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ALGUMAS REFERÊNCIAS BIBLIOGRÁFICAS

[Long-term clinical outcome of extracorporeal shock wave lithotripsy monotherapy for staghorn calculi]

Hinyokika Kiyo 1998 Aug;44(8):541-6 (ISSN: 0018-1994)
Ashida S; Yamamoto A; Oka N; Masuda S; Yuasa K; Terao N [Find other articles with these Authors]
Department of Urology, Kochi Takasu Hospital.
We treated 97 patients with staghorn calculi by ESWL monotherapy using a Lithostar Lithotriptor (Siemens) between January 1989 and December 1996. Seventeen patients (18 renal units) out of 45 patients (47 renal units) who could be followed up for more than 12 months after ESWL had no stones on radiographs at 3 months after the treatment. The actuarial non-recurrence (or stone-free) rate was 88.9% at 1 year, 79.0% at 3 years, and 63.2% at 5 years after ESWL (Kaplan-Meier method). The actuarial non-regrowth rate (regrowth < 1 mm) was 96.6% at 1 year, 72.8% at 3 years, and 63.7% at 5 years (Kaplan-Meier method). History of urinary stones was a significant risk factor for stone recurrence, while patient sex, affected side, stone number, pyuria (> or = 10/HPF), hydronephrosis on DIP, and staghorn type were not significantly associated with stone recurrence or regrowth (Cox proportional hazard model). Late complications associated with ESWL included renal dysfunction (serum Cr > or = 1.1 mg/dl) in 2 patients, hypertension (> or = 160 mmHg) in 3, and renal atrophy (two-dimensional size < or = 80%) in 5. ESWL exerted adverse effects in a session-dependent manner on the kidney resulting in renal atrophy. Therefore, we highly recommend that ESWL should be limited to less than 10 sessions

Long-term follow-up after primary extracorporeal shockwave lithotripsy monotherapy of staghorn calculi: results after more than 6 years.

Traitement des calculs coralliformes par lithotritie extra-corporelle par ondes de choc chez l'enfant.]
Ann Urol (Paris) 1999;33(5):315-9 (ISSN: 0003-4401)
Garat JM [Find other articles with this Author]
Service d'Urologie Pediatrique, Fundacio Puigvert, Barcelona, Espagne.
To evaluate the efficacy of monotherapy with extracorporeal shock-wave lithotripsy (ESWL) for staghorn calculi in children. Material and methods: Between September 1987 and December 1998, 27 children (18 boys and 9 girls) with a mean age of 5.2 years (9 months to 147 years) were managed in our department for staghorn or pseudo-staghorn calculi. They were treated with a Lithostar Siemens-Ultra lithotriptor ith ultrasound detection. The "Puigvert method", which starts with low energy which is then gradually increased, allows satisfactory painless fragmentation, avoiding the need for general anaesthesia. RESULTS: the success rate was 70% with two sessions (37% with a single session). In one case, lithotripsy was not indicated and percutaneous nephrolithotomy was necessary. Two cystine stones ina girl (probably longstanding stones) could not be fragmented and open surgery was required. The other five systine staghorn calculi ere treated successfully. Ureteral catheterization was not required and only one double J stent was placed preventively in a girl with a solitary kidney. No major complication was detected. CONCLUSION: ESWL with the Siemens-Ultra lithotriptor is a safe and effective first-line method for the treatment of staghron calculi in children.

Staghorn calculi in children: treatment with monotherapy extracorporeal shock wave lithotripsy.

