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H.-G. Tiselius, D. Ackermann, P. Alken, C. Buck, P. Conort, M. Gallucci, T. Knoll
© European Association of Urology 2006
TABLE OF CONTENTS
1. Background 1.1 References Classification 2.1 Categories of stone formers 2.2 Specific risk factors for stone formation 2.3 References Diagnostic procedures 3.1 Diagnostic imaging 3.1.1 Allergy to contrast medium 3.1.2 Metformin 3.1.3 Reduced renal function Risk factors for the development of reduced renal function Dosage of iodine 3.1.4 Untreated hyperthyroidism 3.1.5 References 3.2 Analysis of stone composition 3.2.1 References 3.3 Biochemical investigations 3.3.1 Analytical work-up in the acute phase 3.3.2 Analysis of urine in search for risk factors of stone formation 3.3.3 Comments on the analytical work-up 3.3.4 References Stone burden 4.1 References Treatment of patients with renal colic 5.1 Pain relief 5.1.1 Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) 5.1.2 Prevention of recurrent episodes of renal colic 5.1.3 Effects of diclofenac on renal function 5.2 References Indications for active stone removal 6.1 References Active removal of stones in the kidney 7.1 Extracorporeal shock wave lithotripsy (ESWL) for stone removal 7.1.2 ESWL for removal of large renal stones 18.104.22.168 Location of the stone mass 22.214.171.124 Stone burden 126.96.36.199 Composition and hardness of the stone 188.8.131.52 References 7.2 Percutaneous removal of renal stones 7.2.1 Complications 7.2.2 References 7.3 Aspects on staghorn stone treatment and importance of stone burden 7.3.1 ESWL 7.3.2 Percutaneous nephrolithotomy (PNL) 7.3.3 ESWL and PNL 7.3.4 Percutaneous surgery versus ESWL for removal of renal stones 7.3.5 References 7.4 Open surgery for removal of renal stones 7.4.1 Indications for open surgery 7.4.2 Operative procedures 7.4.3 References
5 6 6 6 6 7 8 8 8 8 9 9 9 10 10 11 12 12 12 13 15 16 19 19 19 19 19 20 20 20 21 21 22 22 23 23 24 24 25 30 30 30 31 31 31 31 32 32 33 33 33 34
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Chemolytic possibilities 7.5.1 Infection stones 7.5.2 Brushite stones 7.5.3 Cystine stones 7.5.4 Uric acid stones 7.5.5 Calcium oxalate and ammonium urate stones 7.5.6 References Recommendations for removal of renal stones
35 35 35 35 35 36 36 37 38 38 39 42 42 42 43 43 44 44 44 44 45 45 45 45 45 46 49 49 50 52 52 53 53 53 53 53 53 54 55 55 58 59 61 61 61 61 62 63 64 64 65 65 66
Active removal of stones in the ureter 8.1 ESWL for removal of ureteral stones 8.1.1 References 8.2 Retrograde manipulation of stones 8.2.1 Stenting 8.2.2 References 8.3 Ureteroscopy for removal of ureteral stones 8.3.1 Standard endoscopic technique 8.3.2 Anaesthesia 8.3.3 Assessment of different devices 184.108.40.206 Ureteroscopes 220.127.116.11 Disintegration devices 18.104.22.168 Baskets 22.214.171.124 Dilatation and stenting 126.96.36.199 Clinical results 188.8.131.52 Complications 184.108.40.206 Conclusion 8.3.4 References 8.4 Should ESWL or ureteroscopy (URS) be used for stone removal? 8.4.1 References 8.5 Recommendations for active removal of ureteral stones: all sizes General recommendations and precautions for stone removal 9.1 Infections 9.2 Bleeding 9.3 Pregnancy 9.4 Pacemaker 9.5 Hard stones 9.6 Radiolucent stones 9.7 References Complete or partial staghorn stones Managing special problems 11.1 References Residual fragments 12.1 References Steinstrasse 13.1 References Preventive treatment in calcium stone disease 14.1 General recommendations 14.1.1 References 14.2 Pharmacological agents in prevention of recurrent calcium stone formation 14.2.1 Thiazides and thiazide-like agents 14.2.2 Alkaline citrate 14.2.3 Orthophosphate 14.2.4 Magnesium 14.2.5 Allopurinol
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1 References 66 66 66 67 72 73 74 74 74 75 75 76 77 77 78 78 15.2.1 References Pharmacological treatment of infection stone disease 14.3 14.2.4 14.5.2. 16.7 Pyridoxine 14.3.5 14.14. 17.1 References Pharmacological treatment of cystine stone disease 14.9 References Pharmacological treatment of uric acid stone disease 220.127.116.11 Cellulose phosphate 14. ACKNOWLEDGEMENTS ABBREVIATIONS USED IN THE TEXT APPENDICES A1 Approximate stone surface area with known diameters of the stone A2 Devices for endoscopic disintegration of stones A3 References 4 UPDATE JUNE 2005 .8 Recommendations 14.
When two procedures were considered equally useful they have been given the same number. Table 1: Level of evidence (LE) Level 1a 1b 2a 2b 3 4 Type of evidence Evidence obtained from meta-analysis of randomized trials Evidence obtained from at least one randomized trial Evidence obtained from one well-designed controlled study without randomization Evidence obtained from at least one other type of well-designed quasi-experimental study Evidence obtained from well-designed non-experimental studies. 22. BACKGROUND Patients with urolithiasis constitute an important part of everyday urological practice. that no attempt has been made to cover the literature completely. The criteria for level of evidence (LE) (Table 1) and grades of recommendation (GR) (Table 2) are shown below (1). an increased understanding of the mechanisms of stone formation and advancements in pharmacological treatment of the various aspects of stone disease. This does not mean that other methods are not applicable. It is also essential to have a basic understanding of the aetiological factors of stone formation and how a metabolic risk evaluation should be carried out in order to provide a sound basis for appropriate recurrence preventive measures. since discussing associated economic issues may be . as such a step was beyond the possibilities of our work. 2.beyond the scope of a European guideline document.1. The first alternative always has the number 1. The abbreviations LE and GR are used in the tables and recommendations given in these guidelines. we focused mainly on medical aspects. It needs to be emphasized. when a certain form of therapy is not recommended. 20. the scientific basis for the various recommendations or statements has been classified in terms of level of evidence and grade of recommendation when appropriate. 18. During the past few decades. UPDATE JUNE 2005 5 . the rational treatment of acute stone colic and the modern principles of stone removal. but our intention has been to highlight the alternatives that appear most convenient for the patient in terms of low invasiveness and risk of complications. According to the principles set by the European Association of Urology (EAU) Guidelines Office. The optimal clinical management of this disease requires knowledge of the diagnostic procedures. The guidelines and recommendations given below are based on results presented in the modern literature. A number of tables throughout the text give an overview of the most appropriate methods for stone removal for different stone situations and stone compositions (tables 15. 24 & 26). correlation studies and case reports Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities Table 2: Grade of recommendation (GR) Grade A B C Nature of recommendations Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial Based on well-conducted clinical studies. 16. When recommendations were formulated. this has been specifically stated. 5) have been allocated to the procedures according to the consensus reached. whereas other statements rely on a substantial clinical experience. The current edition of Guidelines on Urolithiasis published here is an update of our previously published document (2. but without randomized clinical trials Made despite the absence of directly applicable clinical studies of good quality The various recommendations are supported by comments based on the most important relevant publications. 3. However. 19. 4.3). We are very well aware of the different treatment and technical facilities available geographically. Numbers (1. however.due to the extensive geographical diversity and variability between the financial systems in the health care sector . such as comparative studies. Some of the therapeutic principles are the result of evidence obtained from randomized or controlled studies. the whole field of treatment of patients with urolithiasis has been characterized by changes that are attributable to pronounced technical achievements.
Agency for Health Care Policy and Research. 1992. Buck C.1 CLASSIFICATION Categories of stone formers A system for subgrouping stone-forming patients into different categories is shown in Table 3.pdf Tiselius HG. http://www. Switzerland 2001 (ISBN 90-806179-3-9). Ackermann D.40:362-371. Ackermann D. In: EAU guidelines. 6 UPDATE JUNE 2005 .ncbi. 2.1.ahcpr.nlm. Alken P. Alken P. Guidelines on urolithiasis.2 Specific risk factors for stone formation Risk factors for stone formation are listed in Table 4. 2. Gallucci M.1 1.3). REFERENCES US Department of Health and Human Services. Conort P.gov/ Tiselius HG.org/files/uploaded_files/urolithiasis. Conort P. Table 3: Categories of stone formers Definition Infection stone Uric acid/ammonium urate/sodium urate stone Cystine stone First-time stone former without residual stone or fragments First-time stone former with residual stone or fragments Recurrent stone former with mild disease and without residual stone(s) or fragments Recurrent stone former with mild disease and with residual stone(s) or fragments Recurrent stone former with severe disease with or without residual stone(s) or fragments or with specific risk factors irrespective of otherwise defined category (Table 4) Category INF UR CY So Sres Rmo Rm-res Rs NON-CALCIUM STONES CALCIUM STONES 2. Buck C. Guidelines on urolithiasis. Edition presented at the 16th EAU Congress. 3.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11713390 2. http://www. These different categories are useful when making decisions regarding the need for metabolic evaluation and medical treatment (1.2. http://www. Eur Urol 2001. Geneva. Gallucci M. Public Health Service.gov/entrez/query.uroweb. pp 115-127.nih.
nih.gov/entrez/query. BJU Int 2003. caliceal cyst ■ ureteral stricture ■ vesico-ureteral reflux ■ horseshoe kidney ■ ureterocele 2.40:362-371. Etiology and investigation of stone disease. CaHPO4. http://www. Tiselius HG. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11713390 3. Alken P.nih. Guidelines on urolithiasis.3 1.Table 4: Risk factors for recurrent stone formation • Onset of disease early in life. Curriculum in Urology. REFERENCES Tiselius HG. Ackermann D.2H2O) • Strong family history of stone formation • Only one functioning kidney (only one kidney does not mean an increased risk of stone formation.ncbi. Conort P. Eur Urol 2001. below 25 years of age • Stones containing brushite (calcium hydrogen phosphate. Epidemiology and medical management of stone disease.gov/entrez/query. Eur Urol 1998.ncbi.nlm.e. Gallucci M.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12709088 Tiselius HG.nlm. 2.. but these patients should be particularly considered for measures to prevent stone recurrence) • Diseases associated with stone formation ■ hyperparathyroidism (HPT) ■ renal tubular acidosis (RTA) (partial/complete) ■ cystinuria ■ primary hyperoxaluria ■ jejunoileal bypass ■ Crohn’s disease ■ intestinal resection ■ malabsorptive conditions ■ sarcoidosis ■ hyperthyroidism • Medication associated with stone formation ■ calcium supplements ■ vitamin D supplements ■ acetazolamide ■ ascorbic acid in megadoses (> 4 g/day) ■ sulphonamides ■ triamterene ■ indinavir • Anatomical abnormalities associated with stone formation ■ tubular ectasia (medullary sponge kidney) ■ pelvo-ureteral junction obstruction ■ caliceal diverticulum. Buck C.91:758-767. UPDATE JUNE 2005 7 . i.33:1-7.
1 Allergy to contrast medium Where there is a need for administration of contrast medium to patients who have reported allergic reactions (Table 7). given 1 hour before contrast administration. IVP) has been established as a gold standard. vomiting and mild fever.g. 8 UPDATE JUNE 2005 . In case of an acute stone colic. LE = level of evidence. CT = computed tomography. Special examinations carried out in selected cases include retrograde pyelography. In randomized prospective studies. The diagnostic work-up of all patients with symptoms of urinary tract stones requires a reliable imaging technique (Table 5).1. or in those who are at such a risk. prednisolone 30 mg) between 12 and 2 hours before the contrast medium is injected. antegrade pyelography and scintigraphy.1 Excretory urography Standard 3.11). and when the diagnosis of stone is in doubt.1 Unenhanced helical CT A/1 1-10 3. but the intake of metformin should be stopped from the time of the radiological examination until 48 hours have passed and the serum creatinine remains normal. ureters and bladder (KUB) combined with ultrasonography (US). In selected cases. However. particularly in the presence of reduced renal function (i.1. 3.e. the specificity and sensitivity of this method for patients with acute flank pain was found to be similar to that obtained with urography (4.13): • Always use low-molecular non-ionic contrast medium. An alternative and commonly applied method for evaluating patients with acute flank pain is a plain film of kidneys.g. Unfortunately. the advantage of a non-contrast imaging modality has to be balanced against the higher radiation dose given to the patient during CT investigation (3.2 Metformin Administration of metformin (a drug used to treat diabetes type II) might give rise to lactic acidosis in case of contrast-induced anuria (14-16). • In metformin-treated patients with a normal serum creatinine. According to the recommendations given by the European Society of Urogenital Radiology (12.5-9). Table 5: Imaging modalities in the diagnostic work-up of patients with acute flank pain Examination GR and/or LE References Comment KUB + US B/2a 6 3.13) the serum creatinine level should be measured in every patient with diabetes being treated with metformin. • This medication might be combined with an intramuscular injection of an anti-histamine agent (e.3.. unenhanced helical computed tomography (CT) examinations have been introduced as a quick and contrast-free alternative (1. KUB = kidney. Patients with renal stone colic usually have characteristic loin pain. • Give a corticosteroid (e. It is therefore essential to have a basic understanding of the risks associated with the use of contrast medium and the necessary precautions..3). This is an unusual complication caused by retention of dimethylbiguanide.1 GR = grade of recommendation. This will immediately help to decide if a conservative approach is justified or if another treatment should be considered. The clinical diagnosis should be supported by an appropriate imaging procedure.1 DIAGNOSTIC PROCEDURES Diagnostic imaging Stone disease very often presents as an episode of acute stone colic. contrast medium is occasionally used as an auxiliary procedure for stone localization during shock wave lithotripsy.2. There is a huge bulk of experience to show that these two methods are sufficient in a large proportion of patients for the diagnosis of a ureteral stone. Imaging is imperative in patients with fever or a solitary kidney.. 3. serum creatinine > 130 µmol/L). which are radiolucent on plain films. contrast medium can be administered. ureters and bladder urography. 3.10). During recent years. clemastine 2 mg). Another advantage is the ability of CT to detect alternative diagnoses (7. lactic acidosis is associated with high mortality and great care needs to be taken when using contrast medium in patients taking metformin. Although the intravascular administration of contrast medium is usually a concern for the radiologist. Many urologists also take responsibility for the diagnostic radiological work-up of patients with stone problems. and they may have a history of stone disease. excretory urography (intravenous pyelography. US = ultrasound.5. additional information regarding renal function may be obtained by combining CT with contrast infusion. One great advantage of CT is the demonstration of uric acid and xanthine stones. the following precautions should be taken (12.
hyperpnoea. medication with metformin should be stopped and administration of contrast medium delayed until 48 hours have passed after the last intake of metformin. anorexia.age) x kg/(0. Avoid repeated injections of contrast medium at intervals less than 48 (see section 3. The administration of Nacetylcysteine 600 mg twice on the day before contrast injection has been recommended to prevent renal failure caused by contrast medium (18).13).73m2 Body surface area = kg0.1. Treatment with metformin may resume 48 hours after the examination provided that serum creatinine remains at the pre-examination level. In a situation when contrast medium has been administered to a patient on metformin treatment. UPDATE JUNE 2005 9 .1. Patients with multiple myeloma should either be examined with an alternative method or after adequate hydration.) .72 hours. In a situation where no information on renal function is available. or with a reduced renal function.82 x serum creatinine) For patients < 20 years. epigastric pain. lactic acid and blood pH should be monitored.425 x height(cm)0.25 and serum lactic acid concentration > 5 mmol/L (14. Dosage of iodine Reduced renal function means that the serum creatinine > 140 µmol/L or that the GFR is < 70 ml/min.73m2 body surface area (12. For a patient with a GFR of 80-120 mL/min. Table 6: Formulae for calculating glomerular filtration rate (GFR) and body surface area (17) Men: GFR = (140 .age) x kg/(0. Table 6 lists useful formulae for calculating GFR and body surface area (17). the administered dose of iodine should not exceed 80-90 g.• • • In patients with reduced renal function. Nephrotoxicity caused by contrast medium is diagnosed by the demonstration of a 25% or 44 µmol/L increase in serum creatinine during the 3 days that follow intravascular administration of the agent when there is no alternative explanation.5 x height(cm)/serum creatinine) x (kg/70)0.2. Symptoms of lactic acidosis are vomiting. without information on the renal function. administration of metformin should be stopped immediately and the patient should be hydrated so that diuresis is > 100 ml/h during 24 hours. diarrhoea and thirst. The investigative findings are a blood pH < 7. the dose of iodine should be limited to the same amount as the GFR expressed in mL/min/1.725 x 0. The vasoconstriction of glomerular afferent arterioles causes a reduced glomerular filtration rate (GFR) and an increased renal vascular resistance.82 x serum creatinine) Women: GFR = (0.16). When the GFR is reduced to a level between 50-80 mL/min. lethargy. such as non-steroidal anti-inflammatory agents (NSAIDs) and aminoglycosides (the latter should be stopped for at least 24 hours).007184 In patients with a serum/plasma-creatinine level exceeding 140 µmol/L (1.6 mg/100 mL) hydration before and after the use of contrast medium may be beneficial in order to prevent nephropathy. alternative imaging techniques should be used.85 x (140 . 3. Risk factors for the development of reduced renal function The following risk factors should be noted before intravenous contrast medium is used: • increased serum creatinine • dehydration • age over 70 • diabetes • congestive heart failure • concurrent treatment with nephrotoxic drugs.3 Reduced renal function Intravenous administration of contrast medium can bring about a reduced renal perfusion and toxic effect on tubular cells. the following formula should be used: Creatinine clearance = (42.07 GFR = creatinine clearance x 1. somnolence. Serum creatinine.
Prospective comparison of computerized tomography and excretory urography in the initial evaluation of asymptomatic microhematuria. 5.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11930053 Homer JA. 3.nlm.gov/entrez/query.ncbi.ncbi. http://www.1.gov/entrez/query.194:789-794. Davies-Payne DL.1.nih. Covey AM.nih.3 Contrast medium should not be given to. http://www. Rineer SK.gov/entrez/query. J Urol 2001. Peddinti BS.3. Glickman MG. Watanabe J. Randomized prospective comparison of non-contrast enhanced helical computed tomography and intravenous urography in the diagnosis of acute ureteric colic. Kane CJ. Verga M.nih. or avoided in the following circumstances Patients with an allergy to contrast media When the serum or plasma creatinine level is > 150 µmol/L To patients on medication with metformin To patients with myelomatosis LE = level of evidence 3. 10 UPDATE JUNE 2005 .166:97-101.4 Untreated hyperthyroidism For patients in whom hyperthyroidism is suspected the TSH (thyroid stimulating hormone) level should be assessed before use of contrast medium.159:735-740 http://www.ncbi. Goff WB. J Urol 2003. Aus Radiol 2001. Smith RC.ncbi. Amling CL. 6. 8. Choe KA.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7862980 Smith RC. Urology 1998. Rosenfield AT. Verga M.gov/entrez/query. Prospective comparison of non-enhanced helical computerized tomography and Doppler ultrasonography for the diagnosis of renal colic. Graham IR. Acute flank pain: Comparison of non-contrast-enhanced CT and intravenous urography.nlm.ncbi.223:98-105. Rosenfield AT.nlm. Essenmacher KR. The value of unenhanced helical computerized tomography in the management of acute flank pain.13 13 13-16 13 Comment 3. Ala-Opas M. 4.nih.5 1. Donovan MS.ncbi. Clinical characteristics of ureteral calculi detected by non-enhanced computerized tomography after unclear results of plain radiography and ultrasonography. Prospective comparison of unenhanced computed tomography and intravenous urogram in the evaluation of acute flank pain. Ogura K. Vanninen RL.gov/entrez/query. Am J Roentgenol 1996.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9474137 2.52:982-987. Patients with acute flank pain: comparison of MR urography with unenhanced helical CT.2 3. http://www. Bove P.gov/entrez/query. REFERENCES Smith RC.nih. J Urol 1998. Diagnosis of acute flank pain: value of unenhanced helical CT.ncbi. Buckley RG. http://www. Lange RC.nlm.nlm. Heino A.nlm.ncbi. http://www.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12913701 Sudah M.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11257642 Gray Sears CL. http://www. Kainulainen S.nlm.45:285-290. 7. http://www. Radiol 1995.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8571915 Kobayashi T.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9836541 Dalrymple NC. McCarthy S. Malinen A.nih.ncbi.1.170:799-802. Abdulmaaboud M. Sears ST.1 3.nih.nlm. Nishizawa K.1. Rosenfield AT.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12441939 Miller OF.gov/entrez/query.1 3.nih. Contrast medium should not be given unless these patients are appropriately treated. Partanen K. Puckett MF. J Urol 2002. Anderson KR.168:2457-2460. Kane CJ. Radiol 2002. 9.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11531750 Shokeir AA.nih. http://www.1.1. Ward JF. Table 7: Considerations regarding excretory urography LE 4 3 3 Selected references 12. Verga M. Reichard SR.165:1082-1084.
nih. a lot more information.gov/entrez/query. http://www. 16.ncbi. 13. or any other cystine test). Murchinson LE. http://www.nih. Thomsen HS. Prevention of radiographiccontrast-agent-induced reductions in renal function by acetylcysteine.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11511894 Thomsen HS.ncbi.g. Jeffrey RB. Murray AD.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12913702 Morcos SK.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9915507 Thompson NW. Morcos SK.fcgi?cmd=Retrieve&db=pubmed&dopt Abstract&list_uids= 10671870 Cockcroft DW.nih. Prediction of creatinine clearance from serum creatinine.gov/entrez/query. Laufer U. Unenhanced helical CT evaluating acute abdominal pain: a little more cost. http://www. McHardy K.11:1720-1728. or excreted as fragments following disintegration. http://www.nlm. • Demonstration of crystals of struvite or cystine upon microscopic examination of the urinary sediment. Cleveland T. Gault MH. can be expected to have influenced the stone composition. http://www.gov/entrez/query. When stone(s) or stone material have not been retrieved. 17.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9630271 McCartney MM. Prevention of generalized reactions to contrast media: a consensus report and guidelines.nih. Drugs and intravenous contrast media.gov/entrez/query. 12. • Radiographical characteristics of the stone. 15. • Serum urate (in cases where a uric acid or urate stone is a possible alternative). Metformin and contrast media . Contrast Media Safety Committee of the European Society of Urogenital Radiolology. Gaines PA. Love MH.ncbi. J Urol 2003. should be subjected to stone analysis to determine their composition (1-5).a dangerous combination? Clin Radiol 1999.nih.ncbi. http://www. Clinical risk associated with contrast angiography in metformine treated patients: a clinical review. Thompson TJ. • Urine pH (low in patients with uric acid stones. ask for urease-producing microorganisms). Mindelzun RE.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12893691 Nawaz S.343:180-184.nlm. dietary habits.nlm. http://www.nih.ncbi. environment or diseases. Gilbert FJ. Eur Radiol 2001.76:513-518. http://www.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9314959 Shinokara K.16:31-41.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10900277 3. Repeated analysis is indicated when any changes in urine composition. N Eng J Med 2000. • Bacteriuria/urine culture (in the case of a positive culture.10.nih. Clin Radiol 1998.ncbi.ncbi. due to medical treatment.54: 29-33.. Zidek W.2 Analysis of stone composition Stones that pass spontaneously.gov/entrez/query.nlm. BJU Int 2000.nlm. All patients should have at least one stone analyzed.170:803.nlm. 11.gov/entrez/query. Pearson D.nih. Nephron 1976. UPDATE JUNE 2005 11 . Editorial: Choosing imaging modality in 2003.gov/entrez/query. are removed surgically. Webb JA. Schwarzfeld C. high in patients with infection stones). Young MR. Van der Giet M. Radiol 1997. Contrast media and the kidney: European Society of Urogenital Radiology (ESUR) guidelines.53:342-344.gov/entrez/query. 14. Brand’s test (6). The preferred analytical procedures are X-ray crystallography and infrared spectroscopy.nih.85:219-221.nlm. http://www. 18.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1244564 Tepel M. Chan P. conclusions on stone composition may be based on the following observations: • Qualitative cystine test (e. Liermann D.nlm. An appropriate quantitative or semi-quantitative analysis of the stone material should enable conclusions to be drawn regarding the main constituent or constituents. Br J Radiol 2003. sodium nitroprusside test.ncbi.205:43-45.
