The Management of Lithiasis The Rational Deployment of Technology

EDITEDBY

J amsheer Talati Roger A.L. Sutton Farhat Moazam Mushtaq Ahmed

The Aga Khan University Medical Center, Karachi, Pakistan

SPRINGER SCIENCE+BUSINESS MEDIA, B.V.

Library of Congress Cataloging-in-Publication Data is available.

ISBN 978-94-010-6270-1 ISBN 978-94-011-5396-6 (eBook)DOI 10.1007/978-94-011-5396-6

Printed on acid-free paper

All Rights Reserved © 1997 Springer Science+Business Media Dordrecht

Originally published by Kluwer Academic Publishers in 1997 No part of the material protected by this copyright notice may be reproduced or utilized in any form or by any means, electronic or mechanical, inc1uding photocopying, recording or by any information storage and retrieval system, without written permission from the copyright owners.

Typeset by EXPO Holdings, Malaysia

The Management of Lithiasis

DEDICATION

To our families and mentors, and especially to Mr Robert J. McCormack, FRCS, and Mr W. Selby Tulloch, FRCS, master craftsmen and teachers extraordinary.

Developments in Nephrology

Volume 38

A list of the titles in this series can be found at the end of the book.

Frontispiece: Artist's impression of lithotripsy [Jimmy Engineer[ (Thi s painting was commiss ioned for the book and the original hangs in the corridors of the Lithotripsy suite at the Aga Khan Uni ve rsi ty Medical Center).

f"; - -..... ,..

Figures 1.9- 1.11 Varying morphological characteristics of renal calculi.

Figure 17. 1 Stone as viewed through the nephroscope

Contents

List of contributors Foreword Preface Acknow ledgements

Section I: EPIDEMIOLOGY AND AETIOLOGY OF URINARY TRACT CALCULI

Urolithiasis: Composition, symptomatology and pathology A. Memon, 1. Talati

2 Radiology in urolithiasis

xi xv

xvii XIX

3

S. Hussain II

3 Epidemiology of urolithiasis in Pakistan 1. Talati, F. Khan, H. Drago, E. Lall, M.z. Khan, A. Talati, 1. Noordzij 21

4 Urolithiasis in the Middle East: Epidemiology and pathogenesis S.R. El-Faqih, I. Hussain 35

5 Epidemiology of urolithiasis in the Western world K. Hamawy, S. Hussain, Y.M. 0 'Meara 43

6 Metabolic and dietary risk factors for urolithiasis R.A.L. Sutton, 1. Talati 51

7 Oxalate and urolithiasis R.A.L. Sutton 57

8 Familial clustering and sex incidence of urolithiasis 1. Talati 69

Section II: CHOICES IN THE MANAGEMENT OF URINARY TRACT CALCULI

9 Decisions! Decisions! 1. Talati

10 Advantages and hazards of open surgery 1. Talati

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79

85

Vlll Contents

11 Choices, limitations, hazards and value of technology in the treatment of lithiasis J. Talati

12 Bioeffects of shock waves: An overview J.E. Lingeman Bioeffects of shock waves F. Abbas

13 Laser fragmentation of urinary calculi G. Watson, T.K. Shah

14 ESWL today: Spectrum of stone disease treated on the extracorporeal lithotriptor J. Talati

15 Management of renal stones by operation J. Talati

16 ESWL for kidney stones and options for calyceal calculi J. Talati

17 Percutaneous nephrolithotomy for renal stones T. Shah, S. Hussain

18 Management of staghom calculi J. Talati

19 Management of ureteric stones J. Talati

20 Clinical results of laser fragmentation of ureteric stones G. Watson, T. Shah

21 Management of vesical and urethral stones z.A. Hotiana, J. Talati

Section III: ENHANCEMENT OF EFFICACY AND SAFETY OF TREATMENT

22 Patients at risk for excessive post-ESWL bleeding M. Khursheed, J. Talati

23 Patients with pacemakers N. Basir

24 Safeguarding foetus and gonads J. Talati

25 Other high-risk patients J. Talati

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Contents IX

26 The role of ESWL in patients with leprosy and stone disease G. Warren

27 Factors determining need for multiple treatments on the Dornier HM3 J.A. Belis, G. Halenda

28 Factors determining need for multiple treatments: Decisions based on stone bulk, composition and acoustic efficiency 1. Talati

