Zusammenfassung
Mehr als 30 % aller stationären Aufnahmen in einer urologischen Klinik erfolgen zur Behandlung von Harnsteinen. Die Therapie erfolgt heute in fast allen Fällen minimalinvasiv durch extrakorporale Stoßwellenlithotripsie (ESWL), Ureterorenoskopie (URS) oder perkutane Nephrolithotomie (PCNL). Technische Weiterentwicklungen in der Endourologie und gewachsene Erfahrung mit der ESWL haben in den letzten Jahren zu einem Rückgang der ESWL-Behandlungen und einem häufigeren Einsatz endoskopischer Techniken geführt. Diese sind zwar im Vergleich zur ESWL invasiver, führen jedoch in den meisten Fällen zu einer rascheren Steinfreiheit. Durch die Einführung des Fallpauschalensystems (DRGs) wird auch die ökonomische Seite der Steintherapie immer wichtiger werden. Steinprävention führt zu einer Kostenreduktion im Gesundheitswesen, weshalb eine geeignete Steinmetaphylaxe durchgeführt werden sollte. Die vorliegende Übersichtsarbeit stellt daher die aktuellen Therapieempfehlungen der interventionellen Harnsteintherapie und Steinmetaphylaxe dar und zeigt Möglichkeiten auf, eine sowohl medizinisch als auch ökonomisch rationale Therapie durchzuführen.
Abstract
More than 30 % of all admissions to an urologic clinic are for the treatment of urinary stones. In almost all cases, the treatment is minimally invasive employing extracorporeal shock wave lithotripsy (ESWL), ureterorenoscopy (URS) or percutaneous nephrolithotomy (PCNL). Technical advances in endourology and a growing expertise in ESWL led to a decline in ESWL and an increase in endoscopic techniques. In comparison with ESWL, the endoscopic techniques are more invasive but in most cases achieve a stone free state faster. With the introduction of diagnosis related groups (DRG), the economic aspect of stone therapy is gaining in importance. Stone prevention leads to a cost reduction in the health care system, justifying the use of an appropriate stone metaphylaxis. This review article presents the current recommendations for interventional urinary stone therapy and lists the options of conducting both medical and economically rational therapy.
Schlüsselwörter
Harnsteine - extrakorporale Stoßwellenlithotripsie (ESWL) - Ureterorenoskopie (URS) - perkutane Nephrolithotomie (PCNL) - Fallpauschalensystem (DRG) - Kostenreduktion
Key words
Urinary stones - extracorporeal shock wave lithotripsy (ESWL) - ureterorenoscopy (URS) - percutaneous nephrolithotomy (PCNL) - diagnosis related groups (DRG) - cost reduction
Literatur
-
1
Tiselius H G, Ackermann D, Alken P, Buck C, Conort P, Gallucci M.
Guidelines on urolithiasis.
Eur Urol.
2001;
40 (4)
362-371
-
2
Tiselius H G.
Possibilities for preventing recurrent calcium stone formation: principles for the metabolic evaluation of patients with calcium stone disease.
BJU Int.
2001;
88 (2)
158-168
-
3
Brandle E, Hautmann R, Alken P, Hesse A, Schafer R, Richter-Reichhelm M. et al .
Metaphylaxis of urinary calculi.
Urologe A.
1997;
36 (6)
588-593
-
4
Rochell B, Roeder N.
DRG: the new hospital reimbursement system for Germany. Part 1: Introduction.
Urologe A.
2003;
42 (4)
471-484
-
5
Knoll T, Michel M S, Kohrmann K U, Alken P.
Urologic interventional therapy of kidney calculi (I)-extracorporeal shockwave lithotripsy.
Ther Umsch.
2003;
60 (2)
98-102
-
6
Brandle E, Hautmann R, Alken P, Hesse A, Schafer R, Richter-Reichhelm M. et al .
Techniques for interventional and operative therapy of calculi.
Urologe A.