nlm. Calcium stones.1 Analytical work-up in the acute phase For patients with an acute stone episode.fcgi?cmd=Retrieve&db=PubMed&list_uids=13954078& dopt=Abstract Daudon M. indinavir). Harris MH.nih. J Urol 1962. In cases of fever.fcgi?cmd=Retrieve&db=PubMed&list_uids=2291252&dopt= Abstract Herring LC. http://www. 3.The following calcium stones not associated with infection are referred to as radio-opaque stones: • Calcium oxalate • calcium oxalate monohydrate • calcium oxalate dihydrate • Calcium phosphate • hydroxyapatite • carbonate apatite • octacalcium phosphate • brushite • whitlockite. 12 UPDATE JUNE 2005 .ncbi.nih. Jungers P. uric acid/urate stones and cystine stones associated with infection are referred to as ‘stones with infection’. Clinical value of crystalluria and quantitative morphoconstitutional analysis of urinary calculi.g. http://www. Schwandt W.98:31-36. 2004. Infection stones have the following typical constituents: • Magnesium ammonium phosphate • Carbonate apatite. 3.18(Suppl):9-12. Observations on the analysis of ten thousand urinary calculi.24:205-210.nlm.gov/entrez/query.gov/entrez/query. Blaschke R.gov/entrez/query. xanthine and various drug metabolites (e.gov/entrez/query.8-dihydroxyadenine. Scand J Urol Nephrol 1990. • White cells and bacteria (nitrite).nlm. http://www. sulphonamide.nlm.035 stone analyses: a contribution to epidemiology of urinary stone disease. The following stones not associated with infection are referred to as uric acid/urate stones: • Uric acid • Ammonium urate • Sodium urate.17:85-92. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15499212 Otnes B. and a blood white cell count and urine culture carried out. Biloon S.nih. 6.ncbi.ncbi. • Approximate pH level. http://www.1 1.. 4. 5.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6867630&dopt= Abstract Leusmann DB. Nephron Physiol. C-reactive protein (CRP) should be assessed. 2. Cystinuria: Excretion of cystine complex which decomposes in the urine with the liberation of cystine.fcgi?cmd=Retrieve&db=PubMed&list_uids=2237297&dopt= Abstract Brand E.nih. Urol Res 1990.3. 3.3 Biochemical investigations 3.nih.2.nlm. • Serum creatinine should be analyzed as a measure of the renal function. Stone analysis.ncbi. the routine laboratory investigations should include: • Urinary sediment/dipstick test for demonstration of red cells. Results of 5. Crystalline composition of urinary stones in Norwegian patients. Less common stone constituents include 2. J Clin Chem 1980.88 545-562.ncbi. Scand J Urol Nephrol 1983. REFERENCES Asper R.86:315.
Rmo.3 mol/L sodium azide Spot urine sample The excretion of each urine variable is related to the creatinine level Two 24-hour collections Option 2 Option 3 Option 4 The presence of hydrochloric acid (HCl) prevents the precipitation of calcium oxalate and calcium phosphate in the container during storage. plasma) and urine analyses recommended for such patients are shown in Table 10. In acidified samples. Two urine collections for each set of analyses are recommended. In this respect. In order to avoid the need for future repeated blood analyses in the search for metabolic risk factors. pH Limited urine analysis (only fasting spot urine) Yes (see Table 11) Limited urine analysis (only fasting spot urine) Yes (see Table 11) Yes (see Table 11) Prevention Follow-up Yes Yes Yes No Yes No Yes Yes A patient with uncomplicated stone disease is one who is either stone-free after the first stone episode or who has a history of mild recurrent disease with long intervals between stone episodes (categories So. pH Urate.2 Analysis of urine in search for risk factors of stone formation For an identification of metabolic risk factors of stone formation. The urine collections are repeated when necessary (1-3).3. UPDATE JUNE 2005 13 . uric acid precipitates and has to be dissolved by alkalinization if urate excretion is of interest. A number of alternative collection options are feasible.3 mol/L sodium azide One 24-hour collection Sample collected in a bottle containing 30 mL of 6 mol/L hydrochloric acid One 16-hour urine collection Sample 1 collected between 06. 3.00 hours in a bottle and one 8-hour urine collection containing 20 mL of 6 mol/L hydrochloric acid Sample 2 collected between 22. Urate can be analyzed in samples collected with sodium azide. Table 9: Analytical programme for patients with stone disease Category INF UR CY So Sres Rmo Rm-res Rs Blood analysis (serum / plasma) Creatinine Creatinine. serum sodium and serum potassium levels should be measured.In cases of vomiting. a sample collected with sodium azide is useful. A collection of urine without HCl is necessary for pH measurement. Table 8: Options for urine collection Option 1 Sample 1 collected in a bottle containing 30 mL of 6 mol/L hydrochloric acid Sample 2 collected in a bottle containing 30 mL of 0. blood (serum. Urate Creatinine Yes (see Table 10) Yes (see Table 11) Yes (see Table 10) Yes (see Table 11) Yes (see Table 11) Urine analysis Culture. The stone.00 and 22. it might be helpful to assess levels of serum calcium and serum urate at this point in time.00 and 06. an analytical programme for the different categories of stone formers is shown in Table 9. HCl also counteracts the oxidation of ascorbate to oxalate. pH Cystine. A night-time urine sample in which pH is measured soon after the urine has been collected is useful because the pH may be altered when urine is stored. Table 3). with a few examples listed in Table 8.00 hours in a bottle containing 10 mL of 0.
or has not been. Optional analysis. As uric acid precipitates in acid solutions.5 Urea2. Special tests that may be required are shown in Table 12 (13-18). Rm-res. excluded by other means. Table 3). dipstick test for: • pH • Leucocytes/bacteria3 • Cystine test4 Either analysis of calcium + albumin to correct for differences in calcium concentration attributable to the albumin binding or direct analysis of ionized (free) calcium. the remaining 8 hours of the 24-hour period can be used to collect urine with sodium azide for analysis of urate. helpful in suspected uric acid/urate stone disease. Urea. First-time stone formers with residual fragments may also be considered in this respect (categories: Rs. Table 11: Analysis in patients with complicated stone disease Stone analysis In every patient one stone should be analyzed Urine analysis Fasting morning spot urine sample: Dipstick test pH Leucocytes/bacteria3 Cystine test4 Urine collection during a defined period of time: Calcium Oxalate Citrate Urate6 Magnesium2. Urine collection should be postponed until at least 4 weeks have passed after stone removal or after an episode of obstruction and should never be carried out in the presence of infection or haematuria. urate has to be analyzed in a sample that has not been acidified or following alkalinization to dissolve uric acid. Blood analysis Calcium Albumin1 Creatinine Urate2 1 2 3 4 A patient with complicated stone disease has a history of frequent recurrences. Sres. 24-hour urine.5 Creatinine Volume Either analysis of calcium + albumin to correct for differences in calcium concentration attributable to the albumin binding. Urine culture in case of bacteriuria. Cystine test if cystinuria cannot be.4 Phosphate2. A spot urine sample can be used with creatinine-related variables (7). Blood analysis Calcium Albumin1 Creatinine Urate2 1 2 3 4 5 6 14 UPDATE JUNE 2005 .Table 10: Blood and urine investigations required for analysis of risk factors in patients with uncomplicated stone disease Stone analysis In every patient one stone should be analyzed Urine analysis Fasting morning spot urine sample. 16-hour + 8-hour urine or any other collection period can be chosen provided normal excretion data are available (4-7). phosphate.5 Sodium2.4. such as AP(CaOx) index and AP(CaP) index (8-12). The stone. Analysis of magnesium and phosphate is necessary to calculate estimates of supersaturation with calcium oxalate (CaOx) and calcium phosphate (CaP). blood and urine analyses recommended for these patients are shown in Table 11 (4-12). When a 16-hour urine sample has been collected in a bottle with an acid preservative. Optional analysis.5 Potassium2. sodium and potassium measurements are used to assess the dietary habits of the patient. or direct analysis of ionized (free) calcium. with or without residual fragments or stones in the kidney or specific risk factors.
Factors for other collection periods can be found in reference 5. sodium. oxalate. The additional analytical work-up in patients with calcium stone disease is summarized in Table 12. A pH above 5. 4 hours or even spot urine samples.07 x P0. it is clearly demonstrated with a CT examination. A fasting morning urine sample (or a spot morning urine sample) should be used to measure pH (25). 15 UPDATE JUNE 2005 15 .12 x V-1. phosphate and sodium helps to reflect dietary factors of therapeutic significance. Various collection periods. 12 hours.3 Comments on the analytical work-up The purpose of analyzing serum or plasma calcium is to identify patients with hyperparathyroidism (HPT) or other conditions associated with hypercalcaemia.60 mmol/L). In the same fasting morning or spot urine sample.31 The AP[CaP] index approximately corresponds to 10 x APCaP (where APCaP is the ion-activity product of calcium phosphate).3. Urate forms uric acid in the acidified urine and has to be analyzed either following complete dissolution with alkali or in a urine sample that has not been acidified. It might occasionally be useful to carry out a calcium loading test. it has to be assessed in the same sample when creatinine-related variables are used and also for conclusions on the completeness of the collection. the urine volume (V) is expressed in litres and the urine variables (Ca. oxalate. magnesium. preferably with HCl. The protein intake can be derived from the urea excretion (Uurea.18) + 13 Estimates of the ion-activity products of calcium oxalate (AP[CaOx] index) and calcium phosphate (AP[CaP] index) can be calculated as follows (31-37): AP[CaOx] index = 1. Although the creatinine concentration might be slightly affected. oxalate and phosphate in solution.84 x Ox x Cit-0.03 In this formula. bacteriuria and cystinuria can be excluded or confirmed by an appropriate test (27). The factor 1.70 x (pH . For a 16-hour urine sample. this factor is 2. citrate and phosphate has to be acidified. are useful for this purpose provided a set of normal values is available for the collection period (4-7). mmol/L) and urine volume in litres (V) as follows (30): Intake of protein (gram) during the 24h period = (Uurea x 0. chloride and potassium. The optional analysis of urea. 17 hours. it is the concerted action of the various urine constituents which result in supersaturation and crystallization of the stone. calcium. For other collection periods. magnesium) in mmol excreted during the collection period. • To prevent the in-vitro oxidation of ascorbate to oxalate (28. Hypokalaemic hypocitraturia may be one reason for therapeutic failures in patients treated with thiazides. In those patients in whom a stone analysis has not been carried out.8 x Cit-0. The recommendation to collect two urine samples is based on observations that such an approach will increase the likelihood of detecting urine abnormalities. A relationship between abnormalities in urine composition and severity of calcium stone formation has been demonstrated (38-44). the reader should consult reference 5. In this regard it needs to be emphasized that whereas a uric acid stone is usually invisible on a plain film (KUB).5)6. a high serum urate level together with a radiolucent stone support the suspicion of a uric acid stone. The following urine variables can be analyzed in the acidified sample: calcium. citrate. the diagnosis of HPT should be established or excluded by repeated calcium analyses and assessment of the parathyroid hormone level (19-24). during and after the collection period. In the case of a high calcium concentration (> 2.7 x 10-3 x Ca1. phosphate. The aim of adding serum potassium to the analytical programme is to obtain further support for a diagnosis of suspected RTA. The AP[CaP] index for a 24-hour urine sample is calculated in the following way: AP[CaP] index = 2. The reasons for this acidification are: • To maintain calcium.29).4. but this test is not often used clinically today (13).9 is specific for the 24-hour period. oxalate.9 x Ca0. It must be emphasized that the urine sample used for analysis of calcium. Ox. Mg. It should be noted that although individual abnormal urine variables might indicate a risk of stone formation. Cit.22 x Mg-0. urea. such as for 24 hours.3. citrate. • To prevent bacterial growth and the associated alteration of urine composition. 8 The AP[CaOx] index approximately corresponds to 10 x APCaOx (where APCaOx is the ion-activity product of calcium oxalate). 16 hours.3.20 x V-1.8 in fasting morning urine raises the suspicion of incomplete or complete renal tubular acidosis (RTA) (26).
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fcgi?cmd=Retrieve&db=PubMed&list_uids=7966783&dopt= Abstract Streem SB.gov/entrez/query. Hennequin C. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy.gov/entrez/query.nih.ncbi. Merlo F. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis patients. Schmidt A. Guarneri A. Front Biosci 2003. http://www.nih. A prospective study. 38. Harris MM. Gault MH. 30.ncbi. Factors influencing the course of calcium oxalate stone disease. Brown JM. Kidney Int 2005. 27.fcgi?cmd=Retrieve&db=PubMed&list_uids=9355942&dopt= Abstract Tiselius HG. Hanak T. J Biol Chem 1930. Coe FL.ncbi. http://www. Jocham D. Abstract.151:5-9. Lacour B.nih.gov/entrez/query. D’Andre SD. J Urol 1998.8:1330-1338.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9783922&query_hl=7 Daudon M.nlm. http://www. Chafe L.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516443&query_hl=1 Robertson WG. Davis PA. Schuster C. McWhinney BC.gov/entrez/query. Lunz C.155:1186-1190.67:1934-1943.ncbi.ncbi.nlm.gov/entrez/query. 37. Jelinek P. Boujelben G.153:27-32. 33. 35.16:256.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126804&dopt= Abstract Mitch WE. Chalmers AH. J Urol 1994.nih. The fate of residual fragments after extracorporeal shock wave lithotripsy. http://www.26. http://www.gov/entrez/query. Gambaro G. Yost A. Del Nero A. http://www. Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. 29.32:2073-2074 and 1986. 36. Streem SB. http://www.nih. 1986. Enteric hyperoxaluria and urolithiasis. Kladensky J.gov/entrez/query. Montanari E. Saunders: Philadelphia.nlm.151:834-837. http://www. Baggio B.gov/entrez/query.ncbi. J Urol 1997. Long-term results in ESWL-treated urinary stone patients. Preminger GM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12957848&query_hl=3 Strauss AL.ncbi. J Urol 1995. Factors that predict the relapse of calcium nephrolithiasis during treatment.fcgi?cmd=Retrieve&db=PubMed&list_uids=8632527&dopt= Abstract Zanetti G.ncbi.nlm. Vol II.nlm. 34.nih.6:217-218.41:159-162. Pak YC. Williams HE.gov/entrez/query. Seveso M. Kumstat P.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=3762602&dopt= Abstract Wandzilak TR. Turjanica M. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8254832&dopt= Abstract Fine JK. Clin Nephrol 1994. Liedl B. 160:1640-1642.nlm. Walser M. 42. 3rd ed. Effect of high dose vitamin C on urinary oxalate levels.11:305-307. 28. J Urol 1994. 39. Anselmo G. First morning urine pH in the diagnosis on renal tubular acidosis with nephrolithiasis. Effectiveness of ESWL for lowerpole caliceal nephrolithiasis: evaluation of 452 cases. Am J Med 1982.nih.nlm. Parks JH. Mascha E.315:970-971. http://www.nlm. Maccatrozzo L. N Engl J Med 1986. In: The kidney.fcgi?cmd=Retrieve&db=PubMed&list_uids=8187359& dopt=Abstract Brand E. Fandella A. 41.158:352-355. 31. http://www. Renal stone fragments following shock wave lithotripsy.36:363-370.ncbi. Cicerello E. 40.gov/entrez/query. 32.nlm. Serial crystalluria determination and the risk of recurrence in calcium stone formers.nlm.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15840041&query_hl=10 18 UPDATE JUNE 2005 .nlm. Trinchieri A. pp 1759-1790.nih. Nutritional therapy of the uremic patient.ncbi. Metabolic abnormalities in patients with caliceal diverticular calculi. Eur Urol 1999. Bub P.gov/entrez/query. http://www. J Endourol 1992. Nespoli R. Eisenberger F.nih.72:17-24. J Endourol 1997.86:315.ncbi. Jungers P.nih. Bildon S.nlm. Rector FC Jr (eds). http://www. Brenner BM. Deutsch L. Cystinuria: excretion of a cystine complex which decomposes in the urine with the liberation of free cystine.ncbi.ncbi.nlm.nih. Coxley DM. J Urol 1996. Urol Res 1988.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224301&dopt= Abstract Pacik D.nih. A risk factor model of stone formation.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7058820&query_hl=5 Hsu TH.
5. 5. Pain relief involves the administration of the following agents by various routes: • Diclofenac sodium (LE: 1b) • Indomethacin • Ibuprophen • Hydromorphone hydrochloride + atropine sulphate • Methamizol • Pentazocine • Tramadol.1 Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) A double-blind study comparing diclofenac and spasmofen (a narcotic analgesic) (1) demonstrated a better effect with diclofenac and fewer side effects. REFERENCES Tiselius HG.ncbi. Dunthorn M. With knowledge of the length (l) and the width (w). the efficacy of diclofenac (2) was clearly demonstrated. Fornander AM. In another double-blind. we have based our recommendations on the stone surface area as well as on the largest stone diameter.gov/entrez/query.6 x SA1.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12600431 Ackermann D. http://www. J Endourol 2004. Tiselius HG. Crystallization properties in urine from calcium oxalate stone formers. The surface area can also be measured using computerized systems and from CT scans. i.27 In this guideline document.1 TREATMENT OF PATIENTS WITH RENAL COLIC Pain relief The relief of pain is usually the most urgent therapeutic step in patients with an acute stone episode. Bek-Jensen H. J Endourol 1989.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15072623&query_hl=15 4. but these are not always easy procedures.nlm.. J Urol 1995. UPDATE JUNE 2005 19 .ncbi. Newman RC. Griffith DP. Andersson A. Finlayson B. http://www.18:157-161. Auge BK.e.1 1.nlm.nlm. Stone burden in an average Swedish population of stone formers requiring active stone removal: how can the stone size be estimated in the clinical routine? Eur Urol 2003. the length of the stone as measured on the plain film. Calculation of stone volume and urinary stone staging with computer assistance.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7637098&query_hl=12 Raj GV.nih. 2.gov/entrez/query. Assimos D.154:940-946.1. 5. 4. http://www. STONE BURDEN The size of a concrement (stone burden) can be expressed in different ways. Nilsson MA.ncbi.3:355-359.25 For a quick estimate of the stone surface area.nih. With knowledge of the surface area. 43:275-281. Preminger GM.43.nih. 44. placebo-controlled study. the stone volume can be calculated by the formula below (2): Volume = 0. please refer to Table A1 (Appendix). Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys. an appropriate estimate of the stone surface area (SA) can be obtained for most stones (1): SA = l x w x π x 0. A notation of the largest diameter is the most common way of expressing size in the literature.
Scand J Urol Nephrol 1993.nih. 5. Prostaglandin-synthetase inhibition of diclofenac sodium in the treatment of renal colic: comparison with use of a narcotic analgesic.nih.ncbi. 5. Wåhlander LA. Kral JG. When pain relief cannot be obtained by medical means. double-blind. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8529732 Lundstam SO. ketoprofen is the only drug approved for the treatment of renal colic. Hydromorphone and other opiates without simultaneous administration of atropine should be avoided because of the increased risk of vomiting. suppositories or tablets of diclofenac sodium.3 Effects of diclofenac on renal function Although the renal function can be affected in patients with an already reduced function.nlm. NSAID = non-steroidal anti-inflammatory drug.ncbi.ncbi.gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6122892 Lundstam SO. http://www. 1096-1097. Oral diclofenac in the prophylactic treatment of recurrent renal colic.28:108-111. GFR = glomerular filtration rate.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8290910 2. Wåhlander LA. The effect was most pronounced in the first 4 treatment days (5). GR = grade of recommendation. placebo-controlled trial. Passage of the stone and normalization of renal function should be confirmed using appropriate methods. morphine chlorhydrate (with titration) is indicated.nih. comparative study.3 with normal renal function Diclofenac sodium is recommended as a method to counteract recurrent pain after 1b/A 5 5. Curr Ther Res 1980. Leissner KH. 3.1 Diclofenac sodium affects GFR in patients with reduced renal function.2 Prevention of recurrent episodes of renal colic In a double-blind. Gronseth JE. 5. Analgesic effect and tolerance of ketoprofen and diclofenac in acute ureteral colic.gov/entrez/query.1. 20 UPDATE JUNE 2005 . Treatment of ureteral colic by prostaglandin-synthetase inhibition with diclofenac sodium. 4. A double-blind comparison with placebo. In case of contraindication (pregnancy) or allergy to non-steroidal anti-inflammatory drugs. The recommendation is to start with diclofenac whenever possible (Table 13) and change to an alternative drug if the pain persists. Fagertun HE. it was shown that recurrent pain episodes of stone colic were significantly fewer in patients treated with 50 mg of diclofenac three times daily during the first 7 days. 50 mg administered twice daily over 3-10 days. the resistant index was reduced in patients with renal colic when NSAID treatment was given (4). Walden M. Comment: In France. REFERENCES Laerum E.1.nlm.2 an episode of ureteral colic LE = level of evidence.1. Eur Urol 1995. no differences were recorded between the two substances (3).nlm. Lancet 1982. might therefore be useful in reducing the inflammatory process and the risk of recurrent pain. Lahtinen J.1. Elvander E. Ommundsen OE.27:323-325. Kral LG. Christiansen A. For patients with ureteral stones that are expected to pass spontaneously.gov/entrez/query.28:355-358.2 1.When diclofenac was compared with ketoprofen in a randomized.1. this is not the case for normally functioning kidneys (6). Moreover. drainage by stenting or percutaneous nephrostomy (PN) or by stone removal should be carried out. The patient should be instructed to sieve the urine in order to retrieve a concrement for analysis. Table 13: Recommendations and considerations regarding treatment of the patient with renal colic Recommendations LE/GR Selected references 1-4 Comment Treatment should be started with an NSAID 1b/A 5. but not in patients 2a 6 5. taking account of the side-effects.
