Guidelines on

H.-G. Tiselius, D. Ackermann, P. Alken, C. Buck, P. Conort, M. Gallucci, T. Knoll

© European Association of Urology 2006

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 Location of the stone mass Stone burden Composition and hardness of the stone 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










7.6 8.

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 Ureteroscopes Disintegration devices Baskets Dilatation and stenting Clinical results Complications 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


10. 11.





3 14.3 14.3. 17. 16.2. 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 .9 References Pharmacological treatment of uric acid stone disease 14.1 References Pharmacological treatment of infection stone disease 14.7 Pyridoxine 14.6 Cellulose phosphate References 66 66 66 67 72 73 74 74 74 75 75 76 77 77 78 78 15.1 References Pharmacological treatment of cystine stone disease 14.8 Recommendations 14.5 14.14.

beyond the scope of a European guideline document. however. when a certain form of therapy is not recommended. an increased understanding of the mechanisms of stone formation and advancements in pharmacological treatment of the various aspects of stone disease. When recommendations were formulated. we focused mainly on medical aspects.1. 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. 3. 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. 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. The current edition of Guidelines on Urolithiasis published here is an update of our previously published document (2. as such a step was beyond the possibilities of our work. 5) have been allocated to the procedures according to the consensus reached. It needs to be emphasized.due to the extensive geographical diversity and variability between the financial systems in the health care sector . 20. However. 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. such as comparative studies. 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. Numbers (1. The optimal clinical management of this disease requires knowledge of the diagnostic procedures. 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. The first alternative always has the number 1. The abbreviations LE and GR are used in the tables and recommendations given in these guidelines. whereas other statements rely on a substantial clinical experience. During the past few decades. According to the principles set by the European Association of Urology (EAU) Guidelines Office. the whole field of treatment of patients with urolithiasis has been characterized by changes that are attributable to pronounced technical achievements. 4. The criteria for level of evidence (LE) (Table 1) and grades of recommendation (GR) (Table 2) are shown below (1). Some of the therapeutic principles are the result of evidence obtained from randomized or controlled studies. UPDATE JUNE 2005 5 . the scientific basis for the various recommendations or statements has been classified in terms of level of evidence and grade of recommendation when appropriate. This does not mean that other methods are not applicable. the rational treatment of acute stone colic and the modern principles of stone removal. 2. We are very well aware of the different treatment and technical facilities available geographically. since discussing associated economic issues may be . The guidelines and recommendations given below are based on results presented in the modern literature. When two procedures were considered equally useful they have been given the same number. 24 & 26). 16. 18. that no attempt has been made to cover the literature completely.3). BACKGROUND Patients with urolithiasis constitute an important part of everyday urological practice. 22. 19. this has been specifically stated.

2. 1992. 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. Agency for Health Care Policy and Research. REFERENCES US Department of Health and Human Services. Switzerland 2001 (ISBN 90-806179-3-9).gov/ Tiselius HG.ncbi. Public Health Service. Alken P. 2. 6 UPDATE JUNE 2005 .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 ( Eur Urol 2001. pp 115-127.1 CLASSIFICATION Categories of stone formers A system for subgrouping stone-forming patients into different categories is shown in Table Geneva.1. Ackermann D.uroweb.nlm.2 Specific risk factors for stone formation Risk factors for stone formation are listed in Table 4. Gallucci M. 3. Buck C. Conort P.1 1. In: EAU guidelines. 2. Gallucci M. Conort P.nih. http://www. Alken P.pdf Tiselius HG.40:362-371. Buck C. Guidelines on urolithiasis. Guidelines on urolithiasis. http://www. Ackermann D. Edition presented at the 16th EAU Congress.ahcpr.

BJU Int 2003.40:362-371. Gallucci M.Table 4: Risk factors for recurrent stone formation • Onset of disease early in life.33:1-7.nlm. Curriculum in Urology. REFERENCES Tiselius HG.ncbi.2H2O) • Strong family history of stone formation • Only one functioning kidney (only one kidney does not mean an increased risk of stone formation. Alken P. Etiology and investigation of stone disease. Eur Urol 1998.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12709088 Tiselius HG.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11713390 Buck C. http://www. i. Ackermann D.3 1. Guidelines on urolithiasis. UPDATE JUNE 2005 7 .nlm. below 25 years of age • Stones containing brushite (calcium hydrogen phosphate. CaHPO4.. Eur Urol 2001.ncbi. http://www. 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. caliceal cyst ■ ureteral stricture ■ vesico-ureteral reflux ■ horseshoe kidney ■ ureterocele 2.91:758-767. Epidemiology and medical management of stone disease. 2.e. Conort P. Tiselius

the specificity and sensitivity of this method for patients with acute flank pain was found to be similar to that obtained with urography (4. the following precautions should be taken (12. 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. • This medication might be combined with an intramuscular injection of an anti-histamine agent (e.2. contrast medium can be administered. Patients with renal stone colic usually have characteristic loin pain. given 1 hour before contrast administration. ureters and bladder (KUB) combined with ultrasonography (US). unenhanced helical computed tomography (CT) examinations have been introduced as a quick and contrast-free alternative (1.. which are radiolucent on plain films..g. 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. • Give a corticosteroid (e.11).. Special examinations carried out in selected cases include retrograde pyelography. Another advantage is the ability of CT to detect alternative diagnoses (7. 8 UPDATE JUNE 2005 .3. IVP) has been established as a gold standard.1.1 GR = grade of recommendation. 3.5-9). 3.3). or in those who are at such a risk. In selected cases. serum creatinine > 130 µmol/L). lactic acidosis is associated with high mortality and great care needs to be taken when using contrast medium in patients taking metformin.g. This is an unusual complication caused by retention of dimethylbiguanide.1 DIAGNOSTIC PROCEDURES Diagnostic imaging Stone disease very often presents as an episode of acute stone colic. Unfortunately. ureters and bladder urography. particularly in the presence of reduced renal function (i. antegrade pyelography and scintigraphy. An alternative and commonly applied method for evaluating patients with acute flank pain is a plain film of kidneys. and when the diagnosis of stone is in doubt.13): • Always use low-molecular non-ionic contrast medium. clemastine 2 mg).1 Excretory urography Standard 3. vomiting and mild fever. This will immediately help to decide if a conservative approach is justified or if another treatment should be considered. Although the intravascular administration of contrast medium is usually a concern for the radiologist.13) the serum creatinine level should be measured in every patient with diabetes being treated with metformin. The diagnostic work-up of all patients with symptoms of urinary tract stones requires a reliable imaging technique (Table 5). Many urologists also take responsibility for the diagnostic radiological work-up of patients with stone problems. LE = level of evidence. The clinical diagnosis should be supported by an appropriate imaging procedure. In randomized prospective studies.1. However. One great advantage of CT is the demonstration of uric acid and xanthine stones.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). KUB = kidney. prednisolone 30 mg) between 12 and 2 hours before the contrast medium is injected.1 Allergy to contrast medium Where there is a need for administration of contrast medium to patients who have reported allergic reactions (Table 7). • In metformin-treated patients with a normal serum creatinine. and they may have a history of stone disease. additional information regarding renal function may be obtained by combining CT with contrast infusion. US = ultrasound.1 Unenhanced helical CT A/1 1-10 3. CT = computed tomography. During recent years.e.5. 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. Imaging is imperative in patients with fever or a solitary kidney. It is therefore essential to have a basic understanding of the risks associated with the use of contrast medium and the necessary precautions. 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 3.10). excretory urography (intravenous pyelography. According to the recommendations given by the European Society of Urogenital Radiology (12. 3. contrast medium is occasionally used as an auxiliary procedure for stone localization during shock wave lithotripsy. In case of an acute stone colic.

