Daniele Castellani et al., 2024: Extracorporeal shock wave lithotripsy, ureterolithotripsy, and percutaneous nephrolithotripsy challenges in managing spinal cord neuropathy patients. Lessons learned from a scoping review

Tuesday, 29 October 2024

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Daniele Castellani 1 , Carlo Brocca 1 , Demetra Fuligni 1 , Carlo Giulioni 1 , Angelo Antezza 1 , Angelo Cormio 1 , Arianna Rubino 1 , Lucia Pitoni 1 , Virgilio De Stefano 1 , Giulio Milanese 1 , Luigi Cormio 2 3 , Bhaskar Kumar Somani 4 , Vineet Gauhar 5 , Andrea Benedetto Galosi 1
1Urology Unit, Azienda Ospedaliero-Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy.
2Department of Urology and Renal Transplantation, Policlinico Riuniti, University of Foggia, Foggia, Italy.
3Department of Urology, Bonomo Teaching Hospital, Andria, Italy.
4Department of Urology, University Hospitals Southampton, NHS Trust, Southampton, United Kingdom.
5Department of Urology, Ng Teng Fong General Hospital, Singapore, Singapore.

Abstract

Introduction: We aim to review the outcomes of shock wave lithotripsy (SWL), ureteroscopy, and percutaneous nephrolithotripsy (PCNL) for renal and ureteral stones in spinal cord neuropathy patients (SNP).

Material and methods: A literature search was performed on 8th March 2023 using PubMed, EMBASE, and Google Scholar with no date limit. Preclinical/animal studies, reviews, letters to the editor, case reports, and meeting abstracts were excluded. Only English papers were accepted.

Results: Thirty-five articles were accepted. Five studies focused on SWL, 17 on PCNL, and 6 on ureteroscopy. The remaining articles employed more than one procedure. Stone composition has shifted from struvite to the more common calcium phosphate. SWL showed a very poor stone-free rate (SFR) likely due to challenges in patient positioning, stone visualization, localization, and inability to pass fragments spontaneously. Flexible ureteroscopy and PCNL were associated with a high incidence of infectious complications, long hospital stays, high blood transfusion rate, and intensive care admissions. There were also cases of death. Both procedures were challenging due to genitourinary reconstruction, scoliosis and kyphosis, rib-cage deformity, lower limb contractures, and severe comorbidity which also affected anesthesia. SFR was lower than in non-neurological patients.

Conclusions: SWL, ureterolithotripsy, and PCNL should be considered challenging procedures in SNP due to positioning issues, an increased risk of intra and peri-operative morbidity, and even mortality. Computed tomography should be recommended to assess residual fragments as it becomes imperative to minimize a re-intervention in SNP who should be preferably treated in referral centers.

Cent European J Urol. 2024;77(1):89-110. doi: 10.5173/ceju.2023.123. Epub 2024 Jan 11.
PMID: 38645817 PMCID: PMC11032027

Comments 1

Hans-Göran Tiselius on Tuesday, 29 October 2024 10:00

It is well-recognized that stone removal is difficult in patients with spinal cord diseases or injuries. The authors have addressed this problem by an extensive review of the literature in which SWL, URS or PCNL had been applied.
The result is presented in 15 pages (!) of tables One table with patient and stone characteristics and one with procedures and outcomes. Urologists with specific interest in this subject should scrutinize these tables. The result, however, is difficult to elucidate because many of the patients were subject to a combination of treatment modalities. The reviewer therefore only has read the authors’ conclusions without going into detail in the tables.
Some patients obviously had struvite stones, but it is not completely clear which other stone composition that was treated, neither is it obvious what the authors mean by calcium phosphate stones; CaP? CaP+CaOx? or CaOx + CaP? But the composition of the stones is not mentioned in the tables.
SWL was used in five studies and it is not surprising that the stone-free rate was low, only 25%, but as many as 79% had markedly reduced stone volumes. One important factor for fragment clearance is adequate patient mobility, which is absent in this group of patients.
Although auxiliary procedures such as stents and nephrostomy catheters commonly were used, nothing is mentioned on the possibility to clear infection stones (struvite) by combining SWL with percutaneous chemolysis [1,2]. That approach is opened if nephrostomy catheters are inserted and with the possibility also to add contrast medium for better stone localization.
Without the help of chemolysis in case of infection stones, it is reasonable to agree with the authors that the invasive procedures URS and PCNL are superior for these patients.
References
1. Tiselius HG, Hellgren E, Andersson A, Borrud-Ohlsson A, Eriksson I. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis. Scand J Urol Nephrol. 1999 Oct;33(5):286-90.PMID: 10572989
2. Tiselius HG, Chaussy CG. Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective.
Urol Res. 2012 Oct;40(5):433-46. doi: 10.1007/s00240-012-0485-z. Epub 2012 Jun 27.PMID: 22736393 Review.