• Mid-ureteral stones: 45%.nlm. • Distal ureteral stones: 70%.nlm. Acta Chir Scand 1956. Hafner R. Rotenberg Z. http://www.54:455-458.nlm. It should also be observed that small stones (< 6-7 mm) residing in a calix can cause considerable pain or discomfort (6-12).ncbi. Time to stone passage for observed ureteral calculi: a guide for patient education.5. J Urol 1999. Comparison of ketorolac and diclofenac in the treatment of renal colic.nih.ncbi. For stones with a diameter > 7 mm. site and shape of the stone at the initial presentation are factors that influence the decision to remove the stone (Table 14). Farage Y. Abdulmaaboud M. BJU Int 1999. Patel KP. The likelihood of spontaneous passage must also be evaluated. Eur J Clin Pharmacol 1998.nlm. Studies have shown that asymptomatic stones in the kidney sooner or later give rise to clinical problems (5).fcgi?cmd=Retrieve&db=PubMed&list_uids=1988715&dopt= Abstract Ibrahim AI. Br J Urol 1991. A narrow caliceal neck may require dilatation. Shelty SD. http://www.gov/entrez/query. Mutabagani H. UPDATE JUNE 2005 21 . REFERENCES Sandegard E.nih. Spontaneous stone passage can be expected in up to 80% in patients with stones < 4 mm in diameter. 4. http://www.gov/entrez/query. Prognostic factors in the conservative treatment of ureteric stones.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10458343&dopt =Abstract 2. Such stones should be removed with a technique that is as little invasive as possible. Garty M.nlm. J Urol 1991. Table 14: Indications for active stone removal LE/GR Selected references 1-5 Active stone removal should be considered when the stone diameter is 2A/B > 7 mm because of a low rate of spontaneous passage When adequate pain relief cannot be achieved 4/B When stone obstruction is associated with infection* 4/B When there is a risk of pyonephrosis or urosepsis* 4/B In single kidneys with obstruction* 4/B Bilateral obstruction* 4/B * Diversion of urine with a PN catheter or bypassing the stone with a stent are minimal requirements in these patients. LE = level of evidence. 3. Cohen E.ncbi.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9776434&dopt= Abstract Shokeir AA.fcgi?cmd=Retrieve&db=PubMed&list_uids=13394022&dopt =Abstract Morse RM.fcgi?cmd=Retrieve&db=PubMed&list_uids=2032074&dopt= Abstract Miller OF. INDICATIONS FOR ACTIVE STONE REMOVAL The size. Kane CJ. Fadilla M. Ureteral calculi: natural history and treatment in an era of advanced technology.nlm. the chance of spontaneous passage is very low (1-4).84:249-251.nih. http://www. Resnick MI.nih. Prognosis of stone in the ureter.1 1. Resistive index in renal colic: the effect of nonsteroidal anti-inflammatory drugs. 6.(Suppl 219):1-67. GR = grade of recommendation 6. http://www. http://www.gov/entrez/query.gov/entrez/query.67:358-361. Awad RM. Stone removal is accordingly indicated for stones with a diameter exceeding 6-7 mm.ncbi. The overall passage rate of ureteral stones is: • Proximal ureteral stones: 25%.ncbi.162:688-691.145:263-265.gov/entrez/query.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10468715 6.
have changed the type and rate of complications.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2393803 Streem SB.gov/entrez/query. Lingeman JE. Generally.nih. Sylven M. Porpaczy P. Numerous authors have addressed this issue in recent years (3-12). It is reasonable to assume. in comparison with the Dornier HM3-lithotripter. Painful caliceal calculi. Eur Urol 1990.gov/entrez/query. for example.gov/entrez/query. Andersson L. 7. or superior to. Sonda LP. Accumulated experience has clearly shown that the success rate of ESWL is directly related to the size (volume) of the concrement and that an increased stone burden is associated with an increase in the retreatment rate. but also of all the diagnostic and ancillary procedures associated with ESWL treatment.ncbi. Currently. In the case of infected stones or bacteriuria. The latter factor probably has become more important with later generations of lithotripters. part of a uroradiological table which allows the application of not only ESWL treatment. Yost A.32:119-123. Chen MT. but at a lower cost and with greater versatility. http://www.130:752-753. Huang JK. the disintegrating power of ESWL is very good and the concerns about ESWL treatment of large stones are mainly related to the common occurrence of residual fragments and the need for repeated sessions. Small renal caliceal calculi as a cause of pain. J Urol 1987. 11. http://www. There are no clearly established rules on how often ESWL sessions can be repeated. severe skeletal malformations. J Urol 1992. 7. otherwise a percutaneous lithotripsy might be considered as a more rational option.nih.nlm. Scand J Urol Nephrol 1993. Modern lithotripters are smaller and. 9. Lee YH. Kvist Kristensen J.2).ncbi. All these factors give an efficacy that is the same as. the contraindications to ESWL treatment are restricted to pregnancy.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8493473 7. however.gov/entrez/query.gov/entrez/query. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup.1 ACTIVE REMOVAL OF STONES IN THE KIDNEY Extracorporeal shock wave lithotripsy (ESWL) for stone removal Twenty years after the worldwide dissemination of ESWL technology.nih. Moreover. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6887409 Psihramis KE.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3116280 Coury TA.ncbi.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2261935 Hübner W.nlm.gov/entrez/query. 8. http://www. Treatment of painful caliceal stones. J Urol 1983. severe obesity and aortic and/or renal artery aneurysms (1.138:707-711. This has led to the conclusion that large stones are better treated with a percutaneous approach (see below).ncbi. the development of lithotripters. When repeated treatments are necessary. http://www.nih. http://www.5.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3400135 Lee MH. Dretler SP. not a contraindication. it is recommended that the number of shock waves and the power used should be restricted in order to avoid damage to the renal tissue and bleeding complications (see below). The treatment of small nonobstructing caliceal calculi in patients with symptoms.nih. as well as modified indications and principles for treatment.ncbi. Management of painful caliceal stones by extracorporeal shock wave lithotripsy. in the vast majority of cases.27:75-76.nih.66:9-11. Lange P. Chang LS. because of their smaller focal volumes.nlm.nlm. Kahnoski RJ. 10. ESWL should not be carried out in patients with uncontrolled blood coagulation or uncontrolled urinary tract infection. Treatment of caliceal calculi. It is recommended that the number of ESWL sessions should not exceed three to five (dependent on the lithotripter used). that the interval between two successive sessions must be longer for electrohydraulic and electromagnetic lithotripsy than for treatments with piezoelectric equipment. In addition to the size of the stone. 6. antibiotic therapy should be given before ESWL treatment and continued for at least 4 days after the treatment.gov/entrez/query.18:211-214. http://www.nlm.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1507327 Brandt B. that of the first lithotripters on the market. Even the indications for stone removal were modified when shock wave lithotripsy was introduced. http://www. 22 UPDATE JUNE 2005 . Ostri P. Br J Urol 1990. A pacemaker is. however.148:1043-1046.ncbi. the intrarenal position and chemical composition of the stone are determinants of the treatment results. Urology 1988.
1 Location of the stone mass Lower caliceal stones are considered to have a lower successful clearance rate than stones located elsewhere in the kidney.255 cases. that the interval should be determined by the energy level used and the number of shock waves given. There are some reports indicating that ESWL is also useful in patients with medullary sponge kidneys (tubular ectasia) and nephrocalcinosis (18. and occasional urosepsis due to difficulties in passage of stone particles especially in case of insufficient disintegration (53-58). It has been observed that the lower calices are insufficiently cleared of disintegrated stone material in up to 35% of ESWL-treated patients.1. Moreover. with one study showing that only 50% of the patients were stone-free at 3-months follow-up (14).100 patients treated for kidney stones with ESWL. Some authors claim that percutaneous surgery is the treatment of choice for these patients (16. the risk of damage is most pronounced with treatments directed towards stones in the kidney.2 ESWL for removal of large renal stones ESWL for the treatment of large renal stones often causes problems. This number again depends on the type of lithotripter and the shock wave power used.Moreover. even when ultrasonography does not reveal any dilatation. It might. In one treatment series the incidence of auxiliary procedures was reported to be 24% and the re-treatment rate 27% (15). satisfactory disintegration was recorded in 32. In transplanted kidneys. the efficacy of ESWL is similar to that in normal kidneys and well tolerated. hydronephrosis. One factor that might affect the result of ESWL treatment is the presence of anatomical abnormalities. In a series of 35. the obstructive and infective complications after ESWL due to large renal stones are reduced. There is no consensus on the maximum number of shock waves that can be delivered at each session. A faster clearance of upper pole stones has been observed. The success rate depends mainly on the lithotripter used and varies between 53% and 60%. In ectopic kidneys.19). Almost since the introduction of ESWL.2. By using a double-J stent. It is still unknown why stones preferentially develop in the lower pole calices. • Total stone burden. In the horseshoe kidney. Malformations of the renal collecting system can be the reason for stone formation due to an altered mechanism of urine elimination and thus to an impaired stone fragment passage. stents are not efficient in draining purulent or mucoid material.1. however. In view of the numerous lithotripters presently in use it is not possible to give a general recommendation in this regard. It stands to reason. Insertion of the stent before ESWL is advocated for stones with a diameter > 20 mm (54. Such fragments either emerge from stones originally found in this part of the kidney or from stones at other locations. 7. Attempts have been made to explain the insufficient clearance of fragments and to predict the outcome of ESWL-treatments from geometrical observations of the lower calix anatomy. and shorter intervals between treatment sessions are usually acceptable for stones in the ureter. the incidence of stones is around 20%. a PN tube is necessary. be helpful to note that the time required for resolution of contusions in the renal tissue is in the range of about 2 weeks (13) and it might accordingly be wise to allow 10-14 days to pass between two successive ESWL sessions for stones in the kidney. Clinical experience supports this view. it is well recognized that most residual fragments are lodged in the lower caliceal system. Stone particles may pass easily along stents while urine flows in and around the stent.17). UPDATE JUNE 2005 23 . The stone-free rate in these patients was 70% with re-treatments in 10. the efficacy of ESWL is strictly related to the position of the kidney. • State of contralateral kidney: nephrectomy or functionless kidney on the other side. without any particular side-effects (20). The following factors are crucial with respect to treatment success: • Location of the stone mass (pelvic or caliceal). In case of fever lasting for a few days. there has been a continuous debate on the best way to treat stones in the lower calix. fever. however. but in view of the greater morbidity and complication rate of this technique percutaneous lithotripsy can only be recommended when previous ESWL treatment has failed. which is 92%.55). although the accumulation of fragments in this position is most probably due to the effect of gravity. The need of auxiliary procedures in these patients is high. This is an important issue because a large number of kidney stones are located in this part of the kidney.5% (2152). • Composition and hardness of the stone (53). Sometimes. This usually prevents obstruction with loss of ureteral contraction. Frequent complications are pain. 7. leading to a risk of obstructive pyelonephritis.
there is no clear cut-off for a critical stone size. for cystine stones with a diameter greater than 15 mm. as well as the infundibulum length and width. however. the size of the stones has been found to be the most important determining factor (64. a long infundibulum (59. ESWL can still be considered an option for treatment. but larger stones are also successfully treated with ESWL in some centres. that the risk of complications of the combined treatment or PNL alone is higher than for ESWL monotherapy. ESWL monotherapy provided satisfactory results only in patients with pelvic stones smaller than 1 cm. ESWL is the recommended treatment. At least for stones with a largest diameter of 20 mm (surface area ~ 300 mm2).2 Stone burden Although the problems associated with removal of stones from the kidney increases with the volume of the stone. The recommended upper size limit for ESWL in this document is 20 mm (300 mm2). It is of note. Several authors have shown that a better stone-free rate can be obtained with PNL. ESWL as monotherapy is currently not recommended.or struvite-containing stones provides reasonable results in terms of stone removal and complications (58). It is important to note that there are two types of cystine stone morphology: smooth and rough.63) have a negative influence on fragment clearance. the results are contradictory and there is no strong evidence that these variables can be used to predict the outcome of ESWL. Instead of multiple ESWL sessions. 7. Another factor that most certainly is of great importance is the less well-understood caliceal physiology (63. The success rate for larger stones was only 43% after 3 months with ESWL monotherapy. a stonefree rate of about 71% was reported.1. Since residual fragments are found in patients with stones smaller than 20 mm (300 mm2) and since very large stones can be successfully disintegrated with only one ESWL session. ESWL should be considered to be the first choice for treatment. a success rate of 86% (stone-free or residual material likely to undergo spontaneous discharge) after 3 months was described for stones with an area smaller than that. With ESWL monotherapy (only stent). rather than above. It appears that an area of 40 x 30 mm (940 mm2) could represent an upper limit for ESWL alone. Stones composed of uric acid and calcium oxalate dihydrate have a better coefficient of fragmentation than those composed of calcium oxalate monohydrate and cystine. several authors have concluded that an acute infundibulum angle (59-63). The invariance and morbidity of PNL undoubtedly needs to be taken into account. with success rates of 71-96% and acceptable morbidity and complications.2. no such relationship has been demonstrated (64-69). respectively (8). a long calix neck or a narrow calix can undoubtedly counteract elimination of fragments. ESWL after PNL seems to be more effective than PNL after ESWL. however. Stone composition can be an important factor in the disintegration and subsequent elimination of fragments. A total of 76% of cystine stones have a maximum diameter larger than 25 mm (while only 29% of all stone patients have stones of this size). the problem might be more rationally solved using PNL. In the absence of a geometrical explanation. Although an acute angle.By taking measurements of the infundibulopelvic angle. Below this size. particularly when the stones become larger. About 1% of all patients treated for urinary tract stones by ESWL have cystine stones. and in one report the authors even noted that the clearance of fragments was better with an infundibulopelvic angle below. even if the stone has an area larger than 40 x 30 mm (57). a figure that dropped to 40% when the diameter exceeded 20 mm (9). PNL. 24 UPDATE JUNE 2005 . In the case of a solitary kidney. 70° (68). In other studies. provided the pros and cons are clear. For larger stones. it is difficult to formulate specific guidelines on how to remove stones from the kidney.67. For cystine stones with a diameter less than 15 mm. The indication for open stone surgery has become extremely rare because of the invasiveness of this approach (55.3 Composition and hardness of the stone ESWL monotherapy of large calcium. is an effective treatment for all other patients with cystine stones (70. In the treatment of stones with an area larger than 40 x 30 mm.2.56). However.66. the combination of PNL and ESWL (sandwich approach) has emerged as a solution. It might be relevant to note that a previous percutaneous procedure in one study (69) was considered as a negative determinant of fragment clearance.69). Today most authors consider a largest stone diameter of 20 mm as a practical upper limit for ESWL. despite the lower clearance of fragments. The latter is much more susceptible to shockwaves than the first one (72). This conclusion was based both on observations in a randomised prospective study comparing ESWL and PNL (66) and in a multivariate analysis (64).69).1.71). possibly combined with ESWL. Thus.63) and/or a narrow infundibulum (59-61. it might be feasible to try ESWL monotherapy first. 7. Success rates for these two groups of stones were shown to be 38-81% and 60-63%. Patients with large cystine stones need up to 66% more ESWL sessions and shock waves to reach satisfactory results in comparison with other stone patients (70).
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Percutaneus nephrolithotomy: an update.nlm.2. In selected cases with anatomical anomalities. However. Bleeding is generally avoided by an anatomically oriented access. percutaneous procedures have different degrees of difficulty. placement of a nephrostomy tube and secondary intervention at a later date.gov/entrez/query.nlm.ncbi. if ESWL is available. and to ensure that organs adjacent to the kidney (such as the spleen. However.2 1. bleeding results from an arterial injury and can be managed by angiographic superselective embolization. the indications for PNL should be limited to cases in which a less favourable outcome is expected after ESWL. treatment time increases with stone size. Bhatta KM. In the least traumatic access. as described above. Pre-procedural sonography of the kidney and the surrounding structures is recommended to determine the optimal access site and the position of the stone in the kidney (ventral or dorsal). The procedure should only be carried out by experienced surgeons in these cases. Dretler SP. large bowel.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12692448 30 UPDATE JUNE 2005 . 7.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2795746 7. tubeless percutaneous nephrolithotomy may be a safe alternative (7). it is still a surgical procedure and thus it is necessary to carefully consider the patient’s anatomy in order to avoid complications.nih. Cystine calculi-rough and smooth: a new clinical distinction. Dilatation of the tract is possible with the Amplatz system.ncbi. 13:235-41. availability and costs. After completion of the procedure.72. These images will also give some indication as to whether the stones will respond poorly to ESWL (such as stones composed of cystine. electrohydraulic. There are no major vessels in this region and there is only minimal bleeding. which is why this method is recommended only for stones with a diameter < 20 mm (4). REFERENCES Kim SC. However. continuous removal of small fragments by suction or extraction is preferred. Kuo RL. The most frequently used access site is the dorsal calix of the lower pole. a self-retaining balloon nephrostomy tube is the best choice to secure tamponading of the tract and access to the collecting system. The choice is a matter of experience. such as stones in diverticulae or stones completely filling the target calix. so-called ‘mini-perc’ instruments have smaller dimensions with 12-20 F. Furthermore. These small-calibre instruments possibly have a lower rate of tract dilation-related complications such as bleeding or renal trauma.gov/entrez/query. calcium oxalate. pleura and lungs) are not within the planned percutaneous path (1. liver. CT-guided renal access may be an option (3). the puncture site on the skin lies in the extension of the long axis of the target calix and the puncture goes through the papilla. To reduce the number of residual fragments. The percutaneous puncture may be facilitated by the preliminary placement of a balloon ureteral catheter to dilate and opacify the collecting system. Prien EL Jr.2 Percutaneous removal of renal stones Principally.142:937-940. laser or hydropneumatic probes.nih. Venous bleeding stops in most cases when the nephrostomy tube is clamped for some hours. such a catheter will prevent fragments from falling into the ureter. http://www. Major bleeding during the procedure requires termination of the operation. it is the method of choice for percutaneous stone removal in children (5-7).2). in selected patients. dilatation and instrumentation.1 Complications Major complications are lesions to adjacent organs. The puncture can be performed under combined ultrasound and X-ray control or under biplanar fluoroscopy. A difficult procedure is indicated by anatomical conditions that offer only limited space for the initial puncture. clinically significant. Persistent.8). While the value of mini-perc in adults has not been determined. It is also the safest point of access because it uses the infundibulum as a conduit to the pelvis. Sepsis and ‘transurethral resection syndrome’ indicate a poor technique with high pressure within the collecting system during manipulation. the majority of renal stones can be removed by percutaneous surgery.2. As with open surgery. Stones can be extracted straightaway or following disintegration by ultrasound. calcium monohydrate. Curr Opin Urol 2003. Although PNL is minimally invasive. Lingeman JE. brushite) or if fragments are unlikely to pass (large stones. caliceal diverticula). balloon dilators or metallic dilators. The use of ultrasound allows easy identification of neighbouring organs and therefore lowers the risk of injuries to adjacent organs. J Urol 1989. While standard nephroscopes have shaft calibres of 2430 F. 7. These problems can be avoided by using continuous flow instruments or an Amplatz sheath (1. This can be avoided by puncture under ultrasound guidance. Pre-procedural KUB and intravenous urography or uroCTscan are used to plan access. http://www.
http://www. 7. Urology 1998.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11549477 Troxel SA. Streem SB.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446796 Feng MI. Ridhorkar V.ncbi. there is no dilatation of the collecting system and the stone has a small volume (2). http://www.170:45-7.e. 27:617-22.40:619-24. stone volume. These are stones with a large. Staghorn stones with a large central stone volume in the access calix and the renal pelvis and one or two small extensions in the middle and upper caliceal group.ncbi.ncbi.. Computerized tomography guided access for percutaneous nephrolithotomy.3.nlm. J Urol 2003. Percutaneous management.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12352390 7.nlm. Bellman GC. UPDATE JUNE 2005 31 . Minimally invasive PCNL in patients with renal pelvic and caliceal stones. Desai M.nlm.gov/entrez/query. Dyer RB.ESWL.nih. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11098760 Matlaga BR. J Endourol 1999. 7. Stones with large volume extensions into the calices. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. Bichler KH. with obstruction of the collecting system.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12796641 Lahme S.nih.gov/entrez/query.gov/entrez/query.13:359-64. the use of flexible nephroscopes can reduce the need for multiple accesses (4). Gotz T.nih.58:345-50. 5. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. Prospective randomized study of various techniques of percutaneous nephrolithotomy.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9763096 Desai M. http://www. are not suitable for this approach. Seguea JW.are included in the treatment strategy (1).3. Urol Clin North Am 2000. Urology 2001. Low RK. every effort must be made to preserve functioning nephrons. Strohmaier WL.ncbi. 4. Eur Urol 2001. centrally located.2. Mikhail A.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11805407 Jackman SV. If the global kidney function is reduced or if there is bilateral stone disease.nih.52:697-701. i. Kaptein JS.168:1348-51. as well as in their secondary effects on renal anatomy and function. Shah OD. Peters CA. 3. http://www. Ramakumar S. Tamaddon K.ncbi.nlm.nih. There is no generally accepted classification system that allows for determination of success and complication rates of single or combined procedures.ncbi.ncbi.gov/entrez/query. 7. 8.nih. http://www.2 PNL Percutaneous nephrolithotomy (PNL) may be used for stones of larger volume that expand and obstruct the collecting system and in which the majority of the stone volume lies within the renal pelvis and the target calix.3. Renal intrapelvic pressure during percutaneous neprolithotomy and its correlation with the development of postoperative fever.nlm. 7. composition and distribution within the collecting system. http://www. Bapat S.3 Aspects on staghorn stone treatment and importance of stone burden Staghorn stones may significantly vary in size.3 ESWL and PNL A combined procedure should be planned in such a way that each single step is successful in itself.gov/entrez/query. Renal calculi. Thus. J Urol 2002. all techniques .gov/entrez/query. surgery and partial or complete nephrectomy . Assimos DG. 6.1 ESWL Staged ESWL in combination with a double-J stent may be used in cases where the stone image mimics a normal contrast-filled collecting system. PNL. Docimo SG. without obstruction of these calices. Although multi-tract PNL only moderately increases morbidity. The use of two or more percutaneous accesses should follow the same rules (3). Hedican SP.gov/entrez/query. Patel S.nih. are good indications for a combined procedure. Zagoria RJ.
