Already one of the most prevalent urological conditions worldwide, kidney stone disease is increasing in most populations as a result of changing lifestyles and dietary habits. More stones mean more treatment decisions, as well as more complex treatment decisions.
“We often see stones in the lower pole because it is the dependent area physiologically,” said Mahesh R. Desai, MD, MS, Medical Director of Muljibhai Patel Urological Hospital in Gujarat, India. “You might be able to treat small stones with dietary changes or with pharmacotherapy, but medical therapy is almost always needed when stones grow larger than a few millimeters. By the time you get to a centimeter and larger, you really only have three choices: external shock wave lithotripsy, ureteroscopy and laser lithotripsy or percutaneous nephrolithotomy. There is no one modality that is ideal for all stones.”
During Tuesday’s Plenary I session, Dr. Desai will present a series of increasingly complex stone cases to a panel of three international experts who will discuss the pros and cons of different treatment approaches. The 30-minute presentation, titled Stones: 15 mm Lower Pole Stone, will begin at 10:25 a.m. in Hall A in the San Diego Convention Center.
The three panelists are Kenneth T. Pace, MD, Head of Urology at St. Michael’s Hospital and associate professor of Urology at the University of Toronto; Olivier Traxer, MD, professor of Urology at the University Pierre et Marie Curie and Head of Minimally Invasive Urology Surgery at Tenon Hospital in Paris, France; and Michael Y.C. Wong, MD, Medical Director and Senior Consultant for the Urology, Fertility and Gynaecology Centre at Mount Elizabeth Hospital in Singapore.
All three technologies offer advantages and potential problems, Dr. Desai noted. External shock wave lithotripsy (SWL) can be highly effective for small to medium sized stones, but is less effective for larger stones. Certain types of stones may be better suited to fragmentation using one technique or another, or may be removed intact using percutaneous nephrolithotomy (PCNL). Most clinical guidelines call for SWL or endoscopic treatment for stones smaller than 1 cm and PCNL for stones 2 cm or larger, leaving a broad gray area where a multitude of factors can affect treatment decisions.
“Stone size is only one factor in the calculation,” Dr. Desai said. “A 1.5 cm stone can be easy or difficult to deal with depending on whether you have favorable anatomy or unfavorable anatomy. Stone composition can make a difference because of the difference in fragmentation time, fragment size and time to complete clearance. If you fragment a stone in the upper calyx, the fragments are likely to migrate to the lower calyx. If the fragments settle in the lower calyx, you have another problem.”
Although PCNL is typically indicated for larger stones, newer generations of micro and mini percutaneous devices allow the use of PCNL on smaller stones that may be more difficult to manage endoscopically, or stones for which endoscopic management has failed. These smaller devices enable direct extraction and retrieval of stones using smaller incisions, and lower risks of complications compared to standard PCNL devices.
“You cannot depend on a single modality to treat all, or even most of your patients with stones. You have to plan each case,” Dr. Desai said. “You have to consider why you would want to use each of these modalities for a particular 15 mm stone. Is the anatomy favorable or unfavorable to one modality or another? The density of the stone is important. So is imaging to verify whether you have stones in a single kidney or in both kidneys, a single stone or multiple stones. There are a multitude of factors that will guide you to the modality of choice for any particular patient. This session will be convenient to learn some of the latest tricks of the trade from the leading stone experts in the world.”
Plenary I Preview
Stones: 15 mm Lower Pole Stone
Presenter: Mahesh R. Desai, MD, MS
10:25 – 10:55 a.m. Tuesday
Hall A, San Diego Convention Center