Vietnam Urology

I was invited by Dr Vu Le Chuyen (Urology Chief, of General Plan Binh Dan Hospital, Ho Chi Minh City) of Vietnam Urology & Nephrology Association to lecture at their Annual Scientific Meeting held at the beach town of  Quang Binh on 8 August 2014.  There are no direct flights, even from Kuala Lumpur and the journey took a day!  The tour guide told us that “Vietnam is a poor country” but I am impressed by the country: friendly, metered taxis, clean toilets, clean environment and relatively cheap food. Vietnam has more urologists (~ 800 to population of 90 million)  compared to Malaysia (80 to 30 million). However, English is not widely spoken.  I had lunch and dinner with Dr Rainy Umbas (Director of Asian School of Urology) and about 10 Indonesian urologists: they speak good English and knows exactly about the urology practices in Malaysia!  Rightly, as we move into ASEAN free trade in 2015!!  I attach my edited lecture slides on pyeloplasty, group photo with some ASEAN urologists, dinner with Indonesian urologists

Urinary stones and kidney failure: treat both aggressively!

STONES IN AN ESTABLISHED CKD, DO WE PROCEED?

Dr Clarence Lei Chang Moh,

Consultant Urologist, Kidney & Stone Centre, Normah Hospital, Kuching.

CKD, chronic kidney disease, is diagnosed when there is kidney disease for more than 3 months, structural or biochemical.  There are 5 stages of CKD, with Stage 5 as creatinine clearance less than 15 mls/min. A patient is  likely to have CKD rather than acute kidney disease if he  has risk factors of diabetes, hypertension, increased age, low haemoglobin, low calcium, high phosphate, high PTH.  Ultrasound show echogenic and smaller kidneys unless the patient has diabetes or lymphoproliferative disease. 

Obstructive uropathy can be readily relieved by percutaneous nephrostomy or ureteric stenting, rather than dialysis.  Other indications for stone treatment in CKD include pain from obstruction and infection.  Even patients who need chronic dialysis should undergo stone treatment to maintain urine output such that the patient can enjoy fluid for some months.

Radiolucent uric acid stones can be treated by chemodissolution, once the obstruction has been relieved by ureteric stenting. The side with the “easier” stone can be treated first to allow some recovery of renal function.  Otherwise, the kidney with the better function (good renal size, cortex with less echogenicity) can then be operated.  Upper urinary tract stones less than 2 cm can be readily treated by ESWL, extracorporeal shockwave lithotripsy. 

Stone free rates after treatment are reduced in patients with CKD.  This may partly be related to the lower urine volume in patients with CKD.  In one study of ESWL for proximal ureteric stones, the stone free rate was 50% when the GFR was less than 60 as compared to 93% when the GFR was more than 60.  Therefore, the urologist must be inclined to do more axillary procedures when treating patients with CKD.

Patients who have nephrectomy for stones are more likely to develop CKD as compared to patients who had kidneys preserved.  In the Sarawak General Hospital, 36% of 71 nephrectomies over 32 months were done for stones with infection (reported in MUC 2012).   Uric acid and struvite stones have worse CKD compared to calcium stones (eGFR 55 vs 72).  Hence, stone analysis is important to stratify risk.  Urinary stones per se has a 2 times increased risk of CKD (1% vs 0.5%) even after adjustment for confounders (e.g. age, diabetes, hypertension), even after successful ESWL, and even after a single stone episode.  The basis may be genetic whereby a defect contributes to CKD and  stone formation.  Therefore, stone formers should only donate their kidneys after due consideration.

Managing patients with CKD is teamwork with the nephrologists, nurses, dietitians and the family.  Stones presenting with renal impairment may require urgent treatment e.g. haemodialysis for fluid overload, hyperkalaemia or restlessness due to severe uraemia. Management of stone & CKD includes management of underlying diabetes, hypertension, anaemia, gout and bone disease. According to the Malaysian National Renal Registry data (www.msn.org.my) 1-2 % (data 1993-2013) of renal failure in Malaysian is due to urinary stones whereas it is 0.2% in the US Renal Data System in 2011.

CONCLUSION: Every effort must be made to treat urinary stones especially in CKD. Axillary procedures e.g. ureteric stenting and aggressive medical measures should be implemented in treating stones with CKD.

