LITHOTRIPSY IN PREGNANCYDR RL LEBELO

WSU

OUTLINE• OVERVIEW

• epidemiology

• Renal tract changes in pregnancy

• Impact on pregnancy

• DIAGNOSIS

• clinical

• imaging

• MANAGEMENT

• conservative

• surgical – anaesthesia

• imaging

• modes of intervention

• LITHOTRIPSY

Introduction

• Renal stones during pregnancy can lead to significant morbidity for the woman • also increase the risk of obstetric complications.• Management of renal stones in pregnant women is challenging• the optimum diagnostic tests• treatments are associated with increased risks for both the fetus and

mother

Epidemiology

• The incidence is about 1 in 1500• more common in multiparous women, • 80–90% stones occurring in the second and third trimester. • Ureteral stones are encountered twice as often as renal calculi• 25% have a history of previous stone disease.

Impact of renal stones on pregnancy

• The top cause for non-obstetric hospital admission • Increase risk of recurrent miscarriage, pre- eclampsia, chronic

hypertension, gestational DM, and caesarean deliveries.• premature rupture of membranes • Preterm delivery rates• Risk during management

The balance

Stone promotion (mechanism) Urinary stasis (mechanical compression, progesterone)Hypercalciuria (increased GFR, increased vitamin D) elevated urine pH Increased excretion: uric acid, sodium, and oxalate (increased GFR)

Stone inhibition (mechanism) Hypercitraturia (increased GFR) Increased excretion: magnesium, glycosaminoglycans, uromodulin, and nephrocalcin(increased GFR

presentation

flank pain affecting 89–100%haematuria is seen in 75–95% of cases.Renal stones may also present

as preterm labour or uterine contractions.In one series, 28% of patients

were incorrectly diagnosed as appendicitis, diverticulitis, or placental abruption.

Dysuria and frequency are common

Imaging

• Dilemma due to inherent radiation risk

USMRICT

Radiation consequences

Radiation

Recommendations

• The ACOG Committee on Obstetric Practice makes the following recommendations• Ultrasound should be the first line of investigation• ABD or TV • Where US is inconclusive and symptoms are persistent, an MRU/ low-

dose CT (4 mGy) scan may be considered

Treatment

• The management of symptomatic ureteric stones in pregnancy is initially conservative.• 70% to 80% of ureteric stones will pass spontaneously • treat with hydration, analgesics, and antibiotics if infection.• treatment of the remaining 20-30% require intervention• This is controvential

MET

• can be used as an adjunct to trial of passage. • Alpha blockers have not been studied in humans • but have been shown to be safe in animal studies • and are often used during pregnancy.

Intervention The picture can’t be displayed.

Temporizing vs definite treatment The advantages of temporary drainage Definite treatment

with minimal anesthesia and no radiation exposureit can be done very quickly,. nephrostomy tubes can assist with future access for definitive treatment

Single procedureRadiation is not always requiredDecreased anaesthetic riskCost effective

disadvantages

it is temporary and requires definitive mxmultiple procedures may be required expensive and each exchange incurs a risk on the pregnancy. not tolerated well. dislodge, migrate, uncomfortable, become colonized increasing risk for urinary infection

done under spinal or general anaesthesiaLong procedure

Temporizing vs definite treatment

• outcome of using semi-rigid ureteroscopy with intracorporeal pneumatic lithotripsy vs. temporary ureteric JJ stenting in the management of obstructing ureteric calculi in pregnant women.

Temporizing vs definite treatment

• prospectively studied 43 pregnant with obstructing ureteric calculi.

conclusion: Definitive ureteroscopy, with intracorporeal pneumatic lithotripsy, is an effective and safe treatment for pregnant women.It has a better outcome and is more satisfactory for the patients than a temporary JJ stent.

Lithotripsy Challenges

• Anaesthesia• Imaging• ESWL• PCNL• URS• Electrohydraulic• ultrasonic• Pneumatic• LASER

Anaesthesia

• If a procedure is needed, experienced anesthesiologists, neonatologists, radiologists, urologists, and obstetricians should be involved. • Cardiopulmonary changes during pregnancy make a pregnant woman’s

management more complex. • Teratogenic drugs should be avoided, avoid fetal hypoxia and prevent premature

labor• In prospective studies, there seems to be similar safety between regional

anesthesia (spinal or epidural) versus general anesthesia. • In both techniques, one should avoid hypotension, prevent tracheal aspiration

and move the uterus to the left, ensuring adequate oxygenation, normocarbia and euglycemia. • One must also keep adequate post- operative care, including satisfactory

analgesia, early ambulation, monitoring fetal heart rate and uterine contractions.