1997;
36 (6)
585-587
-
7
Brandle E, Hautmann R, Alken P, Hesse A, Schafer R, Richter-Reichhelm M. et al .
Indication for therapy in urinary calculi.
Urologe A.
1997;
36 (6)
582-584
-
8
Lingeman J E, Kim S C, Kuo R L, McAteer J A, Evan A P.
Shockwave lithotripsy: anecdotes and insights.
J Endourol.
2003;
17 (9)
687-693
-
9
Evan A P, Willis L R, Lingeman J E, McAteer J A.
Renal trauma and the risk of long-term complications in shock wave lithotripsy.
Nephron.
1998;
78 (1)
1-8
-
10
Lingeman J E, Woods J, Toth P D, Evan A P, McAteer J A.
The role of lithotripsy and its side effects.
J Urol.
1989;
141 (3 Pt 2)
793-797
-
11
Chan S L, Stothers L, Rowley A, Perler Z, Taylor W, Sullivan L D.
A prospective trial comparing the efficacy and complications of the modified Dornier HM3 and MFL 5000 lithotriptors for solitary renal calculi.
J Urol.
1995;
153 (6)
1794-1797
-
12
Kohrmann K U, Rassweiler J J, Manning M, Mohr G, Henkel T O, Junemann K P. et al .
The clinical introduction of a third generation lithotriptor: Modulith SL 20.
J Urol.
1995;
153 (5)
1379-1383
-
13
Haecker A, Hatzinger M, Knoll T, Leistner R, Wendt-Nordahl G, Michel M S, Marlinghaus E, Alken P, Koehrmann K U.
Ex-vivo evaluation of renal injury of a new electromagnetic shockwave generation with user selectable dual focus size data.
J Urol.
2004;
171
1874
-
14
Segura J W, Preminger G M, Assimos D G, Dretler S P, Kahn R I, Lingeman J E. et al .
Ureteral Stones Clinical Guidelines Panel summary report on the management of ureteral calculi. The American Urological Association.
J Urol.
1997;
158 (5)
1915-1921
-
15
Muslumanoglu A Y, Tefekli A, Sarilar O, Binbay M, Altunrende F, Ozkuvanci U.
Extracorporeal shock wave lithotripsy as first line treatment alternative for urinary tract stones in children: a large scale retrospective analysis.
J Urol.
2003;
170 (6 Pt 1)
2405-2408
-
16
Landau E H, Gofrit O N, Shapiro A, Meretyk S, Katz G, Shenfeld O Z. et al .
Extracorporeal shock wave lithotripsy is highly effective for ureteral calculi in children.
J Urol.
2001;
165 (6 Pt 2)
2316-2319
-
17
Knoll T, Michel M S, Alken P.
Interventional treatment of urinary calculi.
Dtsch Med Wochenschr.
2003;
128 (27)
1485-1488
-
18
Anagnostou T, Tolley D.
Management of ureteric stones.
Eur Urol.
2004;
45 (6)
714-721
-
19
Bagley D H, Kuo R L, Zeltser I S.
An update on ureteroscopic instrumentation for the treatment of urolithiasis.
Curr Opin Urol.
2004;
14 (2)
99-106
-
20
Elashry O M, Elbahnasy A M, Rao G S, Nakada S Y, Clayman R V.
Flexible ureteroscopy: Washington University experience with the 9.3F and 7.5F flexible ureteroscopes.
J Urol.
1997;
157 (6)
2074-2080
-
21
Menezes P, Dickinson A, Timoney A G.
Flexible ureterorenoscopy for the treatment of refractory upper urinary tract stones.
BJU Int.
1999;
84 (3)
257-260
-
22
Troy A J, Anagnostou T, Tolley D A.
Flexible upper tract endoscopy.
BJU Int.
2004;
93 (5)
671-679
-
23
Chiu K Y, Cai Y, Marcovich R, Smith A D, Lee B R.
