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AN OVERVIEW OF MANAGEMENT OFURINARY STONE DISEASE
A G Phadke
Prof. and Head, Dept. of Urology, Bombay Hospital Institute of Medical Sciences,
Mumbai 400 020.
Last quarter of the century has witnessed such outstanding advances in the treatment of urolithiasis that this period can be called as "Stone age" in Urology.
Prior to 1975, the treatment of urinary calculi was standard. Once it was appreciated that a given stone in the urinary tract was incapable of passing out of the body by itself, it was removed by open urological surgery. The urologists of that period practised and excelled in performing procedures like pyelolithotomies, ureterolithotomies and their modifications. Books on operative urology devoted chapters towards discussing the intricacies of surgical approach to the kidneys and ureters. Blind mechanical lithotripsy was restricted only to vesical calculi. Though these procedures were successful in removing the stones, the patient had to pay a heavy price. He had to stay in the hospital for nearly a week in absence of complications, and undergo painful surgery under anaesthesia with its attending risk and morbidity. A long ugly scar disfigured his body permanently. He could not resume his work for nearly a month after surgery. The scenario was even worse if he developed a recurrent stone or stones in the same site. Re-pyelolithotomies and re-ureterolithotomies were difficult operations to perform. They made surgeon’s life difficult and patient’s life miserable. The repeat surgeries were attended with increased incidence of morbidity. An incisional hernia at the site of surgery was often seen.
The first crack in this monolithic concept of treatment of urinary calculi appeared in 1976, when Fernstrom and Johansson performed percutaneous nephrolithotomy (PCNL) for removal of stones. This technique was perfected and popularized by Drs. Arthur Smith and Dr. Ralph Clayman in USA. This novel procedure performed through a keyhole incision caught the imagination of the urologists all over the world and also became popular with the patients. Short stay in the hospital, relative freedom from pain and short convalescence were the attractive features. Unfortunately PCNL had some drawbacks too. It needed anaesthesia, was attended with some degree of blood loss and needed multiple punctures in the kidney for removal of large or multiple calculi. TUR syndrome was noticed in some cases. Specially designed expensive endoscopic equipments were needed - and above all, the learning curve for mastering the technique of PCNL was long. In 1980 the prayers of the patients for a totally non invasive treatment of kidney stones were finally answered. Dr. Christian Chaussey in collaboration with the engineers at the Dornier Company in Munich introduced the first extra corporeal shock wave lithotripter. This was a totally new concept in the treatment of urolithiasis and can be considered as one of the most significant inventions in the field of urology in the 20th century. In essence, it involved generating pressure waves outside the human body and passing them through it. They were focused on a focal point where they hit the stone and discharged the maximum energy. This energy fragmented the stone. The skill of the operator lies in positioning the patient on the treatment table in such a manner that the stone comes to lie at the focal point. The stone fragments are then passed out with the urine. The attraction of the ESWL treatment lies in the fact that it is an outpatient procedure. The patient does not need anaesthesiaand can return home or to his work on the same day. The present generation of shockwave lithotripters are compact and can be accommodated in small space and are relatively cheap. Experience with PCNL and ESWL has borne out that they are reasonably effective in the treatment of kidney stones and stones situated in the upper 1/3rd of the ureters. Unfortunately, the stones in the middle third and lower third of ureters cannot be treated satisfactorily with these modalities. A relatively new invention during the last 5 years has helped the urologist to overcome the dilemma mentioned above. Miniaturisation of the ureterorenoscopes has enabled the urologists to negotiate the entire length of the ureter with relative ease and safety. Ureterorenoscope was first introduced in operative endourology by Dr. Perez Castro in 1980. The early models of ureterorenoscopes were big in diameter (French 12-14). They often traumatised the ureters and led to complications like perforations and strictures. Today ureterorenoscopes of sizes F6 and F7 are available. Flexible ureterorenoscopes have enabled the urologists to take a look and deal with pathologies not only in the ureter but also in the pelvicalyceal system.
When one familiarises oneself with these modern modalities of treatment of urolithiasis like PCNL, ESWL and URS one wonders if there is any scope left for open urological surgery in the treatment of urolithiasis! Admittedly the scope has contracted considerably. At the same time one cannot lose sight of the fact that in our Country the sophisticated instruments mentioned above and the expertise to make the judicious use of them may not be available in every hospital. Under these circumstances it becomes imperative that the Indian Urologists continue to familiarise themselves with the art and craft of open urological surgery.
With the availability of more than one modalities of treatment like open urological surgery, PCNL, ESWL and URS, it has become increasingly important that the urologist uses his judgement in selecting proper method of treatment to the patient’s advantage. It is important to stress that all these modalities do not compete with each other. In fact, they are complimentary to each other. For example. When a staghorn calculus has been debulked by pyelolithotomy or by PCNL the residual calculi can be treated with ESWL to achieve total stone clearance; Steinstrasse resulting after an effective ESWL can be cleared with URS. Appreciation of these facts have made the treatment of urolithiasis exciting and challenging to the urologists at the turn of the century.
Much has been achieved as described above in the treatment of existing stones in the urinary tract. Unfortunately very little progress has been made in respect of dissolution of the stones or prevention of their formation or recurrence, inspite of voluminous research all over the world. Needless to say, the ultimate goal in the treatment of urolithiasis should be prevention and dissolution of stones with non invasive methods. The urological community and the patients with urolithiasis are looking forward to major breakthroughs in these areas at the turn of the millennium.
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