A percutaneous approach might therefore be preferable. Knapp PM. Stone surface area determination techniques: a unifying concept of staghorn stone burden assessment.5 1. http://www.4 Percutaneous surgery versus ESWL for removal of renal stones PNL and ESWL are complementary rather than competing procedures.nlm. http://www.148:1058-62..ncbi. http://www. Pearle MS.nlm. Clayman RV. Macaluso JN Jr. 7. Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy.nih.nlm. Strohmaier WL. Russo R. Hubmer G. Singh U.1 Location of the stone mass).ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14646431 Srivastava A. Hedican SP. Kumar A. there is no consensus on the usefulness of measuring the infundibulopelvic angle and the length and width of the calix (see above section 7. Gutierrez-Aceves J. Gotz T. 4. Outcome and safety of extracorporeal shock wave lithotripsy as first-line therapy of lower pole nephrolithiasis. stonefree rate.fcgi?cmd=Retrieve&db=PubMed&list_uids=8189589&dopt= Abstract Lam HS.148:1026-29. Preminger GM.1.52:697-701.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9763096 Desai M. REFERENCES Segura JW.1) while percutaneous procedures result in a stone-free rate of up to 97% (4-11).ncbi.gov/entrez/query. Chua GT.ncbi. Kahn RI. it can be stated that.71:350-354.151:1648-51. Teichman J. Lingeman JE.gov/entrez/query. Macaluso JN Jr.nih. 3. 32 UPDATE JUNE 2005 . J Endourol 1999.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14764139 2. Grasso M.nlm.3.nih. Minimally invasive PCNL in patients with renal pelvic and caliceal stones. Numerous studies have addressed the problem of lower pole clearance for stones measuring 10-20 mm (75-300 mm2) and attempts have been made to predict the outcome from analysis of the spatial anatomy of the lower calices.ncbi. Ridhorkar V.7. http://www.166:2072-80.ncbi. Leveillee RJ.nlm. Mandhani A. particularly for patients with an obstructed lower calix or when the stone burden is considerable (i. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis . with overall stone-free rates between 37% and 67% (see section 7. Desai M. BJU Int 2004.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446796 Alabala DM. 5.gov/entrez/query. Docimo SG. Peters CA.nih. Stones > 2 cm in diameter in the renal pelvis or the upper and middle caliceal group without obstruction and dilatation of the collecting system are generally accepted as ideal indications for ESWL.nih. Scott JW. J Urol 2001. Efficacy of extracorporeal shock wave lithotripsy for solitary lower caliceal stone: a statistical model. PNL is associated with more severe complications than ESWL.3.nlm. Principally. Zaman W. 9. The clearance of stone fragments from the lower pole calices varies between different studies but is generally considered as poor. Neprolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi.gov/entrez/query. Eur Urol 2001. initial. diameter exceeding 20 mm or stone surface area more than 300 mm2). J Urol 1992. Patel S. Singh V.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507330&dopt= Abstract Lahme S.nih. Preminger GM.2.initial results. Newman DM. 7. Dretler SP.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11696709 Riedler I. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. Munch LC. Currently.nih. J Urol 1994. Trummer H.93:364-368. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. Urol Int 2003.gov/entrez/query. Lingeman JE. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy.nlm. Lingeman JE.ncbi.gov/entrez/query. http://www.1. http://www. Bichler KH.ncbi. the indication for PNL can also be extended to include so-called ‘easy cases’ when ESWL is not available. http://www.nih. and the best treatment for stones in the lower calices is still controversial. http://www. Kahn RI. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11805407 Jackman SV. Assimos DG.ncbi. Steele RE. However. J Urol 1992. Nakada SY. Urology 1998. Newman RC.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507322&dopt= Abstract Lam HS. Bapat S.nlm. McCullough DL. Lingeman JE.e. 8. although PNL has a higher. 6.nlm. Mosbaugh PG. Assimos DG. Hebel P.13:359-64.2. Woods JR.gov/entrez/query. Denstedt JD.gov/entrez/query.40:619-24.
shockwave sessions will be necessary for complete stone removal. However. • Co-morbid medical disease. it is important that urologists maintain proficiency. • Ureterolithotomy. • Treatment failure with ESWL and/or PNL or failed ureteroscopic procedure.4 Open surgery for removal of renal stones With the advances in ESWL and endourological surgery (ureteroscopy [URS] and PNL) over the past 15-20 years. With today’s limited experience with open stone surgery in many hospitals.gov/entrez/query. • Pyelonephrolithotomy.1 Indications for open surgery Indications for open surgery for stone removal include: • Complex stone burden. or is not. Thus. de Vries R.single procedure in preference to possibly more than one PNL procedure. Poulakis V.ncbi.2 Operative procedures Operative procedures that can be carried out include: • Simple and extended pyelolithotomy. J Urol 2003. It is now accepted that. non-functioning kidney (nephrectomy).4.nlm. • Partial nephrectomy and nephrectomy.nlm. • Stone in an ectopic kidney where percutaneous access and ESWL may be difficult or impossible. there is a place for open surgical removal of calculi.the controversy continues. • Skeletal deformity.10. Akhtar S. • Anatrophic nephrolithotomy. stricture. the indications for open stone surgery have markedly diminished.nih. • Cystolithotomy for giant bladder calculus. • Radial nephrolithotomy. expertize and experience in the surgical treatment of renal tract stones report a need for open surgery in 1-5. Witzsch U. obstruction of the ureteropelvic junction. BMC Urol 2003. Prediction of lower pole stone clearance after shock wave lithotripsy using an artificial neural network. contractures and fixed deformities of hips and legs. Dahm P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12546707 7. • Patient choice following failed minimally invasive procedures . stone in the caliceal diverticulum (particularly in an anterior calix). The latest progress in this area has been the introduction of intra-operative B-mode scanning and Doppler sonography (13. • Removal of calculus with reimplantation of the ureter . skills and expertize in open renal and ureteral surgical techniques. appropriate. • Non-functioning lower pole (partial nephrectomy). UPDATE JUNE 2005 33 . Becht E.ureteroneocystotomy.gov/entrez/query. Stone clearance in lower pole nephrolithiasis after extra corporeal shock wave lithotripsy . in some circumstances. • Intrarenal anatomical abnormalities: infundibular stenosis. • A large stone burden in children because of easy surgical access and the need for only one anaesthetic procedure.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12629337 Ather MH. it is only possible to propose general principles for open surgery based on consensus of opinion from experience and the technical limitations of the less invasive alternative approaches. Whenever the major stone volume is located peripherally in the calices. an open surgical procedure should be preferred. • Morbid obesity.3:1. • Concomitant open surgery.169:1250-1256. Since most of these cases will usually involve difficult stone situations. 7. anatrophic nephrolithotomy (7-10). with the various modalities of treatment that are now available for the surgical management of stones.ncbi. Centres with the equipment. • Pyeloplasty.4. Abid F.12) and renal surgery under hypothermia. especially if these calices are obstructed so that either several percutaneous accesses and several. it may be advisable to send patients to a centre where the urologists still know how to properly perform the techniques of extended pyelocalicotomy (6). there will inevitably be some controversy as to when open operation in a particular case is. Khawaja K. Remplik J.nih. multiple radial nephrotomy (11. • Stone in a transplanted kidney where there may be a risk of damage to the overlying bowel. 7. http://www. 11. http://www. probably unsuccessful.14) to identify avascular areas in the renal parenchyma close to the stone or dilated calices to enable removal of large staghorn stones by multiple small radial nephrotomies without loss of kidney function.4% of cases (1-5).
12.gov/entrez/query.nih. Urology 1981. Alken P. Current surgical approaches to nephrolithiasis.gov/entrez/query.nih. Wickham JEA.gov/entrez/query. 20:255-288. Wainstein MA.nlm. Bonney WW.15:475-477. Weems WL. Riedmiller R. Smith MJV. Donohue JP (eds). pp 1-23.ncbi. Wickham JE. Laparoscopic surgery is also an option.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2746742&dopt= Abstract Segura JW. 7. 34 UPDATE JUNE 2005 . 9. Hample N. Kroonvand RL. http://www. particularly for stones located in a ventral caliceal diverticulum (17).The superiority of open surgery over less invasive therapy in terms of stone-free rates is based on considerable historical experience.fcgi?cmd=Retrieve&db=PubMed&list_uids=9392057&dopt= Abstract Paik ML.nih.nlm.nlm.142:263-267. Smith ER. http://www. 4. Indications for open stone removal of urinary calculi. 3.ncbi. http://www.nih. Letter to the editor.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8948396&dopt= Abstract Bichler KH. morbid obesity in 10% and co-morbid medical diseases in 7% of cases (5). The role of open surgery since extracorporeal shock wave lithotripsy. http://www.gov/entrez/query. J Urol 1980. 5. 10. J Am Diet Assoc 1996. Anatrophic nephrolithotomy: Update 1978.fcgi?cmd=Retrieve&db=PubMed&list_uids=4436892&dopt= Abstract&itool=iconnoabstr Sleight MW. J Urol 1989.1:71-74.nlm.nih.ncbi. Boyce WH. http://www. In: AUA courses in urology. anatomical abnormalities in 24%. Urology 1980. Pounds DM. Anatrophic nephrotomy and plastic calyrhaphy.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2081519&dopt= Abstract Kane MT. while a large stone burden in association with abnormal anatomy limiting endoscopic access in 31% of the cases. Frohneberg D. New surgical concepts in removing renal calculi.nlm. J Urol 1982.651 stone procedures carried out in Singapore (16).59:102-108.fcgi?cmd=Retrieve&db=PubMed&list_uids=7052711&dopt= Abstract Thüroff JW.4.nih.ncbi. Endocrinol Metab Clin North Am 1990. Intrarenal access.nlm. http://www. Commission on Dietetic Registration Dietetics Practice Audit. Harrison LH. J Urol 1998.gov/entrez/query. Ward JP. 13. Gower RL. Localization of segmental arteries in renal surgery by Doppler sonography. 1978. Surgical anatomy of the human kidney and its application. http://www. Trans Am Assoc Genitourinary Surg 1967. Urol Int 1965.fcgi?cmd=Retrieve&db=PubMed&list_uids=7365912&dopt= Abstract Resnick MI.ncbi. Coe N. Reidy C. Urol Int 1997.123:604.nlm. 11. http://www.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6064524&dopt= Abstract Harrison LH. Another report mentions 25 open surgical procedures in 799 treatments for renal stones. REFERENCES Assimos DG.fcgi?cmd=Retrieve&db=PubMed&list_uids=5863978&dopt= Abstract Boyce WH.gov/entrez/query. but (as yet) there are no comparative studies available (LE:4). http://www.nih.159:374-37.nih. In one recent report reasons given to perform open surgery were a complex stone burden in 55%. Hutschenreiter G. One hundred cases of nephrolithotomy under hyporthermia.gov/entrez/query.nih. 8.gov/entrez/query. 6. A 2% need for open surgery was recorded in 2.ncbi. http://www. concurrent surgical procedures in 24% and previously failed endourologic procedures as the reason for open surgery in another 17% of cases is listed in a retrospective study (15).nlm. Lewis C.nlm. 19:912-925.nlm. Vol 1.nih. Euro Urol 1975.ncbi. McCullough DL.1292-1301. Current indications for open stone surgery in the treatment of renal and ureteral calculi. Hohenfellner R. http://www. Cohen AS. Boyce WH. Spirnak P.ncbi. Thüroff S. Williams and Wilkins: Baltimore. failed low invasive surgery in 29%.59:18-24.ncbi.127:863-866. Boyce WH.nlm. Lahme S. 7.3 1.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9649242 Gil-Vernet J.fcgi?cmd=Retrieve&db=PubMed&list_uids=7086985&dopt= Abstract 2. Resnick MI.ncbi. Strohmaier WL.gov/entrez/query.17:367-369.
The time required for dissolution depends on the stone burden. The surface area of the stone or the stone remnants is increased by ESWL. Laparoscopically-assisted percutaneous nephrolithotomy for the treatment of anterior calyceal diverticula.nlm. URS or open surgery for a more complete elimination of stone fragments or residual fragments.2 Brushite stones Brushite is also soluble in the acid solutions mentioned above in section 7. Urology 1995. 2000. Hohenfellner R. Doppler sonography and B-mode ultrasound scanning in renal stone surgery. The pH of these solutions is in the range 8. Riedmiller H. For this purpose. Mahe P. The major advantage of this therapeutic approach is that it can be carried out without anaesthesia and might thus be an option for high-risk patients or for any other patients in whom anaesthesia or other surgical procedures must be avoided (3-13).nih. During appropriate antibiotic treatment the chemolytic solution is allowed to flow in through one nephrostomy catheter and out through another.Stoller ML. This form of treatment must only be used when there is good evidence that the renal tract has healed following surgery and never infused in the immediate post-operative stage.nih.gov/entrez/query. It should be noted that Hemiacidirin and Suby G solutions carry a serious risk of mortality (cardiac arrest) from hypermagnesemia. http://www.ncbi. This option should be considered in patients with residual brushite fragments after other stone-removing procedures.gov/entrez/query. This method involves lowering urate concentration using allopurinol and a high fluid intake.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10497675 Brunet P. the ureter should be protected by a double-J stent during the procedure (1. Bolton DM.45:218-221.5-9. Percutaneous chemolysis is a useful method for complete stone clearance in combination with other stone-removing techniques (14-18).86:1088-1089. 7.ncbi. Ann Acad Med Singapore 1999.5.nlm.1. which is an acid solution with a pH between 3. Foo KT.nlm. This enables irrigation of the renal collecting system while preventing chemolytic fluid from draining into the bladder and reducing the risk of increased intrarenal pressure. Danjou P.23:455-460. Another useful agent is Suby’s solution.5. In the case of a large stone burden. The two solutions can also be used in combination. Oral chemolytic treatment is also a very attractive therapeutic alternative for the removal of uric acid stones.4 Uric acid stones A high concentration of urate and a low (acidic) pH are the determinants of uric acid stone formation.nih. http://www.5.fcgi?cmd=Retrieve&db=PubMed&list_uids=6719663&dopt= Abstract Kane CJ. Urology 1984.5 Chemolytic possibilities Chemolytic dissolution of stones or stone fragments is a useful adjunct to ESWL. Alken P. This is a particularly interesting treatment approach in view of the very high recurrence rate of brushite stones. http://www.gov/entrez/query. PNL. For percutaneous chemolysis. Another option is acetylcysteine. 0. http://www. but several weeks will be necessary to dissolve a complete staghorn stone using chemolysis combined with ESWL. 17.5. 7. however. 7.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11119107 7. This section provides a summary of chemolytic treatment options. Current indications for open stone surgery in an endourological centre. UPDATE JUNE 2005 35 .gov/entrez/query. Wong MYC. Percutaneous dissolution can be accomplished with THAM solutions.6 mol/L trihydroxymethyl aminomethan (THAM) solution can be used. BJU Int.5 and 4. 7.3 Cystine stones Cystine is soluble in an alkaline environment.14. Meria P. Current indications for open stone surgery in Singapore.28:241-244.nih. the patient should have at least two nephrostomy catheters.ncbi. Oral chemolysis is.0.3 or 0.5. Thüroff JW.2).nlm. and increasing the pH to alkali (19-21). 16. 15. the most attractive alternative. The combined treatment of ESWL and chemolysis is a particularly low-invasive option for selected patients with partially or completely infected staghorn stones.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7855969 Sy FY.1 Infection stones Stones composed of magnesium ammonium phosphate and carbonate apatite can be dissolved with a 10% solution of hemiacidrin.ncbi.
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Huang JK. it is important to note that unless percutaneous surgery is carried out with a meticulous technique. Urol Res 1992. Indudhara R. Schüller J.ncbi. 19. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=6699980&dopt= Abstract Sharma SK. Reinke DB.nih.131:1039-1044.gov/entrez/query. an increased rate of dissolution can be obtained following stone disintegration and treatment in this order may be considered for removing large uric acid stones.nlm. UPDATE JUNE 2005 37 . Chang LS. has a low rate of complications and there is no need for regional or general anaesthesia.17. Although residual fragments can develop into new stones.gov/entrez/query. Urology 1979.nih.nih.ncbi.20:19-21.gov/entrez/query.nlm. ESWL has been established as the standard procedure because it is non-invasive. Chaussy C.fcgi?cmd=Retrieve&db=PubMed&list_uids=1736482&dopt= Abstract 7.131:434-438.8:422-423. 22. there is an ongoing debate as to whether large renal stones are best treated with ESWL or with PNL.ncbi. several reports have shown that risk to be reasonably low. it is logical to select a method with low invasiveness and low morbidity.gov/entrez/query. 18. http://www. as well as video-endoscopic retroperitoneal and open surgery. However. 20.1 M THAM and 0. Chem MT.ncbi.nih. For large renal stones.fcgi?cmd=Retrieve&db=PubMed&list_uids=8249225&dopt= Abstract&itool=iconabstr Oosterlinck W. Urol Int 1993.6 Recommendations for removal of renal stones Recommendations on the most appropriate method for removal of stones from the kidney are based on several important considerations. residual fragments of stone may be left behind in these patients. http://www.gov/entrez/query.gov/entrez/query. Such a step might also be used as an auxiliary procedure in the treatment of cystine stones. oral chemolysis is the first choice of treatment for stone disintegration. Miller RP.48:81-86. though it is advantageous in some types of reconstructive surgery. Schmiedt E.ncbi.51:147-151. flexible URS.nih. Chemodissolution of urinary uric acid stones by alkali therapy.fcgi?cmd=Retrieve&db=PubMed&list_uids=433056&dopt= Abstract Schmeller NT. but such a routine is indicated also because of the inherent tendency to new stone formation that characterizes patients with stone disease. A follow-up programme for patients with residual fragments appears necessary. however. Urol Int 1992.fcgi?cmd=Retrieve&db=PubMed&list_uids=1317980&dopt= Abstract Rodman JS. Local chemolysis of obstructive uric acid stones with 0.nih. Williams JJ. Residual fragments of infection stones. Combination of chemolysis and shock wave lithotripsy in the treatment of cystine renal calculi. All these methods are applicable. http://www. Video-endoscopic retroperitoneal surgery has no place as standard procedure for removal of stones from the kidney. 21. Rationale for local toxicity of calcium chelators. More than two decades of experience with low invasive methods have clearly shown that open surgery is necessary only in exceptional cases and mainly for those patients in whom anatomical reconstruction is necessary. It needs to be emphasized. that complete clearance of stones from the caliceal system by a percutaneous technique requires considerable expertize and experience. http://www.nlm.ncbi. Dissolution of cystine calculi by irrigation with acetylcysteine through percutaneous nephrostomy.fcgi?cmd=Retrieve&db=PubMed&list_uids=6726897&dopt= Abstract Lee YH.nlm. J Urol 1984. Dissolution of uric acid calculi. PNL. J Urol 1984. For small stones (up to a maximum diameter of 20 mm or a surface area of 300 mm2). Verbeeck R. For uric acid stones. The drawbacks of ESWL are a frequent need for repeated treatments and the relatively common occurrence of residual fragments. An overview of treatment recommendations according to size and stone type is shown in Tables 15 and 16. The available options are ESWL. Vergauwe D. percutaneous stone removal might be preferable for faster debulking of the stone. However. Although larger stones can also be treated successfully with ESWL. Smith AD. but for any given stone situation. Peterson CM. associated with the most pronounced risk of recurrences can be eliminated with percutaneous chemolysis. http://www.nlm. Cuvelier C.02% chlorhexidine. Lange PH.nlm. The approximate estimates of surface area corresponding to oval stone projections with certain diameters are given in Appendix A. Kersting H.
ESWL = extracorporeal shock wave lithotripsy. 2. When two procedures were considered equally useful they have been given the same number. also including piezolithotripsy. 3. Stent + ESWL + oral chemolysis 2a B Cystine stones 1. degree of impaction and extent to which repeated shock waves sessions are 38 UPDATE JUNE 2005 . ESWL 2a B 2. also including piezolithotripsy. it is possible to remove a ureteral stone using ESWL without regional or general anaesthesia and with a very low rate of complications and side effects.g.Table 15: Recommendations for active removal of renal stones with a diameter < 20 mm* (surface area < 300 mm2) Type of stone Radio-opaque stones Procedure LE GR 1. in most cases. PNL = percutaneous nephrolithotomy. GR = grade of recommendation. GR = grade of recommendation. 4) have been allocated to the procedures according to the consensus reached. Improved results in complicated cases can be achieved by combining ESWL with low-invasive auxiliary procedures (e. The literature comprises numerous reports with a variable success rate. It has been shown clearly that. this technique has been extensively used and a considerable experience has demonstrated that ESWL is very useful for stone removal from the ureter. PNL + flexible nephroscopy 2a B 4. It is. Uric acid/urate stones 1. Oral chemolysis 2a B 2. PNL + ESWL 2a B 3. however. PNL 1b A Infection stones and These stones should be managed like any other 2a B stones with infection stones provided there is no obstruction and that a symptomatic infection has been adequately treated. Open or video-endoscopic retroperitoneal surgery LE= level of evidence. This lack of consistency is obviously related to the type of lithotripter. Oral chemolysis 2a B 2. Uric acid/urate stones 1. * Numbers (1. * Numbers (1. 8. 2. ESWL 1b A 2.1 ACTIVE REMOVAL OF STONES IN THE URETER ESWL for removal of ureteral stones Following an initially sceptical attitude to the use of ESWL for disintegrating stones in the ureter. size and composition of the stone. assumed that ureteral stones generally require higher shock wave energy and a greater number of shock waves. PNL 2a B 2. PNL = percutaneous nephrolithotomy. by stenting or urethral catheters). PNL 1b B 2. Table 16: Recommendations for active removal of renal stones with a diameter > 20 mm* (surface area > 300 mm2) Type of stone Radio-opaque stones Procedure LE GR 1.. ESWL = extracorporeal shock wave lithotripsy. When two procedures were considered equally useful they have been given the same number. PNL 2a B 3. 3) have been allocated to the procedures according to the consensus reached. PNL + ESWL 2a B Infection stones and These stones should be managed like any other 2a B stones with infection stones provided there is no obstruction and that a symptomatic infection has been adequately treated. The first alternative always has the number 1. Open or video-endoscopic retroperitoneal surgery LE = level of evidence. ESWL with or without stenting 2a B 3. The first alternative always has the number 1. 8. Stent + ESWL + oral chemolysis 2a B Cystine stones 1.