Lecture given at Malaysian Urological Conference 2014

I was invited by Dr Vu Le Chuyen (Urology Chief, of General Plan Binh Dan Hospital, Ho Chi Minh City) of Vietnam Urology & Nephrology Association to lecture at their Annual Scientific Meeting held at the beach town of  Quang Binh on 8 August 2014.  There are no direct flights, even from Kuala Lumpur and the journey took a day!  The tour guide told us that “Vietnam is a poor country” but I am impressed by the country: friendly, metered taxis, clean toilets, clean environment and relatively cheap food. Vietnam has more urologists (~ 800 to population of 90 million)  compared to Malaysia (80 to 30 million). However, English is not widely spoken.  I had lunch and dinner with Dr Rainy Umbas (Director of Asian School of Urology) and about 10 Indonesian urologists: they speak good English and knows exactly about the urology practices in Malaysia!  Rightly, as we move into ASEAN free trade in 2015!!  I attach my edited lecture slides on pyeloplasty, group photo with some ASEAN urologists, dinner with Indonesian urologists

urinary stones

MANAGING UROLITHIASIS

Dr Clarence Lei Chang Moh, FRCS Urol, Consultant Urologist, Stone Centre, NMSC

clarencelei@gmail.com

Urinary stones affects 5-15% of populations, with a 50% recurrence rate over 10 years. There is a slight world wide increase in stone incidence. Managing urolithiasis is an important skill for all doctors.  Diagnosis is usually with urinalysis, ultrasound, plain Xray KUB & noncontrast low dose CT.  Prevention is as important as surgery. Ureteric colic is the most severe pain that men can ever experience and the usual analgesia is  Diclofenac. However, if this is given continuously for more than 48 hours, there is a nephrotoxic potential, especially in patients who are dehydrated.  For small stones (< 6 mm) in the lower ureter, removal can be facilitated by uroselective alpha-blockers (e.g. Tamsulosin, Alfuzosin). This is now known as MET medical expulsive therapy! Stones <5mm by="" cause="" complicated="" do="" eventually="" intervention="" large="" not="" o:p="" require="" sepsis="" stones="" unless="" untreated="" urosepsis.="" usually="" whereas="">

The important medical treatment for urinary stones is that of water therapy such that the patient produces 2 litres of urine per day. The fluid intake of the patient depends on his environment.  Ideally, such fluid should be distributed throughout the day.

Uric acid stones can be effectively dissolved by medical therapy by urinary alkalinisation, keeping the urine pH at 7.0.  Uric acid stones comprise about 20% stones and are radiolucent on x-ray but readily seen on ultrasound and plain CT. Even staghorn uric acid calculi can be dissolved over 6 months.   However, the patient should have a good renal function to avoid accumulation of the medications used e.g. potassium, citrate, sodium (in Ural).

Potassium Citrate helps clear stones, eg post ESWL lower pole fragments. In one study Potassium Citrate increased the stone-free rate to 45.5% from 12.5% in control group, over a 12 month period.  The citrate in the urine reduces crystallization of calcium and uric acid stones.  

Stones associated with infection are called struvite stones. Struvite stones are typically soft and faintly radiolucent. The stone and infection should be cleared by surgery and  vigorous antibiotic therapy followed by prophylaxis at night for 6 months, including in children. 

For patients who have underlying metabolic effects, the benefit of the specific medications may not justify the side effects and long term costs. The diet recommendations for patients with recurrent stone formation is that of less salt, low oxalate, and normal calcium. Patients with uric acid stones should take less uric acid in their diet e.g. red meat, nuts.

Open surgery for urinary stones now comprises < 5% of surgical treatment eg in large multiple bladder stones in boys, bulky full staghorn kidney stones and giant ureteric stones. The later can  also be removed by laparoscopic surgery. The mainstay of stone surgery is endourology viz ureteroscopic lithotripsy, URS and percutaneous nephrolithotripsy, PCNL.  URS has a successful outcome in >90% cases but can be hazardous in the  upper ureter. The main complications of PCNL are bleeding & sepsis, occasionally fatal. Main energy sources for lithotripsy include  mechanical (“Lithoclast”), ultrasonic and laser. In recent years equipments have become smaller and better enabling miniPCNL, microPCNL and RIRS, retrograde intrarenoscopy.  ESWL, extra-corporeal shockwave lithotripsy remains the most significant advance in stone treatment, suitable for most upper urinary tract stones <20mm .="" achievable="" alara="" and="" as="" clearance.="" eg="" for="" in="" low="" management="" may="" must="" one="" radiation="" rather="" reasonably="" repeated="" require="" sessions="" some="" span="" stenting="" stones="" style="mso-spacerun: yes;" than="" the="" ultrasound="" ureteric="" use="" with="">  surgeon control of fluoroscopy, protection for staff and patient.

Efficient and safe clearance of the stone, with  followup preventive measures are needed for proper management of urinary stones.

College of Surgeons of Malaysia, Kuching, Annual Meeting, 25 May 2014, pages 45-46