Nonstaghorn Calculi.

In examining the efficacy of SWL in the treatment of patients

with renal calculi, passage of stone debris rather than fragmentation of the stone is the primary
limiting
factor (Renner et al, 1999). There is general agreement that stone free is the most rigorous
definition of successful outcome of any stone removal procedure and that complete stone
clearance should be the preferred goal of any intervention (Psihramis et al, 1992). However,
because SWL outcome is dependent on spontaneous stone clearance, treatment results are often
reported in terms of success rates, which may be defined as patients who are either stone free
or who have asymptomatic, small, residual fragments. Various cutoff points between 2 and 5
mm are used in the literature to define the size of these fragments, making study comparisons
difficult. In many cases, failure of SWL is not due to a failure of stone fragmentation but rather a
failure to clear the resulting stone fragments. Failure to clear stone fragments is a concern,
because it results in a higher re-treatment rate as well as a higher number of ancillary procedures.
Clayman and associates (1989) suggested that in comparing the results of SWL and PNL or in
comparing different lithotripters, the parameters of stone-free rate, re-treatment rate, and number
of auxiliary procedures should be combined into an effectiveness quotient that may better
express treatment results and allow one to compare different treatment modalities:
% stone free
100% + re treatment + % auxillary procedures
For example, Netto and associates (1991), in a study comparing PNL and SWL for
patients with lower pole calculi, reported overall stone-free rates of 93.6% and 79.2% for PNL
and SWL, respectively; these values were not significantly different. However, the effectiveness
quotients of 93.7% and 55.9% for PNL and SWL did differ significantly because this calculation
incorporated the 41% re-treatment rate for the SWL group.
The negative effect of an increasing stone burden (size and number) on the results of
SWL has been described by a number of groups, dating from the initial reports of SWL to
the present generation of lithotripters (Drach et al, 1986; Lingeman et al, 1986a; El-Assmy et
al, 2006a; Tan et al, 2006). A now-axiomatic principle of SWL is that as stone burden
increases, the stone-free rate declines and the need for ancillary procedures and re-
treatment rises. Importantly, stone burden is not defined solely on the basis of the largest stone
present in the kidney but also it takes into account the overall number of stones present.


Furthermore, larger stone burdens are associated with a higher rate of residual stones, a point of
particular concern in the treatment of patients with struvite calculi (Preminger et al, 2005).
Figure 483 illustrates the effect of the size of solitary renal stones on the results of SWL.
PNL, although more invasive and often associated with higher morbidity, achieves better stone-
free rates than does SWL and is not affected by stone size (Lingeman et al, 1987a).

Ureteroscopy, an alternative treatment for patients with renal calculi, is also negatively affected
by increasing stone burden, although to a lesser degree than is SWL, because stone fragments are
often removed or vaporized. Thus, as stone burden increases, PNL becomes more efficient than
either SWL or ureteroscopy.
Importantly, 50% to 60% of all solitary renal calculi are less than 10 mm in
diameter (Cass, 1995; Renner and Rassweiler, 1999; Logarakis et al, 2000). Treatment results
of SWL for this substantial group of patients are generally satisfactory and independent of
stone location or composition. Although better results can be achieved with PNL or ureteroscopy
for patients with stones smaller than 10 mm, these procedures are more invasive, are associated
with greater morbidity, and may be reserved for special circumstances (e.g., anatomic
malformation causing obstruction, SWL failure).
Patients with calculi between 10 and 20 mm are often treated with SWL as first-line
management. However, stone location and composition can meaningfully affect the results of


SWL for patients with calculi in this size range and should be carefully considered. For example,
SWL results for patients with 10- to 20-mm stones in the lower pole are inferior (55%) to SWL
results for patients with stones in the upper and middle pole calyces (71.8% and 76.5%,
respectively) (Saw and Lingeman, 1999). A prospective, randomized controlled trial compared
SWL and PNL for patients with lower pole renal calculi; the stone-free rate for PNL was 95%,
versus 37% for SWL( Albala et al,2001). Stone composition merits consideration when
evaluating treatment alternatives for patients with stones larger than 10 mm, as cystine calculi
and brushite calculi both respond poorly to SWL treatment. This effect is particularly
pronounced for stones larger than 15 to 20 mm. Therefore, patients with renal stones of 10 to 20
mm and factors predicting poor treatment outcomes with SWL should be advised about
alternative therapeutic modalities. Both PNL and ureteroscopy are less affected by stone location
and composition, and good results may be attained with these modalities for patients with 10- to
20-mm renal stones.
Patients with renal calculi greater than 2 cm who are treated with SWL monotherapy
commonly experience poor treatment outcomes, a fact that was first recognized over two decades
ago in an NIH Consensus Conference. Interestingly, the 2 cm threshold for SWL first noted in
that conference document is still valid in the present day (Consensus Conference, 1988). Murray
and coworkers (1995) reported that SWL monotherapy for renal calculi greater than 3 cm yielded
an overall success rate of 27% at 3 months follow-up. The best stone-free rate (60%) was
obtained for stones smaller than 500 mm 2 that were located primarily within the renal pelvis;
the stone-free rate for stones with surface areas larger than 1000 mm 2 was a dismal 8%.
Notably, steinstrasse occurred in 23% of patients. El-Assmy and colleagues (2006a) reported on
patients with large-volume renal calculi treated with SWL monotherapy. Long-term follow-up
demonstrated a stonefree rate of 59%; significant Complications occurred in 13%, and unplanned
secondary Procedures were Required in 18.4% of cases.
As an alternative to SWL for large-volume calculi, ureteroscopy emerged in the 1990s as
a viable treatment option. Grasso and associates (1998) provided one of the earliest series of
patients with large (> 2 cm) upper urinary tract stones treated by ureteroscopy. One third of
patients with renal stones required a second-look endoscopy; and in three patients with renal
calculi, conversion to PNL was necessary. The overall success rate, defined as pulverization of
the stone to dust or fragments smaller than 2 mm, after the second ureteroscopy procedure was


91%, which is comparable to PNL results. However, the 6-month follow-up data, which were
available for 25 patients, demonstrated that only 60% of patients were stone free, whereas 24%
had small lower pole debris and 16% had new stone growth. As surgical techniques and
technology have evolved, ureteroscopy has been applied to patients with progressively larger
stone burdens with acceptable results and morbidity (Mariani, 2007; Ricchiuti et al, 2007; Breda
et al, 2008). In general, these treatment approaches have relied on a staged approach to achieve a
successful outcome.
In summary, for patients harboring nonstaghorn stones smaller than 10 mm, SWL
is usually the primary approach. For patients with stones between 10 and 20 mm, SWL can
still be considered a first-line treatment unless factors of stone composition, location, or
renal anatomy suggest that a more optimal outcome may be achieved with a more invasive
treatment modality (PNL or ureteroscopy). Patients with stones larger than 20 mm should
primarily be treated by PNL unless specific indications for ureteroscopy are present
(e.g.,bleeding diathesis, obesity).