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fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2351188&query_hl=6 Mobley TB.nlm.ncbi.nlm. Low energy lithotripsy with the Lithostar: treatment results with 19. Burkhard FC.ncbi. Grine WB. It needs to be emphasized. Honey RJ.gov/entrez/query. Clayman RV. http://www. Jordan WR. Myers DA. http://www.168:446-449.gov/entrez/query.ncbi. Jenkins JM. Clayman RV. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18. but it is difficult to find definite evidence for this assumption in the literature.1 Stenting The value of an expanding fluid chamber around the stone is the rationale for using a ureteral catheter that either bypasses the stone or is placed just below the stone. 8.gov/entrez/query. Weir MJ. Soble JJ.ncbi.nlm.ncbi.9.gov/entrez/query. J Urol 2002. 41.149:1419-1424. Extracorporeal shock wave lithotripsy of middle ureteral stones: are ureteral stents necessary? Urology 1995.nlm.17:200-202. Grine WB.35. J Urol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=7495114&dopt= Abstract Pace KT. Jenkins JM.nlm.nih. Jordan WR. 36.fcgi?cmd=Retrieve&db=PubMed&list_uids=8201687&dopt= Abstract 2.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501781 Mobley TB.46:649-652.ncbi.825 calculi using the Lithostar lithotripter.fcgi?cmd=Retrieve&db=PubMed&list_uids=7495114&dopt= Abstract Simon J. Although slightly better results have been reported with this procedure.ncbi.962 renal and ureteral calculi. experience with 165 patients.gov/entrez/query.nih. http://www.2. 8. REFERENCES Nakada SY. McClennan BL. J Urol 1994.7. Studer UE. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18. analgesia and radiation-free extracorporeal shock wave lithotripsy for stones in the most distal ureter. http://www.ncbi.152:66-67. Grine WB. 38.34:93-98. Salvatore FT. Myers DA.nih.2 1. 39. Gardner SM. Soble JJ. An innovative approach to management of lower third ureteral calculi.gov/entrez/query. http://www.gov/entrez/query.gov/entrez/query. http://www. 42 UPDATE JUNE 2005 . Eur Urol 1990. http://www.825 calculi using the Lithostar lithotriptor. Vanden Bosshe M.nlm.gov/entrez/query. Gardner SM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12131285 Mobley TB.nih. Nakada SY.nih. In situ extracorporeal shock wave lithotripsy of middle and lower ureteral stones: A boosted. Vandenberg T. 40.46:649-652. Macaluso JN.11). Non-invasive anaesthesia. http://www. Extracorporeal shock wave lithotripsy of middle ureteral stones: are ureteral stents necessary? Urology 1995. http://www.nlm.152:53-56.ncbi. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11061877 Ghobish A.nlm. Jenkins JM. the retreatment rate was usually not significantly lower (3.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9693242 Jermini FR. It might. J Urol 1994. that the success rate associated with pushing the stone up to the kidney varied considerably and it can be extremely difficult or impossible to manipulate large or impacted stones. retrograde manipulation resulted in stone-free rates of 73-100% (5. J Urol 1993. Schulmann CC. J Urol 2000. Shock wave treatment of ureteric stones in situ with second generation lithotriptor. Another reason for stenting might be to aid in the location of small and less radio-opaque stones. Taroq N. When compared with stone-free rates of 62-97% following in situ treatment (1-10). Eur Urol 1998. 37.149:1427-1430. Pearle MS.nih. Pearle MS. McClennan BL.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501779 Thomas R.8-14). be of some help to use a ureteral catheter when treating large and impacted ureteral stones.nlm. as well as to fill the collecting system with contrast medium for detecting radiolucent stones.nih. Low success rate of repeat shock wave lithotripsy for ureteral stones after failed initial treatment.2 Retrograde manipulation of stones The push-back technique has been applied in order to avoid problems with insufficient disintegration of ureteral stones.164:1905-1907.ncbi.nih.nih.nlm. stentless ventral technique. however.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8201687&query_hl=19 8. 3. Jordan WR.2.nih. however. Danuser H. Mattei A.gov/entrez/query. Myers DA.
fcgi?cmd=Retrieve&db=PubMed&list_uids=8252017&dopt= Abstract Hendriks AJM.ncbi. Intramural ureteral dilatation is not indicated routinely.fcgi?cmd=Retrieve&db=PubMed&list_uids=8345592&dopt= Abstract Tiselius HG. Joyce AD.fcgi?cmd=Retrieve&db=PubMed&list_uids=3656518&dopt= Abstract Watson RB. it is an invasive technique compared to ESWL. Extracorporeal shock wave lithotripsy in situ or after push up for upper ureteral calculi: a prospective randomized trial.3. Do upper ureteral stones need to be manipulated (pushed back) into the kidneys before extracorporeal shock wave lithotripsy? J Urol 1992. Alken P.nih. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8490668&dopt= Abstract Cass AS. Oosterhof GON. Nonstent or noncatheter extracorporeal shock-wave lithotripsy for ureteral stones.nlm.nih. and secured to the drapes.gov/entrez/query. 6.nlm.gov/entrez/query.ncbi. Hasun R.nlm. http://www. Anaesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones. Studer UE. http://www.72:683-687. Extracorporeal shock wave lithotripsy of ureteric stones with the Modulith SL 20. The operating room must have fluoroscopic equipment. Debruyne FMJ. Güler C. http://www.gov/entrez/query. J Urol 1987. However. http://www. J Endourol 1990.ncbi. Rassweiler J. 8. New ureteroscopes (semi-rigid and flexible) and lithotripsy devices have recently become available. A pre-operative plain film of the urinary tract is obtained to confirm the location of the stone.fcgi?cmd=Retrieve&db=PubMed&list_uids=2056608&dopt= Abstract Hofbauer J.gov/entrez/query. Are obstructing ureteral stones more difficult to treat with extracorporeal electromagnetic shock wave lithotripsy? J Endourol 1993.nih.nih. 5. URS has dramatically changed the management of ureteral calculi.nih. 12. Zingg E.nlm. 10.fcgi?cmd=Retrieve&db=PubMed&list_uids=1732591&dopt= Abstract Lingeman JE.nlm.138:720-723.gov/entrez/query. the patient is placed in the lithotomy position. http://www. URS is extensively used in many urological centres all over the world. The procedure starts with rigid or flexible cystoscopy.fcgi?cmd=Retrieve&db=PubMed&list_uids=7514472&dopt= Abstract 8. Treatment of ureteral stones by extracorporeal shock wave lithotripsy: with ureteral catheter or in situ? J Endourol 1994.ncbi. Okamoto M.2). J Urol 1991.gov/entrez/query. Shirrell WL.7:277-279. 9. http://www. http://www.nih.nlm. James AN.nlm. 13.nih.150:824826. Steele RE.gov/entrez/query. Nowadays. Newman D.gov/entrez/query. Under general spinal anaesthesia or intravenous sedation. Inaba Y.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281394&dopt= Abstract&itool=iconabstr Cass AS. but UPDATE JUNE 2005 43 . Köhrmann KU.nih.4:353359.ncbi. 7. http://www.gov/entrez/query. Höbarth K.ncbi. Urology 1993. Bierkens AF.1 Standard endoscopic technique The basic endoscopic technique has been well standardized for many years (1.gov/entrez/query.ncbi.147:349-251. 8. A guide wire is introduced under endoscopic and fluoroscopic control.ncbi. J Urol 1993.nih. Esen A. Antibiotic prophylaxis should be administered before the procedure to ensure sterile urine. Br J Urol 1992. Br J Urol 1993. 14.70:594-599. Ackermann DK.fcgi?cmd=Retrieve&db=PubMed&list_uids=1486384&dopt= Abstract Danuser H. Kirkali Z. Tuerk C.ncbi. Henkel TO.11:54-58.nih. ESWL in situ or ureteroscopy for ureteric stones? World J Urol 1993.3 Ureteroscopy for removal of ureteral stones During the past two decades. Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. and the treatment of choice for ureteral stones with diameters of 1 mm or larger is still controversial.nlm. Woods JR.43:178-181. Marberger M. Mosbaugh PG. Manning M. 11.nlm.146:8-12. Extracorporeal shock wave lithotripsy for ureteric calculi with the Dornier MFL 5000 lithotriptor at a multi-user centre.fcgi?cmd=Retrieve&db=PubMed&list_uids=8116112&dopt= Abstract Harada M. Marth DC.8:9-11.ncbi. Celebi I.nlm. Treatment of proximal and midureteral calculi: a randomized trial of in situ and push back extracorporeal lithotripsy.4. http://www.
In the lower ureter. a flexible ureteroscope. regardless of the hardness of the stone (16). This device offers an excellent cost-performance ratio (40). 8.3).3. Dilatation of the intramural ureter and use of a laser usually requires the insertion of a single/double pigtail stent under fluoroscopic guidance. 44 UPDATE JUNE 2005 . It is dependent on the injury to the ureteral mucosa due to the stone or the ureteroscope. The 200 µm fibre is more expensive but it is the only fibre that minimally impairs maximal tip deflection and is therefore recommended for fragmentation of intrarenal calculi (12. If the stone is impacted.18.14. Its cost-effectiveness is three times that of laser lithotripsy (9.18).2 Anaesthesia The improvement of ureteroscopes and stone retrieval instruments allows ureteroscopic procedures to be carried out under sedation analgesia with a similar success rate (88-97%) to general anaesthesia. The safety guide wire prevents the risk of false passage in case of perforation. The small diameter (6. This technique is particularly useful for removal of distal ureteral stones in women (2. The stent will usually remain in place for about 1 week.3. Stent placement at the end of the procedure is optional and a matter of debate (2).5 F) allows easier progression of the ureteroscope up to the proximal ureter.6. The use of flexible ureteroscopes (7-7.4).20). They are suitable for access to the upper part of the ureter and renal collecting system. because of its tendency to fall back into the bladder. as minimal deflection is required to access the stone. Endoscopic lithotripsy is based on the use of different devices in order to break the stone into dust or fragments with diameters < 2 mm. Flushing of large fragments or the stone itself up to the renal pelvis or calices or perforation of the ureteral wall may occur. for ureteral calculi < 15 mm in diameter. Retrograde access to the upper urinary tract is usually obtained under video-guidance with a rigid ureteroscope (9. but may be substantially longer for flexible URS. An operating time for laser lithotripsy of between 7 minutes and 45 minutes is acceptable (18). Small stones and fragments < 5 mm in diameter are best retrieved with a basket or a grasper (3. Nevertheless. The operating time is generally between 10 and 60 minutes.5). If manipulated with care. electrohydraulic devices should not be used as a standard procedure. without dilating the intramural ureter in over 75% of cases. The ideal energy and frequency settings are less than 1.5 F) has been evaluated (1.depends on the size of the ureteroscope and width of the ureter. The Nd:YAG (frequencydoubled) laser has a lower efficacy than the Ho:YAG system and is not suitable for very hard stones or cystine stones. electrohydraulic lithotripsy. laser lithotripsy will require a longer operating time than the electrohydraulic technique (5) but because of the greater risk of tissue damage. However.5-11 F). It is the only applicable method when performing flexible URS (12.3. A 365 µm holmium:yttrium aluminium garnet (Ho:YAG) laser fibre is the best choice for ureteral stones. A low capital cost and simple and safe handling are major advantages of this type of device. A flexible ureteroscope is inserted either alongside a second 0.035-inch safety guide wire with a floppy tip or in a 10-13 F sheath.0-7.7). Irrigation facilitated with a piston syringe or a flow control unit is needed to ensure good direct vision.2 Disintegration devices Laser lithotripsy is a reliable method for the treatment of ureteral stones.1 Ureteroscopes Semi-rigid and thin ureteroscopes are available.3. Laser lithotripsy using pulsed dye laser has shown similar results to those obtained using the Ho:YAG laser (21). 8.3. the best approach is to insert a ureteral stent for several days prior to the URS (2). but provides a sufficiently efficient alternative for most stone compositions.0 J and 5-10 Hz.2. ultrasonography or intravenous urography after 2-12 weeks (2. The recently developed (semi-)flexible ureterorenoscopes (Storz) with enhanced maximal deflection provide particular advantages for ureteroscopic surgery (36-39). 8. Ballistic lithotriptors (pneumatic or electropneumatic) using a 2.5 F).11-15).0-8.19). migration of stones towards the renal pelvis from the mid.3 Assessment of different devices 8. a semi-rigid ureteroscope (6. Miniaturization avoids dilatation of the intramural ureter (with associated complications) in more than 50% of cases (8-10).or proximal ureter might be a limiting factor of ballistic lithotripsy (25).3. Patients should be followed up by plain abdominal film.22-24).4 F probe in a semi-rigid ureteroscope provide excellent fragmentation rates (90-96%). The stone may be fragmented by ultrasonic lithotripsy. the laser does not damage the ureteral mucosa (16. is not recommended (1. Ho:YAG lithotripsy seems to give better stone-free results at 3 months than electrohydraulic lithotripsy (97% versus 87%) for distal ureteral stones (5). laser lithotripsy or ballistic (or pneumatic) lithotripsy.17.
When the material was stratified into results for proximal and distal ureteral stones. both ESWL and URS can be considered acceptable treatment alternatives for stones in these positions.4 Dilatation and stenting Over recent years it has been attempted to modify the standard technique of dilatation and stenting. 8. This last result is considerably better than the results reviewed before 1997 (25.8-10.3.13.28. Analysis of the literature for the past 3 years indicates an improvement in stone-free rates.3.3 Baskets Ureteroscopic removal of small ureteral stones with a basket is a relatively quick procedure with a lower morbidity rate than lithotripsy (3. respectively (27). Members produced a report for guidelines in August 1997. The major acute complication remains ureteral avulsion (9. An access sheath may faciltate URS. There is a strong relationship between the complication rate and the equipment used and/or the expertize of the urologist (31. particularly when the ureter has to be re-entered several times. Most procedures can.33). 8.3.11). The overall complication rates reported in recent literature are 5-9%.8. Thus. The cost-effectiveness of ureteroscopic treatment has not been assessed. such as for instance in case of a great stone burden (41) and when it is desirable to maintain low pressure inside the upper urinary tract. Patient discomfort is modest and satisfactorily controlled by oral analgesics (21. New requirements for endoscopic sterilization could dramatically increase the cost of the procedures. respectively. respectively.20.32-35). The tipless nitinol basket is non-traumatic and allows excellent control inside calices. Reduced need for dilatation (0-40%).3. be carried out without an access sheath (42). Similar results were observed in children and in obese patients (11. with the estimated rate being 1%. The basket technique should be attempted first for small distal ureteral calculi. 8.3. with a 1% rate of significant complications (3. Ureteral perforation at the site of the stone is the primary risk factor for stricture. especially in the proximal ureter (5). accessories and the URS technique have led to a significant increase in the success rate for the removal of ureteral stones and a decreased morbidity (3). Ureteral strictures were the only long-term complication reported. The best results were reported with Ho:YAG laser lithotripsy. even with a parallel decrease in operating time and complication rate.3.29). Most perforations seen during the procedure are successfully treated with approximately 2 weeks of stenting (8). in obese patients or in those with less visible stones (9. the stone-free rates were 56% and 89% for proximal and distal stones. Small ureteral stones or fragments can be removed fast and safely with forceps which can be better controlled than a basket. Semi-rigid and/or flexible ureteroscopes provide 90-100% stone-free rates for distal ureteral calculi and only a 74% stone-free rate in the proximal ureter.12.7 Conclusion Improvements in the design of ureteroscopes. A total of 95% of patients were successfully treated with only one endoscopic procedure.3.26). Laser or electrohydraulic lithotripsy may break the wires of the basket (16).30). the overall stone-free rates were 72% and 90%. This means that in experienced hands the new generation of ureteroscopes can be used for the treatment of proximal as well as distal ureteral stones. The nitinol tipless basket is more effective than a flat-wire basket because of its greater flexibility (4. This latter technique might be a good alternative to ESWL.3.32).3.3. An access sheath of a suitable dimension can be introduced over a guide wire. for example. 23). particularly when the stone diameter < 10 mm.29. Autologous transplantation or uretero-ileoplasty are the methods of choice in cases of avulsion (33). UPDATE JUNE 2005 45 . 8. however. Several new designs of endoscopic stone retrieval baskets are available. operating time and post-operative ureteral stenting have resulted from the use of thin ureteroscopes Routine stent placement following uncomplicated URS may be unnecessary.5 Clinical results The Ureteral Clinical Guidelines Panel of the American Urological Association have conducted a meta-analysis of relevant studies between 1966 and 1996. For ureteral stones with a diameter < 10 mm.6 Complications Significant acute complication rates of 11% and 9% have been reported for the proximal and distal ureters. Randomized and prospective studies are needed in order to compare all forms of stone removal from the ureter. which was published in the Journal of Urology (27).4).
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Dunn M. Treatment of lower ureteral stones: extracorporeal shockwave lithotripsy or intracorporeal lithotripsy? J Endourol 1999. ESWL can be considered a low-invasive and gentle procedure. J Urol 1999. The argument against the routine use of ureteral access sheaths. Hoenig DM.nih.nlm.gov/entrez/query. Isen K. http://www. Furthermore. Mutz J. Bercowsky E.nih.nlm. URS is considered to be a one-step procedure that in the majority of studies has been carried out under anaesthesia. Nakada SY. http://www. Although the need for re-treatment is definitely greater with ESWL than with URS. J Endourol 1999.nlm. but URS-disintegrated stones also require elimination of residual fragments.and distal ureter ureteroscopically.13:161-164.nlm. 8.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11547053 Biri H. several groups concluded that ESWL is preferable in view of its lower degree of invasiveness. http://www. Karaoglan Ü.gov/entrez/query. Nadler R. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi. Even with the addition of auxiliary procedures. a remarkable improvement has been noticed in recent years with lithotripters that have the capacity to disintegrate ureteral stones as efficiently as.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10213099 Pardalidis NP. than the HM3 machine. Abrahams HM.gov/entrez/query. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10037364 Park H. Several comparative studies between URS and ESWL can be found in the literature. Park M. Janetschek G.161:45-47. but most focus on stones in the distal ureter (1-10). J Endourol 1998. Sinik Z. 4.ncbi. The urologist’s experience. Stoller ML. Park T. Wolf JS.ncbi. Kosmaoglou EV. http://www. Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation.nlm. J Urol 2001.ncbi. Shalhav AL. which obviously were inferior to the initial HM3-device.162:1909-1912. However. http://www. Bartsch G. J Urol 1999.42. Küpeli B. A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the treatment of distal ureteral calculi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10569535 Pearle MS. McDougall EM. the advantages of ESWL are non-invasiveness and no need for regional or general anaesthesia. Chen C. Although the access to flexible ureteroscopes and efficient laser devices has made it more attractive to treat stones in the mid.ncbi. or even more so.gov/entrez/query. http://www. Bozkirli I. Figenshau S.4.ncbi. Although these studies demonstrate what has been mentioned above.nih. Clayman RV.ncbi.31:83-87.nih. REFERENCES Peschel R.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10360494 Turk TMT. Jenkins AD. In conclusion.16:1255-1260.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15040404 8. Arguments have been presented for and against both these procedures. access to adequate equipment and specific circumstances are probably the best determinants of which method will be most appropriate for a particular patient. http://www. Urol Clin North Am 2004. The size of ureteral stones has also been considered a limiting factor for ESWL. Sundaram C.nih.nlm. 5. It can be assumed that the production and marketing of lithotripters.nlm.ncbi.13:77-81. 3.1 1.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9895251 2. Endoscopy vs extracorporeal shock wave lithotripsy in the treatment of distal ureteral stones: ten years’ experience. have contributed to a less favourable attitude to ESWL from urologists.4 Should ESWL or URS be used for stone removal? This is indeed a controversial issue for which there is a lack of consensus. the need for anaesthesia is unchanged. Kapotis CG. it is difficult or impossible to give priority to either of these procedures. little information is available on how the ureter reacts to repeated ureteroscopic procedures.gov/entrez/query.nih.gov/entrez/query. 6. On the other hand.12:501-504.nih.gov/entrez/query. UPDATE JUNE 2005 49 .
J Urol 2004. Video-endoscopic retroperitoneal surgery is a minimally invasive alternative to open surgery. e. Weigl A.nih. Biri H.167:1972-1976. but ESWL usually can be carried out without anaesthesia and has a low morbidity.gov/entrez/query.gov/entrez/query. in patients with a stone proximal to a ureteral stricture. Alkibay T.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15540749 8.. Eur Urol 1998.nlm. Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives.gov/entrez/query.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516445 Lam JS. http://www. Gupta M.172:1899-1902. Chen CS.34:474-479.7. not those composed of ammonium urate or sodium urate. Strohmaier WL.5). Isen K. cystine stones and pure calcium phosphate stones.ncbi. Rosenkranz T. Lin CL. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11956420 Küpeli B. Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study. particularly for those situated in the lower ureter. percutaneous chemolytic irrigation can be used to increase the clearance rate of stone fragments. 50 UPDATE JUNE 2005 . There are advantages and disadvantages of both these procedures. J Urol 2002. Schubert G.nlm.5 Recommendations for active removal of ureteral stones: all sizes In case of failure with minimally invasive techniques. 10. http://www. There is controversy as to whether ESWL or URS is the best method for removal of ureteral stones. Onaran M. The principles of chemolytic treatment are outlined above (see section 7.ncbi. can be dissolved by oral chemolytic treatment. These techniques also have to be applied when there are contraindications for ESWL and URS. It is of note that only uric acid stones. in our opinion they are considered equally useful for the removal of distal ureteral stones. In selected cases with infection stones. 8.nlm. http://www. the location can be facilitated by means of a ureteral catheter or a double-J stent.ncbi.nih. Lin WY. Shee JJ. Although retreatments are necessary in a substantial fraction of ESWL-treated patients. uric acid stones.nlm. Greene TD.gov/entrez/query. an open surgical procedure might be required to remove the stone.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9831788 Wu CF.nih. Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with Holmium-YAG laser lithotripsy for treating large proximal ureteral stones. For stones with a low radiodensity. Treatment of proximal ureteral calculi: Holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy.ncbi.36:376-379. Karaogan Ü. Bozkirli I.g. 9. Eur Urol 1999.
3. prone positiona 1. PNL + URS in antegrade direction LE = level of evidence. Ureteral catheter or intravenous contrast + ESWL 2. Percutaneous URS in antegrade direction Cystine stones 1. Stent + oral chemolysis 3. When two procedures were considered equally useful they have been given the same number. ESWL in situ. URS + contact disintegration: .Table 18: Principles of active stone removal (all sizes) in the proximal ureter* Type of stone Radio-opaque stones Procedure LE GR 1. ESWL in situ 1a A 2. also including piezolithotripsy. Ureteral catheter or intravenous contrast + ESWL 2. Percutaneous antegrade URS These stones should be managed like any other stones provided there is no obstruction and that a symptomatic infection has been adequately treated 1.semi-rigid or flexible URS 4. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 3. ESWL in situ. The first alternative always has the number 1. ESWL in situ (with i.semi-rigid or flexible URS 2. ESWL in situ 2a B 2. PNL = percutaneous nephrolithotomy with or without lithotripsy.semi-rigid or flexible URS 2.v. URS + contact disintegration: . 2. or retrograde contrast ) + oral chemolysis 3. prone positiona 1. URS + contact disintegration: . GR = grade of recommendation. ESWL following retrograde manipulation of B the stone (‘push up’) 3. ESWL following retrograde manipulation of the stone (‘push up’) 3. ESWL = extracorporeal shock wave lithotripsy. URS = ureteroscopy. PNL + URS in antegrade direction Infection stones and These stones should be managed like any other 1a A stones with infection stones provided there is no obstruction and that a symptomatic infection has been adequately treated Uric acid/urate stones 1. Table 19: Principles of active stone removal (all sizes) in the mid ureter* Procedure 1. Stent + oral chemolysis 2b B 2. Percutaneous antegrade URS LE 2a 2a GR B B Type of stone Radio-opaque stones Infection stones and stones with infection 2a B Uric acid/urate stones 2a 2a B B UPDATE JUNE 2005 51 .semi-rigid or flexible URS 4. Whether proximal ureteral stones should be ESWL-treated in supine or prone position is directed by the type of lithotriptor in use and its geometrical properties. URS + contact disintegration: . URS + contact disintegration: .semi-rigid or flexible URS 4. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 2. * Numbers (1. 4) have been allocated to the procedures according to the consensus reached.