29 Prevention of steinstrasse J. Talati

30 Urinary tract infection, stones and ESWL J. Talati

31 The judicious use of stents J. Talati, M. Amanullah, S. Adil

32 Protection of hospital personnel J. Talati, S. Khan

Section IV: HIGH TECHNOLOGY AT AFFORDABLE COST

33 Introduction: High technology at affordable cost J. Talati

34 The economics of stone disease therapy: An economist's views S.K. Qureshi

35 Selecting a lithotriptor: Hospital perspectives N.M. Khan, M. Dhanani

36 Lithotriptor sharing R. Vleeming, J. W. Noordzij, Th.M. de Reijke, N.F. Dabhoiwala

37 Cost factors in equitable care J. Talati

38 Commencing and expanding lithotripsy services J. Talati

39 Financing the 1ithotriptor M. Kakalia

Section V: PREVENTION OF URINARY TRACT CALCULI

40 Introduction: Prevention of urinary tract calculi J. Talati

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x Contents

41 The residual calcular fragment: A risk factor for recurrent stone disease J. Talati 269

42 Primary hyperparathyroidism in urinary tract stone disease in Pakistan and the West J. Talati, S.R. Biyabani 275 Overview T.S. Harrision 275

43 The role of diet in the prevention of urolithiasis S.H. Badruddin 289

44 Systematic follow-up of patients with recurrent nephrolithiasis: A guide for the practising urologist N.F. Dabhoiwala 297

45 Follow-up of urolithiasis patients: A guide for urologists in developing countries J. Talati 301

Section VI: PAEDIATRIC UROLITHIASIS

46 Urolithiasis in children Z. Nazir, F. Moazam

Section VII: BILIARY TRACT STONES

47 ESWL in gallstone therapy: History, current status and expectations

307

L. Greiner 345

48 Current management of gallstone disease: Perspective from a developing country M. Ahmed, T. Pishori 329

Epilogue J. Dirks 337

Appendix: Non-visual laser Lithotripsy T.K. Shah, z.x. Jiang, G. W. Watson 339

Index 345

List of contributors

Farhat Abbas, MBBS, FCPS, FRCS Assistant Professor, Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan

Salman Adil, MBBS Lithotripsy resident, Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan

Mushtaq Ahmed, MBBS, FRCS Hassanali Sajan Professor of Surgery, Chief of General Surgery, Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan

Muneer Amanullah, MBBS Resident, Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan

Salma H. Badruddin, PhD Dietitian, Associate Professor, Departments of Medicine and Community Health Sciences, The Aga Khan University Medical Center, Karachi, Pakistan

Nageeb Basir, MBBS, MRCP Assistant Professor, Department of Medicine, The Aga Khan University Medical Center, Karachi, Pakistan

John A. Belis, MD Professor of Urology, The Milton S Hershey Medical Center, Hershey University, Hershey, Pennsylvania, USA

S. Raziuddin Biyabani, MBBS, FCPS Instructor, Department of Surgery (Urology), The Aga Khan University Medical Center, Karachi, Pakistan

Noshir F. Dabhoiwala, MD, FRCS Attending Urologist, Boerhave Kliniek and Teacher in Urology, Academisch Centrum, University of Amsterdam, Amsterdam, The Netherlands

Mansur Dhanani Materiels Manager, The Aga Khan University Medical Center, Karachi, Pakistan

Hermie Drago, MBBS General Practitioner, Mirpurkhas, Sindh, Pakistan

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xii List of contributors

Salah R EI-Faqih, MD, FRCS (Eng), FRCS (Ed) Chairman, Department of Surgery and Professor and Consultant Urologist, King Saud University Faculty of Medicine, Riyadh, Saudi Arabia

