UOEH 　 urology

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