UPDATE JUNE 2005 9 . or with a reduced renal function.age) x kg/(0. 3.13).6 mg/100 mL) hydration before and after the use of contrast medium may be beneficial in order to prevent nephropathy. Patients with multiple myeloma should either be examined with an alternative method or after adequate hydration. epigastric pain. Table 6: Formulae for calculating glomerular filtration rate (GFR) and body surface area (17) Men: GFR = (140 . Serum creatinine.2. In a situation where no information on renal function is available. The vasoconstriction of glomerular afferent arterioles causes a reduced glomerular filtration rate (GFR) and an increased renal vascular resistance.• • • In patients with reduced renal function. Treatment with metformin may resume 48 hours after the examination provided that serum creatinine remains at the pre-examination level. diarrhoea and thirst. hyperpnoea.3 Reduced renal function Intravenous administration of contrast medium can bring about a reduced renal perfusion and toxic effect on tubular cells.25 and serum lactic acid concentration > 5 mmol/L (14. For a patient with a GFR of 80-120 mL/min. without information on the renal function. anorexia. lethargy. administration of metformin should be stopped immediately and the patient should be hydrated so that diuresis is > 100 ml/h during 24 hours. When the GFR is reduced to a level between 50-80 mL/min. medication with metformin should be stopped and administration of contrast medium delayed until 48 hours have passed after the last intake of metformin.) . such as non-steroidal anti-inflammatory agents (NSAIDs) and aminoglycosides (the latter should be stopped for at least 24 hours). the administered dose of iodine should not exceed 80-90 g.725 x 0.age) x kg/(0. lactic acid and blood pH should be monitored.07 GFR = creatinine clearance x 1.5 x height(cm)/serum creatinine) x (kg/70)0.007184 In patients with a serum/plasma-creatinine level exceeding 140 µmol/L (1. the dose of iodine should be limited to the same amount as the GFR expressed in mL/min/1. somnolence.16).72 hours.73m2 Body surface area = kg0. In a situation when contrast medium has been administered to a patient on metformin treatment.1. 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. the following formula should be used: Creatinine clearance = (42. alternative imaging techniques should be used. Dosage of iodine Reduced renal function means that the serum creatinine > 140 µmol/L or that the GFR is < 70 ml/min. The investigative findings are a blood pH < 7. Table 6 lists useful formulae for calculating GFR and body surface area (17).73m2 body surface area (12. 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. Symptoms of lactic acidosis are vomiting.82 x serum creatinine) For patients < 20 years. 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).82 x serum creatinine) Women: GFR = (0.1.85 x (140 .425 x height(cm)0. Avoid repeated injections of contrast medium at intervals less than 48 (see section 3.

fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12913701 Sudah 9.ncbi. Rosenfield AT. http://www.3 Contrast medium should not be given to. http://www. Covey AM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7862980 Smith RC.nih.3. http://www. Clinical characteristics of ureteral calculi detected by non-enhanced computerized tomography after unclear results of plain radiography and ultrasonography. Am J Roentgenol 1996. 6. Amling CL.nlm. Heino A. Ogura K.168:2457-2460.13 13 13-16 13 Comment 3. J Urol 1998. Davies-Payne DL.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8571915 Kobayashi T.223:98-105. Smith RC.nlm. http://www.1. Rosenfield AT. The value of unenhanced helical computerized tomography in the management of acute flank pain. Rineer SK. Malinen A.1.nih.1 3. 4.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12441939 Miller OF.166:97-101. Randomized prospective comparison of non-contrast enhanced helical computed tomography and intravenous urography in the diagnosis of acute ureteric 9474137 9836541 Dalrymple NC. Prospective comparison of non-enhanced helical computerized tomography and Doppler ultrasonography for the diagnosis of renal colic. McCarthy S. Watanabe J. Prospective comparison of unenhanced computed tomography and intravenous urogram in the evaluation of acute flank pain.ncbi. REFERENCES Smith RC. J Urol 2002.194:789-794. 7. Table 7: Considerations regarding excretory urography LE 4 3 3 Selected references 12. Abdulmaaboud M. Radiol 1995.nlm. Reichard SR.nlm. Essenmacher KR. 8.1.1 Vanninen RL. 10 UPDATE JUNE 2005 .2 3. Radiol 2002. Partanen K. Graham Glickman MG. Ward JF.nlm. Sears ST. Bove P. J Urol 2001.170:799-802. Nishizawa K.nih.nih. Verga M. 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 3.165:1082-1084.nih. Rosenfield AT.1.nlm. Lange RC. Choe KA. J Urol Donovan MS.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11930053 Homer JA. http://www.nih. http://www. Peddinti BS.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11531750 Shokeir AA. Ala-Opas M.nlm.ncbi. Prospective comparison of computerized tomography and excretory urography in the initial evaluation of asymptomatic microhematuria.45:285-290.nih. Verga Patients with acute flank pain: comparison of MR urography with unenhanced helical CT. Aus Radiol 2001. Verga http://www.1.52:982-987.159:735-740 http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11257642 Gray Sears CL. Puckett MF.4 Untreated hyperthyroidism For patients in whom hyperthyroidism is suspected the TSH (thyroid stimulating hormone) level should be assessed before use of contrast medium. Kane CJ. Contrast medium should not be given unless these patients are appropriately treated.nlm.nlm. 5. Urology 1998. Goff WB. Acute flank pain: Comparison of non-contrast-enhanced CT and intravenous urography.5 1. Diagnosis of acute flank pain: value of unenhanced helical CT. Kane CJ.1. 3.nih. Kainulainen S. Anderson KR. Buckley RG. http://www.

Contrast media and the kidney: European Society of Urogenital Radiology (ESUR) guidelines. sodium nitroprusside Drugs and intravenous contrast media. 16. Contrast Media Safety Committee of the European Society of Urogenital Radiolology. All patients should have at least one stone analyzed.. N Eng J Med 2000.343:180-184. Murray AD. Mindelzun should be subjected to stone analysis to determine their composition (1-5). Liermann D. http://www. Cleveland T. Unenhanced helical CT evaluating acute abdominal pain: a little more McHardy K.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10900277 3. Gaines PA. Brand’s test (6).fcgi?cmd=Retrieve&db=pubmed&dopt Abstract&list_uids= 10671870 Cockcroft DW.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1244564 Tepel M.nlm. 11.nih. Gilbert 12893691 Nawaz S. 18. Van der Giet M. conclusions on stone composition may be based on the following observations: • Qualitative cystine test (e. high in patients with infection stones). http://www. Repeated analysis is indicated when any changes in urine composition. or excreted as fragments following disintegration. J Urol Murchinson LE. Gault MH.10. Jeffrey RB.76:513-518. Zidek W. http://www.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9314959 Shinokara K. When stone(s) or stone material have not been retrieved. a lot more Pearson D.ncbi. 14.nih. http://www.nih.nlm.16:31-41. Br J Radiol 2003. Prevention of generalized reactions to contrast media: a consensus report and guidelines.nlm.205:43-45. http://www.nlm.53:342-344. Prediction of creatinine clearance from serum creatinine.nlm. Metformin and contrast media . Clinical risk associated with contrast angiography in metformine treated patients: a clinical review. Thomsen dangerous combination? Clin Radiol 1999.nih. http://www. Nephron 1976.ncbi.54: 29-33.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9630271 McCartney MM. can be expected to have influenced the stone composition. 12. • Serum urate (in cases where a uric acid or urate stone is a possible alternative). environment or diseases.85:219-221. • Demonstration of crystals of struvite or cystine upon microscopic examination of the urinary sediment.ncbi. Radiol 1997. Prevention of radiographiccontrast-agent-induced reductions in renal function by acetylcysteine. Young MR.ncbi. dietary habits. are removed surgically. 15. Thompson TJ.ncbi. • Bacteriuria/urine culture (in the case of a positive Schwarzfeld C.170:803. BJU Int 2000.g. due to medical treatment.2 Analysis of stone composition Stones that pass spontaneously. http://www. 17. Webb JA.nlm.nlm.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9915507 Thompson NW. An appropriate quantitative or semi-quantitative analysis of the stone material should enable conclusions to be drawn regarding the main constituent or constituents.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11511894 Thomsen HS.nlm. The preferred analytical procedures are X-ray crystallography and infrared spectroscopy. • Urine pH (low in patients with uric acid stones.ncbi.nih. Clin Radiol 1998. • Radiographical characteristics of the stone. Editorial: Choosing imaging modality in 2003.nih. http://www.ncbi. Eur Radiol 2001. Laufer U. 13. Morcos SK.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12913702 Morcos SK. UPDATE JUNE 2005 11 .11:1720-1728. Love MH. or any other cystine test). Chan P. ask for urease-producing microorganisms).

