Commentary
Comment to “Invasive treatment trends in urinary calculi in a third level hospital”
Comentario editorial a: «Tendencia en los tratamientos invasivos en la litiasis urinaria en un Hospital de 3.er nivel»
F. Ramón de Fata
Servicio de Urología, Hospital Universitario de Getafe, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain
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Its excellent safety profile, its application on an outpatient basis, without requiring general anesthesia, and the high acceptance of this treatment by patients turned it into a serious competitor of percutaneous renal surgery, introduced in 1976 by Fernström and Johansson<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> and perfected in the 1980s by Peter Alken.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Both of them, especially PNL, gradually left aside open surgery as the treatment of large renal stones, particularly in developed countries, with a first-class health status.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Currently the clinical guidelines of the European Association of Urology<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> consider ESWL as first-line treatment of 2<span class="elsevierStyleHsp" style=""></span>cm lower renal lithiasis, along with flexible ureteroscopy, except for those located in the lower calyx, where the latter is the preferred option. However, ESWL has certain limitations and disadvantages, such as its lower rate of lithiasic clearance, its high retreatment rate, and the need for auxiliary procedures, when compared to other treatment options. We identified as unfavorable prognostic factors of ESWL the composition and hardness of the stone (calcium oxalate monohydrate, cystine, brushite, >1.000<span class="elsevierStyleHsp" style=""></span>HU), size (>2<span class="elsevierStyleHsp" style=""></span>cm), the particular characteristics of some patients (morbid obesity, skeletal deformities, coagulation disorders) and special adverse anatomic considerations of the lower calyceal group such as: infundibulum-pyelic angle <45°, length (>30<span class="elsevierStyleHsp" style=""></span>mm) and diameter (<5<span class="elsevierStyleHsp" style=""></span>mm) of the infundibulum. This implies that the results of ESWL are unpredictable in terms of effectiveness and it is not free from complications, despite its ‘theoretically’ excellent safety profile.</p><p id="par0015" class="elsevierStylePara elsevierViewall">On the other hand, the development and improvement of the technique and material of retrograde intrarenal surgery (RIRS) and the progressive decrease in the size of the instrumental of percutaneous renal surgery (miniperc and microperc) have made it possible to reduce the invasiveness and, therefore, the morbidity of the treatment of renal lithiasis, while maintaining high efficiency. All this has led to a drastic reduction in the indications of ESWL, despite continuing as ‘official’ first-line option. However, the reality is quite different and the expert groups in endourology have reduced its use, and some even relegate it to auxiliary procedure in selected cases. The satisfaction of the patients treated with RIRS is higher than that of those receiving ESWL, due to the higher rate of lithiasic clearance in only one session of the endourological technique and to its lower retreatment rate.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is therefore an increasing tendency to reduce the use of ESWL because of the great advantages of the existing endourological procedures, which make it possible to obtain lithiasic clearance rates >90%, with reduced morbidity and without the need for multiple sessions. It is not surprising that both patients and professionals opt for new treatment modalities. Although García-Galisteo et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">6</span></a> refer to an increase in clinical practice in recent years of endourological procedures, they still have a high percentage of patients treated with ESWL.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ramón de Fata F. Comment to “Invasive treatment trends in urinary calculi in a third level hospital”. Actas Urol Esp. 2015;39:38–39.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extracorporally induced destruction of kidney stones by shock waves" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "W. Chaussy Ch Brendel" 1 => "E. 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Straub" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:2 [ "tituloSerie" => "Eur Assoc Urol" "fecha" => "2013" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Retrograde intrarenal surgery vs extracorporeal shock wave lithotripsy for intermediate size inferior pole calculi: a prospective assessment of objective and subjective outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.P. Singh" 1 => "J. Prakash" 2 => "S.N. Sankhwar" 3 => "U. Dhakad" 4 => "P.L. Sankhwar" 5 => "A. Goel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.urology.2013.12.026" "Revista" => array:6 [ "tituloSerie" => "Urology" "fecha" => "2014" "volumen" => "83" "paginaInicial" => "1016" "paginaFinal" => "1022" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24560970" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0035" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Tendencia en los tratamientos invasivos en la litiasis urinaria en un Hospital de 3.er nivel" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E. García-Galisteo" 1 => "N. Sánchez-Martínez" 2 => "P. Díaz-Molina" 3 => "B. López-Rueda" 4 => "V. Baena-González" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Actas Urol Esp." "fecha" => "2015" "volumen" => "39" "paginaInicial" => "32" "paginaFinal" => "37" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/21735786/0000003900000001/v1_201501230116/S2173578614001528/v1_201501230116/en/main.assets" "Apartado" => array:4 [ "identificador" => "6274" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/21735786/0000003900000001/v1_201501230116/S2173578614001528/v1_201501230116/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2173578614001528?idApp=UINPBA00004N" ]
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