Are new-generation flexible ureteroscopes better than their predecessors?.
BJU Int.
2004;
93 (1)
115-119
-
24
Shvarts O, Perry K T, Goff B, Schulam P G.
Improved functional deflection with a dual-deflection flexible ureteroscope.
J Endourol.
2004;
18 (2)
141-144
-
25
Collins J W, Keeley Jr F X, Timoney A.
Cost analysis of flexible ureterorenoscopy.
BJU Int.
2004;
93 (7)
1023-1026
-
26
Delvecchio F C, Preminger G M.
Endoscopic management of urologic disease with the holmium laser.
Curr Opin Urol.
2000;
10 (3)
233-237
-
27
Grasso M, Chalik Y.
Principles and applications of laser lithotripsy: experience with the holmium laser lithotrite.
J Clin Laser Med Surg.
1998;
16 (1)
3-7
-
28
Sofer M, Watterson J D, Wollin T A, Nott L, Razvi H, Denstedt J D.
Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients.
J Urol.
2002;
167 (1)
31-34
-
29
Teichman J M, Vassar G J, Glickman R D.
Holmium:yttrium-aluminum-garnet lithotripsy efficiency varies with stone composition.
Urology.
1998;
52 (3)
392-397
-
30
Teichman J M, Rao R D, Rogenes V J, Harris J M.
Ureteroscopic management of ureteral calculi: electrohydraulic versus holmium:YAG lithotripsy.
J Urol.
1997;
158 (4)
1357-1361
-
31
Michel M S, Knoll T, Ptaschnyk T, Kohrmann K U, Alken P.
Flexible ureterorenoscopy for the treatment of lower pole calyx stones: influence of different lithotripsy probes and stone extraction tools on scope deflection and irrigation flow.
Eur Urol.
2002;
41 (3)
312-316
-
32
Cybulski P A, Joo H, Honey R J.
Ureteroscopy: anesthetic considerations.
Urol Clin North Am.
2004;
31 (1)
43-47
-
33
Jeong H, Kwak C, Lee S E.
Ureteric stenting after ureteroscopy for ureteric stones: a prospective randomized study assessing symptoms and complications.
BJU Int.
2004;
93 (7)
1032-1034
-
34
Srivastava A, Gupta R, Kumar A, Kapoor R, Mandhani A.
Routine stenting after ureteroscopy for distal ureteral calculi is unnecessary: results of a randomized controlled trial.
J Endourol.
2003;
17 (10)
871-874
-
35
Lifshitz D A, Lingeman J E.
Ureteroscopy as a first-line intervention for ureteral calculi in pregnancy.
J Endourol.
2002;
16 (1)
19-22
-
36
Dogan H S, Tekgul S, Akdogan B, Keskin M S, Sahin A.
Use of the holmium:YAG laser for ureterolithotripsy in children.
BJU Int.
2004;
94 (1)
131-133
-
37
Satar N, Zeren S, Bayazit Y, Aridogan I A, Soyupak B, Tansug Z.
Rigid ureteroscopy for the treatment of ureteral calculi in children.
J Urol.
2004;
172 (1)
298-300
-
38
Andreoni C, Afane J, Olweny E, Clayman R V.
Flexible ureteroscopic lithotripsy: first-line therapy for proximal ureteral and renal calculi in the morbidly obese and superobese patient.
J Endourol.
2001;
15 (5)
493-498
-
39
Albala D M, Assimos D G, Clayman R V, Denstedt J D, Grasso M, Gutierrez-Aceves J. et al .
Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results.
J Urol.
2001;
166 (6)
2072-2080
-
40
Lingeman J E, Siegel Y I, Steele B, Nyhuis A W, Woods J R.
Management of lower pole nephrolithiasis: a critical analysis.
J Urol.
1994;
151 (3)
663-667
-
41
Kim S C, Kuo R L, Lingeman J E.
Percutaneous nephrolithotomy: an update.