Lucas Greiner, Dr Med. Professor, Director Medical Klinik A, Klinikum Wuppertal GmbH, Universitat Witten-Herdecke, D-42283 Wuppertal, Germany

Gregory Halenda, MD Urologist, The Milton S Hershey Medical Center, Hershey University, Hershey, Pennsylvania, USA

Karim Hamawy, MD Fellow, Department of Radiology, Boston University Medical Center, Boston, USA

Timothy S. Harrison, MD Emeritus Professor of Surgery and Physiology, The Milton S Hershey Medical Center, Hershey University, Hershey, Pennsylvania, USA

Ziaul Amin Hotiana, MBBS, FRCS Assistant Professor, Department of Surgery (Urology), The Aga Khan University Medical Center, Karachi, Pakistan

Imtiaz Hussain, MD, FRCS Consultant Urologist, Bedford District General Hospital, Bedford, UK; formerly Professor and Chief of Urological Surgery, Department of Surgery, College of Medicine, Riyadh, Saudi Arabia

Sarwat Hussain, MD, FRCR Head, General Radiology, Boston University Medical Center, Boston, USA

Z.X.Jiang Lecturer, Laser Physics Department, University of Leeds, Leeds, UK

Meher Kakalia Student, London School of Economics, London, UK

Farakh Khan, MBBS, FRCS, DU Professor and Chairman, Department of Urology, The King Edward Medical College, Lahore, Pakistan

Nadeem Mustafa Khan Director, Professional Services, The Aga Khan University Medical Center, Karachi, Pakistan

Naeemuz Zafar Khan, MBBS, FRCS Professor and Chief of Pediatric Surgery, Children's Hospital, Pakistan Institute of Medical Sciences, Islamabad, Pakistan

Mohammed Khursheed, MBBS, MRCPath Professor and Chairman, Department of Pathology, The Aga Khan University Medical Center, Karachi, Pakistan

List of contributors xiii

Ernest Lall, MBBS Chief of Surgery, The Christian Hospital, Taxila, Pakistan

James E. Lingeman, MD Director of Research, Methodist Hospital, Unit for Kidney Stone Disease, Indianapolis, Indiana, USA

Amanullah Memon, MBBS, FRCS Assistant Professor, Department of Surgery (Urology), The Aga Khan University Medical Center, Karachi, Pakistan

Farhat Moazam, MBBS, FACS Quaid-i-Azam Professor of Surgery, Chairperson, Department of Surgery, Chief of Pediatric Surgery, Associate Dean for Postgraduate Education, The Aga Khan University Medical Center, Karachi, Pakistan

Zafar Nazir, MBBS, FCPS, FRCS Assistant Professor, The Aga Khan University Medical Center, Karachi, Pakistan

Joop W. Noordzij, MD Urological Surgeon, Military Hospital, Utrecht, The Netherlands

Yvonne M. O'Meara, MD Director Clinical Nephrology, Boston University Medical Center, Boston, USA

Turab Pishori, MBBS, FCPS Senior Instructor, Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan

Sarfaraz K. Qureshi, PhD Executive Director, Pakistan Institute of Development Economics, Quaid-i-Azam University, Islamabad

Th.M. de Reijke, MD Consultant Urologist, Academic Center, Amsterdam, The Netherlands

Tariq K. Shah, MD, FRCS Consultant Urologist, Bradford District Hospital, Bradford, UK: formerly Assistant Professor of Surgery (Urology), Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan; Lecturer and Research Fellow, Institute of Urology, London, UK; and Consultant Urologist, Lister HospitaL Stevenage, UK

Roger A.L. Sutton, DM, FRCP, FRCPC Professor and Chairman, Department of Medicine, The Aga Khan University Medical Center, Karachi, Pakistan; formerly Professor and Chairman, Department of Medicine, University of British Columbia, Vancouver, British Columbia,

