Stone Diseases in Algeria:URS Replaces Slowly Open

Surgery 

H. KOUICEM, Algeria

Algerian Association of Urology

In Algeria, urolithiasis is a wide-spread health problem. Until recently, stone diseases were almost exclusively treated via open surgery, due to financial restrictions leading to a lack of minimally invasive technological infrastructure. Only recently, ureterorenoscopy and LASER stone fragmentation are introduced.

Introduction

Open Surgery Ureteroscopy

OPEN SURGERY

Therapeutic Options

available Until 2014

Roboflex Avicenna 2014

SWL

PCNL

Davancci Robot

MET

Laparoscopy

Ureteroscopy

Study Cases

A case series of 6 large ureter stones 1-2 cm are treated through a modern approach and would have otherwise undergone open surgery.

The underneath mentioned cases reflect the endourological approaches adopted even going back to OPEN SURGERY though abrasive and morbid.

Case One

DiagnosisFemale, 36 Years

L P U stone: 14 mm

Possible Options

•MET•Open surgery•PCNL•Ureteroscopy•Laparoscopy•Robot

What would you opt for?

DiagnosisMale, 54 years

One right kidney

Anuria

R L U stone: 14 mm

Case Two Possible Options

•MET•Open surgery•PCNL•Ureteroscopy•Laparoscopy•Robot

What would you opt for?

Case

ThreeDiagnosisFemale, 35 years

L P U stone: 15 mm

Possible Options

•MET•Open surgery•PCNL•Ureteroscopy•Laparoscopy•Robot

What would you opt for?

Case

FourDiagnosisMale, 47 years

R P U stone: 10 mm MET failed

Possible Options

•MET•Open surgery•PCNL•Ureteroscopy•Laparoscopy•Robot

What would you opt for?

Case

Five

DiagnosisMale, 44 years

L L U stone: 22 mm

Possible Options

•MET•Open surgery•PCNL•Ureteroscopy•Laparoscopy•Robot

What would you opt for?

Case

Six

DiagnosisFemale, 56 years

R K stone : 20 mm

Possible Options

•MET•Open surgery•PCNL•Ureteroscopy•Laparoscopy•Robot

What would you opt for?

EAU Recommendat

ions

EAU Algorithm 2014

Recommendations for MET LE GR

For MET, α-blockers are recommended 1a A

Patients should be counselled about the attendant risks of MET, including associated drug side effects, and should be informed that it is administered off-label ϯ**

A*

Patients who elect for an attempt at spontaneous passage or MET, should have well-controlled pain, no clinical evidence of sepsis, and adequate renal functional reserve.

A

Patients should be followed once between 1 and 14 days to monitor stone position and be assessed for hydronephrosis.

4 A*

Stone location and size First choice Second choice

Proximal ureter < 10 mm SWL

Proximal ureter > 10 mm URS (retrograde or antegrade or SWL

Distal ureter < 10 mm URS or SWL

Distal ureter > 10 mm URS SWL

Recommended treatment option (if indicated for active stone removal) (GR: A*)

EAU Guidelines 2014

Kidney stones • Complex stone burden

• Failure of SWL, PNL, or ureteroscopic procedure

• Intrarenal anatomical abnormalities: infundibular stenosis; stone in the calyceal diverticulum (particularly in an anterior calyx); obstruction of the ureteropelvic junction; and stricture if endourologic procedures have failed or are not promising

• Morbid obesity

• Skeletal deformity, contractures and fixed deformities of hips and legs

• Comorbidity

• Concomitant open surgery

• Non-functioning in lower pole (partial nephrectomy), non-functioning kidney (nephrectomy)

• Patient choice (after failed minimally invasive procedures, a single procedure avoiding the risk of multiple PNL procedures might be preferred by the case)

• Stone in an ectopic kidney where percutaneous access and SWL may be difficult or impossible.

• For the paediatric population, the same considerations apply as for adults.

Indications for open surgery

Fallouts

Sometimes, though financial resources and technical platforms are available, the urologist is obliged to opt for a decision that does NOT logically shadow the EAU Recommendations!!!

Case One

URS scheduled. Spontaneous stone passage through MET after 3 weeks.

Case TwoSemi-rigid ureteroscopy. Fragmentation with ballistic lithotripter.

Post-OP JJ.

Case ThreeSemi-rigid ureteroscopy. Fragmentation with ballistic lithotripter.

Post-OP JJ.

Cases Four & Five

Case Four

Case FiveFragmentation with semi-rigid ureteroscope LASER.

Post-OP JJ.

Case SixThe stone was found embedded in the ureteropelvic

junction. Up to 50% of the stone was fragmented with flexible LASER. Cloudy urines observed. JJ placed. Treatment completed using delayed SWL.

Comments

Though MET and Open Surgery are still practiced due to the restricted financial resources of patients as well as the availability and the limits of the technical platforms;

URS is gaining ground slowly!

What are the appropriate treatment choices to be recommended?

All in All

Open surgery has been the main if not the only treatment for stones in Algeria. Ureteroscopy has opened a path towards minimally invasive surgery in our country:

It has re-instated confidence in the use of conservative treatments as a first option.

Algeria has embarked towards a path to negligibly aggressive modern stone treatment.

The successful management of all aspects of stones treatment requires both competence and equipments.

The Algerian urologist is obliged to find the best solution to relieve his patients’ sufferings; nevertheless reality is rather problematic!

Conclusions