EAU 2018: Case-Based Debate: How Can We Evaluate and Treat the High-Risk Stone Former?
Following, the patient underwent PNL again to remove the residual fragments, utilizing two previous access tracts with one new anterior middle calyx. On PNL, the patient did indeed have multiple stone fragments, while none of them were causing an obstructing. The patient presented back in the emergency room with a stone obstruction within 24 hours post-procedure and was admitted for pain caused by the obstruction.
In January 2015, a ureteroscopic procedure was conducted to place a JJ stent. The procedure was repeated in February 2015 and an additional JJ stent was placed. In December of that same year, the patient presented with obstructed kidney. A left JJ stent removal was performed and the patient was determined to be stone-free on CT KUB. In April 2017, the patient was re-admitted to the outpatient clinic with left mild flank pain and could not to regular follow-up visits due to her lack of education. CT KUB 16 months post-procedure found a new stone formation, despite a relative short period of time. Left PNL was planned.
Dr. Gabaro begins the discussion by asserting that a metabolic evaluation should have been conducted when the patient first presented. However, he also mentions that, should an idiopathic stone disease have been presented, there are no current standard of care for patients with this type of disease. Regardless, however, due to the patient’s young age and recurrent disease, he re-iterates that metabolic evaluation should definitely have been conducted to at least rule-out hypercalciuria, hypocitraturia, and hyperoxaluria.
Dr. Bach enters the debate in stark contrast with Dr. Gabaro and asserts that empiric prevention is more sufficient. Not only are the logistics of a 24-hour metabolic evaluation more difficult, he notes that the current recommendations for these metabolic evaluations are not highly supported in guidelines. Citing a study in Annals of Internal Medicine [Medical Management to Prevent Recurrent Nephrolithiasis in Adults – A Systematic Review], Dr. Bach summarizes the following recommendation: (1) increasing fluid intake to decrease recurrence rates is not feasible, (2) decreased soft drink intake is beneficial only in patients with high previous intake, and (3) medications are not effective without co-interventions without increased fluid intake (i.e. reduced oxalate intake).
The debate concludes with the assertion that modern endourology is a highly effective in treating the first stone and recurrence presentations and may have significantly lower comorbidity and side effects. It is important to note, however, that endourology is still a treatment (not a prevention method). As such, informed decision making should take care to consider issues such as patient compliance, willingness to follow-up, and durability of long-term behavioral interventions.
Presented by: Moderator - K Sarica, MD Istanbul, Turkey | Discussants: T Bach, MD and Gabaro, MD
Written by: Linda M. Huynh, BS, Department of Urology, University of California-Irvine at the 2018 European Association of Urology Meeting EAU18, 16-20 March, 2018 Copenhagen, Denmark