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Recent Advances in Endourology, 3
M. Akimoto, E. Higashihara
H. Kumon, Z. Masaki, S. Orikasa
(Eds.)
Treatment of Urolithiasis
With 43 Figures, Including 1 in Color
, Springer
Masao Akimoto, M.D.
Professor and Chairman, Department of Urology, Nippon Medical SchooL 1-1-5 Sendagi.
Bunkyo-ku, Tokyo 113-8603, Japan
Eiji Higashihara, M.D.
Professor, Department of Urology, Kyorin University, 6-20-2 Shinkawa, Mitaka. Tokyo 181-
8611, Japan
Hiromi Kumon, M.D.
Professor, Department of Urology, Okayama University Graduate School of Medicine and
Dentistry, 2-5-1 Shikata-cho. Okayama 700-8558, Japan
Zenjiro Masaki, M.D.
Professor, Department of Urology. Saga Medical School. 5-1-1 N abeshima, Saga 849-8501. Japan
Seiichi Orikasa, M.D.
Professor, Department of Urology. Tohoku University, 1-1 Seiryo-machi. Aoba-ku, Sendai 980-
8574, Japan
ISBN-13: 978-4-431-68519-7
Library of Congress Cataloging-in-Publication Data
Treatment of urolithiasis / M. Akimoto ... let al.], (eds.).
p. : cm. - (Recent advances in endourology : 3)
Includes bibliographical references and index.
ISBN-13: 978-4-431-68519-7 e-ISBN-13: 978-4-431-68517-3
DOl: 10.1007/978-4-431-68517-3
1. Urinary organs-Calculi-Treatment. 2. Extracorporeal shock wave lithotripsy. I.
Akimoto, Masao, 1935-II. Series.
[DNLM: 1. Urinary Calculi-therapy. 2. Lithotripsy. WJ 100 T784 2001]
RC916.T74 2001
616.6'2206-dc21
2001032081
Printed on acid-free paper
© The Japanese Society of Endourology and ESWL 2001
Softcover reprint of the hardcover 1s t edition 2001
This work is subject to copyright. All rights are reserved, whether the whole or part of the material
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and therefore free for general use.
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Typesetting: Best-set Typesetter Ltd .. Hong Kong
SPIN: 10833358 series number 4130
Preface
Urolithiasis is not only one of the most frequently encountered diseases at uro
logical clinics; it is also the disorder whose treatment has shown the most rapid
progress in the past decade. In that period, medicine has experienced a real
revolution, characterized by minimally invasive treatments, improvement of the
quality of life, and cost-effectiveness in treatment outcomes. In urology, the
revolution started with the development of endoscopic retrograde treatment of
urolithiasis in the upper urinary tract, which led to development of the percuta
neous antegrade maneuver in the latter half of the 1970s. The most remarkable
event occurred in 1982, when clinical use of extracorporeal shock wave lithotripsy
was introduced by the Munich group, represented by Dr. Christian Chaussy, at
the 18th Congress of the International Society of Urology in San Francisco. With
the advent of these new strategies, open surgery for urolithiasis has all but dis
appeared. Today, with the availability of new technology and equipment, guide
lines for the treatment of urolithiasis have changed in all developed countries.
It is quite timely that the Meeting of International Consultation on Urolithiasis
will be held in Paris in June 2001 to establish international guidelines for
urolithiasis.
Looking through this textbook for urolithiasis, I was greatly impressed to learn
that we have already drawn up some guidelines. The book includes all the
updated advances of urolithiasis presented by the most prominent and experi
enced urologists from all around the world. I am quite confident that a great
benefit will be assured not only for those who are new to the field but also for
specialists, in obtaining the latest knowledge of urolithiasis and treatment
techniques.
March 2001
YOSHIO Aso, M.D.
Honorary President, JSEE
Immediate Past President, SIU
Professor Emeritus, The University of Tokyo
v
Contents
Preface ........................................................ V
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX
Clinical Practice Guidelines for Ureteral Stones: Implications in Japan
and Limitations
E. HIGASHIHARA ............................................... 1
Management of Urolithiasis: Guidelines in the USA
S. RAMAKUMAR and 1.W. SEGURA ................................. 12
Epidemiology of Urolithiasis in Japan
A. TERAI and 0. YOSHIDA ....................................... 23
Urolithiasis-Patient Evaluation and Medical Treatment
D.A. LIFSHITZ, A.L. SHALHAV, and 1.E. LINGEMAN . . . . . . . . . . . . . . . . . . . 37
Contemporary Management of Distal Ureteral Calculi
M.T. GETTMAN and M.S. PEARLE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60
Percutaneous Nephrolithotripsy (PNL): What Factors Make PNL
Difficult and What Are the Ways to Prevent and Solve Those Problems?