2. laser or electrohydraulic disintegration . * Numbers (1. URS = ureteroscopy. Type of stone Radio-opaque stones 9.1. URS + contact disintegration 3 B . Screening with dipsticks might be sufficient in uncomplicated cases. 9. a For lithotripters with the shock wave source below the patient. US = ultrasound. The first alternative always has the number 1. PN = percutaneous nephrostomy. 3) have been allocated to the procedures according to the consensus reached. Percutaneous antegrade URS LE = level of evidence.rigid URS + US. urine culture is necessary. prone positiona 2a B 1. ESWL in situ (i. URS = ureteroscopy. contrast medium) 3 B 1. Ureteral catheter (+ contrast medium) + ESWL 3.semi-rigid URS 2.semi-rigid or flexible ureteroscopy 2. 2.1 GENERAL RECOMMENDATIONS AND PRECAUTIONS FOR STONE REMOVAL Infections A test for bacteriuria should be carried out in all patients in whom stone removal is planned.semi-rigid URS 2. Ureteral catheter + ESWL Infection stones and These stones should be managed like any other 1b A stones with infection stones provided there is no obstruction and that a symptomatic infection has been adequately treated Uric acid/urate stones 1. several days of drainage procedures by a stent or a percutaneous nephrostomy should precede the active intervention for stone removal. PN + antegrade contrast + ESWL in situ Cystine stones 1. The first alternative always has the number 1. In others. ESWL in situ.v. URS + contact disintegration 3 B 2. When two procedures were considered equally useful they have been given the same number. also including piezolithotripsy. ESWL in situ 1b A 1. Ureteral catheter + ESWL 2. ESWL = extracorporeal shock wave lithotripsy. When two procedures were considered equally useful they have been given the same number. Cystine stones Table 20: Principles of active stone removal (all sizes) in the distal ureter* Procedure LE GR 1. ESWL = extracorporeal shock wave lithotripsy.rigid URS + US. Whether distal ureteral stones should be ESWL-treated in supine or prone position is directed by the type of lithotriptor in use and its geometrical properties. In cases with clinically significant infection and obstruction. 3) have been allocated to the procedures according to the consensus reached. * Numbers (1. GR = grade of recommendation. laser or ballistic/ pneumatic disintegration . also including piezolithotripsy. ESWL in situ 3 B 1. GR = grade of recommendation. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 3. Ureteral catheter + ESWL LE = level of evidence. URS + contact disintegration: 1b A . 52 UPDATE JUNE 2005 . URS with lithotripsy: 2a B .
10:40-42. the following treatments are contraindicated: extracorporeal shock wave lithotripsy (ESWL). Cystine stones are of two types . Br J Urol 1996. not sodium urate or ammonium urate stones. but it must be emphasized that complications of this procedure might be difficult to manage. This may mitigate in favour of percutaneous removal of such stones. thereby avoiding too much shock wave energy to the renal tissue.nih. For large ESWL-resistant stones.1 B C C 9.2 Bleeding Bleeding disorders and anticoagulant treatment should be considered. REFERENCES O’Regan S.nlm. ESWL. positive dip-stick test or suspicion of an infective component Treatment with salicylates should be stopped 10 days before the planned stone removal ESWL and PCNL are contraindicated in pregnant women ESWL is possible in patients with a pacemaker GR = grade of recommendation. it is recommended that the patient’s cardiologist is consulted before undertaking ESWL treatment.7 1.4 Pacemaker Although the rule is that patients with a pacemaker can be treated with ESWL. Curr Opin Urol 1994.4 9.ncbi. PNL and URS are contraindicated.77:17-20.gov/entrez/query.3 9. Urolithiasis in pregnancy. Johansson JE. Homsy Y. Carringer M.gov/entrez/query. Swartz R.nlm. http://www. Stones in pregnancy and in children.6 Radiolucent stones Uric acid concrements can be localized with ultrasound.9. Management of ureteric calculi during pregnancy by ureteroscopy and laser lithotripsy.nih. Hofbauer J. PNL is the best alternative for efficient removal.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6698085 Kroovand RL. 3. B Comment 9.gov/entrez/query. 4. Laberge I. In expert hands.3 Pregnancy In pregnant women. PCNL = percutaneous nephrolithotripsy. The possibility of chemolytic treatment of brushite stone fragments is noteworthy in view of the high recurrence rate seen with this type of stone. either with a percutaneous nephrostomy catheter. ESWL = extracorporeal shock wave lithotripsy. It is of note that only uric acid stones. a double-J stent or a ureteral catheter (1-7). In patients with coagulation disorders. http://www.ncbi.2 9. 9. or with intravenous or retrograde administration of contrast medium.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8653305 2. These patients should be referred to an internist for appropriate therapeutic measures during the stone-removing procedure.those responding well to ESWL and those responding poorly (8).5 Hard stones Stones composed of brushite or calcium oxalate monohydrate are characterized by particular hardness. Table 21: Special considerations GR Treatment with antibiotics should precede stone-removing procedures in case of a positive urine culture. J Urol 1992. URS has been successfully used to remove ureteral stones during pregnancy. Problems and complications in stone disease. ureteroscopy (URS) and open surgery. particularly if they are large. 9.4:234238. 9. UPDATE JUNE 2005 53 . 9. can be dissolved by oral chemolytic treatment. In such women.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1507336 Marberger M. percutaneous nephrolithotomy (PNL) with or without lithotripsy.ncbi. http://www. Eur Urol 1984. the preferred treatment is drainage.nih.148:1076-1078.nlm.
Antibiotics + PNL + ESWL 1b A 3. Mertz JH. COMPLETE OR PARTIAL STAGHORN STONES A staghorn stone is defined as a stone with a central body and at least one caliceal branch. Nephrectomy should be considered in the case of a non-functioning kidney. De Lisa A.nih. Dretler SP. 4. uric acid and calcium phosphate stones. cystine. PNL 1b A 2. Scarpa RM.gov/entrez/query.138:485-490. Steele RE. 54 UPDATE JUNE 2005 .nih. ESWL + PNL 2a B LE = level of evidence.gov/entrez/query. In: Shock Wave Lithotripsy 2. a complete staghorn stone fills all calices and the renal pelvis. Renal colic during pregnancy: a case for conservative treatment.nih. Antibiotics + PNL 1b A stones with infection 2. Antibiotics + ESWL + local chemolysis 2a B 5.nlm. Treatment of both types of staghorn stone is detailed in Table 22.155:875-877. 10. Lingeman JE. J Urol 1998. Plenum Press: New York. ESWL + PNL 1b A 4. Howard PJ Jr. The principles of chemolytic treatment are discussed in Section 7. PNL + ESWL 1b A 2.gov/entrez/query. ESWL = extracorporeal shock wave lithotripsy. 7. PNL + ESWL 1b A 3. Prien EL Jr. 2. Lal A. PNL/ESWL + oral chemolysis 1b A 3. repeated ESWL sessions with a stent can be a reasonable treatment alternative. also including piezolithotripsy.nlm. Kahnoski RJ. 3. Coury TA.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9649240 Lingeman JE.5. Table 22: Active removal of complete and partial staghorn stones* Type of stone Radio-opaque stones Procedure LE GR 1. pp 55-59. Wollin MR. ESWL + PNL 1b B Cystine stones 1.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8583596 Parulkar BG. GR = grade of recommendation. PNL = percutaneous surgery. J Urol 1996. In selected cases with infection.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3625845 Bhatta KM. The first alternative always has the number 1. http://www. Open surgery standard Infection stones and 1. Hopkins TB. Woods JR. Newman DM (eds). *Numbers (1. Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes. Usai E. Newman DM. PNL 1b A 2. 159:365-368. the combined use of ESWL and chemolysis may be useful. When two procedures were considered equally useful they have been given the same number. PNL + ESWL 2a B 3. Cystine calculi: two types. In patients with small staghorn stones and a non-dilated system.ncbi.ncbi. http://www. J Urol 1987. 5) have been allocated to the procedures according to the consensus reached. Antibiotics + open surgery standard Uric acid/urate stones 1. Antibiotics + ESWL + PNL 1b A 4.ncbi. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy.5. 6. Mosbaugh PG. PNL 2a B 2. 1989.. http://www. 8.nlm. Whereas a partial staghorn stone fills up only part of the collecting system.
stones can be removed at the same time as the outflow abnormality is corrected either with percutaneous endopyelotomy (15-35) or with open reconstructive surgery. Chang LS.35:407-411.nih. MANAGING SPECIAL PROBLEMS Caliceal diverticulum stones are treated using ESWL. Walden T.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126827&dopt= Abstract Escovar Diaz P.fcgi?cmd=Retrieve&db=PubMed&list_uids=8124346&dopt= Abstract Gaur DD.nih. Electrohydraulic lithotripsy for stones in Kock pouch. Retroperitoneal endoscopic ureterolithotomy: our experience in 12 patients. J Endourol 1990. Gonzalez Zerpa RD. well-disintegrated stone material will remain in the original position.nih. UPDATE JUNE 2005 55 . [Ureterolitotomia laparoscopia. Albert PS. 9.gov/entrez/query. The principles of videoendoscopic surgery are outlined elsewhere (1-5). Cuervo R.1 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=2336770&dopt= Abstract Chen KK. that according to the anterior position of the kidney.nlm. 8. Loffreda R. Laparoscopic ureterolithotomy.gov/entrez/query. It needs to be emphasized.39:223-225.ncbi.. 5.fcgi?cmd=Retrieve&db=PubMed&list_uids=2714327&dopt= Abstract Weinerth JL. 7.ncbi. http://www.nih. Extracorporeal shock wave lithotripsy in horseshoe kidney.ncbi. Retroperitoneal laparoscopic ureterolithotomy.nlm. Urology 1992.nlm. These patients may become asymptomatic as a result of stone disintegration only.gov/entrez/query.ncbi. J Endourol 1993. ESWL. Transureteral endopyelotomy with Ho:YAG laser endopyelotomy is another alternative to correct such an abnormality. Steinbock GS.7:501-503. Khatri VP.e. Ferzli GS.11:175-177.46:633637.11.nih.nlm. http://www. Webster GD.nih.] Arch Esp Urol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=8239742&dopt= Abstract Locke DR. Eur Urol 1989.fcgi?cmd=Retrieve&db=PubMed&list_uids=8401638&dopt= Abstract Gaur DD. Each stone problem has to be considered and treated individually.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507351&dopt= Abstract 2.nlm. Incision with an Acucise balloon catheter may also be considered provided the stones can be prevented from falling down into the pelvo-ureteral incision (36-39). however. J−ζUrol 1992. Experience with management of stones formed within Kock pouch continent urinary diversions.nih. Darshane AS. Chen MT.16:110-113.nlm. PNL or open surgery are the options in obese patients. Rodriguez Cordero M. Lee YH. 6. J Urol 1994. PNL (if possible) or retrograde URS. http://www. Purohit KC. http://www.ncbi.gov/entrez/query. it is commonly necessary to carry out ESWL treatment with the patient in the prone position (i.nlm. In the case of a narrow communication between the diverticulum and the renal collecting system.gov/entrez/query. Agarwal DK. la Riva Rodriguez F. Retroperitoneal laparoscopic pyelolithotomy. Lopez Escalante JR. In patients with obstruction of the ureteropelvic junction.148:1129-1130. Urology 1990.ncbi.ncbi. Finlayson B.151:927-929. Garcia JL. Newman RC. World J Urol 1993. http://www. 4. Recommended procedures for the removal of stones in transplanted kidneys are ESWL and PNL.4:149-154. REFERENCES Raboy A. An optional method for removal of diverticular stones is video-endoscopic retroperitoneal surgery. http://www. The stones formed in a continent reservoir present a varied and often difficult problem (7-14). Pollack MS. ESWL or video-endoscopic laparoscopic surgery is recommended. [Spanish] http://www.ncbi.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1532102&dopt= Abstract Gaur DD.gov/entrez/query.nih. with shock wave entrance from the abdominal side). Multiple large calculi in a continent urinary reservoir: a case report. http://www.nlm. General directions for the management of this problem cannot be given. Rey Pacheco M. Horseshoe kidneys may be treated according to the principles of stone treatment presented above (6). For pelvic kidneys. 3. 11.
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uric acid. The corresponding stone-free rate was 20% (1). Patients with residual fragments or stones should be regularly followed up to monitor the course of their disease.2 years (16).0% and 41. The role of CIRF has been a matter of debate and concern for some time (2-13). In other cases. the recurrence rates were 6.7%.2% after 1. For calcium stones. the term ‘clinically insignificant residual fragments’ (CIRF) was introduced. After 6. cystine and brushite. which are otherwise radiolucent.3% of patients by 2 years of follow-up. 78% of the patients with stone fragments 3 months after treatment experienced stone progression. For stones in the upper and middle calices. a 20% risk of recurrent stone formation was recorded during the first 4 years after ESWL. 6. In asymptomatic patients where the stone is unlikely to pass. Moreover. In a 2. Table 23: Recommendations for the treatment of residual fragments Symptomatic residuals Stone removal Stone removal Asymptomatic residuals Reasonable follow-up Consider appropriate method for stone removal Residual fragments.6 years. It is our recommendation that the results of a stone-removing procedure are based on the findings of a good-quality KUB and that CT examination is only necessary for uric acid stones.3 years. it is important to rule out obstruction and to treat this problem if present. The longest follow-up period was reported by Yu and co-workers (14). In a follow-up of patients with < 4 mm residual fragments during a 4-year period. CT scans cannot be carried out everywhere. 28. Residuals with a diameter of 5 mm or more should be termed residual stones. Stone recurrences were thus reported to be 8. stones (largest diameter) < 4-5 mm > 6-7 mm 58 UPDATE JUNE 2005 . 40% showed decreased disease or remained stable. In data on 104 patients with residual fragments. most frequently presenting in the lower calix following disintegration of large stones. there is no data in the literature demonstrating the clinical value of being able to detect small tiny concretions visible only on CT scan. necessary therapeutic steps need to be taken to eliminate symptoms. Reports on residual fragments therefore vary from one institution to another depending on which imaging method is used. Thus. 3 and 5 years. Percutaneous chemolysis is an alternative treatment for stone fragments composed of magnesium ammonium phosphate. Table 23 summarizes the recommendations for the treatment of residual fragments. lower pole resection is an alternative treatment to be considered (21).5 years and 7% after 3. Stone residuals with a largest diameter of 4 mm should be termed residual fragments.3 years.6 years (18). the residual fragments increased in size in 37% of patients. However. carbonate apatite. For a group of Swedish patients with calcium stones. The greatest risk was seen in patients with stones containing a high content of calcium phosphate (20). 20% after 3. Double-J stenting before ESWL is recommended for stones with a largest diameter of more than 20 mm (300 mm2) in order to avoid problems with an accumulation of stones obstructing the ureter. residual fragments may occur following ESWL for all sizes of stones. there was obvious increase in size in 37% and a need for retreatment in 12% (17).2 year follow-up of 53 patients. RESIDUAL FRAGMENTS Residual fragments are commonly seen after ESWL.7% after 3. New stone formation is another aspect to consider in ESWL-treated patients because of the assumption that the fraction of stone-free patients is overestimated. with an average follow-up of 3. Most studies on the long-term course of the disease in patients with residual fragments are restricted to periods between 1 and 6 years. stone growth was observed in 26% of patients and recurrent stone formation in 15%. with further intervention necessary in 9.12. In a Japanese report. 9. respectively (19). During a follow-up of between 7 and 96 months.4% after 1 year. known as a Steinstrasse (see Section 13) (22-34). a CT or topographic examination both demonstrate small fragments better than a standard film (KUB). A CT scan also has the capacity to demonstrate uric acid concrements. However. URS with contact disintegration is another treatment option. Different imaging techniques have variable degrees of sensitivity. In symptomatic patients. Identification of biochemical risk factors and appropriate stone prevention may be particularly indicated in patients with residual fragments or stones. 25% of patients with infection stones had formed new stones after 2 years.8% after 1. A new stoneremoving procedure was undertaken in 22% of patients (15). The risk of recurrence in patients with residual fragments after treatment of infection stones is well recognized. treatment should be applied according to the relevant stone situation. The clinical problem of asymptomatic stone residuals in the kidney is related to the risk of developing new stones from such nidi.4 years. For a kidney with stones or fragments in the lower caliceal system and with no functioning parenchyma in that part. while 5% progressed during a mean follow-up of 1.
gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8254832&dopt= Abstract Fine JK. http://www.nih. Gladstone K.nih.ncbi.gov/entrez/query.155:1186-1190. 15.nih. Fandella A. Comprehensive metabolic evaluation of stone formers is cost effective.gov/entrez/query.6:217-218.nih. 9.nlm.ncbi.ncbi.nlm. 3. Marberger M. UPDATE JUNE 2005 59 . Lin AT.nlm. http://www. Editors: AL Rodgers.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507326&dopt= Abstract Yu CC. Nespoli R. Seveso M. J Stone Dis 1993. J Urol 1991.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281395 Candau C. Long-term results in ESWL-treated urinary stone patients. Chang LS.148:1040-1041. 16. The definition of success. J Urol 1997. 37:18-22.5:8-18.nlm.gov/entrez/query. Br J Urol 1993. Lang H. Roy C.nlm. Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for urinary calculi: comparison of immediate and long-term effects. Urol Res 1988.ncbi. Roth RA. Mulley AG Jr. Cape Town: University of Cape Town.nlm. Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. Bub P. http://www. Jacqmin D. Preminger GM. REFERENCES Beck EM. Lee YH.44:1023-1024. Extracorporeal shock wave lithotripsy for lower calyceal stones: can clearance be predicted? Br J Urol 1997. Chen MT.nlm. Gambaro G. Tuerk C. Merlo F. http://www. Schuster C.nih. Huang JK.158:352-355. Mascha E. Br J Urol 1993.ncbi. http://www. J Urol 1992.ncbi. Kladensky J. 11.ncbi. Trinchieri A. Maccatrozzo L. http://www. The fate of residual fragments after extracorporeal shock wave lithotripsy monotherapy of infection stones. pp 349-355. Abstract. Natural history of residual renal stone fragments after ESWL.nih. http://www. 12. 10. J Urol 1995. J Endourol 1992. Baggio B.12. In: Urolithiasis 2000. Jelinek P. Steinkogler I. Eur Urol 2000. Guarneri A.151:5-9.nlm. Anselmo G. Chang LS. Huang JK. Pak YC.fcgi?cmd=Retrieve&db=PubMed&list_uids=10148257&dopt =Abstract Sabnis RB. Liedl B. Lunz C. Effectiveness of SWL for lower-pole caliceal nephrolithiasis: evaluation of 452 cases.ncbi. Dretler SP. Naik K. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7966783&dopt= Abstract Streem SB.145:6-9.ncbi.nih. Del Nero A.gov/entrez/query.nlm. Bapat SD. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy.nlm. Schmidt A.72:688-691. Riehle RA Jr. Lee YH.nlm.1 1.nih.ncbi. http://www. Jocham D. J Urol 1996. Kumstat P. 2.fcgi?cmd=Retrieve&db=PubMed&list_uids=8632527&dopt= Abstract Zanetti G.11:305-307. 4. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy. Chen KK. Renal stone fragments following shock wave lithotripsy. Faure F.gov/entrez/query. B Hess. Turjanica M. 8.80:853-857. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=9439396&dopt= Abstract Yu CC.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281395&dopt= Abstract Carlson KJ. Saussine C. Cicerello E. GM Preminger. Chen MT. Hatziandreu E. J Endourol 1997.ncbi.nih.gov/entrez/query.gov/entrez/query.ncbi. Lin AT. 13.gov/entrez/query. Arch Esp Urol 1991. 7. BE Hibbert. 6.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224301&dopt= Abstract Pacik D. Desai MR.153:27-33.72:688-691. Extracorporeal shock wave lithotripsy retreatment (“stir-up”) promotes discharge of persistent caliceal stone fragments after primary extracorporeal shock wave lithotripsy. Patel SH.gov/entrez/query. Chen KK. http://www.nlm.nih. J Urol 1994. 14. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy. 5.16:256. The fate of residual fragments after extracorporeal shock wave lithotripsy. Montanari E. Krings F.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1984100 Eisenberger F. Yost A.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10671779 Tiselius HG. http://www. Hanak T. SR Khan.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9355942&dopt= Abstract Segura JW.