6. Urol Res 1990.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. Nephron Physiol.98:31-36.18(Suppl):9-12.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15499212 Otnes B. Less common stone constituents include 2.24:205-210. 12 UPDATE JUNE 2005 . http://www.nlm. and a blood white cell count and urine culture carried out. Scand J Urol Nephrol 1990. C-reactive protein (CRP) should be assessed.g.nlm. sulphonamide. the routine laboratory investigations should include: • Urinary sediment/dipstick test for demonstration of red cells.ncbi. xanthine and various drug metabolites (e. Harris MH. 3.17:85-92..fcgi?cmd=Retrieve&db=PubMed&list_uids=2291252&dopt= Abstract Herring LC. 3. 5. Observations on the analysis of ten thousand urinary Analytical work-up in the acute phase For patients with an acute stone episode.fcgi?cmd=Retrieve&db=PubMed&list_uids=6867630&dopt= Abstract Leusmann DB. Stone analysis.88 545-562.nih. The following stones not associated with infection are referred to as uric acid/urate stones: • Uric acid • Ammonium urate • Sodium urate. 2004.nih.nih. • Approximate pH level.ncbi.nlm. • White cells and bacteria (nitrite). • Serum creatinine should be analyzed as a measure of the renal function. Scand J Urol Nephrol 1983.8-dihydroxyadenine. http://www.nlm. J Clin Chem 1980.035 stone analyses: a contribution to epidemiology of urinary stone disease.1 Biloon S. 2. J Urol 1962. Blaschke http://www. uric acid/urate stones and cystine stones associated with infection are referred to as ‘stones with infection’. http://www. Crystalline composition of urinary stones in Norwegian patients. Infection stones have the following typical constituents: • Magnesium ammonium phosphate • Carbonate apatite.ncbi. Calcium stones.86:315. 3.ncbi.3. Schwandt W. Results of 5.3 Biochemical investigations 3. REFERENCES Asper R. Clinical value of crystalluria and quantitative morphoconstitutional analysis of urinary calculi. In cases of fever. indinavir) dopt=Abstract Daudon M.nlm. Cystinuria: Excretion of cystine complex which decomposes in the urine with the liberation of cystine.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2237297&dopt= Abstract Brand E. 4. Jungers P.

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.00 and 22. with a few examples listed in Table 8. pH Urate. a sample collected with sodium azide is useful. 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. Urate can be analyzed in samples collected with sodium azide. A collection of urine without HCl is necessary for pH measurement.3.2 Analysis of urine in search for risk factors of stone formation For an identification of metabolic risk factors of stone formation. The stone.In cases of vomiting.00 hours in a bottle containing 10 mL of 0.00 hours in a bottle and one 8-hour urine collection containing 20 mL of 6 mol/L hydrochloric acid Sample 2 collected between 22. In this respect.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. Table 3). Two urine collections for each set of analyses are recommended. A number of alternative collection options are feasible. In acidified samples. UPDATE JUNE 2005 13 . 3. an analytical programme for the different categories of stone formers is shown in Table 9. 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 0.00 and 06. serum sodium and serum potassium levels should be measured. In order to avoid the need for future repeated blood analyses in the search for metabolic risk factors. pH Cystine. it might be helpful to assess levels of serum calcium and serum urate at this point in time. blood (serum. plasma) and urine analyses recommended for such patients are shown in Table 10. HCl also counteracts the oxidation of ascorbate to oxalate.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. uric acid precipitates and has to be dissolved by alkalinization if urate excretion is of interest. Rmo. The urine collections are repeated when necessary (1-3). 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. 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.

urate has to be analyzed in a sample that has not been acidified or following alkalinization to dissolve uric acid. Sres.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. such as AP(CaOx) index and AP(CaP) index (8-12). 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. Urine culture in case of bacteriuria. As uric acid precipitates in acid solutions. helpful in suspected uric acid/urate stone disease. sodium and potassium measurements are used to assess the dietary habits of the patient.5 Potassium2. the remaining 8 hours of the 24-hour period can be used to collect urine with sodium azide for analysis of urate. Blood analysis Calcium Albumin1 Creatinine Urate2 1 2 3 4 5 6 14 UPDATE JUNE 2005 . Optional analysis. excluded by other means. Optional analysis. When a 16-hour urine sample has been collected in a bottle with an acid preservative. 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 Magnesium2.4. Special tests that may be required are shown in Table 12 (13-18). Analysis of magnesium and phosphate is necessary to calculate estimates of supersaturation with calcium oxalate (CaOx) and calcium phosphate (CaP).5 Urea2.4 Phosphate2. 16-hour + 8-hour urine or any other collection period can be chosen provided normal excretion data are available (4-7). blood and urine analyses recommended for these patients are shown in Table 11 (4-12). or has not been. 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 stone.5 Sodium2. with or without residual fragments or stones in the kidney or specific risk factors. Cystine test if cystinuria cannot be. phosphate. First-time stone formers with residual fragments may also be considered in this respect (categories: Rs. or direct analysis of ionized (free) calcium. A spot urine sample can be used with creatinine-related variables (7). Table 3). 24-hour urine. Urea. Rm-res. Blood analysis Calcium Albumin1 Creatinine Urate2 1 2 3 4 A patient with complicated stone disease has a history of frequent recurrences.5 Creatinine Volume Either analysis of calcium + albumin to correct for differences in calcium concentration attributable to the albumin binding.