Curr Opin Urol.
2003;
13 (3)
235-241
-
42
Lahme S, Bichler K H, Strohmaier W L, Gotz T.
Minimally invasive PCNL in patients with renal pelvic and calyceal stones.
Eur Urol.
2001;
40 (6)
619-624
-
43
Desai M R, Kukreja R A, Desai M M, Mhaskar S S, Wani K A, Patel S H. et al .
A prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless.
J Urol.
2004;
172 (2)
565-577
-
44
Raj G V, Auge B K, Weizer A Z, Denstedt J D, Watterson J D, Beiko D T. et al .
Percutaneous management of calculi within horseshoe kidneys.
J Urol.
2003;
170 (1)
48-51
-
45
Francesca F, Felipetto R, Mosca F, Boggi U, Rizzo G, Puccini R.
Percutaneous nephrolithotomy of transplanted kidney.
J Endourol.
2002;
16 (4)
225-227
-
46
Martin X, Murat F J, Feitosa L C, Rouviere O, Lyonnet D, Gelet A. et al .
Severe bleeding after nephrolithotomy: results of hyperselective embolization.
Eur Urol.
2000;
37 (2)
136-139
-
47
Knoll T, Michel M S, Kohrmann K U, Alken P.
Urologic interventional therapy of kidney calculi (II)-Endoscopic methods: ureterorenoscopy and percutaneous nephrolitholapaxy.
Ther Umsch.
2003;
60 (2)
103-107
-
48
Knoll T, Heger K, Haecker A, Osman M, Alken P, Kohrmann K U. et al .
Percutaneous nephrolithotomy: Experience from 348 procedures.
Eur Urol.
2004;
3
42
-
49
Zegel H G, Pollack H M, Banner M C, Goldberg B B, Arger P H, Mulhern C. et al .
Percutaneous nephrostomy: comparison of sonographic and fluoroscopic guidance.
AJR Am J Roentgenol.
1981;
137 (5)
925-927
-
50
Skrepetis K, Doumas K, Siafakas I, Lykourinas M.
Laparoscopic versus open ureterolithotomy. A comparative study.
Eur Urol..
2001;
40 (1)
32-36
-
51
Keeley F X, Gialas I, Pillai M, Chrisofos M, Tolley D A.
Laparoscopic ureterolithotomy: the Edinburgh experience.
BJU Int.
1999;
84 (7)
765-769
-
52
Segura J W, Preminger G M, Assimos D G, Dretler S P, Kahn R I, Lingeman J E. et al .
Nephrolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. The American Urological Association Nephrolithiasis Clinical Guidelines Panel.
J Urol.
1994;
151 (6)
1648-1651
-
53
Murray M J, Chandhoke P S, Berman C J, Sankey N E.
Outcome of extracorporeal shockwave lithotripsy monotherapy for large renal calculi: effect of stone and collecting system surface areas and cost-effectiveness of treatment.
J Endourol.
1995;
9 (1)
9-13
-
54
Zhong P, Preminger G M.
Mechanisms of differing stone fragility in extracorporeal shockwave lithotripsy.
J Endourol.
1994;
8 (4)
263-268
-
55
Gupta N P, Singh D V, Hemal A K, Mandal S.
Infundibulopelvic anatomy and clearance of inferior caliceal calculi with shock wave lithotripsy.
J Urol.
2000;
163 (1)
24-27
-
56
Keeley Jr F X, Moussa S A, Smith G, Tolley D A.
Clearance of lower-pole stones following shock wave lithotripsy: effect of the infundibulopelvic angle.
Eur Urol.
1999;
36 (5)
371-375
-
57
Elbahnasy A M, Clayman R V, Shalhav A L, Hoenig D M, Chandhoke P, Lingeman J E. et al .
Lower-pole caliceal stone clearance after shockwave lithotripsy, percutaneous nephrolithotomy, and flexible ureteroscopy: impact of radiographic spatial anatomy.