Streem SB. Fate of clinically insignificant residual fragment (CIRF) after ESWL. 4:234-238.gov/entrez/query.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8808851 Tiselius HG.gov/entrez/query.748-749.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8863540 Lahme S. Eur Urol 1997.ncbi.nih.ncbi. 21.nlm. [The staghorn calculus: anatrophic nephrolithotomy versus percutaneous litholapxy and extracorporeal shockwave therapy versus extracorporeal shockwave lithotripsy monotherapy.nlm. Urol Clin North Am 1988.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=3407040&dopt= Abstract Saltzman B.ncbi.nlm. Curr Opin Urol 1994. Extracorporeal shock wave lithotripsy for large renal stones. Gleeson MJ. 23. Jaeger P.nih. Claus R.gov/entrez/query. 26. Alund G.nih. http://www.nih.nih. http://www. Hofbauer J. Stent use with extracorporeal shock wave lithotripsy.nlm. 29.nih.gov/entrez/query. Ohshima S. J Urol 1989. 18.fcgi?cmd=Retrieve&db=PubMed&list_uids=3609094&dopt= Abstract 60 UPDATE JUNE 2005 . 31.gov/entrez/query. J Endourol 1993. Hauri D. http://www. http://www. Schneider M.ncbi. Eur Urol 1987.3:31-36. 24.ncbi. Long-term stone recurrence rate after extracorporeal shock wave lithotripsy. Br J Urol 1977. Hautmann R.4:152-157. J Endourol 1988. 20.ncbi. J Urol 1996. Use of internal polyethylene ureteral stents in extracorporeal shock wave lithotripsy of staghorn calculi. Shapiro A. 19. Pfau A. http://www. 30.156:1267-1271.15:5-8. Knönagel H.fcgi?cmd=Retrieve&db=PubMed&list_uids=9032530&dopt= Abstract Ackermann D. A report of over 6 years’ experience] Urologe A 1989. Pode D. Wilbert DM. 25. 27. Problems and complications in stone disease. McDermott TE.nlm. Schmidt JD.gov/entrez/query. Grainger R. Bichler KH. Extracorporeal shock wave lithotripsy for lower pole calculi: long-term radiographic and clinical outcome. Recker F.gov/entrez/query. http://www. Konstantinidis K. Extracorporeal shock wave lithotripsy for stones in solitary kidney. Hauri D. Urology 1990.gov/entrez/query. Griffith DP.nlm. Indications. Urolithiasis 2000.fcgi?cmd=Retrieve&db=PubMed&list_uids=3043868&dopt= Abstract Constantinides C.nlm.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=597695&dopt= Abstract&itool=iconabstr Miller K. Scheiber K.fcgi?cmd=Retrieve&db=PubMed&list_uids=8518830&dopt= Abstract Marberger M. http://www. Ureteral stents.fcgi?cmd=Retrieve&db=PubMed&list_uids=2368232&dopt= Abstract Shabsigh R.28:152-157.nih.nlm. Extracorporeal shock wave lithotripsy as monotherapy of staghorn renal calculi. Extracorporeal shock wave lithotripsy experience with large renal calculi. J Urol 1996.ncbi. Norman RW. Kamihira O. Partial nephrectomy for stone disease. 28. Thornhill JA.15:481-491.fcgi?cmd=Retrieve&db=PubMed&list_uids=2585613&dopt= Abstract Anderson PAM. J Stone Dis 1992. Awad SA.15:493-497. J Endourol 1989. Zehntner C. 32. Yamada S.nih.gov/entrez/query.nih.ncbi.36:52-54. To what size is extracorporeal shock wave lithotripsy alone feasible? Eur Urol 1988. Saltzman B.ncbi. Percutaneous nephrolithotomy and extracorporeal shock wave lithotripsy versus ureteral stent and ESWL for the treatment of large renal calculi and staghorn calculi a prospective randomized study: preliminary results.nih.gov/entrez/query.ncbi. The benefits of stenting on a more-or-less routine basis prior to extracorporeal shock wave lithotripsy. Chen RN. 33. Follows OJ. Jaeger P. http://www. Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility.7: 155-162. http://www.nih.ncbi. Mizutani K. Verstandig A.fcgi?cmd=Retrieve&db=PubMed&list_uids=2741262&dopt= Abstract Chen AS. 22. Recurrent stone formation in patients treated with extracorporal shock wave lithotripsy.gov/entrez/query. Rose MB. http://www. Recker F.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215235&dopt= Abstract Cohen ES.156:1572-1575.nlm.17.nih. Urol Clin North Am 1988. variations and complications. Butler MR. [German] http://www. Bachor R. Ono Y. http://www.2:131-135.49:605-610.142:1415-1418. Lennon GM. 3 years of experience.13:174-175.nlm.gov/entrez/query.31:24-29. Katoh N.
ncbi. The role of ureteral stent placement in the prevention of steinstrasse. Ureteral calculi. STEINSTRASSE A Steinstrasse or fragment column in the ureter is an accumulation of gravel that does not pass within a reasonable period of time and that interferes with urine passage (1).1 1. pp. irrespective of stone composition. Harrison LH.nlm. When two procedures were considered equally useful they have been given the same number. McCullough DL (eds). In all patients with signs of infection.gov/entrez/query. In: State of the Art Extracorporeal Shock Wave Lithotripsy. the 24-h urine volume should exceed 2. The first alternative always has the number 1. ESWL ESWL 1. ESWL 3. 14.1 General recommendations Preventive treatment in patients with calcium stone disease should be started with conservative measures. for instance. Pharmacological treatment should be instituted only when the conservative regimen fails. For a normal adult. New York 1987. http://www. http://www. For distally located accumulations of fragments.fcgi?cmd=Retrieve&db=PubMed&list_uids=8490666&dopt= Abstract Griffith DP.a mixed balanced diet with contributions from all food groups.000 mL. Sulaiman MN. REFERENCES Tolley DA. PREVENTIVE TREATMENT IN CALCIUM STONE DISEASE 14. URS might be useful to remove the leading stone fragment by contact disintegration. World J Urol 1993. Care must be taken. 4) have been allocated to the procedures according to the consensus reached.fcgi?cmd=Retrieve&db=PubMed&list_uids=10360492&dopt =Abstract 13. PN PN Proximal ureter 1. ESWL 2. it is necessary to give antibiotics and to provide adequate drainage as soon as possible. Insertion of a PN catheter usually results in passage of the fragments (2). and particular attention should be paid to situations in which an unusual loss of fluid occurs. ESWL ESWL 1.34. PN PN Mid ureter 1. 2. also including piezolithotripsy. Stent 4. however. Mt Kisco. Buchholz NP.nih. Stent 3. Diet should be of a ‘commonsense’ type . The intake of fruits and vegetables should be encouraged because of the beneficial effects of fibre (3). URS = ureteroscopy. 13. URS 2. * Numbers (1.nih. 2. to avoid fruits and vegetables that are rich in oxalate. Futura Publishing Co.gov/entrez/query. This advice is valid. J Endourol 1999. The frequency of this complication has decreased with the liberal insertion of double-J stents before ESWL of large renal stones. Kandel LB. but without excesses of any kind (2). URS ESWL = extracorporeal shock wave lithotripsy. Patients should be encouraged to have a high fluid intake (1). PN = percutaneous nephrotomy. Recommendations for treatment are summarized in Table 24. PN PN Distal Ureter 2. but the supersaturation level should be used as a guide to the necessary degree of urine dilution. the UPDATE JUNE 2005 61 . ESWL 3. Wheat bran.13:151-155. Consensus of lithotriptor terminology. Table 24: Recommendations for treatment of Steinstrasse* Unobstructed Position of stone Obstructed and/or symptomatic 1. is rich in oxalate and in order to avoid an oxalate load.ncbi. 281-310. The fluid intake should be evenly distributed over a 24-hour period.11:37-42.nlm. Clark PB. ESWL 1. 3.
Supplements of calcium are not recommended except in cases of enteric hyperoxaluria.fcgi?cmd=Retrieve&db=PubMed&list_uids=3306314&dopt= Abstract Yendt ER. Ohkawa T. 9. Commentary: Renal calculi . Guerra A.nih.gov/entrez/query. anchovies. Mauron H. The intake of food particularly rich in urate should be restricted in patients with hyperuricosuric calcium oxalate stone disease (15-20). 62 UPDATE JUNE 2005 .gov/entrez/query. 14. • Tea leaves 375-1450 mg oxalate/100 g. Calcium intake should not be restricted unless there are very strong reasons for such advice.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126804&dopt= Abstract Sutton RA. 5. Nephron 1999. Kataoka K. Borghi L. Williams HE. http://www.nih. J Lithotripsy Stone Dis 1990. Kohri K.Diagnosis. 10.151:834-837. • Cocoa 625 mg oxalate/100 g.nlm.nih. Results of long-term rice bran treatment on stone recurrence in hypercalciuric patients. in which additional calcium should be ingested with meals.ncbi. Iguchi M.nih.ncbi. Miner Electrolyte Metab 1994. as well as in patients with uric acid stone disease.2:164-172. This is of particular importance in patients in whom high excretion of oxalate has been demonstrated. • Herring with skin.13:228-234. Yasukawa S.twenty years later.nih. Dietary intake and habits of Japanese renal stone patients. Morimoto S.ncbi. http://www. J Urol 1994.fcgi?cmd=Retrieve&db=PubMed&list_uids=7783697&dopt= Abstract Auer BL.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9589801&dopt= Abstract Robertson WG. Takada M. Animal protein should not be ingested in excessive amounts (8-14).36:143-147.excessive intake of products rich in oxalate should be limited or avoided. http://www. D’Andre SD. Vitamin C in doses up to 4 g/day can be taken without increasing the risk of stone formation (5-7). Katoh Y. Meschi T.nlm. Davis PA. http://www. sardines. Diet and calcium stones. Rodger AL. • Nuts 200-600 mg oxalate/100 g.nih.ncbi. Schianchi T. 1996. 3. 8. • Poultry skin 300 mg urate/100 g.fcgi?cmd=Retrieve&db=PubMed&list_uids=9873212&dopt= Abstract Hess B. Kodama M. 4.gov/entrez/query. The effects of ascorbic acid ingestion on the biochemical and physicochemical risk factors associated with calcium oxalate kidney stone formation. Urine volume stone risk factor and preventive measure. Wandzilak TR. 36:136-143. 7. http://www. The minimum daily requirement for calcium is 800 mg and the general recommendation is 1000 mg/day. • Kidneys 210-255 mg urate/100 g.gov/entrez/query.ncbi. 6. J Urol 1990.gov/entrez/query. Below are examples of food rich in urate (21): • Calf thymus 900 mg urate/100 g. Walker VR. and it is recommended that animal protein intake is limited to approximately 150 g/day. http://www. Katayama Y.ncbi. Miner Electrolyte Metab 1987. Ackermann D.67:237-40.gov/entrez/query. Jaeger P.1 REFERENCES 1. pp. Novarini A. The following products have a high content of oxalate (4): • Rhubarb 530 mg oxalate/100 g.fcgi?cmd=Retrieve&db=PubMed&list_uids=10420035&dopt =Abstract Ebisuno S.nlm.nlm. Umekawa T. treatment and prevention of recurrence.gov/entrez/query.81(suppl):31-37. Briganti A.nlm. Tiselius HG. http://www.nlm.nlm. The intake of urate should not exceed more than 500 mg/day. Br J Urol 1991.ncbi.nih. • Spinach 570 mg oxalate/100 g. Allegri F. Effects of a ‘common sense diet’ on urinary composition and supersaturation in patients with idiopathic calcium urolithiasis. Karger: New York.fcgi?cmd=Retrieve&db=PubMed&list_uids=1902388&dopt= Abstract Hesse A.fcgi?cmd=Retrieve&db=PubMed&list_uids=2342165&dopt= Abstract 2. http://www.1. Clin Chem Lab Med 1998. sprats 260-500 mg urate/100 g. Eur Urol 1999. Jahnen A.20:352-360. In: Urinary stones . Kurita T. Enteric and mild hyperoxaluria. • Liver 260-360 mg urate/100 g. Ishikawa Y.143:1093-1095. Effect of high dose vitamin C on urinary oxalate levels. Auer D.gov/entrez/query. 62.
Hofbauer J.gov/entrez/query. and in some situations pyridoxine and oxabsorb. allopurinol.diagnosis. The effects of dietary excesses in animal protein and sodium on the composition and the crystallization kinetics of calcium oxalate monohydrate in urines of healthy men. Diet and calcium stones.nlm. 14. The scientific basis of these forms of treatment is briefly summarized below. orthophosphate.11. treatment and prevention of recurrence.15:227-229.nih. Favus MJ. Goodman HO.gov/entrez/query. 21. Papapoulos SE. Norman RW. 19. Iestra JA. 13.nih. In this respect.4). http://www. 1996. Hyperuricosuric calcium stone disease.3. UPDATE JUNE 2005 63 . Endocrinol Metab Clin North Am 1990. http://www.nlm.71:861-867. http://www.nih. In: Urinary stones .44:366-372.gov/entrez/query. Kidney Int 1983. Ettinger B. Parks JH.ncbi. Britton F.nlm. 285-293.24:392-403. 20. Kok DJ. Eur Urol 1988.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7424690&dopt= Abstract Pak CY. sodium cellulose phosphate. http://www. Hyperuricosuric calcium oxalate nephrolithiasis. pp. information has been added on recent studies with special emphasis on data from randomized studies. http://www. should a pharmacological approach be considered in addition to the drinking and dietary recommendations.nih. pp.fcgi?cmd=Retrieve&db=PubMed&list_uids=8377380&dopt= Abstract Coe FL. http://www. The pharmacological agents most commonly used in patients with recurrent calcium stone formation are thiazides. Miner Electrolyte Metab 1987. 12.4:130-136.ncbi. it is essential to choose the most appropriate form of treatment.fcgi?cmd=Retrieve&db=PubMed&list_uids=3306317&dopt= Abstract Zechner O. Zechner O.nih. 15. The hyperuricosuric calcium oxalate stone former. 88.ncbi. Can Med Assoc J 1992.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215256&dopt= Abstract Sarig S. Germany in 1996 and form the basis for the abovementioned recommendations (1). Wickham JEA. Buck AC (eds).146:137-143. We believe that the latter approach is theoretically most attractive but it needs to be emphasized. Tiselius HG. 1990. Peterson R. The role of diet in the pathogenesis and therapy of nephrolithiasis. 16. pp. Hart LJ. 851-858. Assimos DG. J Clin Endocrinol Metab 1990.gov/entrez/query. magnesium.nih. An extensive review and interpretation of literature results were carried out by the European Urolithiasis Research group at a Consensus Conference in Mannheim.fcgi?cmd=Retrieve&db=PubMed&list_uids=2081512&dopt= Abstract Hughes J. 14. Lippincott-Raven Publishers: Philadelphia.nlm. 18. Only when such treatment turns out to be unsuccessful. We have given our recommendations for the various agents both for when they are given in a nonselected way (Table 25) and when given for a specific urine abnormality (Table 26). The conclusions of the Consensus Conference have been published separately (2.2 Pharmacological agents in prevention of recurrent calcium stone formation The general opinion is that attempts should always be made to correct abnormalities in urine composition and to eliminate risk factors of pathological crystallization by advice regarding drinking and dietary habits.fcgi?cmd=Retrieve&db=PubMed&list_uids=2401715&dopt= Abstract Goldfarb S. The ideal pharmacological agent should halt the formation of calcium stones.ncbi. cellulose phosphate. Crowther C. In the present edition of the Urolithiasis guideline document.nlm.gov/entrez/query. Holt K.6). 1996. Hyperuricosuric calcium oxalate lithiasis.nlm.13:251-256. 17. http://www.ncbi. All these aspects are of utmost importance in order to achieve a reasonably good compliance. Churchill Livingstone: Edinburgh. be free of side effects and easy to administer.nih. that there is no absolute consensus on such a view (5. Pak CYC. Doorenbos CM. monopotassium urate. Kidney Int 1993. Hesse A. however. monoammonium urate and monosodium urate in hyperuricosuric calcium oxalate nephrolithiasis. In: Renal tract stone.ncbi. Coe FL. Assessment of pathogenetic roles of uric acid. Karger: New York.fcgi?cmd=Retrieve&db=PubMed&list_uids=1310430&dopt= Abstract Holmes RP.gov/entrez/query. In: Kidney stones: medical and surgical management. Preminger GM (eds). Impact of allopurinol treatment on the prevention of hyperuricosuric calcium oxalate lithiasis. Miner Electrolyte Metab 1980. Relationship of protein intake to urinary oxalate and glycolate excretion.19:805-820. Ward D. Jahnen A (eds).gov/entrez/query.ncbi. The recommendations given in this guideline document are based on what has been published in this field.
In the absence of a high calcium excretion. A significantly reduced rate of stone formation was also noted when a thiazide was given intermittently to recurrent stoneformers (22). A reduced rate of recurrence was also observed in a number of other studies in which the treated patients were compared with patients not given any pharmacological agent (23-26). a significantly reduced recurrence rate was recorded.2. the overall impression is that potassium citrate (31.1 Thiazides and thiazide-like agents Hydrochlorothiazide. The purpose of thiazide treatment is to reduce the excretion of calcium in hypercalciuric patients. a significant effect was reported in five. other forms of treatment may be more appropriate first-choice alternatives. a thiazide-induced reduction in urinary oxalate is not a consistent finding in the clinical studies.14. however.35-40) has a greater potential for preventing recurrence than sodium potassium citrate (2. The clinical effect of thiazide treatment has accordingly been evaluated in 10 randomized studies. or used also in patients without this abnormality. potassium citrate.8). It has. potassium bicarbonate and sodium bicarbonate.3 and 4. Alkaline citrate has been used in four randomized studies. but it has been stated that calcium reduction is also seen in patients with normocalciuria (7). that the major indication for choosing a thiazide or a thiazide-like agent should be hypercalciuria. a large number of reports have been published. A positive effect of thiazide treatment was further supported by a meta-analysis of randomized trials which showed significantly better results with active treatment than with placebo or no treatment (p < 0.3 years in comparison with conservatively treated patients (19-21).33. Following the initial report by Yendt in 1970 (12). the results were less convincing (27. In several other studies. Although the general principle is to give citrate preparations. there is no strong scientific basis for a recommendation in this regard. It is our opinion. Other non-randomized studies with alkaline citrate have shown a variable outcome. cannot be definitely concluded from the various studies. A favourable effect was also reported with potassium magnesium citrate. sodium potassium in one (33) and sodium magnesium citrate in another (34). Due to the frequent occurrence of hypercalciuria also in an unselected group of stoneformers. In the other seven randomized trials. 14.32. A low citrate excretion is a frequent finding in patients with calcium stone disease. Administration of an alkaline salt brings about an increased pH and an increased excretion of citrate. There are also reports of favourable clearance of residual fragments during treatment with alkaline citrate (see below). three studies selected hypercalciuric patients (19-21) and all three showed a significantly positive effect of thiazides. The major drawback of thiazide treatment is the occurrence of side-effects. Whether or not thiazide treatment should be reserved only for patients with hypercalciuria. potassium magnesium citrate. whereas no effect was noted with sodium potassium citrate compared with an untreated group. The role of calcium is important because citrate chelates calcium and thereby reduces the ion-activity products of both calcium oxalate and calcium phosphate. This observation is also supported by the different effects of potassium citrate and sodium citrate on urine composition (43). four of which included placebo-treated patients. In the two studies with potassium citrate. Compliance is usually in the range of only 50-70%. moreover. As in all situations when pharmacological treatment is considered. Potassium citrate was used in two (31. contribute to a low tolerance and a high drop-out rate.02) (29). in which no selection was made. Suffice it to mention that of the randomized studies.41. Moreover. most of which support a positive effect of recurrence prevention. However. citrate is an inhibitor of growth and aggregation of these crystals (30).32). Although two short-term placebo-controlled studies (13.2. possibly by a reduced intestinal absorption of calcium (911). bendroflumethiazide.14) failed to confirm a positive effect of thiazides. There is more than 30 years’ clinical experience with thiazides as a method for stone prevention.28). with only a small fraction of the administered citrate being excreted in urine.2 Alkaline citrate Treatment with alkaline citrate is commonly used as a method to increase urinary citrate in patients with hypocitraturia. a significantly reduced recurrence rate was recorded in three 3-year follow-up studies (15-18). development of diabetes and gout. However. trichlorothiazide and indapamide have been used for recurrence prevention in patients with calcium stone disease. sodium citrate. A similar result was also obtained in three groups of patients treated with thiazides for 2. The alkalinizing agents used to prevent recurrent calcium stone formation are sodium potassium citrate. 64 UPDATE JUNE 2005 . it is the alkalinization of the tubular cells that is the most important factor affecting increased citrate excretion. The hypocalciuric action of thiazides is thought to be mediated by an increased reabsorption of calcium in the proximal as well as in the distal parts of the nephron (7. as well as erectile dysfunction.42). a judgment must be made between the positive and the negative effects of the medication. been suggested that thiazides might decrease the excretion of oxalate. The unmasking of normocalcaemic HPT.
Although potassium magnesium citrate appears efficient in prevention of recurrent stone formation, this agent is not yet generally available. Further studies are necessary to show whether this preparation is superior to potassium citrate. Whether or not alkaline citrate preparations should be reserved for patients with hypocitraturia or used in a non-selective way has not been appropriately addressed in any study. An attempt to compare literature data has suggested a trend towards selective treatment (44). In a meta-analysis of randomized trials it was not possible to adequately analyze the therapeutic outcome (29). The usefulness of alkaline citrate as a means to increase the stone clearance after shock wave lithotripsy has been studied by several groups and has recently been the subject of a European multicentre investigation (not yet finally analyzed). It was accordingly shown that sodium potassium citrate (45), as well as potassium citrate (40, 46), increased clearance of stone fragments. The frequency of side effects is fairly high and compliance with alkaline citrate administration was shown to be no better than approximately 50%. Because of the many effects on calcium oxalate and calcium phosphate crystallization and stone formation, treatment with alkaline citrate can be recommended as a treatment for preventing recurrent stones. The recommended agent is potassium citrate. Although it is likely that this form of treatment is most beneficial for patients with a low citrate excretion, so far there is no solid evidence in the literature to support this assumption and further studies are necessary. The risk of forming calcium phosphate stones as a result of the increased pH is theoretical, but there are no reports of this problem in the literature. 14.2.3 Orthophosphate The theoretical rationale for giving orthophosphate to patients with recurrent calcium oxalate stone formation is to reduce the excretion of calcium and increase the excretion of pyrophosphate. Pyrophosphate is an inhibitor of both calcium oxalate and calcium phosphate crystal growth. The effect on urinary calcium is assumed to be mediated by formation of 1,25 (OH)2-vitamin D with an associated decreased absorption of calcium and reduced bone resorption. Administration of orthophosphate (neutral) has been reported to also increase urinary citrate. There are only a few studies in the literature that deal with the effect of orthophosphate on stone formation. In a randomized, placebo-controlled study on potassium acid phosphate given during a period of 3 years, stone formation increased in the orthophosphate-treated group (47). The rate of stone formation during 3 years of treatment with phosphate was also studied in two randomized studies (16,17). The number of patients in each of these studies was small and there were no statistically significant differences between treated and untreated patients. In some, less well-controlled, studies (48,49), it was also not possible to confirm a reliable effect of phosphate treatment. A reduced rate of stone formation was, however, noted by others (50,51). In reviews of literature results, there is a lack of scientific evidence that phosphate is effective in preventing calcium stone formation (29,52). Although patient compliance with treatment is reported as good, side effects such as diarrhoea, abdominal cramps, nausea and vomiting are common. Moreover, a possible effect on PTH (parathyroid hormone) needs consideration. It is possible that the pattern of side effects is favourably affected by slowrelease potassium phosphate (53). The effect of phosphate administration on calcium stone phosphate formation has not been elucidated. In conclusion, there is only very weak evidence that orthophosphate significantly reduces calcium oxalate stone formation. Although this form of treatment may be a possible option in patients with absorptive hypercalciuria, so far there is insufficient evidence to recommend its use. 14.2.4 Magnesium An increased excretion of magnesium might reduce the ion-activity product of calcium oxalate and inhibit the growth of calcium phosphate crystals. There are also observations of an increased excretion of citrate (54). Magnesium is also considered important for the transformation between various calcium phosphate crystal phases. A high urinary concentration of magnesium is thus thought to decrease the risk of brushite formation. Magnesium oxide, magnesium hydroxide, potassium magnesium citrate and magnesium aspartate have been used. The effect of potassium magnesium citrate is discussed under Section 14.2.2 on alkaline citrate and will not be further discussed here. There are two randomized studies on the clinical effects of magnesium, one in which treatment with magnesium hydroxide was compared with a placebo control group (55) and one with magnesium oxide and untreated controls (16). None of them showed a statistically significant effect on stone formation despite followup periods of four and three years, respectively. The positive effects of magnesium administration that have been reported previously (56, 57) have not been confirmed by recent controlled studies (52,29). Thus, there is insufficient evidence to recommend magnesium as monotherapy in calcium stone prevention.