mmol/L) and urine volume in litres (V) as follows (30): Intake of protein (gram) during the 24h period = (Uurea x 0. It must be emphasized that the urine sample used for analysis of calcium. calcium.07 x P0. The reasons for this acidification are: • To maintain calcium. For a 16-hour urine sample. but this test is not often used clinically today (13). the urine volume (V) is expressed in litres and the urine variables (Ca.7 x 10-3 x Ca1.31 The AP[CaP] index approximately corresponds to 10 x APCaP (where APCaP is the ion-activity product of calcium phosphate). magnesium. • To prevent the in-vitro oxidation of ascorbate to oxalate (28. The optional analysis of urea. preferably with HCl.9 is specific for the 24-hour period. A fasting morning urine sample (or a spot morning urine sample) should be used to measure pH (25).60 mmol/L). citrate and phosphate has to be acidified.3. In those patients in whom a stone analysis has not been carried out. this factor is 2. The additional analytical work-up in patients with calcium stone disease is summarized in Table 12.3 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. it is clearly demonstrated with a CT examination. citrate. during and after the collection period.8 in fasting morning urine raises the suspicion of incomplete or complete renal tubular acidosis (RTA) (26). The protein intake can be derived from the urea excretion (Uurea. 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. Ox.5)6. oxalate.3. Hypokalaemic hypocitraturia may be one reason for therapeutic failures in patients treated with thiazides. oxalate. chloride and potassium. oxalate and phosphate in solution. Mg. Although the creatinine concentration might be slightly affected. It might occasionally be useful to carry out a calcium loading test. a high serum urate level together with a radiolucent stone support the suspicion of a uric acid stone.20 x V-1. The factor 1. the reader should consult reference 5.22 x Mg-0. In the same fasting morning or spot urine sample.03 In this formula. Factors for other collection periods can be found in reference 5. 16 hours. it is the concerted action of the various urine constituents which result in supersaturation and crystallization of the stone. The recommendation to collect two urine samples is based on observations that such an approach will increase the likelihood of detecting urine abnormalities.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 = 1.29). 4 hours or even spot urine samples. 8 The AP[CaOx] index approximately corresponds to 10 x APCaOx (where APCaOx is the ion-activity product of calcium oxalate). Cit. For other collection periods. oxalate. It should be noted that although individual abnormal urine variables might indicate a risk of stone formation.84 x Ox x Cit-0. • To prevent bacterial growth and the associated alteration of urine composition. The aim of adding serum potassium to the analytical programme is to obtain further support for a diagnosis of suspected RTA. The following urine variables can be analyzed in the acidified sample: calcium. phosphate.70 x (pH . the diagnosis of HPT should be established or excluded by repeated calcium analyses and assessment of the parathyroid hormone level (19-24).4. In the case of a high calcium concentration (> 2.12 x V-1. 15 UPDATE JUNE 2005 15 .3. In this regard it needs to be emphasized that whereas a uric acid stone is usually invisible on a plain film (KUB). 12 hours.9 x Ca0. The AP[CaP] index for a 24-hour urine sample is calculated in the following way: AP[CaP] index = 2. urea. A pH above 5. Various collection periods. citrate. bacteriuria and cystinuria can be excluded or confirmed by an appropriate test (27). magnesium) in mmol excreted during the collection period. such as for 24 hours. sodium. A relationship between abnormalities in urine composition and severity of calcium stone formation has been demonstrated (38-44). 17 hours. 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. phosphate and sodium helps to reflect dietary factors of therapeutic significance. are useful for this purpose provided a set of normal values is available for the collection period (4-7).8 x Cit-0.

Table 12: Additional analytical work-up in patients with calcium stone disease pH profile (13) Repeated measurements of pH during the 24-hour period Frequent samples should be collected for immediate measurement of pH with pH paper or a glass electrode. An improved method for the routine biochemical evaluation of patients with recurrent calcium oxalate stone disease. 3.4 1. In: Kidney stones: medical and surgical management.fcgi?cmd=Retrieve&db=PubMed&list_uids=8042263&dopt= Abstract&itool=iconabstr Hess 25:365-372. http://www.nlm. Ackermann D.fcgi?cmd=Retrieve&db=PubMed&list_uids=9373919&dopt= Abstract&itool=iconabstr Strohmaier WL. Urol Res Preminger GM (eds).nih.4 or lower indicates no RTA Findings in blood Complete RTA pH Low Bicarbonate Low Potassium Low Chloride High NH4Cl = ammonium chloride. Parks HG.nih. Tiselius HG. Eur Urol 1998.ncbi. http://www. Coe FL. Eur Urol 1997.nih. Larsson L.ncbi.ncbi.nih. Br J Urol 1987. http://www. Incomplete RTA Normal Normal Normal Normal 3. RTA = renal tubular acidosis.00 Breakfast + NH4Cl tablets (0. Value of repeated analysis of 24-hour urine in recurrent calcium Urology 1994. 7.00 Collect urine and measure pH. 6. 8. Jaeger PH. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7105424&dopt= Abstract&itool=iconabstr drink 150 mL 12.ncbi. Bichler KH. http://www. Lippincott-Raven Publishers.32:294-300.nih. drink 150 mL Abstract&itool=iconfft Bek-Jensen H.nlm. Metabolic evaluation of patients with recurrent idiopathic calcium nephrolithiasis.fcgi?cmd=Retrieve&db=PubMed&list_uids=9358216&dopt= Abstract&itool=iconabstr Tiselius HG.fcgi?cmd=Retrieve&db=PubMed&list_uids=3690199&dopt= Abstract&itool=iconabstr Tiselius HG. Szabo N. Evaluation of urine composition and calcium salt crystallization properties in standardized 12-h night urine from normal subjects and calcium stone formers.00 Collect urine and measure pH.122:409-418. Bek-Jensen H.00 Collect urine and measure pH.00 Collect urine and measure pH. pp 33-64. Favus MJ. Repeated urine analysis in patients with calcium stone disease. Nephrol dial transplant 1997.ncbi.nlm. Pak CYC.1 g/kg body weight). Clin Chim Acta 1982.nih. Tiselius HG. lunch Interpretation: a pH of 5. Sampling every second hour or otherwise as appropriate.44:20-25. Hoelz K-J.nih.00 Collect urine and measure pH. Hasler-Strub U. http://www. 16 UPDATE JUNE 2005 . drink 150 mL 10. Acid loading (14-18) This test is carried out together with blood sampling to show whether or not the patient has a complete or an incomplete acidification defect: 08. Philadelphia:1996. Tiselius HG. drink 150 mL 13. Solution chemistry of supersaturation.nlm. Hofbauer J. Spot urine samples for the metabolic evaluation of urolithiasis patients. drink 150 mL 09.nlm.ncbi. The composition of four-hour urine samples from patients with calcium oxalate stone disease. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=9555561&dopt= Abstract&itool=iconabstr Berg C. REFERENCES Hobarth K. http://www.3.

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29. pp 1759-1790. Coe FL. Walser M. McWhinney BC.nlm. Preminger GM. http://www. J Urol 1994.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9783922&query_hl=7 Daudon M.nlm. Brown JM.nih.ncbi. J Urol 1995. Davis PA.6:217-218. Eisenberger F.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7058820&query_hl=5 Hsu TH.72:17-24. Nutritional therapy of the uremic Mascha E. Schmidt A.fcgi?cmd=Retrieve&db=PubMed&list_uids=8632527&dopt= Abstract Zanetti G. Brenner 27. Seveso M.nih. 35. Parks JH. http://www. Baggio B. 33. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis patients. Lacour B. http://www.32:2073-2074 and 1986. Urol Res 1988. Fandella A. Gault MH.315:970-971. http://www. Clin Nephrol 1994. Boujelben G. Trinchieri A. http://www.nlm. Am J Med 41. 30. J Urol 1994. Montanari E. Merlo F. J Urol 1998.155:1186-1190. Williams HE. Cicerello E. http://www.151:834-837. A prospective study.fcgi?cmd=Retrieve&db=PubMed&list_uids=9355942&dopt= Abstract Tiselius HG. Serial crystalluria determination and the risk of recurrence in calcium stone formers. 3rd ed. Jocham D.fcgi?cmd=Retrieve&db=PubMed&list_uids=8187359& dopt=Abstract Brand E. 1986. 32. 31. Yost A. 160:1640-1642.41:159-162.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224301&dopt= Abstract Pacik Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. Abstract. Rector FC Jr (eds).ncbi.158:352-355. Gambaro G. Effect of high dose vitamin C on urinary oxalate levels. Kumstat P.153:27-32.fcgi?cmd=Retrieve&db=PubMed&list_uids=8254832&dopt= Abstract Fine JK.fcgi?cmd=Retrieve&db=PubMed&list_uids=3762602&dopt= Abstract Wandzilak TR.ncbi.nih. http://www. J Urol 1996. Metabolic abnormalities in patients with caliceal diverticular calculi.16:256. 38.ncbi. Harris MM. Del Nero A.nlm.nlm.nih. J Urol 1997.67:1934-1943.151:5-9. http://www.ncbi. Nespoli R. The fate of residual fragments after extracorporeal shock wave lithotripsy. D’Andre SD. First morning urine pH in the diagnosis on renal tubular acidosis with nephrolithiasis.ncbi. N Engl J Med 1986. Effectiveness of ESWL for lowerpole caliceal nephrolithiasis: evaluation of 452 cases. Front Biosci 2003. Coxley DM. Hanak T. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy. Factors influencing the course of calcium oxalate stone disease.ncbi. 28. Hennequin C. Deutsch L.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15840041&query_hl=10 18 UPDATE JUNE 2005 . Long-term results in ESWL-treated urinary stone patients. Factors that predict the relapse of calcium nephrolithiasis during treatment. J Endourol 40. Turjanica Chafe L. 34. Schuster C. Bub P. Guarneri A. Maccatrozzo L. Pak YC. http://www. http://www. 37.nlm.nih. Jelinek P. Renal stone fragments following shock wave lithotripsy.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126804&dopt= Abstract Mitch WE.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516443&query_hl=1 Robertson WG.nih.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12957848&query_hl=3 Strauss AL.26. A risk factor model of stone formation. Bildon S. J Biol Chem 1930.nih. Kidney Int 2005. Chalmers AH. Enteric hyperoxaluria and urolithiasis.fcgi?cmd=Retrieve&db=PubMed&list_uids=7966783&dopt= Abstract Streem SB. Lunz C.nlm. Vol Cystinuria: excretion of a cystine complex which decomposes in the urine with the liberation of free cystine. Kladensky J. Eur Urol 1999.nlm. J Endourol 1997.nlm.nih.ncbi.nih. Saunders: Philadelphia.nih. Anselmo Liedl B. Streem SB. Jungers P. 36. In: The kidney. http://www.

