Kruck S et al, 2011: Interventional stress in renal stone treatment
Kruck S, Sonnleithner M, Hennenlotter J, Walcher U, Stenzl A, Herrmann TR, Nagele U
Department of Urology, University of Tuebingen , Tuebingen, Germany
ABSTRACT PURPOSE: To compare current minimally invasive strategies in renal stone treatment-shockwave lithotripsy (SWL), retrograde intrarenal surgery (RIRS), and minimally invasive percutaneous nephrolitholapaxy-with regard to interventional stress, measured by changes in interleukin (IL)-6 and C-reactive protein (CRP) serum levels during treatment.
PATIENTS AND METHODS: 143 patients underwent stone therapy for renal pelvic stone (SWL, n=40, mean age±standard error of the mean [SEM]: 48.3±3.1 years; RIRS, n=74, 54.5±1.8; and minimally invasive percutaneous nephrolitholapaxy (MIP), n=29, 54.6±2.7) between 2006 and 2007. Blood samples were prospectively collected 24 hours before and 24 hours after the procedure. Interventional stress was analyzed by changes of the acute phase proteins IL-6 and CRP.
RESULTS: Mean IL-6 (ng/L) difference (±SEM; 95% confidence interval [CI]) before and after therapy was +8.7 (±10.5; -13.9-31.2), +7.3 (±3.2; 1.5-13.1), and +20.5 (±8.1; 4.0-36.0) in the SWL, RIRS, and MIP groups, respectively (P=0.20). Differences in mean CRP (mg/dL) levels (±SEM; 95% CI) ranged between +0.9 (±1.6; -2.3-4.1) in SWL, +1.6 (±0.5; 0.6-2.5) in RIRS, and +1.8 (±,0.3, 1.2-2.5) in MIP patients (P=0.79). Mean stone sizes (mean/median mm(2)±SEM) differed significantly between SWL (27/20±3), RIRS (70/16±36), and MIP groups (346/160±104, P<0.0005).
CONCLUSION: Contrary to common opinion that SWL is the least invasive therapy, the reported stress parameters did not show significant differences between SWL, RIRS, and MIP, although significantly bigger stones were treated with MIP.
J Endourol. 2011 Jun;25(6):1069-73. doi: 10.1089/end.2010.0590
PMID: 21668328 [PubMed - in process]
This paper closes a small gap in our knowledge about the changes of acute phase parameters like IL 6 and CRP after urological procedures.
We already knew that ESWL had no influence (Reference 15: Fornara P, Doehn C, Seyfarth M, Jocham D. Why is urological laparoscopy minimally invasive? Eur Urol 2000;37: 241–250.) and that MiniPNL or PNL had a small impact on these parameters ( Reference 28 and 29: 28. Aghamir SM, Mojtahedzadeh M, Meysamie A, et al. Comparison of systemic stress responses between percutaneous nephrolithotomy (PCNL) and open nephrolithotomy. J Endourol 2008;22:2495–2500. 29. Li LY, Gao X, Yang M, et al. Does a smaller tract in percutaneous nephrolithotomy contribute to less invasiveness? A prospective comparative study. Urology 2010;75:56–61) .
Now we know that RIRS also has no effect.
I would not agree to the authors conclusion that: ”changes in IL-6 and CRP levels showed no significant difference between SWL, RIRS, and MIP.” The post procedural rise was up to2 fold after SWL and RIRS but 6-7 fold after MIP. The authors fail to explain why SWL patients had elevated pre- and post procedural CRP levels.