A. YAMAGUCHI, K. MIYAZAKI, H. MEIRI, 1. UOZUMI, and Z. MASAKI 75
Technology of Shockwave Lithotripsy
G.K. CHOW and S.B. STREEM .................................... 88
Ureteroscopic Lithotripsy
M. Grasso III ................................................. 98
Calyceal Calculi
1. KOURAMBAS and G.M. PRE MINGER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Urolithiasis in Children-ESWL and Auxiliary Measures
P.-M. BRAUN, 1. HOANG-BoHM, and P. ALKEN ...................... 135
Treatment of Complicated Urolithiasis
S. ORIKASA, N. IORITANI, Y. CHIBA, S. HOSHI, and A. FUKUZAKI 143
VII
VIII Contents
Common and Uncommon Complications Related to ESWL
Y. NASU, T. KURASHIGE, and H. KUMON ........................... 153
Complications of Urolithiasis Treatment (PNL)
T. NISHIMURA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167
Subject Index ................................................... 183
Contributors
Aiken, P. 135 Masaki, Z. 75
Meiri. H. 75
Braun, P.-M. 135 Miyazaki. K. 75
Chiba, Y. 143 Nasu, Y. 153
Chow, G.K. 88 Nishimura. T. 167
Fukuzaki. A. 143 Orikasa, S. 143
Gettman, M.T. 60 Pearle, M.S. 60
Grasso III, M. 98 Pre minger, G.M. 107
Higashihara, E. 1 Ramakumar, S. 12
Hoang-B6hm, I 135
Hoshi, S. 143 Segura, IW. 12
Shalhav, AL. 37
Ioritani, N. 143 Streem, S.B. 88
Kourambas, I 107 Terai, A 23
Kumon. H. 153
Kurashige, T. 153 Uozumi. I 75
Lifshitz, D.A 37 Yamaguchi. A 75
Lingeman, IE. 37 Yoshida, O. 23
IX
Clinical Practice Guidelines for
Ureteral Stones: Implications in
Japan and Limitations
Em HIGASHIHARA
Historical and Social Background of the Development of
Clinical Practice Guidelines
Owing to the development of systematic and structured abstraction methods,
evidence-based guidelines have been proposed in many disciplines, mainly in the
United States of America [1]. A social background which forces practitioners to
draw up clinical guidelines is especially strong in the USA, where the medical
supply system is exposed to a market economy. The problem of escalating medical
costs in the USA prompted the government and the medical insurance compa
nies to introduce clinical practice guidelines. These guidelines were introduced
to control medical costs and quality, because many studies had shown wide vari
ations in physician practice patterns and the use of the health services [1]. The
health services are used inappropriately in some cases, and the health outcome
is made uncertain by the use or nonuse of the various services and procedures.
Initially, it was mainly the users of the services who began to develop guidelines,
but professionals soon recognized the importance of clinical practice guidelines.
The involvement of diverse groups in guidelines development has intensified
the need to create and improve scientific methods to develop these guidelines,
otherwise they will not be accepted by all groups whatever their economic inter
ests and attitudes.
Purpose of Guidelines
The purpose of clinical guidelines is to standardize treatment outcomes and the
costs of treatment. The treatment procedures selected for a particular disease and
its expected outcome vary among physicians, and these variances should be min
imized by using clinical guidelines. The process of minimizing these variations not
Department of Urology, Kyorin University School of Medicine, 6-20-2 Shinkawa, Mitaka,
Tokyo 181-8611, Japan
2 E. Higashihara
only reduces the range of distribution, but also improves the average level of
treatment outcomes, because the groups in which the best possible outcome is
already achieved will not generally be affected.
The guidelines are basically a summary of published treatments with statis
tical analyses of their clinical outcomes. The method used to summarize the
outcome of different treatment procedures is statistical metaanalysis. Therefore,
the results inevitably depend on published findings. Metaanalysis is limited by
the source of information rather than by the methods used.