STONE BURDEN The size of a concrement (stone burden) can be expressed in different ways. 5.43. we have based our recommendations on the stone surface area as well as on the largest stone diameter. 4.1 1. A notation of the largest diameter is the most common way of expressing size in the literature. REFERENCES Tiselius HG.ncbi. Finlayson B. Crystallization properties in urine from calcium oxalate stone formers. Griffith DP. J Endourol 1989. 44. With knowledge of the length (l) and the width (w).e. http://www. J Urol 1995. http://www. UPDATE JUNE 2005 19 .25 For a quick estimate of the stone surface area. With knowledge of the surface area.27 In this guideline document. Newman RC. Nilsson MA.ncbi.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. J Endourol 2004. an appropriate estimate of the stone surface area (SA) can be obtained for most stones (1): SA = l x w x π x 0.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7637098&query_hl=12 Raj GV. Andersson A. Dunthorn M. placebo-controlled study.. Calculation of stone volume and urinary stone staging with computer assistance. http://www. Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys.ncbi.nih. 5. the length of the stone as measured on the plain film.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15072623&query_hl=15 4. i. the stone volume can be calculated by the formula below (2): Volume = 0.154:940-946. In another Fornander 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. 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. Auge BK.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12600431 Ackermann D. Tiselius HG.6 x SA1.nih. the efficacy of diclofenac (2) was clearly demonstrated. 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. Assimos D. but these are not always easy procedures. The surface area can also be measured using computerized systems and from CT scans. 2. Bek-Jensen H.3:355-359.18:157-161. Preminger 43:275-281. please refer to Table A1 (Appendix). 5.

Christiansen A. 4. Leissner KH.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6122892 Lundstam SO. The effect was most pronounced in the first 4 treatment days (5). this is not the case for normally functioning kidneys (6). Wåhlander LA.1. Lahtinen Prostaglandin-synthetase inhibition of diclofenac sodium in the treatment of renal colic: comparison with use of a narcotic analgesic. 50 mg administered twice daily over 3-10 days. Curr Ther Res 1980. Elvander E. double-blind. Lancet 1982.nih. Eur Urol 1995. 5. In case of contraindication (pregnancy) or allergy to non-steroidal anti-inflammatory drugs. but not in patients 2a 6 5. http://www.1.When diclofenac was compared with ketoprofen in a randomized. Fagertun HE. 5.nih. no differences were recorded between the two substances (3).3 with normal renal function Diclofenac sodium is recommended as a method to counteract recurrent pain after 1b/A 5 5. Passage of the stone and normalization of renal function should be confirmed using appropriate methods.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8290910 2.27:323-325. comparative study. Comment: In France.2 1. might therefore be useful in reducing the inflammatory process and the risk of recurrent pain. Wåhlander LA.ncbi.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8529732 Lundstam SO.nih.1. ketoprofen is the only drug approved for the treatment of renal colic. When pain relief cannot be obtained by medical means. 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. GFR = glomerular filtration rate. morphine chlorhydrate (with titration) is indicated. Hydromorphone and other opiates without simultaneous administration of atropine should be avoided because of the increased risk of 20 UPDATE JUNE 2005 .nlm. Moreover. NSAID = non-steroidal anti-inflammatory drug.1 Diclofenac sodium affects GFR in patients with reduced renal function.3 Effects of diclofenac on renal function Although the renal function can be affected in patients with an already reduced function. The recommendation is to start with diclofenac whenever possible (Table 13) and change to an alternative drug if the pain persists. placebo-controlled trial.ncbi. the resistant index was reduced in patients with renal colic when NSAID treatment was given (4). Kral LG. http://www. For patients with ureteral stones that are expected to pass spontaneously. 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. 5.2 Prevention of recurrent episodes of renal colic In a double-blind. Walden M.nlm. Oral diclofenac in the prophylactic treatment of recurrent renal colic. The patient should be instructed to sieve the urine in order to retrieve a concrement for analysis.28:108-111.1. taking account of the side-effects. Scand J Urol Nephrol 1993. drainage by stenting or percutaneous nephrostomy (PN) or by stone removal should be carried out.2 an episode of ureteral colic LE = level of evidence. GR = grade of recommendation. 1096-1097.ncbi. Treatment of ureteral colic by prostaglandin-synthetase inhibition with diclofenac sodium. REFERENCES Laerum E. Kral JG.1. http://www. 3. suppositories or tablets of diclofenac sodium. Analgesic effect and tolerance of ketoprofen and diclofenac in acute ureteral colic. Gronseth JE. Ommundsen A double-blind comparison with placebo.

Garty M. Time to stone passage for observed ureteral calculi: a guide for patient education. The overall passage rate of ureteral stones is: • Proximal ureteral stones: 25%. Br J Urol 1991.nlm.ncbi.nih. Shelty SD.nih. It should also be observed that small stones (< 6-7 mm) residing in a calix can cause considerable pain or discomfort (6-12). Studies have shown that asymptomatic stones in the kidney sooner or later give rise to clinical problems (5). Stone removal is accordingly indicated for stones with a diameter exceeding 6-7 Comparison of ketorolac and diclofenac in the treatment of renal colic. Farage Y. Prognostic factors in the conservative treatment of ureteric stones. 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. Resnick MI. Mutabagani H.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10468715 6. http://www. Awad RM. • Distal ureteral stones: 70%.ncbi.ncbi. Such stones should be removed with a technique that is as little invasive as possible. Acta Chir Scand 1956. http://www. Cohen E.nih. J Urol 1999. 3.5.nlm.nih. 6. the chance of spontaneous passage is very low (1-4). Patel KP. J Urol INDICATIONS FOR ACTIVE STONE REMOVAL The size.84:249-251.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=13394022&dopt =Abstract Morse RM.fcgi?cmd=Retrieve&db=PubMed&list_uids=9776434&dopt= Abstract Shokeir AA. Resistive index in renal colic: the effect of nonsteroidal anti-inflammatory drugs.fcgi?cmd=Retrieve&db=PubMed&list_uids=1988715&dopt= Abstract Ibrahim AI. http://www. REFERENCES Sandegard E. Eur J Clin Pharmacol 1998. http://www. Ureteral calculi: natural history and treatment in an era of advanced technology.nlm. The likelihood of spontaneous passage must also be evaluated. UPDATE JUNE 2005 21 . Fadilla M.nlm. Spontaneous stone passage can be expected in up to 80% in patients with stones < 4 mm in diameter.1 1. GR = grade of recommendation 6. Kane CJ. Prognosis of stone in the ureter.(Suppl 219):1-67.nih. site and shape of the stone at the initial presentation are factors that influence the decision to remove the stone (Table 14). 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=10458343&dopt =Abstract LE = level of evidence.162:688-691.54:455-458.67:358-361. Hafner R.ncbi. Rotenberg Z.145:263-265. BJU Int 1999. For stones with a diameter > 7 mm.nlm. http://www.nih. A narrow caliceal neck may require dilatation. • Mid-ureteral stones: 45%. Abdulmaaboud M.fcgi?cmd=Retrieve&db=PubMed&list_uids=2032074&dopt= Abstract Miller

