ROLE OF OPEN SURGERY IN ERAOF ENDOSCOPIC UROLOGY
AJIT M VAZE
Hon. Urologist and Andrologist, Jaslok Hospital, Sir HN Hospital, Lilavati Hospital and Research Centre, Mumbai.
The surgical treatment of nephrolithiasis has changed dramatically in the last 20 years. Previously the majority of patients requiring stone removal were subjected to open surgery. Advances in endoscopic management of calculous disease, in the form of ureteroscopy as well as percutaneous nephrolithotomy initially promoted a rapid decrease in the use of this approach. The subsequent introduction of extracorporeal shock wave lithotripsy further reduced the incidence of open surgery. In the current age of minimally invasive therapy open surgical procedures for calculous removal are still performed. Paik et al reported an open stone surgery rate of 5%, Bichler et al 2.7% and Boyle et al 2%. At Wake Forest University, Baptist Medical Centre a total of 986 procedures were performed between January 1, 1998 and May 31, 2001 for the purpose of stone removal or fragmentation. Of these 986 procedures, 387 (39.3%) were ureteroscopy (URS), 298 (30.2%) percutaneous nephrolithotomy (PNL), 294 (29.8%) shock wave lithotripsy (SWL) and 7 (0.7%) open surgery. A review of the literature from as recent as a decade ago confirms a decreasing incidence of open surgery. The reasons for this decrease are 3-fold.
1. There have been significant advances in endourological technology. The development of small caliber, semirigid and flexible ureteroscopes has improved the efficacy of treatment using these devices. All areas of the ureter and intrarenal collecting system may be safely and expediently accessed. Stone removal techniques have benefited from devices such as the holium laser and pneumatic lithotriptors, as well as flexible grasping devices and end circle baskets.
2. Improvement in the technical expertise of endourological surgeons has also promoted a decrease in open surgery, as there is a well-documented learning curve in the endoscopic treatment of patients with urinary calculi. Weinberg et al described a 29% failure rate during their firs 2 years using ureteroscopic techniques, compared to an 8% failure rate during the following 9 months.
3.The development of retrograde and antegrade techniques to correct anatomic obstructions associated with stone disease has promoted the successful endoscopic treatment of these patients. Reported success with antegrade endopyelotomy, which can be done in conjunction with precutaneous nephrostolithotomy, approaches that achieved with open surgical pyeloplasty. Caliceal diverticular cavities containing stones can be managed by either a percutaneous or retrograde approach, with stone removal and diverticular ablation success rates approximating those of open procedures.
Despite refinement of endourological technology, increasing technical expertise, and development of improved retrograde and antegrade endoscopic techniques there are still individuals who are best treated by open surgical stone removal. Patients who are potential candidates for this approach include those with large volume, staghorn calculi in complex collecting systems, or large volume calculi in anterior caliceal diverticula or in cavities communicating with the central portion on the renal collecting system. Patients with calculi and concomitant ureteropelvic junction obstruction who are not expected to have good results with endopyelotomy, or those who harbour stones in a nonfunctioning kidney or non functioning polar region may also be considered for this approach. Finally, patients in whom endourological treatment has failed may achieve a favourable outcome with an open surgical procedure. In current practice this latter indication should be extremely rare. Recent advances in laparoscopic techniques have made many of these indications for open surgical procedures indication for laparoscopic intervention. There have been reports of the successful performance of every type of "Lithotomy" procedure using a laparoscopic approach except anatrophic nephrolithotomy, the latter being accomplished in a porcine model. In the future, as more urologist become facile with laparoscopic techniques and procedures, the incidence of open surgery is likely to decline further. Ultimately, the only patients under going open stone surgery will likely be those with calculous disease requiring complex anatrophic nephrolithotomy treatment or those with xanthogranulomatous pyelonephritis requiring nephrectomy.
Fig.1 Wake forest university (1998-2001) Fig.2 Jalok Hospital (1997-2001)
EXPERIENCE IN INDIA
Jaslok Hospital and Research Centre is one of the foremost Hospital for advanced endourological care.
Here PCNL was started in 1987, URS was started in 1988, ESWL was in 1986. Over last 10-12 years, there is a steady fall in open surgery for stone. At present the only indication for open surgery are.
1.Very large stone (Wickham grade IV stone).
3.Accidental injury/inability to create an adequate access to PC system.
4.Inadvertent major complication in form of bleeding, injury or vessels/renal unit.
5.Nonavailability of instruments or expertise.
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