Imaging during lithotripsy

• Aim for no radiation• with technical refinements ,• it has become possible to perform these endoscopic procedures

without/min exposure to radiation• ALARA- Principles

ESWL in pregnancy

• ESWL is contraindicated • risk of miscarriage and detached placenta • fetal damage and death observed in animal studies, particularly with

exposure later in pregnancy.• However, there are case reports of successful delivery of healthy

babies despite inadvertent exposure to ESWL during pregnancy, • and therefore, some have advocated further research in this area.

PCNL in pregnancy

• PCNL is not advised during pregnancy • it requires general anaesthesia, • prolonged fluoroscopy time, and • prone position of the patient.

• 2 cases of PCNL in early pregnancy have been reported with good outcome.

URS

• For stone that just won't go down

URS- lithotripters

• a variety of methods have been used safely and successfully for stone fragmentation,• holmium:YAG laser is advocated as the safest option in pregnancy • It has little periureteral thermal effect and does not result in energy

transmission to the fetus. • It also has lower sound intensities compared to US and

electrohydraulic probes, thus reducing any potential risk of damage to fetal hearing

URS- lithotripters

the interventional group(44 pts) delivered at term with no fetal or maternal complications. There was no morbidity during and after the operation

URS- lithotripters

Laser lithotripsy is safe and efficacious in pregnant patients who have ureteral stone that does not respond to conservative management.

URS safety and efficacy- lithotripters

to compare pneumatic and holmium:YAG laser in the treatment of impacted ureteral stones with different locations and to identify the risk factors for complications

URS safety and efficacy- lithotripters

so

• Holmium:YAG laser is a more safe and effective lithotripter • large scale studies are needed.

Recommendations

Recommendations

In pregnant patients with ureteral stones, clinicians may offer URS to patients who fail observation. Ureteral stent and nephrostomy tube are alternative options with frequent stent or tube changes usually being necessary. Strong Recommendation; Evidence Level Grade C

conclusion

• Where expertise and resources are available, URS should be considered as first-line treatment • where contraindicated ,temporizing treatment with stent or PCN. • a multidisciplinary team; obstetricians, Urologist, radiologist,

anaesthesiologist and neonatologists is essential in the management of this population

THANK YOU

References

• ACOG COMMITTEE OPINION. Guidelines for Diagnostic Imaging During Pregnancy and Lactation. Vol. 130, No. 4, October 2017

• American Urological Association (AUA). Endourological Society Guideline• European Association of Urology (EAU). Management of urinary stone and related

problems. 2017• Eisner B. Imaging Calculi in Pregnancy—Is the Future Ultra Low Dose Computerized

Tomography with Iterative Reconstruction Technique? THE JOURNAL OF UROLOGY; Vol. 188, 12-13, July 2012

• Borofsky MS, Shah O. Advances in Ureteroscopy. Urol Clin N Am 40 (2013) 67–78 • Nejdlova M. Johnson T. Anaesthesia for non-obstetric procedures during pregnancy.

Continuing Education in Anaesthesia, Critical Care & Pain Vol 12 No 4 (2012)

References

• Teleb et al. Definitive ureteroscopy and intracorporeal lithotripsy in treatment of ureteral calculi during pregnancy. Arab Journal of Urology (2014) 12, 299–303

• D’Addessi et al .Complications of Extracorporeal Shock Wave Lithotripsy for Urinary Stones: ToKnow and to Manage. The Scientific World Journal Vol 2012

• Degirmenci T et al. Comparison of Ho:YAG laser and pneumatic lithotripsy in the treatment ofimpacted ureteral stones: An analysis of risk factors. Kaohsiung Journal of Medical Sciences (2014) 30, 153-158

• Semins MJ, Matlaga BR. Management of urolithiasis in pregnancy. International Journal ofWomen’s Health 2013:5 599–604

• Preminger GM, Curhan GC. Nephrolithiasis during pregnancy – UpToDate Jan 2018.

References

• Shirvan M et al. The Evaluation of Ureteroscopy and Pneumatic Lithotripsy Results in Pregnant Women With Urethral Calculi. Nephro-Urology Monthly. 2013 September; 5(4):874-8.

• Meher S et al. Renal stones in pregnancy. Obstetric Medicine 2014, 7(3): 103–110 • Razzaghi et al. Safety and Efficacy of Pneumatic Lithotripters Versus Holmium Laser in

Management of Ureteral CalculiA Randomized Clinical Trial. UROLOGY JOURNAL Vol. 10 | No. 1 | Winter 2013 | 762-166