9. otherwise a percutaneous lithotripsy might be considered as a more rational option.148:1043-1046.nlm. Chang LS.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2261935 Hübner W. Treatment of caliceal calculi. Small renal caliceal calculi as a cause of pain.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6887409 Psihramis KE. 10. Kahnoski RJ.138:707-711. This has led to the conclusion that large stones are better treated with a percutaneous approach (see below). severe skeletal malformations. The latter factor probably has become more important with later generations of lithotripters.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1507327 Brandt Andersson There are no clearly established rules on how often ESWL sessions can be repeated. Chen MT. All these factors give an efficacy that is the same as.nlm. Lingeman JE.nih. Kvist Kristensen J. 7.ncbi. Ostri P. Painful caliceal J Urol 1992. In the case of infected stones or but at a lower cost and with greater versatility.2). The treatment of small nonobstructing caliceal calculi in patients with symptoms. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. http://www. not a contraindication. Even the indications for stone removal were modified when shock wave lithotripsy was introduced. http://www.nih. 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. It is recommended that the number of ESWL sessions should not exceed three to five (dependent on the lithotripter used).gov/entrez/query.ncbi. Sonda LP.ncbi. Scand J Urol Nephrol 1993. Lee YH.ncbi.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. but also of all the diagnostic and ancillary procedures associated with ESWL treatment.66:9-11.nlm. or superior to. J Urol 1987. Numerous authors have addressed this issue in recent years (3-12). A pacemaker is. as well as modified indications and principles for treatment. Lange P. 8. however.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3116280 Coury TA. have changed the type and rate of complications. Generally. 22 UPDATE JUNE 2005 . J Urol 1983. in the vast majority of cases.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8493473 7.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2393803 Streem SB. severe obesity and aortic and/or renal artery aneurysms (1. 11. 6. http://www. ESWL should not be carried out in patients with uncontrolled blood coagulation or uncontrolled urinary tract infection.nlm. the intrarenal position and chemical composition of the stone are determinants of the treatment results. in comparison with the Dornier HM3-lithotripter. that the interval between two successive sessions must be longer for electrohydraulic and electromagnetic lithotripsy than for treatments with piezoelectric equipment. Yost A.130:752-753. http://www.nlm.ncbi. Br J Urol 1990. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup.ncbi. http://www. Currently. 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. part of a uroradiological table which allows the application of not only ESWL treatment. 7. however.nlm.nih. When repeated treatments are necessary. antibiotic therapy should be given before ESWL treatment and continued for at least 4 days after the treatment.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3400135 Lee MH. In addition to the size of the stone. Urology 1988. 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). It is reasonable to assume. Porpaczy P. http://www. Modern lithotripters are smaller and.nih. for example. Treatment of painful caliceal stones. Huang JK. Dretler SP. because of their smaller focal volumes.nlm.ncbi. the development of lithotripters.27:75-76. the contraindications to ESWL treatment are restricted to pregnancy. Management of painful caliceal stones by extracorporeal shock wave lithotripsy. Eur Urol 1990. that of the first lithotripters on the market. Sylven M.nih.nih.

It has been observed that the lower calices are insufficiently cleared of disintegrated stone material in up to 35% of ESWL-treated patients. 7. a PN tube is necessary. 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. the incidence of stones is around 20%.19). and shorter intervals between treatment sessions are usually acceptable for stones in the ureter. It stands to reason. Such fragments either emerge from stones originally found in this part of the kidney or from stones at other locations. A faster clearance of upper pole stones has been observed. fever. the efficacy of ESWL is strictly related to the position of the kidney.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.5% (2152). The need of auxiliary procedures in these patients is high. In the horseshoe kidney. 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.Moreover. One factor that might affect the result of ESWL treatment is the presence of anatomical abnormalities. with one study showing that only 50% of the patients were stone-free at 3-months follow-up (14).255 cases. In case of fever lasting for a few days. the risk of damage is most pronounced with treatments directed towards stones in the kidney. 7. By using a double-J stent. the obstructive and infective complications after ESWL due to large renal stones are reduced. hydronephrosis. even when ultrasonography does not reveal any dilatation. however. leading to a risk of obstructive pyelonephritis. however. In one treatment series the incidence of auxiliary procedures was reported to be 24% and the re-treatment rate 27% (15). although the accumulation of fragments in this position is most probably due to the effect of gravity. It is still unknown why stones preferentially develop in the lower pole calices. there has been a continuous debate on the best way to treat stones in the lower calix. This is an important issue because a large number of kidney stones are located in this part of the kidney.17). In ectopic kidneys. There is no consensus on the maximum number of shock waves that can be delivered at each session. In view of the numerous lithotripters presently in use it is not possible to give a general recommendation in this regard. There are some reports indicating that ESWL is also useful in patients with medullary sponge kidneys (tubular ectasia) and nephrocalcinosis (18. • State of contralateral kidney: nephrectomy or functionless kidney on the other side.55). it is well recognized that most residual fragments are lodged in the lower caliceal system. It might. the efficacy of ESWL is similar to that in normal kidneys and well tolerated.2.1.2 ESWL for removal of large renal stones ESWL for the treatment of large renal stones often causes problems. This usually prevents obstruction with loss of ureteral contraction. 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. Stone particles may pass easily along stents while urine flows in and around the stent. that the interval should be determined by the energy level used and the number of shock waves given. stents are not efficient in draining purulent or mucoid material. Sometimes. and occasional urosepsis due to difficulties in passage of stone particles especially in case of insufficient disintegration (53-58). In a series of 35. UPDATE JUNE 2005 23 . Almost since the introduction of ESWL.100 patients treated for kidney stones with ESWL. This number again depends on the type of lithotripter and the shock wave power used. Clinical experience supports this view. The following factors are crucial with respect to treatment success: • Location of the stone mass (pelvic or caliceal).1. which is 92%. • Total stone burden. Some authors claim that percutaneous surgery is the treatment of choice for these patients (16. In transplanted kidneys. Insertion of the stent before ESWL is advocated for stones with a diameter > 20 mm (54. The success rate depends mainly on the lithotripter used and varies between 53% and 60%. The stone-free rate in these patients was 70% with re-treatments in 10. satisfactory disintegration was recorded in 32. without any particular side-effects (20). Moreover. • Composition and hardness of the stone (53). 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. Frequent complications are pain.