J Urol 1999 Sep;162(3 Pt 2):1229-33 (ISSN: 0022-5347)
Orsola A; Diaz I; Caffaratti J; Izquierdo F; Alberola J; Garat JM [Find other articles with these Authors]
Uropediatric and Radiology Units, Fundacio Puigvert, Barcelona, Spain.
PURPOSE: We evaluated the effectiveness of monotherapy extracorporeal shock wave lithotripsy (ESWLT) for treating children with staghorn calculi. MATERIALS AND METHODS: From February 1992 to December 1997, 11 boys and 4 girls 14 months to 13 years old (median age 4 years) presented to our institution with staghorn calculi. In these patients ESWL was performed using a Siemens Lithostar-ULTRA with ultrasound stone localization and with intravenous sedation or without anesthesia. Using the Puigvert method the frequency and energy of the shock waves delivered were increased progressively to desensitize cutaneous nerve receptors, making the procedure less painful and improving stone fragmentation. RESULTS: Overall stones resolved in 11 of the 15 patients (73.3%) after an average of 2 ESWL sessions. Of the 11 patients 7 were stone-free after only 1 session, 2 with fragments less than 5 mm. required no further intervention, and 2 required additional surgery, including percutaneous nephrolithotomy to remove large residual stone fragments in 1 and open renal surgery to remove a cystine staghorn calculus in 1. Ureteral stents were not required in any patients. One case of post-ESWL fever resolved promptly with antibiotics. CONCLUSIONS: ESWL using the Siemens Lithostar-ULTRA is simple, effective and safe primary treatment in children with staghorn calculi
Acta Urol Belg 1997 Oct;65(3):41-5 (ISSN: 0001-7183)
Mattelaer P; Wolff JM; Jung P; Feistkorn C; Jakse G [Find other articles with these Authors]
Dept. of Urology, AZ St.-Jozef, Oostende, Belgium.
OBJECTIVE: We retrospectively investigated 58 patients suffering from 60 staghorn calculi, who were treated with primary extracorporeal shockwave lithotripsy (ESWL) monotherapy, in order to determine long-term results and the fate of the residual stones. MATERIAL AND METHODS: Mean follow-up was 72.4 months. There were 49 partial staghorn calculi (C4) and 11 complete C5 stones according to Rocco's classification. The mean number of ESWL sessions needed for disintegration was 3.6. The mean amount of shockwaves was 10,244. ESWL monotherapy alone was performed in 26 staghorn calculi (43.3%). In treating the other 34 staghorn calculi 56 auxiliary procedures were necessary. RESULTS: At discharge 28.3% of the patients were free of stones. Fifty-five percent had small remnant particles (< 4 mm) and 16.7% had rest-fragments (> 4 mm). After a mean follow-up period of 72.4 months 36 patients were free of stones (60%). Twenty-four patients still have residual stones. The fragments in 2 patients did not change in size, in 14 patients fragments became bigger and 8 patients had a real recurrence (13.3%). CONCLUSIONS: Primary ESWL monotherapy of staghorn calculi is justified because of the comparable results with open surgery and percutaneous nephrolithotomy (PCNL). Prognostic good factors are small stone mass with most of the stone mass in the upper and middle calices, the absence of dilatation and the absence of anatomical anomalies.

SANDWICH" THERAPY FOR THE TREATMENT
OF COMPLEX RENAL STONES
LEE E. PONSKY, STEVAN B. STREEM
Department of Urology, Cleveland Clinic Foundation, Cleveland, Ohio, USA

ABSTRACT

Purpose: Shock wave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) are well accepted, minimally invasive modalities available for the treatment of calculi. In this paper we review and discuss the technique of combination "sandwich therapy" for the treatment of select patients with large, extensively branched, or otherwise complex stones.
Materials and Methods: A review of the literature on combined percutaneous nephrolithotomy and shock wave lithotripsy for the management of "staghorn" calculi was performed and evaluated.
Results: Stone free rates after one month of follow up approach 70%, while the remaining patients are left with residual dust or gravel. Complications occur in less than 30% of patients, and no nephrectomies or mortality have been reported with this approach. The probability of new stone formation has been estimated to be 37% at five years, and renal function has been shown to remain stable or improve in 96% of patients.
Conclusion: The use of combination therapy for the treatment staghorn calculi is safe and effective and can limit much of the associated morbidity of SWL or PCNL monotherapy. We recommend this combined "sandwich" approach as the treatment of choice for select patients with large, extensively branched, or otherwise complex staghorn calculi.

Key words: kidney, calculi, shock wave lithotripsy, percutaneous nephrostolithotomy
Braz J Urol, 26: 18-23, 2000

The use of ESWL for staghorn stones has had success rates ranging from 51% to 74% in contemporary series, with re-treatment rates as high as 90% (Table I).[14-20(A)
With regard to staghorn renal stones, PCNL success rates in contemporary series are as high as 92% (Table III).[14,35-41](B)

(A)

1. Winfield HN, Clayman RV, Chaussy CG, et al: Monotherapy of staghorn renal calculi: A comparative study between percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy. J Urol 139:895-899, 1988.
2. Pode D, Verstandig A, Shapiro A, et al: Treatment of complete staghorn calculi by extracorporeal shock wave lithotripsy monotherapy, with special reference to internal stenting. J Urol 140:260-265, 1988.
3. Constantinides C, Recker F, Jaeger P, et al: Extracorporeal shock wave lithotripsy as monotherapy of staghorn renal calculi: 3 years of experience. J Urol 142:1415-1418, 1989.
4. Michaels EK, Fowler JE: ESWL monotherapy for large-volume renal calculi: Efficacy and morbidity. Urology 34:96-99, 1989.
5. Vandeurson H, Baert L: ESWL monotherapy for staghorn stones with second-generation lithotriptors. J Urol 143:252-256, 1990.
6. Lam HS, Lingeman JE, Barron M, et al: Staghorn calculi: Analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. J Urol 147:1219-1225, 1992.
7. Yamaguchi A: ESWL monotherapy for staghorn calculi. Eur Urol 25:110-115, 1994.
8. Lingeman JE: Prospective randomized trial of ESWL and percutaneous nephrostolithotomy for lower-pole nephrolithiasis. J Endourol 9(suppl):S64, 1995