Hans-Göran Tiselius

It is well-recognized that stone removal is difficult in patients with spinal cord diseases or injuries. The authors have addressed this problem by an extensive review of the literature in which SWL, URS or PCNL had been applied.
The result is presented in 15 pages (!) of tables One table with patient and stone characteristics and one with procedures and outcomes. Urologists with specific interest in this subject should scrutinize these tables. The result, however, is difficult to elucidate because many of the patients were subject to a combination of treatment modalities. The reviewer therefore only has read the authors’ conclusions without going into detail in the tables.
Some patients obviously had struvite stones, but it is not completely clear which other stone composition that was treated, neither is it obvious what the authors mean by calcium phosphate stones; CaP? CaP+CaOx? or CaOx + CaP? But the composition of the stones is not mentioned in the tables.
SWL was used in five studies and it is not surprising that the stone-free rate was low,  only 25%, but as many as 79% had markedly reduced stone volumes. One important factor for fragment clearance is adequate patient mobility, which is absent in this group of patients.
Although auxiliary procedures such as stents and nephrostomy catheters commonly were used, nothing is mentioned on the possibility to  clear infection stones (struvite) by combining SWL with percutaneous chemolysis [1,2]. That approach is opened if nephrostomy catheters are inserted and with the possibility also to add contrast medium for better stone localization. 
Without the help of chemolysis in case of infection stones, it is reasonable to agree with the authors that the invasive procedures URS and PCNL are superior for these patients.
References
1.	Tiselius HG, Hellgren E, Andersson A, Borrud-Ohlsson A, Eriksson I. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis. Scand J Urol Nephrol. 1999 Oct;33(5):286-90.PMID: 10572989
2.	Tiselius HG, Chaussy CG. Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective.
Urol Res. 2012 Oct;40(5):433-46. doi: 10.1007/s00240-012-0485-z. Epub 2012 Jun 27.PMID: 22736393 Review.

Hans-Göran Tiselius

It is well-recognized that stone removal is difficult in patients with spinal cord diseases or injuries. The authors have addressed this problem by an extensive review of the literature in which SWL, URS or PCNL had been applied. The result is presented in 15 pages (!) of tables One table with patient and stone characteristics and one with procedures and outcomes. Urologists with specific interest in this subject should scrutinize these tables. The result, however, is difficult to elucidate because many of the patients were subject to a combination of treatment modalities. The reviewer therefore only has read the authors’ conclusions without going into detail in the tables. Some patients obviously had struvite stones, but it is not completely clear which other stone composition that was treated, neither is it obvious what the authors mean by calcium phosphate stones; CaP? CaP+CaOx? or CaOx + CaP? But the composition of the stones is not mentioned in the tables. SWL was used in five studies and it is not surprising that the stone-free rate was low, only 25%, but as many as 79% had markedly reduced stone volumes. One important factor for fragment clearance is adequate patient mobility, which is absent in this group of patients. Although auxiliary procedures such as stents and nephrostomy catheters commonly were used, nothing is mentioned on the possibility to clear infection stones (struvite) by combining SWL with percutaneous chemolysis [1,2]. That approach is opened if nephrostomy catheters are inserted and with the possibility also to add contrast medium for better stone localization. Without the help of chemolysis in case of infection stones, it is reasonable to agree with the authors that the invasive procedures URS and PCNL are superior for these patients. References 1. Tiselius HG, Hellgren E, Andersson A, Borrud-Ohlsson A, Eriksson I. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis. Scand J Urol Nephrol. 1999 Oct;33(5):286-90.PMID: 10572989 2. Tiselius HG, Chaussy CG. Aspects on how extracorporeal shockwave lithotripsy should be carried out in order to be maximally effective. Urol Res. 2012 Oct;40(5):433-46. doi: 10.1007/s00240-012-0485-z. Epub 2012 Jun 27.PMID: 22736393 Review. Hans-Göran Tiselius

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