Canada

Ardesheer Talati, BA PhD Student, Cornell University, New York, USA

XIV List of contributors

Jamsheer Talati, MBBS, FRCS Habiba Sabjaali Jiva Professor of Surgery, Chief of Urological Surgery, Department of Surgery, The Aga Khan University Medical Center, Karachi, Pakistan

R. Vleeming, MD Urologist, Academic Centre, Amsterdam, The Netherlands

Grace Warren, MD, FRCAS, Dame Leprologist, Minoram Leprosy Hospital, Minoram, Thailand; Chief Leprosy Consultant, Leprosy Mission, London; Leprosy consultant to Mission Hospital, Minoram, Thailand; Leprosy consultant to Marie Adelaide Hospital and Manghopir Leprosy KMC Hospital, Karachi; formerly Leprosy Surgeon, Chang Mai Hospital, Hong Kong

Graham Watson, MD, FRCS Consultant Urologist, Eastboume District Hospital, Eastboume, UK; formerly Senior Lecturer and Honorary Consultant and Research Fellow, Institute of Urology, London, UK

Foreword

The last twenty years has seen the biggest revolution in the treatment of renal tract stone that has ever been experienced in the history of urolithiasis. The treatment of upper tract renal stone has progressed from the days of a very traumatic and morbid procedure to the relatively innocuous, walk in/walk out therapy of extracorporeal lithotripsy.

This progression of events has resulted in a complete reappraisal of management of all types of urinary calculi. From an initial reluctance to treat many stones because of the trauma involved, we have now passed to a situation where smaller and asympto­matic stones may be pre-emptively treated before the treatment of serious clinical problems. It is true to say that in Westemized societies the problem of urolithiasis has almost completely been solved by the advent of advanced technology.

In this volume, attention is drawn to the fact that there are still persistent difficulties in treating urolithiasis in the less developed and less affluent societies. The differences in epidemiology of urolithiasis in various areas of the world are highlighted, noting a rapid decrease in the incidence of bladder calculi in impover­ished areas where affluence increases. Coupled with this progression of affluence however is the well documented increase in the incidence of upper tract renal stones of oxalate nature. This scenario has been almost universal across all coun­tries in the last few decades.

Whilst in the ideal situation it is possible to clear practically all urolithiasis atrau­matically by either endoscopy or extracorporeallithotripsy, it is obviously not ra­tional to recommend such treatment to patients where facilities are not available. Installation of expensive extracorporeal lithotriptors is obviously impossible because of their prohibitive price and for poorly affluent countries, alternative means of therapy still need to be addressed. This consequently means that it is still necessary for many patients to be treated by open renal surgical techniques. As ex­perience develops however, it should gradually be possible for more and more en­doscopic procedures to be carried out even if extracorporeal lithotriptors cannot be afforded.

The book also highlights the problems of treating patients in diffuse areas where it is difficult for patients to come to the treatment centre, in contrast to those in large urban conurbations where patients can easily access centres for lithotripsy or endoscopic surgery. In more rural areas there would appear to be some benefit in taking treatment facilities direct to the patient, utilizing mobile Iithotriptors and mobile teams of physicians.

This volume also explores the metabolic aetiology and the medical control of calculus disease in difficult climatic and economic conditions. The cost of all medical therapies is now coming under immense scrutiny, especially in the more

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xvi Foreword

affluent areas. Therapies are being examined both for evidence of their efficacy and their cost effectiveness. There is little doubt in the area of stone disease described in this volume that endoscopic stone removal and extracorporeal lithotripsy have more than justified their place in the surgical armamentarium on the grounds of outstanding efficiency and cost effectiveness when compared with previous methods of open surgery. Such effective new technology, saving as it does much expense, must surely be the way forward for any society, particularly where re­sources are radically cost contained and difficult to access for the poorer members of the community.

Hopefully in the next twenty years economies will have improved so that a full range of interventional therapy for urolithiasis will become available to all popula­tions in all parts of the world. Under the guidance of such enlightened physicians as Dr Talati and his colleagues, I am sure this will come about.

