The 10 th Catholic International Urology Symposium, 2008 14 June 2008 Catholic University, Seoul Overview of stone management in Japan Tetsuro Matsumoto, MD, PhD Department of Urology, University of Occupational and Environmental Health

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Incidence and management of stone diseases in Japan

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Incidence rate of urinary stone in Japan

（

/100,000 population

）

2005 Male First diagnosis 192.0

Reccurence 116.9

Incidence rate (/year) 308.9

Female 79.3

40.3

119.6

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Incidence rate in whole life

(Incidence/year x average life expectancy x 100)

1995 Male ： Female ： 122.6/100,000 × 76.36

× 100= 9.4% 49.4/100,000 × 82.84

× 100= 4.1% 2005 Male ： Female ： 192.0/100,000 × 78.53

× 100=15.1% 79.3/100,000 × 85.49

× 100= 6.8%

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Incidence rate of upper urinary tract stone Incidence (/100,000) Male Female Total Incidence after demographycal correction Male Female Total

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Chronological change of incidence rate classified by age (Every 10 years) Male Female

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Incidence of upper urinary stone classified by age (First diagnosis/Recurrence) (/100,000) Male first Female first Male recurrence Female recurrence First:Recurrence Male Female

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Constituent of upper urinary tract stone in Japam

Male

2005

Female

Urate stone Others Infection stone Cystine Others Urate stone Infection stone Cystine Ca stone Ca stone

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Constituent of lower urinary tract

Male

stone in Japan 2005

Female

Cystine Urate stone Cystine Urate stone Infection stone Ca stone Infection stone Ca stone

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Chronological change of constituent of upper urinary tract stone classified by age Male Others Cystine Urate Struvite Ca stone Female

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Past history and basic disease in patients History Family history 2005

Rate (%)

Basic disease 9.7

Rate (%)

Hyperuricemia 13.7

Hypertension 21.7

Hypercalciuria 3.1

Diabetes 9.8

Hyperuricuria 3.2

Hyperlipidemia 14.1

Hyperoxaluria 1.5

Osteoporosis 2.0

Hypocitruria 2.0

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Management of stone diseases in Japan No. (%) ESWL only TUL only ESWL + TUL ESWL + TUL TUL only Others Total ESWL only

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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 (2) Middle; TUL or ESWL (3) Distal; <10mm; ESWL >10mm; TUL

Option: (TUL, PNL) UOEH urology

Experience in our hospital

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The UOEH urolithiasis guideline

UOEH hospital 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 (B) Middle; ESWL (C) Distal; (1) 5 to 10mm; ESWL (2)>10mm; TUL Option:(TUL or PNL)

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Number of new patients in Urology service in outpatient clinic in UOEH hospital UOEH hospital

2500 2000 1500 1000 500 0 20 01 20 02 20 03 20 04 20 05 20 06 20 07 year

Around 10% is stone diseases

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Location of stones

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350 300 250 200 150 100 50 0 2001 2002 2003 2004 2005 2006 2007

year

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Ureteral stone

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)

a

-blocker; 29%(significant) Tamsulosin (20% increase)> Nifedipine (significant) 2007 Guideline for the management of ureteral calculi (EAU, AUA)

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No. of patients received surgical management UOEH hospital

350 300 250 200 150 100 50 0 2001 2002 2003 2004 2005 2006 2007

year

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2007 Guideline for the management of ureteral calculi (EAU, AUA) Index Patient Nonpregnant adult Unilateral noncystine/nonuric acid radiopaque stone Normal contralateral renal function Healthy patient 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.

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Surgical management

UOEH hospital

200 150 100 50 0 2001 2002 2003 2004 2005 2006 2007

year

TUL PNL ESWL

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Stone free rates for SWL and URS in the overall population Overall population SWL URS Statistics Distal ureter Distal ureter <10mm Distal ureter >10mm Mid ureter 74% 86% 74% 73% 94% 97% 93% 86% significant significant significant ns Mid ureter <10mm Mid ureter >10mm Proximal ureter 84% 76% 82% 91% 78% 81% ns ns ns Proximal ureter <10mm 90% 80% ns Proximal ureter >10mm 68% 79% significant 2007 Guideline for the management of ureteral calculi (EAU, AUA)

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Results of TUL

（

2005

～

2007

）

UOEH hospital U1 U2 U3 Cases

１５ ９ ２４

Stone free rate

１１（

73

％） ５（

56

％） ２２（

91.6

％）

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Conversion from ESWL to TUL

UOEH hospital 2005 2006 2007 Total ESWL cases Conversion to TUL 81 2 (2.4%) 82 7 (8.5%) 60 223 4 (6.6%) 13 (5.8%)

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A case of problem stone

Patient ; 61y, Female Present 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

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DIP 22

×

12mm

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 Lt ureter 12mm port

×

5mm port

× ×

N Ureterotomy Stone

2 weeks after ope 3 months after ope Retroperitoneal laparoscopipc ureterolithotomy is one of option for long-term impacted stone.

Stone disease is infectious diseases?

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UTI and urinary stone are closely related.

Urinary stone induces UTI.

UTI causes urinary stone.

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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 pneumoniae Many kinds of autoimmune diseases, Collagen diseases Benign prostatic hyperplasia etc, etc Urinary stone is also infectious disease?

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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

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Urea splitting enzyme-producing bacteria causes struvite stone

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Many kinds of urea splitting enzyme -producing bacteria; cause complicated UTI.

Urease –producing bacteria Microorganism Almost all producing Sometimes producing GNR GPC Mycoplasma Fungi

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While struvite stone is caused by UTI, Apatite stone is also caused by infection?

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Nanobacteria

Kajander & Ciftcioglu (Finnish researcher, PNAS 1998) -Putative cell-walled microorganism -Low diameter; 0.2

m

m -Apparent culture -Partially characterized Ribosomal RNA -Isolated from human and cow blood -Microscopic mineral structure (Ca, P) =Biomineralization -Not culturable in

g

irradiated blood

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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 entity CNPs 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

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Conclusion Infection is quite interesting.

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