In the case of a solitary kidney. PNL. respectively (8). for cystine stones with a diameter greater than 15 mm. In other studies. Today most authors consider a largest stone diameter of 20 mm as a practical upper limit for ESWL.69). ESWL is the recommended treatment. it might be feasible to try ESWL monotherapy first. 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. and in one report the authors even noted that the clearance of fragments was better with an infundibulopelvic angle below. a long infundibulum (59. the results are contradictory and there is no strong evidence that these variables can be used to predict the outcome of ESWL. ESWL after PNL seems to be more effective than PNL after ESWL. Stone composition can be an important factor in the disintegration and subsequent elimination of fragments.2 Stone burden Although the problems associated with removal of stones from the kidney increases with the volume of the stone. Another factor that most certainly is of great importance is the less well-understood caliceal physiology (63. the size of the stones has been found to be the most important determining factor (64. Below this size. In the absence of a geometrical explanation. a long calix neck or a narrow calix can undoubtedly counteract elimination of fragments. but larger stones are also successfully treated with ESWL in some centres. 24 UPDATE JUNE 2005 . even if the stone has an area larger than 40 x 30 mm (57). At least for stones with a largest diameter of 20 mm (surface area ~ 300 mm2). It appears that an area of 40 x 30 mm (940 mm2) could represent an upper limit for ESWL alone. Several authors have shown that a better stone-free rate can be obtained with PNL. 7. The invariance and morbidity of PNL undoubtedly needs to be taken into account.56).2. ESWL should be considered to be the first choice for treatment.66. This conclusion was based both on observations in a randomised prospective study comparing ESWL and PNL (66) and in a multivariate analysis (64). ESWL can still be considered an option for treatment. ESWL monotherapy provided satisfactory results only in patients with pelvic stones smaller than 1 cm. For cystine stones with a diameter less than 15 mm. 7. The recommended upper size limit for ESWL in this document is 20 mm (300 mm2). 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). there is no clear cut-off for a critical stone size. Stones composed of uric acid and calcium oxalate dihydrate have a better coefficient of fragmentation than those composed of calcium oxalate monohydrate and cystine. possibly combined with ESWL. the combination of PNL and ESWL (sandwich approach) has emerged as a solution.63) and/or a narrow infundibulum (59-61. however. it is difficult to formulate specific guidelines on how to remove stones from the kidney.By taking measurements of the infundibulopelvic angle.63) have a negative influence on fragment clearance. 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).69). however.1. Although an acute angle. particularly when the stones become larger. 70° (68).or struvite-containing stones provides reasonable results in terms of stone removal and complications (58). With ESWL monotherapy (only stent). Thus. that the risk of complications of the combined treatment or PNL alone is higher than for ESWL monotherapy.3 Composition and hardness of the stone ESWL monotherapy of large calcium. About 1% of all patients treated for urinary tract stones by ESWL have cystine stones. a stonefree rate of about 71% was reported. is an effective treatment for all other patients with cystine stones (70. The success rate for larger stones was only 43% after 3 months with ESWL monotherapy. several authors have concluded that an acute infundibulum angle (59-63). provided the pros and cons are clear. ESWL as monotherapy is currently not recommended. It is important to note that there are two types of cystine stone morphology: smooth and rough. 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. the problem might be more rationally solved using PNL. However. The latter is much more susceptible to shockwaves than the first one (72). no such relationship has been demonstrated (64-69). Success rates for these two groups of stones were shown to be 38-81% and 60-63%. It is of note. In the treatment of stones with an area larger than 40 x 30 mm. a figure that dropped to 40% when the diameter exceeded 20 mm (9). For larger stones. Instead of multiple ESWL sessions. with success rates of 71-96% and acceptable morbidity and complications. as well as the infundibulum length and width. The indication for open stone surgery has become extremely rare because of the invasiveness of this approach (55. despite the lower clearance of fragments.71).67.1.2. rather than above. It might be relevant to note that a previous percutaneous procedure in one study (69) was considered as a negative determinant of fragment clearance.

fcgi?cmd=Retrieve&db=PubMed&list_uids=8426419&dopt= Abstract Di Silverio F.nlm.ncbi.ncbi. Br J Urol 1988. Staghorn calculi of the kidney: classification and therapy. 11. Lingeman JE. Relative efficacy of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in the management of cystine pp 303-308.fcgi?cmd=Retrieve&db=PubMed&list_uids=3411655&dopt= Abstract Hochey NM. Vadera P. Pusztai C. Staghorn calculi: analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. http://www.nih. Steele 15. Finlayson B. 135:1134-1137. Farkas 8. Clinical comparison of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy in treating renal calculi.147:1219-1225.nih. Challah 1989.nlm. World J Urol 1987.nih.nih.7(Suppl 1):S105. Nelson JB. Woods JR.nlm. Patel S. Szekely JG.ncbi. 12.ncbi. http://www. Coury TA. http://www. Mertz JH. UPDATE JUNE 2005 25 . Use of extracorporeal shock wave lithotripsy in a solitary kidney with renal artery aneurysm.fcgi?cmd=Retrieve&db=PubMed&list_uids=2336770&dopt= Abstract Kunzel KH. 4.nlm. Short term changes in renal function after extracorporeal shock wave lithotripsy in children.nlm. Br J Urol 1990. J Urol 1987.3:273-275.nlm.65:449-452. http://www. 9.nlm. Alpi Nyhuis A.ncbi.nlm.nih. Mertz JH. Loughlin KR. http://www.149:359-360.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8048189&dopt= Abstract Ignatoff JM. Coury Javor E. http://www. Newman DM (eds).nlm.nih.4 REFERENCES Barron M.ncbi. Villanyi KK. Plenum Press: New York.1.ncbi.nih.ncbi. Woods JR. Diederichs W. Sclocker H. Kahnoski RJ.nih.nlm. Scott JW.31:407-411. Six-year follow-up in patients treated with PCNL and ESWL for staghorn stones.nih. Lingeman JE. 10. 14. Lingeman JE. 6. J Urol 1986. http://www. 5. Mosbaugh PG. Arterial blood supply of horseshoe kidneys with special reference to percutaneous lithotripsy. Woods JR. Vol 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=3176212&dopt= Abstract 2. 7.140:479-483. Janetschek G. J Urol 1993.27:240-245.fcgi?cmd=Retrieve&db=PubMed&list_uids=3520015&dopt= Abstract Politis G. Extracorporeal shock-wave lithotripsy in horseshoe kidneys. J Urol 1988. Palfrey E. Lingeman JE. Long term follow-up in 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=3625845&dopt= Abstract Mays N.2. Newman DM. J Urol 1992. Burney P. Steele RE. Kahnoski RJ.003 extracorporeal shock wave lithotripsy patients. Steinbock GS. Urology 1994.fcgi?cmd=Retrieve&db=PubMed&list_uids=1569653&dopt= Abstract Lingeman JE. Gallucci 13. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. Alpi G.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11435873 Locke DR. Mosbaugh PG. J Endourol 1993. http://www. Urology 1990. Cassanelli A et al. Management of urologic problems during pregnancy. Newman DM.166:222-224. Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience. Knapp PM.ncbi. Newman RC. J Endourol 1989. Steele RE. Newmann D. Griffith DP. http://www. 3. Urol 1989.138:485-490.nlm. Relative roles of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy. Creeser ESWL: stone free efficacy based upon stone size and location. Gallucci M.fcgi?cmd=Retrieve&db=PubMed&list_uids=3416143&dopt= Abstract Graff J.44:159-169. In: Shock wave lithotripsy 2: urinary and biliary lithotripsy. Lingeman JE.nih. http://www. Schulze H. Mosbaugh PG.ncbi. Hutchinson CL.fcgi?cmd=Retrieve&db=PubMed&list_uids=2354308&dopt= Abstract Lam HS.297:253-258. J Urol 2001.