This volume is surely to be commended to all who must deal with the multitude of problems within urolithiasis and will be an invaluable guide to the best possible management.

Professor J .E.A. Wickham MS, MD, BSc, FRCS, FRCP, FRCR

The London Clinic and Guy's Hospital, London; Former Dean, Institute of Urology, London

Preface

Urinary bladder calculi in children and infective biliary stones in adults have been afflicting populations in developing countries long before the transition to Western diseases. Now with the addition of renal stones and cholesterol gallstones the disease burden has doubled in developing countries. The Western world has devel­oped minimal access surgery to deal with diseases. The technology to accomplish this is expensive and in order to make it available to deserving patients, developed nations have had to resort to overall cost savings in health care. Hence concepts such as managed care, practice guidelines and evidence based medicine have come into prominence.

With the world now reduced to a global village it does not take long for the tech­nology to permeate to developing countries. The private sector in developing coun­tries avidly takes up such advances in technology; the public sector, unable to bear the costs, remains deprived. In the absence of a price regulatory mechanism, it is obvious that only the rich can afford to purchase sophisticated care. For the man­agement of calculus disease two social classes are likely to emerge: those that can afford minimally invasive procedures and those that can only afford conventional surgery.

This book is a reflection of the times and prevalent concerns in developed as well as developing countries about the management of stone disease. The preven­tion of urinary calculi is discussed. Money spent on health education and disease prevention is likely to have a more even impact on popUlations irrespective of social class. Knowledge of the scientific basis of extracorporeal shock wave lithotripsy (ESWL) should enable health care providers to select equipment to suit their specific needs and circumstances. Considerable emphasis has been given to ra­tional use of minimally invasive procedures. Suggestions are offered for lowering costs by elimination of unnecessary investigations and treatment. Results from min­imally invasive procedures are compared with those from conventional surgery to permit decisions based on cost-benefit analyses. Indications are prioritized for the use of minimally invasive procedures to enable referral systems to develop in poor countries such that the most deserving patients are not denied access. Use of instru­mentation and equipment across specialities could be the basis of developing a cost-effective service for minimally invasive surgery. The implications on surgical training of the modem 'high tech' approach is another area demanding attention and is alluded to in this book.

This book on calculus disease therefore offers its readers a chance to pause and think as we enter the twenty-first century with rapidly advancing technology, soaring costs of health care the world over and attempts to disseminate technology

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XVlll Preface

to developing countries where huge populations live under widely disparate condi­tions and the disease burden is compounded by changing life styles.

J. Talati R.A.L. Sutton

F.Moazam M.Ahmed

Acknowledgements

The editors are very grateful to the authors, who have dedicated time and effort in spite of their busy schedules; to Dr Raziuddin Biyabani, for help with checking references; to Ms Martha Travas, Ms Seema T. Khan, Mr Murad Bana and espe­cially Jack Fernandes who shouldered the major secretarial and organizational load; to Messrs Aslam Bashir, Aamir Tariq and Shamsuddin Qureshi in the audiovisual centre of the Aga Khan University for their help in producing illustrations. tables and photographs; to Ms Nynke Coutinho, Phil Johnstone and Boudewijn Commandeur at Kluwer Academic Publishers, for their patient and understanding help; and to the Aga Khan University and the University Hospital, whose critical and thoughtful environment fed, fired, and stoked this book.

We are grateful to the following publishers for permission to reprint material from journals and texts: Plenum Press, New York; Blackwell Science Limited, Oxford; Ferozesons (Pvt) Ltd, Lahore; and Williams and Wilkins, Baltimore.

We are especially grateful to Dr Timothy S. Harrison, whose enthusiasm for pub­lishing material on critical analysis of treatment regimes with special reference to work in constrained circumstances, directed our efforts to this publication; to Drs James Wickham, Scott McDougall, Stephen Dretler, Sarwat Hussain, Imtiaz Hussain and John Belis, who each in their own way has supported this work and made this publication possible.

The editors

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