J Endourol.
1998;
12 (2)
113-119
-
58
Knoll T, Musial A, Trojan L, Ptashnyk T, Michel M S, Alken P. et al .
Measurement of renal anatomy for prediction of lower-pole caliceal stone clearance: reproducibility of different parameters.
J Endourol.
2003;
17 (7)
447-451
-
59
Madbouly K, Sheir K Z, Elsobky E.
Impact of lower pole renal anatomy on stone clearance after shock wave lithotripsy: fact or fiction?.
J Urol.
2001;
165 (5)
1415-1418
-
60
Hollenbeck B K, Schuster T G, Faerber G J, Wolf J S.
Flexible ureteroscopy in conjunction with in situ lithotripsy for lower pole calculi.
Urology.
2001;
58 (6)
859-863
-
61
Pace K T, Weir M J, Tariq N, Honey R J.
Low success rate of repeat shock wave lithotripsy for ureteral stones after failed initial treatment.
J Urol.
2000;
164 (6)
1905-1907
-
62
Wu C F, Shee J J, Lin W Y, Lin C L, Chen C S.
Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with holmium:YAG laser lithotripsy for treating large proximal ureteral stones.
J Urol.
2004;
172 (5 Pt 1)
1899-1902
-
63
Peschel R, Janetschek G, Bartsch G.
Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study.
J Urol.
1999;
162 (6)
1909-1912
-
64
Pearle M S, Nadler R, Bercowsky E, Chen C, Dunn M, Figenshau R S. et al .
Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.
J Urol.
2001;
166 (4)
1255-1260
-
65
Buchholz N P, Meier-Padel S, Rutishauser G.
Minor residual fragments after extracorporeal shockwave lithotripsy: spontaneous clearance or risk factor for recurrent stone formation?.
J Endourol.
1997;
11 (4)
227-232
-
66
Strohmaier W L.
Socioeconomic aspects of urinary calculi and metaphylaxis of urinary calculi.
Urologe A.
2000;
39 (2)
166-170
-
67
Hesse A, Brandle E, Wilbert D, Kohrmann K U, Alken P.
Study on the prevalence and incidence of urolithiasis in Germany comparing the years 1979 vs. 2000.
Eur Urol.
2003;
44 (6)
709-713
-
68
Caramia G, Di Gregorio L, Tarantino M L, Galuffo A, Iacolino R, Caramia M.
Uric acid, phosphate and oxalate stones: treatment and prophylaxis.
Urol Int..
2004;
72 Suppl 1
24-28
-
69
Chandhoke P S.
When is medical prophylaxis cost-effective for recurrent calcium stones?.
J Urol.
2002;
168 (3)
937-940
-
70
Hesse A, Siener R, Heynck H, Jahnen A.
The influence of dietary factors on the risk of urinary stone formation.
Scanning Microsc.
1993;
7 (3)
1119-1127
-
71
Klocke K, Hesse A, Vahlensieck W, Schneeberger W.
Prevention of recurrent stone formation: long time results under treatment based on an extended metabolic investigation.
Urol Res.
1992;
20 (1)
94-95
-
72
Lotan Y, Cadeddu J A, Roerhborn C G, Pak C Y, Pearle M S.
Cost-effectiveness of medical management strategies for nephrolithiasis.
J Urol.
2004;
172 (6 Pt 1)
2275-2281
-
73
Heimbach D, Jacobs D, Muller S C, Hesse A.
Influence of alkaline solutions on chemolitholysis and lithotripsy of uric acid stones. An in vitro study.
Eur Urol.
2000;
38 (5)
621-626
Dr. Thomas Knoll
Urologische Universitätsklinik · Klinikum Mannheim
Theodor-Kutzer-Ufer 1 - 3
68135 Mannheim
Phone: 0621/383-3349
Fax: 0621/383-734080
Email: t.knoll@uro.ma.uni-heidelberg.de
