Overview of stone management in Japan

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Overview of stone management in Japan

Tetsuro Matsumoto, MD, PhDDepartment of Urology, University of

Occupational and Environmental Health

The 10th Catholic International Urology Symposium, 200814 June 2008Catholic University, Seoul

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Incidence and management of stone diseases in Japan

Incidence rate of urinary stone in Japan（ /100,000 population ）

119.640.379.3Female

308.9116.9192.0Male

Incidence rate

(/year)Reccurence

First diagnosis

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2005

Incidence rate in whole life (Incidence/year x average life expectancy x 100)

1995

　 Male ：　 122.6/100,000×76.36×100= 9.4%

　 Female ：　 49.4/100,000×82.84×100= 4.1%

2005

　 Male ：　 192.0/100,000×78.53×100=15.1%

　 Female ：　 79.3/100,000×85.49×100= 6.8%

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Incidence rate of upper urinary tract stoneIncidence (/100,000)

Incidence after demographycal correction

MaleFemale Total

MaleFemale Total

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Chronological change of incidence rate classified by age

Male

Female

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(Every 10 years)

Incidence of upper urinary stone classified by age(First diagnosis/Recurrence)

(/100,000)

Male firstFemale firstMale recurrenceFemale recurrence

MaleFemale

First:Recurrence

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Constituent of upper urinary tract stone in Japam

Male Female

Ca stone

2005

Infection stone

Urate stone

Cystine

Others

Ca stone

Infection stone

Urate stone

Cystine

Others

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Male Female

Ca stone

Infection stone

Urate stone

Cystine

Ca stone

Infection stone

Urate stone

Cystine

2005

Constituent of lower urinary tract stone in Japan

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Chronological change of constituent of upper urinary tract stone classified by age

Male

Female

Ca stone

Struvite

UrateCystine

Others

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Past history and basic disease in patients　　　　　　　　　 Rate (%)

Family history 　　 9.7

Hypertension 　　 21.7

Diabetes 　　　　　 9.8

Hyperlipidemia 　 14.1

Osteoporosis 　　 2.0

　　　 Rate (%)

Hyperuricemia

Hypercalciuria

Hyperuricuria

Hyperoxaluria

Hypocitruria

13.7

3.1

3.2

1.5

2.0

Basic disease

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History

2005

Management of stone diseases in Japan

ESWL only TUL onlyESWL

+TUL

Others Total

ESWL only

TUL only

ESWL + TUL

No.

(%)

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Chronological change of surgical management for upper urinary tract stones

Open surgery

TUL or PNL

ESWL(incl. combined)

% Surgical treatment

% No surgical treatment

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Japanese guidelines for the management of stone diseases Dec, 2002, JUA

Renal stone(1)<20mm; ESWL(2)>20mm or Staghorn; PNL with ESWL

Ureter stone　 (1) Proximal; ESWL 　　　 Option: (TUL, PNL)

(2) Middle; TUL or ESWL(3) Distal; <10mm; ESWL

　　　 >10mm; TUL

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Experience in our hospital

The UOEH urolithiasis guideline

Renal stones (1) 5 to 20mm; ESWL Option:(PNL or TUL) (2)20mm to 30mm ; ESWL with double-J stent Option:(PNL or TUL) (3)>30 mm; PNL (with ESWL) Option:(lithotomy)

Ureter stones 　 (A) Proximal; ESWL 　　　 Option:(TUL or PNL) (B) Middle; ESWL (C) Distal; (1) 5 to 10mm; ESWL (2)>10mm; TUL

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UOEH hospital

Number of new patients in Urology servicein outpatient clinic in UOEH hospital

Around 10% is stone diseases

0

500

1000

1500

2000

2500

他疾患結石患者

year

OthersStones

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UOEH hospital

Location of stones

050100150200250300350

膀胱結石尿管結石腎結石

year

BladderUreterKidney

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UOEH hospital

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Ureteral stone

2007 Guideline for the management of ureteral calculi　 (EAU, AUA)

Stone Passage Rate (Meta analysis) Spontaneous passage <5mm; 68% >5mm, <10mm; 47%

Medical treatment to increase passage (MET) Nifedipine (Ca channel blocker); 9% (not significant) -blocker; 29%(significant) Tamsulosin (20% increase)> Nifedipine (significant)

No. of patients received surgical management

050100150200250300350

経過観察手術患者

year

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No surgerySurgery

UOEH hospital

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For all index patients Standard; Bacteriuria should be treated. (IV) Blind basket catheter should not be performed. (IV)

For ureteral stones <10mm Option; Observation with periodic evaluation. (1A) Standard; Should be counseled on the risks of MET. (IV)

For ureteral stones >10mm Standard; Must be informed about active treatment modality. (IV) Recommendation; SWL and URS first-line treatment (1A-IV) Routine stenting is not recommended (III) Option; Stenting following uncomplicated URS is optional (1A) Percutaneous antegrade ureteroscopy is first-line treatment in selected patients (III) ; impact large stoen in upper ureter, combination with renal stone removal, ureteral stone after urinary diversion, failure of retrograde ureteral access.

