemolysis Results and Complications The Choice of Treatment

References

The Instrumentation and Surgery of Ureteric Calculi. P. ALKEN.

With 13 Figures

I. Introduction ..... II. History . . . . . III. Significance of Symptoms IV. Investigations . . . . . V. Spontaneous Passage and Size of Stone VI. Stone Removal ......... .

Contents

169 171 172 172 173 173 173 178 179

181 181 186 186 187 189 190 192 195 197 199 201 202 204 204 205 212 214 216 217 221 226 227

235 235 235 236 240 241

Contents XIII

1. Retrograde Techniques Under X-Ray Control 241 a) Indications 241 b) Technique ............. 241 c) Other Techniques .......... 243 d) Ureteric Stone Disintegration Under Radiologic

Control 244 2. Ureterorenoscopy 245

a) Technique 245 b) Endoscopy 250 c) Eliminating the Stone 251 d) Aftercare 252 e) Complications 252 f) Results 254

3. Antegrade Removal 254 4. Shockwave Lithotripsy 254 5. Open Surgery 257

References ........ 259

Treatment of Bladder Stones. R. HAUTMANN. With 9 Figures

1. Surgical Removal of Bladder Stones 263 1. Historical Perspective 263

a) Perineal Lithotomy 263 b) Suprapubic Lithotomy 263 c) Transurethral Li thotresis 264 d) Litholapaxy 264

2. Indications 265 a) Patient Selection 265 b) Anesthesia 265 c) Prereq uisi tes 267 d) Contraindications 267 e) Conclusion 267

II. Techniques of Litholapaxy 268 1. The Ultrasonic Lithotrite 268

a) Definition of Ultrasound 268 b) The Effect of Ultrasound on Urinary Calculi 268 c) The Instrument 268 d) The Technique of Ultrasound Litholapaxy 270 e) Technical Reliability of the Lithotrite 272 f) The Complications of Ultrasonic Litholapaxy 272 g) Conclusion 273

2. Electrohydraulic Litholapaxy 273 a) Definition of Electrohydraulic Shockwaves 273 b) Principle of the Operation 274 c) Instrumentation 274 d) Technique of Electrohydraulic Lithotresis 274

XIV Contents

e) Reliability f) Complications g) Contraindications h) Conclusion

3. Microexplosion Cystolithotresis a) Definition and Physical Principles of Microexplosion

Cystolithotresis b) Experimental Studies ...... . c) Instrumentation . . . . . . . d) Clinical Experience and Complications e) Conclusion

4. Viewing Litholapaxy ....... . 5. Blind Litholapaxy . . . . . . . . 6. Combined Transurethral and Suprapubic Litholapaxy 7. Unusual Transurethral Techniques

a) The Stone Basket . b) The Proctoscope ..... .

8. Suprapubic Cystotomy . . . . . 9. Pregnancy and Litholapaxy for Bladder Calculi 10. Conservative Treatment . . . . . . . . . 11. Drug Therapy for Bladder Calculi (Cystolitholysis) 12. Stones in Conduits

References

Treatment of Urethral Stones. H.-J. SCHNEIDER.

I. Prevalence ........ . II. Pathogenesis ....... . III. Symptomatology and Diagnosis IV. Treatment References .......... .

Extracorporeal Shockwave Lithotripsy (ESWL) in the Treatment of Kidney and Ureter Stones. CH. CHAUSSY and E. SCHMIEDT. With 19 Figures

I. Introd u.ction 1. Method . 2. Fundamentals 3. Shockwaves - Ultrasonic Waves

II. Shockwave Generation and Focussing 1. Equipment 2. Stone Localization 3. Respiratory Mobility 4. Procedure 5. Trial Runs

275 275 275 276 277

277 277 278 278 278 279 283 285 286 286 287 287 288 288 289 289 290

293 293 294 295 296

297 298 298 298 299 301 302 302 303 303

Contents

6. Anesthesia .... 7. Shockwave Exposure 8. ECG Triggering . . 9. Readjustment During Treatment

III. Subsequent Treatment After ESWL 1. Results ..... 2. Auxiliary Procedures 3. Renal Function

IV. Indications 1. Infected Stones 2. Stone Size 3. High-Risk Patients 4. Ureteric-Stone Patients 5. Obstruction and Noncontrastive Stones

V. Conclusion References

Preventive Measures. H.-J. SCHNEIDER. With II Figures

xv

303 304 304 304 306 306 308 309 309 309 312 315 315 316 318 319

I. The Role of Prevention in the Management of Urolithiasis 321 II. Risk Factors and Persons at Risk 324

1. Nutrition .... 324 2. Metabolic Disorders .... 327 3. Drugs .......... 330 4. Infection and Outflow Obstruction 331 5. Occupation and Environment 333 6. Calculating the Risk; of Stone Formation 334

III. Health Education and Behavior Patterns 339 References 341

Subjectindex 351