(B)

1. Patterson DE, Segura JW, LeRoy AJ: Long-term follow-up of patients treated by percutaneous ultrasonic lithotripsy for struvite staghorn calculi. J Endourol 3:177, 1987.
2. Kerlin RK, Kahn RK, Laberge JM, et al: Percutaneous removal of renal staghorn calculi. Am J Roentgenol 145:797-801, 1985.
3. Segura JW, Patterson DE, LeRoy JA, et al: Percutaneous removal of kidney stones: Review of 1000 cases. J Urol 134:1077-1081, 1985.
4. Snyder JA, Smith AD: Staghorn calculi: Percutaneous extraction versus anatrophic nephrolithotomy. J Urol 136:351-354, 1986.
5. Gleeson M, Lerner SP, Griffith DP: Treatment of staghorn calculi with ESWL and percutaneous nephrolithotomy. J Urol 38:145-151, 1991.
6. Chibber PJ: Percutaneous nephrolithotomy for large and staghorn calculi. J Endourol 7:293-295, 1993.
7. Netto NR, Almeida-Claro JF, Ferreira U: Is percutaneous monotherapy for staghorn calculus still indicated in the era of ESWL? J Endourol 8:195-197, 1994

Litotripsia Extracorpórea por Ondas de Choque (LECO)
IndicaçõesAtualmente, todos os cálculos urinários com indicação cirúrgica podem ser tratados com a ajuda da Litotripsia Extracorpórea por Ondas de Choque, salvo aqueles casos que se enquadram nas contra-indicações.Assim sendo, todos os cálculos levando a obstrução ureteral e/ou renal com dor forte persistente, têm indicação para LECO.Cerca de 3% dos casos requerem algum procedimento urológico associado, e menos de 2% são encaminhados para cirurgia.
Contra Indicações Menos de 5% dos pacientes são excluidos da LECO por apresentarem contra-indicações.As principais contra-indicações podem ser divididas em clínicas, urológicas e técnicas. As contra-indicações clínicas são as coagulopatias não corrigidas. A hipertensão arterial não controlada, sendo necessário o controle rigoroso dos níveis pressóricos antes do tratamento. Aneurisma de aorta ou de artéria renal. Entretanto, a calcificação das artérias renais ou da aorta não apresentam contra indicações formais, desde que alguns trabalhos mostraram que ondas de choque não afetam as calcificações arteriais. A gravidez é ainda contra-indicada, por não se saber se as ondas de choque apresentam algum efeito teratogênico e também pela exposição aos Raios-X durante o tratamento. Aqueles pacientes portadores de marca-passo cardíaco e arritmias devem ser cuidadosamente avaliados pelo cardiologista antes de se submeterem à LECO, sendo importante a presença Desse especialista durante o procedimento.As contra-indicações urológicas são devidas a alterações anatômicas ou funcionais que dificultam a saida dos fragmentos: como estenose distal ao cálculo, cálculos em cálices crônicamente distendidos, alteração funcional da mobilidade ureteral e anomalias anatômicas graves.As contra-indicações por dificuldades técnicas são variáveis dependendo do tipo do litotritor. A obesidade pode ser uma contra-indicação, por não se conseguir colocar o paciente no ponto focal das ondas de choque. As anomalias esqueléticas, rins ectópicos, o tamanho dos pacientes também podem apresentar as mesmas dificuldades técnicas.O cálculo radiotransparente pode trazer alguma dificuldade, principalmente se o equipamento não apresentar ultra-som ou se o cálculo se encontra em nível de ureter médio, onde se torna difícil a visualização também pelo ultra-som.A posição do cálculo, principalmente em nível de ureter médio, é uma contra-indicação relativa, em vista da dificuldade de fragmentação devido à atenuação das ondas de choque pelos ossos do quadril. Quando aplicadas por via anterior, pode existir a interposição de alças intestinais com ar em seu interior, alterando a onda e reduzindo sua capacidade de fragmentação, além dos riscos de lesão nessas alças.

Referências Bibliográficas

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