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14.2.5 Allopurinol Treatment with allopurinol in order to counteract the formation of calcium oxalate stones was introduced following demonstration of a relationship between hyperuricosuria and calcium oxalate stone formation (58). The effect of allopurinol on calcium oxalate stone formation may be mediated through a reduced salting-out effect, a decreased risk of uric acid or urate crystals as promoters of calcium oxalate precipitation, complex formation between colloidal urate and macromolecular inhibitors, and/or possibly by a reduced excretion of oxalate. It also needs to be mentioned that allopurinol may influence crystallization by its antioxidative properties. Allopurinol has been used clinically to treat patients both with, and without, hyperuricosuria. In a placebo-controlled randomized study of allopurinol-treated, hyperuricosuric, calcium-oxalate stone formers, 75% of patients given allopurinol were free of recurrent stone formation compared with 45% in the placebo group. This effect was statistically significant. Three other randomized studies compared treatment with allopurinol and placebo or no treatment (16,17,59) in patients not selected because of hyperuricosuria. No significant difference was found between treated and untreated patients in any of these studies. In a long-term follow-up of non-selected, calcium-oxalate stone formers treated with 300 mg of allopurinol daily, no effect was found on stone formation (60). A similar result was recorded in another Swedish study (61). These results are in contrast to those obtained in patients treated for hyperuricosuria (62,63). The tolerance to allopurinol is usually good, but severe side effects have been reported with high doses. There is no information on compliance. The results indicate that allopurinol might be useful for treating patients with hyperuricosuric calcium oxalate stone formation, but it cannot be recommended as treatment for patients with other biochemical abnormalities. 14.2.6 Cellulose phosphate Cellulose phosphate and sodium cellulose phosphate have been used to reduce calcium absorption in patients with absorptive hypercalciuria. Unfortunately, this complex formation may result in hyperoxaluria. Binding of magnesium causes hypomagnesuria and other ions may also be negatively affected by this form of treatment. Of nine studies in the literature, none were randomized (64-71). The overall results showed that 40% of the patients formed new stones. Cellulose phosphate and sodium cellulose phosphate cannot be recommended for prophylactic treatment against stone recurrence. 14.2.7 Pyridoxine Theoretically, administration of pyridoxine (vitamin B6) might favourably influence the endogenous production of oxalate. Such an effect can be explained by an increased transamination of glyoxylate due to the action of pyridoxal phosphate. Pyridoxine has successfully been used together with orthophosphate in the treatment of patients with primary hyperoxaluria (72), as well as patients with idiopathic hyperoxaluria (73,74). There are no controlled studies that presently support the use of pyridoxine in patients with idiopathic calcium oxalate stone disease. Due to the rarity, and severity, of primary hyperoxaluria, there are no randomized studies on the efficacy of pyridoxine. Several reports confirm, however, that a fraction of patients with Type 1 hyperoxaluria responds favourably to large doses of pyridoxine. Because of the lack of other effective forms of treatment, it is definitely worthwhile giving a therapeutic trial of pyridoxine in order to reduce the excretion of oxalate in patients with primary hyperoxaluria Type I. 14.2.8 Recommendations The following forms of treatment are discouraged: magnesium oxide and magnesium hydroxide as monotherapy. Magnesium salts might, however, be useful in combination with thiazides (74). Cellulose phosphate and sodium cellulose phosphate have no place in the prevention of stone recurrence in patients with calcium stone disease. Neither is there a place for synthetic or semisynthetic glycosaminoglycans (GAGs) (e.g., sodium pentosan polysulphate). There is no absolute consensus that a selective treatment is better than a non-selective treatment for recurrence prevention in idiopathic calcium stone disease. An analysis of data from the literature, however, has suggested a slight difference in favour of treatment directed towards individual biochemical abnormalities (6). Recommendations for a selective therapeutic approach are given in Table 25.
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Level of evidence and grade of recommendation for various forms of pharmacological treatment of patients with recurrent calcium stone disease Comment 14.2.1 14.2.2 14.2.5 14.2.3 14.2.4 14.2.7 14.2.6
Pharmacological agent LE GR Selected references Thiazides/thiazide-like agents 1a A 7-29 Alkaline citrate 1b A 2, 30-46 Allopurinol 1b A* 16,17, 58-63 Orthophosphate 3 16,17,29,47-53 Magnesium 3 16, 29, 54-57 Pyridoxine 2b B** 72-73 Cellulose phosphate Not recommended 64-71 Sodium cellulose phosphate * only for patients with hyperuricosuria; ** only for patients with hyperoxaluria. LE = level of evidence; GR = grade of recommendation
Suggested selective treatment of calcium stone formers with known abnormalities in urine composition*
Treatment Thiazides1 Thiazides + magnesium1
Treatment groups 1) Hypercalciuria 2) Brushite stone formation 3) Other abnormalities Alkaline citrate 1) Hypocitraturia 1) RTA 2) Enteric hyperoxaluria 3) Low inhibitory activity2 4) Other abnormalities Allopurinol 1) Hyperuricosuria Pyridoxine 1) Primary hyperoxaluria type 1 2) Mild hyperoxaluria Calcium supplements 1) Enteric hyperoxaluria Orthophosphate3 1) Hypercalciuria 1 Potassium supplements are necessary to avoid hypokalaemia and hypocitraturia caused by hypokalaemic intracellular acidosis. 2 In case the inhibition of crystal growth or crystal aggregation has been assessed. 3 Orthophosphate is not a first-line alternative, but it can be used in patients with hypercalciuria who do not tolerate thiazides. * Numbers (1, 2, 3, 4) have been allocated to the procedures according to the consensus reached. When two procedures were considered equally useful they have been given the same number. The first alternative always has the number 1.
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Buckner P. 68. Eickholt JT. A one day cellulose phosphate test discriminates non-absorptive from absorptive hypercalciuria.331:15531558. Cellulose phosphate and chlorothiazide in childhood idiopathic hypercalciuria. The 24-hour urine volume should be at least 2. Johansson G.nih. Tscöpe W. Smith LH.4). J Clin Pharmacol 1979.nlm.20:353-359.nlm. 74. Mottram BM.ncbi.gov/entrez/query. http://www. 66.19:187-190. Results of long-term treatment with orthophosphate and pyridoxine in patients with primary hyperoxaluria.ncbi. The clinical effect of potassium alkali was shown to be superior to that of sodium alkali (5). Smith LH.nih.ncbi. 67.gov/entrez/query.65. of the three risk factors: a low urine pH. Ljunghall S.123:9-13. 1995. Hering FJ. Robertson WG.ncbi. http://www.aspects on their formation. Proceedings of the Sixth European Symposium on Urolithiasis. Relationship of stone growth and urinary biochemistry in long-term follow-up of stone patients with idiopathic hypercalciuria. J Urol 1978. Lutzeyer W. Marickar YM.57:613-617. 72. 72 UPDATE JUNE 2005 . In: Urolithiasis and related clinical research. removal and prevention.nih. http://www. Sandvall K.ncbi.nih. In: Renal stones . Schwille PO.120:712-715.nlm. http://www.5-7. Plenum Press: New York. Prophylactic treatment of calcium stone formers with hydrochlorothiazide and magnesium.nih.2 (1. Int Urol Nephrol 1988. 303-306.gov/entrez/query. Danielson BG.fcgi?cmd=Retrieve&db=PubMed&list_uids=7351731&dopt= Abstract Pak CY. 14. Hautmann R.3 Pharmacological treatment of uric acid stone disease The principles for prevention or dissolution of uric acid stones all aim at eliminating one. Wilson DM. A cautious use of sodium cellulose phosphate in the management of calcium nephrolithiasis.nlm.nih. Grass L.fcgi?cmd=Retrieve&db=PubMed&list_uids=3458445&dopt= Abstract Milliner DS. Cowley DM. The solubility of potassium urate is greater than that of sodium urate (6.fcgi?cmd=Retrieve&db=PubMed&list_uids=731812&dopt= Abstract Pak CY. Invest Urol 1981.gov/entrez/query. pp.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3170105 Ahlstrand C. pp.ncbi.gov/entrez/query.gov/entrez/query. http://www. http://www. Control of hyperoxaluria with large doses of pyridoxine in patients with kidney stones.nlm. Clinical pharmacology of sodium cellulose phosphate. Tiselius HG. Austr N Z J Med 1986. 71. Oreopoulos DG. Ritz E.nlm.16:43-47.ncbi. 1985. 69. 195-197.ncbi.gov/entrez/query.gov/entrez/query. Treatment of recurrent calcium stone formation with cellulose phosphate. 70.19:451-457. N Eng J Med 1994. Rose GA.nlm. a high excretion of urate and a small urine volume (1-4).fcgi?cmd=Retrieve&db=PubMed&list_uids=489764&dopt= Abstract Backman U. or all. J Urol 1980.fcgi?cmd=Retrieve&db=PubMed&list_uids=7298289&dopt= Abstract Knebel L. http://www. The pH should be increased to a level above 6. Vahlensieck W (eds).5 litres (1-4) and the 24-hour excretion of urate below 4 mmol (5). Br J Urol 1985. Ayiomamitis A.5 and the general recommendation is to get a pH in the range 6. General recommendation nowadays is to use potassium citrate for the alkalinization of urine.fcgi?cmd=Retrieve&db=PubMed&list_uids=4084717&dopt= Abstract Burke JR. University Hospital: Linköping.2. Tiselius HG (ed). Wikström B.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7969325 Mitwalli A. 73. Bergstralh EJ.nih.7) and potassium does not increase the excretion of calcium. The pharmacological treatment of patients with uric stone disease is outlined in Table 27.nih.0-2.nlm. Calcium oxalate stone disease: effects and side effects of cellulose phosphate and succinate in long-term treatment of absorptive hypercalciuria and hyperoxaluria. http://www.
Uric acid nephrolithiasis: current concepts and controversies. 2002. Kidney Int.nih. Waters O.ncbi. Pak CY. 24-hour urine volume exceeding 2. 30:422-428. Stoller ML. 6.000 mL Alkalinization Potassium citrate 6-10 mmol x 2-3 Sodium potassium citrate 9-18 mmol x 2-3 Always reduce urate excretion Allopurinol 300 mg x 1 GR = grade of recommendation B 3-5 B B 1 1 B 1-4 B 1. 24-hour urine volume exceeding 2. Parks JH and Preminger GM (eds). Low RK. Philadelphia. Jahnen A. Cox C. J Urol 2002. 4. 1996.59:426-431 http://www. Karger.gov/entrez/query.ncbi.ncbi. Med Biol Eng 1972. Lopez ML.nih. Barolla D. 1986. In: Kidney stones. http://www.nlm. In: Urinary stones diagnosis.gov/entrez/query. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9048857 Shekarriz B. 7.ncbi. Tiselius HG.gov/entrez/query.nih. 5. Sakhaee K.168:1307-1314. Fuller C. Basel.nih.3. Urol Clin North Am 1997. UPDATE JUNE 2005 73 .nlm.nlm.24:135-148. Arnold L.4 14. pp 73-91.ncbi. Lippincott-Raven Publishers.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3784284 Pak CY. http://www. Rodman JS. Holt K.gov/entrez/query. Klinenberg JR. Mechanism for calcium urolithiasis among patients with hyperuricosuria: supersaturation of urine with respect to monosodium urate.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 5074854 2. http://www.1 REFERENCES 1. pp 973-989.000 mL Alkalinization Potassium citrate 3-7 mmol x 2-3 Sodium potassium citrate 9 mmol x 2-3 In patients with a high serum or urine level of urate Allopurinol 300 mg x 1 Medical dissolution Urine dilution of uric acid stones A high fluid intake.10:522-531. Diagnosis and treatment of uric acid calculi. Kippen I.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14173 Wilcox WR. Sosa E. Pak CYC. Stoller ML.nlm.nlm. Weinberger A. Favus MJ. Successful management of uric acid nephrolithiasis with potassium citrate. Khalaf A. treatment and prevention of recurrence. Uric acid-related nephrolithiasis. Solubility of uric acid and monosodium urate. J Clin Invest 1977.gov/entrez/query. Coe FL.nih. medical and surgical management. Uric acid stones.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12352383 Hesse A. 3.Table 27: Objective Prevention Pharmacological treatment of uric acid stone disease GR B References 1-4 Therapeutic measures Urine dilution A high fluid intake.
4. Joly D.nih.ncbi. 3. Rieu P.nih.gov/entrez/query. Complex formation with cystine For patients with a cystine excretion above 3 mmol/24h: Tiopronin (α-mercapto-propionyl glycine) (250-2. Masai M. Méjean A.nlm.113:96-99. Table 28: Pharmacological treatment of cystine stone disease GR B References 1-3 Therapeutic measures Urine dilution A high fluid intake should be recommended so that the 24-h urine volume exceeds 3. Daudon M.5 74 UPDATE JUNE 2005 .5 Pharmacological treatment of infection stone disease The pharmacological treatment of patients with infection stone disease is outlined in Table 29. Table 29: Pharmacological treatment of infection stone disease GR References 1 B B 2 Therapeutic measures Stone removal Surgical removal of the stone material as completely as possible Antibiotic treatment Short-term antibiotic course Long-term antibiotic course Acidification Ammonium chloride 1 g x 2-3 Methionine 500 mg x 2-3 Urease inhibition In very selected cases with severe infections.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9873246 Barbey F.000 mg/day) or Captopril (75-150 mg) GR = grade of recommendation B 1-3 B 1-7 14.ncbi.nlm. Egoshi K. The long-term outcome of cystinuria in Japan. The alternating use of an alkalizing salt and acetazolamide in the management of cystine and uric acid stones. J Urol 1998. Urol Int 1998. the intake should be at least 150 ml/h Alkalinization For patients with a cystine excretion below 3 mmol/24h: Potassium citrate 3-10 mmol x 2-3 should be given to achieve a pH > 7.163:1419-1423. Streem SB. http://www.5.61:86-89.nih.nih.000 mL. J Urol 1975.nlm. 4. Chow GK.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1113405 2. Ito H. Kotake T. To achieve this goal. http://www. The definition of infection stones is stones composed of magnesium ammonium phosphate and carbonate apatite and caused by urease producing micro-organisms.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9679873 Akakura K. Ueda T. J Urol 2000. treatment with acetohydroxamic acid (Lithostat) might be a therapeutic option GR = grade of recommendation B B 3 4.gov/entrez/query. Nozumi K.1 REFERENCES 1.ncbi.gov/entrez/query.ncbi. Jungers P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10751848 Freed SZ.gov/entrez/query. Contemporary urological intervention for cystinuric patients: immediate and long-term impact and implications.160:341-344.4 Pharmacological treatment of cystine stone disease The pharmacological treatment of patients with cystine stone disease is outlined in Table 28. http://www. Medical treatment of cystinuria: critical reappraisal of long-term results. http://www.nlm. 14.14.
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ureters and bladder level of evidence length (of stone) magnesium frequency doubled laser ammonium chloride non-steroidal anti-inflammatory drug oxalate percutaneous nephrolithotripsy percutaneous nephrostomy percutaneous nephrolithotomy with or without lithotripsy parathyroid hormone recurrent stone former with mild disease and without residual stone(s) or stone fragments recurrent stone former with mild disease with residual stone(s) or stone fragments recurrent stone former with severe disease with or without residual stone(s) or fragments or with specific risk factors irrespective of otherwise defined category renal tubular acidosis stone surface area first time stone former without residual stone or stone fragments first time stone former with residual stone or stone fragments trihydroxymethyl aminomethan thyroid stimulating hormone uric acid/sodium urate/ammonium urate stone ureteroscopy ultrasonography urine volume width (of stone) 76 UPDATE JUNE 2005 . ABBREVIATIONS USED IN THE TEXT This list is not comprehensive for the most common abbreviations APCaOx APCaP AP(CaOx) index AP(CaP) index Ca CaHPO42H2O CaOx CaP CIRF Cit CRP CT CY EHL ESWL GAG GFR GR HCl Ho:YAG HPT INF IVP KUB LE l Mg Nd: YAG NH4Cl NSAID Ox PCNL PN PNL PTH Rmo Rm-res Rs RTA SA So Sres THAM TSH UR URS US V w ion-activity product of calcium oxalate ion-activity product of calcium phosphate approximate estimate of APCaOx approximate estimate of APCaP calcium calcium hydrogen phosphate calcium oxalate calcium phosphate clinically insignificant residual fragments citrate C-reactive protein computed tomography cystine stone electrohydraulic lithotripsy extracorporeal shock wave lithotripsy. also including piezolithotripsy glycosaminoglycan glomerular filtration rate grade of recommendation hydrochloric acid holmium:yttrium aluminium garnet hyperparathyroidism infection stone intravenous pyelography plain abdominal film of the kidneys.16.
1 6.7 31.5 52 69 86 104 121 138 155 173 190 207 225 242 259 276 294 311 328 345 363 380 397 414 432 An approximate estimate of the stone surface area (mm2) can be extracted from the length and width on the KUB.8 23.0 33 44 55 66 15 11.6 35 47 59 71 94 106 118 130 141 153 165 177 188 200 212 224 236 247 259 271 283 294 16 12.4 13 16 19 5 3.3 42 57 71 85 19 14.0 49 66 82 99 115 132 148 165 181 198 214 231 247 264 280 297 313 330 346 363 379 396 412 Table A1.7 6 8 9 3 2.9 15.7 24 31 39 47 94 102 110 118 126 133 141 149 157 165 173 181 188 196 11 8.3 12. 23 18. The calculated surface area for any combination of stone diameters up to 25 mm is shown in Table A1.6 17.4 14 19 24 28 99 104 108 113 118 17.4 47 63 79 94 110 126 141 157 173 188 204 220 236 251 267 283 298 314 330 345 361 377 393 21 16.1 38 50 63 75 88 100 113 126 138 151 163 176 188 201 214 226 239 251 264 276 289 301 314 93 107 120 133 147 160 173 187 200 214 227 240 254 267 280 294 307 320 334 99 113 127 141 155 170 184 198 212 226 240 254 268 283 297 311 325 339 353 17 13.1 14.3 26 35 43 52 95 104 112 121 130 138 147 155 164 173 181 190 199 207 216 12 9.8 37.6 3.8 28 38 47 57 94 104 113 122 132 141 151 160 170 179 188 198 207 217 226 236 13 10.5 33.4 4.Length mm 5 11 16 22 27 33 38 44 49 55 60 66 71 77 82 88 82 75 85 69 78 86 63 71 79 86 57 64 71 78 85 92 50 57 63 69 75 82 88 44 49 55 60 66 71 77 82 88 93 38 42 47 52 57 61 66 71 75 80 85 89 94 31 35 39 43 47 51 55 59 63 67 71 75 79 82 86 90 25 28 31 35 38 41 44 47 50 53 57 60 63 66 69 72 75 94 19 21 24 26 28 31 33 35 38 40 42 45 47 49 52 54 57 59 79 98 13 14 16 17 19 20 22 24 25 27 28 30 31 33 35 36 38 39 6 7 8 9 9 10 11 12 13 13 14 15 16 16 17 18 19 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 A1.7 9.3 27 40 53 67 80 Approximate stone surface area with known diameters of the stone 18 14.3 9.1 28. 22 17. Width mm 1 0.6 2.1 54 72 90 108 126 144 162 181 199 217 235 253 271 289 307 325 343 361 379 397 415 433 451 77 24 18. APPENDICES 7 5.1 36.3 34.6 25.0 22.7 7.9 7.4 3 4 5 UPDATE JUNE 2005 2 1.2 20. Approximate stone surface area (mm2) calculated from the length and width of the stone.6 19 25 31 38 94 100 107 113 119 126 132 138 144 151 157 9 7.5 11.0 16 22 27 33 99 104 110 115 121 126 132 137 8 6.1 9 12 14 4 3.4 31 41 51 61 92 102 112 122 133 143 153 163 173 184 194 204 214 225 235 245 255 99 110 121 132 143 154 165 176 187 198 209 220 231 242 253 264 275 14 11.9 30 45 60 75 89 104 119 134 149 164 179 194 209 224 239 254 268 283 298 313 328 343 358 373 20 15.4 18.7 57 75 94 113 132 151 170 188 207 226 245 264 283 301 320 339 358 377 396 414 433 452 471 .1 21 28 35 42 99 106 113 120 127 134 141 148 155 162 170 177 10 7.8 1.9 12 16 20 24 6 4.1 4.
Devices for endoscopic disintegration of stones ELECTROHYDRAULIC LITHOTRIPSY (EHL) • Principle: electric current generates a flash at the tip of the probe.5 mm results in reduced thermal injuries. LASER-BASED LITHOTRIPSY • The neodymium:yttrium-aluminium-garnet (Nd:YAG) and the holmium:YAG (Ho:YAG) laser are mostly used for intracorporeal laser lithotripsy. • Low cost of the Nd:YAG laser compared to the Ho:YAG laser makes this laser an interesting alternative. • Currently the method of choice for stone treatment by flexible URS (5).12:341-344. • EHL is able to disintegrate stones of all chemical compositions.nlm. • Nd:YAG: frequency-doubled lasers (FREDDY. however. The ultrasound is transmitted to the tip of the probe. not be demonstrated (6). Consigliere D. leading to a vibration that disintegrates the calculi upon contact. • Flexible probes are available but they potentially impair the maximal tip deflection of the scope (2).fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15072622 2. • Laser probe must be in contact with the stone surface.gov/entrez/query. An increased incidence of strictures could. which accounts for the fact that EHL is not used as a standard procedure any more.000-27. • Flexible electrohydraulic probes (EHL) are available in different sizes for use in semirigid or flexible scopes. J Endourol 2004. Kohrmann KU. • Ho:YAG: This laser type (2100 nm) can disintegrate stones of all chemical compositions.4 F probes are frequently used in semirigid URS with disintegration rates of more than 90%.nih. REFERENCES Tan PK.4).000 Hz). Paterson RF. • In comparison with the Nd:YAG low tissue penetration of less than 0. 3.ncbi. In vitro assessment of lithoclast ultra intracorporeal lithotripter. A3. Siqueira TM Jr. McAteer JA. • Efficiency is low for hard stones like calcium oxalate-monohydrate stones. http://www. ULTRASOUND LITHOTRIPSY • Principle: ultrasound-based lithotripsy probes induce high-frequency oscillation which produces ultrasound waves (23. • Several fibres are available for both lasers. http://www. • Perforation of the ureter or the pelvic wall is possible. 1. The insertion of stone baskets or special collecting tools like the ‘stone cone’ can prevent this loss of fragments (1). Ureteroscopic lithoclast lithotripsy: a cost-effective option. Eur Uro 2002. • The risk of stone migration is less than with ballistic probes. 78 UPDATE JUNE 2005 . the resulting heat produces a cavitation bubble leading to a spheric shock wave.ncbi.nih. J Endourol 1998.nlm.18:153-156. • Combined ultrasound/pneumatic probes are available and can be used for semirigid URS and PNL (3. 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.A2. 220µm fibres in flexible scopes (2).gov/entrez/query. Lingeman JE. • Safe usage and excellent cost effectiveness are advantages of these systems (1). 365 µm fibres are typically used in semirigid. • Cystine stones cannot be disintegrated with the Nd:YAG laser.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9726400 Michel MS. Tan SM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12180234 Kuo RL. Knoll T. Ptaschnyk T. Alken P. • The resulting mobilization of fragments into more proximal parts of the urinary tract may decrease the stone-free rate (1).41:312-316. 532 and 1064 nm) are used for lithotripsy. http://www. • The undirected transmission of heat comes with a frequent risk of tissue injury. Evan AP. PNEUMATIC LITHOTRIPSY • Pneumatic or ballistic lithotripsy probes with 2.nlm.gov/entrez/query.nih. Williams JC Jr.
nlm. Watterson JD.gov/entrez/query. 6.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12100916 Sofer M.ncbi.nlm. J Urol 1997. 5. Rogenes VJ. Wollin TA.nlm.ncbi. Razvi H.nih. http://www. Auge BK.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9302119 UPDATE JUNE 2005 79 . Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients. Nott L. http://www. Rao RD. Harris JM. Urology 2002. Zhong P.nih. http://www.167:31-34. J Urol 2002.60:28-32.158:1357-1361. Ureteroscopic management of ureteral calculi: electrohydraulic versus holmium:YAG lithotripsy.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11743269 Teichman JM. Lallas CD.gov/entrez/query.4.gov/entrez/query. Pietrow PK. Preminger GM. Denstedt JD. In vitro comparison of standard ultrasound and pneumatic lithotrites with a new combination intracorporeal lithotripsy device.
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