Index PatientNonpregnant adultUnilateral noncystine/nonuric acid radiopaque stoneNormal contralateral renal functionHealthy patient

2007 Guideline for the management of ureteral calculi　 (EAU, AUA)

Surgical management

0

50

100

150

200

膀胱切石尿管切石腎盂切石膀胱砕石TULPNLESWL

year

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UOEH hospital

VesicolithotomyUreterolithotomyPyelolithotomyVesicolithotripsy

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Stone free rates for SWL and URS in the overall population

Overall population

Distal ureter Distal ureter <10mm Distal ureter >10mmMid ureter Mid ureter <10mm Mid ureter >10mmProximal ureter Proximal ureter <10mm Proximal ureter >10mm

SWL

74%86%74%73%84%76%82%90%68%

URS

94%97%93%86%91%78%81%80%79%

Statistics

significantsignificantsignificant

nsnsnsnsns

significant2007 Guideline for the management of ureteral calculi

　 (EAU, AUA)

Results of TUL （ 2005 ～ 2007 ）

Cases Stone free rate

１５ １１（ 73 ％）

９ ５（ 56 ％）

２４ ２２（ 91.6 ％）

U1

U2

U3

UOEH hospital

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Conversion from ESWL to TUL

ESWL cases Conversion to TUL

82 7 (8.5%)

81 2 (2.4%)

60 4 (6.6%)

Total

2005

2006

2007

223 13 (5.8%)

UOEH hospital

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Patient; 61y, FemalePresent illness: Recurrent UTI for 3 years & Lt hydronephrosis due to Lt ureter stone (U1)

Past history; Kaiser ope 2 times. Ope for Abdominal wall hernia

Complication; Obese Ope scar

A case of problem stone

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22×12mm

DIP

ＣＴ

Impacted stone

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Option of management (U1;Impacted stone)

ESWL; High failure rate to impacted stone

TUL; Difficulty of keeping optical view or push up to kidney

PNL; Damage of Lt kidney

Operation performed; Retroperitoneoscopic ureterolithotomy

Retroperitoneoscopic ureterolithotomy

N ×

×

12mm port

5mm port×

Lt ureter

Ureterotomy Stone

2 weeks after ope 3 months after ope

Retroperitoneal laparoscopipc ureterolithotomy is one of option forlong-term impacted stone.

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Stone disease is infectious diseases?

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UTI and urinary stone are closely related.

Urinary stone induces UTI.

UTI causes urinary stone.

All kind of human diseases is closely related with infection?

Cancer: Uterine cervical cancer;Human papilloma virus Liver cancer; Hepatitis virus C Gastric cancer; Helicobacter pyroli Renal cancer; Virus?

Arteriosclerosis, Myocardial infarction; Chlamydophyla pneumoniaeMany kinds of autoimmune diseases, Collagen diseases Benign prostatic hyperplasia etc, etc

Urinary stone is also infectious disease?UOEH 　 urology

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Stone diseases are infectious diseases?

1. Urea splitting enzyme producing-microorganism; Struvite stone

2. Nanobacteria; Apatite stone

3. Oxalobacter formigenes; Prevent stone 　　　　 formation due to diminish the 　　　　 absorption and excretion of 　　　　　　　 　 oxalate

Urea splitting enzyme-producing bacteria causes struvite stone

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Many kinds of ureasplitting enzyme-producing bacteria;cause complicatedUTI.

GNR

GPC

Mycoplasma

Fungi

Microorganism Almost all producing Sometimes producing

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Urease –producing bacteria

While struvite stone is caused by UTI,

Apatite stone is also caused by infection?

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NanobacteriaKajander & Ciftcioglu (Finnish researcher, PNAS 1998) -Putative cell-walled 　 microorganism -Low diameter; 0.2m -Apparent culture -Partially characterized Ribosomal RNA -Isolated from human and cow blood -Microscopic mineral structure (Ca, P) =Biomineralization -Not culturable in irradiated blood

Nanobacteria ；　 Small, Gram negative Proteobacteria group Needle-shaped calcium apatite cell wall

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Nanobacteria; an infectious cause for kidney stone formation ； Ciftcioglu et al; Kidney Int 1999

SEM;70/72 (97.2%) stones were Nanobacteria positive.

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Nanobacteria; Controversial pathogens in nephrolithiasis and polycystic kidney disease.Kajander et al; Curr Opin Nephrol Hypertens 2001

Direct injection of nanobateria into kidney resulted in stone formation in rats and rabbits

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Nanobac Announces peer reviewed publication verifying self-propagating calcifying nanoparticles as a unique entityCNPs hypothesized to resemble prions

CAL-DETOX; EDTA Nanobac Pharmaceuticals Inc.

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Controversial issue

Cisar J. (NIH, FDA group ； PNAS 　 2000) -Found same structure in same 　　　　 condition -rRNA=Phyllobacterium 　　　　 mysinacearum; contamination -Resistant to almost all antimicrbials and sodium azide -Non sensitive to heat and powerful respiratory inhibitor

　　　　 Conclusion

Infection is quite interesting.UOEH 　 urology