Science-based guidelines serve to improve the quality of clinical care and its
measurement, and to reduce the financial costs of inappropriate care. The major
purposes of guidelines are (1) assisting clinical decision-making by patients and
practitioners, (2) educating individuals or groups, (3) assessing and ensuring the
quality of care, (4) guiding the distribution of resources for health care, and (5)
reducing the risk of legal liability for careless treatment [2]. The potential bene
fits of guidelines are diverse, and the guidelines are not necessarily synonymous
with the coverage policies of health insurance plans. The conflict between the
person who pays, the consumer, and the practitioner cannot be resolved by having
guidelines, but guidelines are rational social judgments about what care should
be covered by public and private health benefit plans.
Clinical practice guidelines should be constructed systematically and based
on good science practice, and structured abstracting methods were developed
for this purpose. In this sense, the scientific guidelines differ from the older type
of guidelines proposed by professional organizations or individuals. Many of the
guidelines and recommendations found in older literature and textbooks adopted
methods which were very different from evidence-based abstraction. Although
scientific abstraction methods have now been introduced, there remain signifi
cant gaps between what is needed and what is known. These gaps are usually
covered by the opinions of leading professionals or their peer group. However,
these opinions are rarely based on evidence; and should be replaced by guide
lines based on future findings.
Background of the Development of Guidelines in Japan
In Japan, the medical insurance and reimbursement system is tightly controlled
by the government, and is not directly exposed to the market economy. The clin
ical practice reimbursement guidelines (CPRGs) booklet and local reimburse
ment judgment committees regulate the reimbursement of medical costs. CPRGs
are decided solely by the government (Department of Health, Welfare, and
Labor). The Japanese Medical Associa tion and other professional medical groups
in Japan cannot directly participate in the construction of CPRGs. The CPRGs
booklet is renewed yearly from an economic standpoint, and taking into account
medical appropriateness. The framework of the CPRGs is limited by supply
side (Government) economics. Hence, the quality of hospital management and
medical care are regulated by budget limitations. The consumer-side needs
Clinical Practice Guidelines 3
(patients' needs) are of secondary importance. In contrast to the USA, the poli
cymaker's involvement in Japan is negligible, and is regarded as being related to
their private interests.
In the Japanese system, a local reimbursement judgment committee checks the
expenditures of individual medical practices. The reimbursement is refused if the
committee regards the expenditure as inappropriate. The application standards
of the local reimbursement judgment committee are based on the CPRGs. The
problems are two-fold. The application standard, i.e., the interpretation of the
CPRGs, differs from committee to committee and from member to member of
the committee, which may reflect personal preferences. The second problem
is the medical limitations of the CPRGs, which do not necessarily keep pace with
the progress of clinical medicine or with what is appropriate in clinical practice.
The Japanese health care reimbursement system works outside market princi
ples. Patients receive medical care as required, and people regard medical care
as being free. In order to safeguard the people's welfare, the medical supply side
is required to supply medical care whenever necessary. The practitioner must
provide what the patient needs as long as it is appropriate in terms of the CPRGs.
This is the background of unlimited medical sourices and escalating medical costs
which resulted in the government's tight control of expenditure.
The 21st century will be the era of the market economy, which will penetrate
into every social field, including government activities, education, and the medical
system. The overwhelming growth of the market economy will widen the dif
ferences in economic status between individuals and between countries. The
gap between industrialized and developing countries will be increased. The rich
people will become richer and poor people will stay poor. A market economy
develops energy-consuming industries and harms the Earth's environment. The
two greatest negative aspects of the market economy will produce two forces
working against its development. Ecological forces and the movement of poor
people will modify the penetration of the market economy. If any industries or
products satisfy market principles as well as environmental protectionism, that
field will expand very rapidly, as experienced recently in industries generating
electricity using solar and wind power.
In spite of the difficulties facing the medical care supply system, the govern
ment, the people (patients), and clinical practitioners in Japan are reluctant to
bring a market economy system even partially into the medical supply system.
However, the tightly regulated government system has a limited ability to adapt
to the rapid progress occurring in clinical medicine. Therefore, highly developed
clinical practices are seen as suitable area to introduce high-technology medicine
at the patient's own expense. In this system, the introduction of a new clinical
practice into an institution is allowed after an evaluation of its appropriateness.
The patient covers the medical costs of the new practice, while all related medical
expenditure is covered by the medical insurance system. The combination of per
sonal payment and a social insurance system makes the medical supply system
flexible. This combination will develop further in circumstances of budgetary
restraint.