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treatment time increases with stone size.72. REFERENCES Kim SC. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2795746 7. However.nih. Dilatation of the tract is possible with the Amplatz system.2. The puncture can be performed under combined ultrasound and X-ray control or under biplanar fluoroscopy. it is the method of choice for percutaneous stone removal in children (5-7). Furthermore. Dretler SP. A difficult procedure is indicated by anatomical conditions that offer only limited space for the initial puncture. clinically significant. continuous removal of small fragments by suction or extraction is preferred. 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). such as stones in diverticulae or stones completely filling the target calix. 13:235-41. The most frequently used access site is the dorsal calix of the lower pole. However. Percutaneus nephrolithotomy: an update. pleura and lungs) are not within the planned percutaneous path (1. Kuo RL. While the value of mini-perc in adults has not been determined. CT-guided renal access may be an option (3). In the least traumatic access. liver. bleeding results from an arterial injury and can be managed by angiographic superselective embolization. Major bleeding during the procedure requires termination of the operation. The use of ultrasound allows easy identification of neighbouring organs and therefore lowers the risk of injuries to adjacent organs. Prien EL Jr. brushite) or if fragments are unlikely to pass (large stones. if ESWL is available.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12692448 30 UPDATE JUNE 2005 . The choice is a matter of experience. so-called ‘mini-perc’ instruments have smaller dimensions with 12-20 F. Lingeman JE. Bleeding is generally avoided by an anatomically oriented access. As with open surgery.2.nlm. The percutaneous puncture may be facilitated by the preliminary placement of a balloon ureteral catheter to dilate and opacify the collecting system. While standard nephroscopes have shaft calibres of 2430 F. http://www. J Urol 1989. availability and costs. Stones can be extracted straightaway or following disintegration by electrohydraulic. a self-retaining balloon nephrostomy tube is the best choice to secure tamponading of the tract and access to the collecting system. Although PNL is minimally invasive. in selected patients. percutaneous procedures have different degrees of difficulty. it is still a surgical procedure and thus it is necessary to carefully consider the patient’s anatomy in order to avoid complications. Pre-procedural KUB and intravenous urography or uroCTscan are used to plan access. However. The procedure should only be carried out by experienced surgeons in these cases. the indications for PNL should be limited to cases in which a less favourable outcome is expected after ESWL.1 Complications Major complications are lesions to adjacent organs. laser or hydropneumatic probes. These problems can be avoided by using continuous flow instruments or an Amplatz sheath (1. This can be avoided by puncture under ultrasound guidance. Cystine calculi-rough and smooth: a new clinical distinction. Curr Opin Urol large bowel. which is why this method is recommended only for stones with a diameter < 20 mm (4). Persistent. Sepsis and ‘transurethral resection syndrome’ indicate a poor technique with high pressure within the collecting system during manipulation. There are no major vessels in this region and there is only minimal bleeding. placement of a nephrostomy tube and secondary intervention at a later date. balloon dilators or metallic dilators.ncbi. as described above. These small-calibre instruments possibly have a lower rate of tract dilation-related complications such as bleeding or renal trauma. 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.2 Percutaneous removal of renal stones Principally.nlm. 7. tubeless percutaneous nephrolithotomy may be a safe alternative (7). After completion of the procedure. 7. dilatation and instrumentation.2 1. the majority of renal stones can be removed by percutaneous surgery.nih. To reduce the number of residual fragments. It is also the safest point of access because it uses the infundibulum as a conduit to the pelvis.ncbi.2). In selected cases with anatomical anomalities. calcium oxalate. caliceal diverticula).8). Bhatta KM. such a catheter will prevent fragments from falling into the ureter. calcium monohydrate. and to ensure that organs adjacent to the kidney (such as the spleen.142:937-940. These images will also give some indication as to whether the stones will respond poorly to ESWL (such as stones composed of cystine. Venous bleeding stops in most cases when the nephrostomy tube is clamped for some hours.

gov/entrez/query.52:697-701. Assimos DG.nih.e. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. Renal calculi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446796 Feng MI. composition and distribution within the collecting system. the use of flexible nephroscopes can reduce the need for multiple accesses (4). http://www.nlm. Peters CA. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12796641 Lahme S. with obstruction of the collecting system. Urology 2001. Zagoria RJ. Ridhorkar V. Although multi-tract PNL only moderately increases morbidity. every effort must be made to preserve functioning nephrons. without obstruction of these calices. Minimally invasive PCNL in patients with renal pelvic and caliceal stones. 5.ncbi.3. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. Patel S.nih. Bichler KH. J Endourol 1999. Urol Clin North Am Percutaneous management. These are stones with a large. http://www.nlm.ESWL. UPDATE JUNE 2005 31 .3 ESWL and PNL A combined procedure should be planned in such a way that each single step is successful in itself. http://www.168:1348-51. Tamaddon K. all techniques . Gotz T. Stones with large volume extensions into the calices.nlm.170:45-7. there is no dilatation of the collecting system and the stone has a small volume (2).fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9763096 Desai M.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11805407 Jackman SV.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12352390 7. 8. Seguea JW.nlm. i.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11098760 Matlaga BR. Shah OD. are good indications for a combined procedure. J Urol 2002.1 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. Computerized tomography guided access for percutaneous nephrolithotomy. http://www. Low RK.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.ncbi.nlm. 6. are not suitable for this approach. stone volume. Thus.ncbi.ncbi.3 Aspects on staghorn stone treatment and importance of stone burden Staghorn stones may significantly vary in size. If the global kidney function is reduced or if there is bilateral stone disease. 7. There is no generally accepted classification system that allows for determination of success and complication rates of single or combined procedures.nih.ncbi. Urology Dyer RB. Desai M. Docimo SG.are included in the treatment strategy (1).nlm. Prospective randomized study of various techniques of percutaneous nephrolithotomy. Kaptein JS. J Urol 2003. 7. The use of two or more percutaneous accesses should follow the same rules (3).gov/entrez/query. Bellman GC. PNL. 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.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11549477 Troxel SA. Mikhail A. 27:617-22. surgery and partial or complete nephrectomy .3. as well as in their secondary effects on renal anatomy and function.. Strohmaier WL. Bapat S.13:359-64.3.nlm. centrally located. 4. Eur Urol 2001. Renal intrapelvic pressure during percutaneous neprolithotomy and its correlation with the development of postoperative fever. Streem SB. Hedican SP. 7. http://www.nih. Ramakumar S.58:345-50.

fcgi?cmd=Retrieve&db=PubMed&list_uids=1507330&dopt= Abstract Lahme S. Scott JW. Grasso M.initial results. The clearance of stone fragments from the lower pole calices varies between different studies but is generally considered as diameter exceeding 20 mm or stone surface area more than 300 mm2). Urology 1998. J Endourol 1999. REFERENCES Segura JW. http://www. Neprolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi.4 Percutaneous surgery versus ESWL for removal of renal stones PNL and ESWL are complementary rather than competing procedures.ncbi. Assimos DG. Kahn RI. Chua GT. http://www.3.nlm. http://www. Trummer H. Desai M.ncbi. initial.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446796 Alabala DM. Docimo SG. Macaluso JN Jr. J Urol Singh U.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14764139 2. Dretler SP. Knapp PM. Munch LC. Newman RC. http://www. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. Preminger GM.93:364-368. Newman DM. Lingeman JE. 7. with overall stone-free rates between 37% and 67% (see section 7. 4.nlm. Currently. Singh V. Peters CA. Assimos DG. Denstedt JD. http://www. Outcome and safety of extracorporeal shock wave lithotripsy as first-line therapy of lower pole nephrolithiasis. there is no consensus on the usefulness of measuring the infundibulopelvic angle and the length and width of the calix (see above section 7.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11696709 Riedler I. http://www. McCullough DL. Macaluso JN Jr.nlm. J Urol 1992.nih. Ridhorkar V.nih.13:359-64.1. Lingeman JE.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507322&dopt= Abstract Lam HS.5 1.ncbi. 6.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9763096 Desai M. J Urol stonefree Zaman W.. Minimally invasive PCNL in patients with renal pelvic and caliceal stones. However. 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. