Schulz AE. et al., 2023: Management of large kidney stones in the geriatric population
Schulz AE, Green BW, Gupta K, Patel RD, Loloi J, Raskolnikov D, Watts KL , Small AC.
Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
Montefiore Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, 1250 Waters Place, Bronx, NY, 10461, USA.
Montefiore Department of Urology, Montefiore Medical Center, Albert Einstein College of Medicine, 1250 Waters Place, Bronx, NY, 10461, USA.
Abstract
Purpose: The aim of this review is to highlight the unique factors that predispose geriatric patients to nephrolithiasis and to compare the utility and efficacy of surgical techniques in this specific patient population.
Methods: PubMed and EMBASE databases were reviewed, and studies were organized according to surgical treatments.
Results: Few prospective studies exist comparing kidney stone removal in the elderly to younger cohorts. In addition, various age cut-offs were used to determine who was considered elderly. Most studies which analyzed Percutaneous Nephrolithotomy (PCNL) found a slightly higher rate of minor complications but comparable stone free rate and operative time. For ureteroscopy (URS) and extracorporeal shockwave lithotripsy (ESWL), there were minimal complications observed and no difference in clinical success in the elderly. All surgical techniques were presumed to be safe in the elderly and most found no difference in stone-free rates.
Conclusions: Unique attributes of the geriatric population contribute to stone formation and must be considered when determining appropriate management modalities. This review provides an overview of the utility and efficacy of PCNL, URS and ESWL in the elderly, as well as a porposed algorithm for management in this population.
World J Urol. 2023 Mar 1. doi: 10.1007/s00345-023-04333-y. Online ahead of print. PMID: 36856833 Review.
Comments 1
This literature review on treatment of large renal stones in geriatric patients had the aim of concluding on safety and efficacy of different available treatment options. The article comprises a systematic analysis and summary of 9 PCNL, 6 URS and 4 SWL studies. Unfortunately, the article gives a rather diffuse description of the various treatment modalities, and the recommendations accordingly are rather weak.
The problems encountered in elderly patients are increased urinary calcium caused by decreased bone mineral density, obesity, diabetes, and hypertension. All these factors must be considered before decisions on stone removal. Not unexpectedly, the conclusion was that for large stones PCNL and URS were most effective. But compared with SWL the complication risk with PCNL and URS was higher!
The bottom-line of the report is that treatment decisions must be based not only by the patients’ age, but also by both stone characteristics and co-morbidities. This strategy is not different from that in other patients and my own conclusion from reading this report is that the treatment decision must be individually based.
Hans-Göran Tiselius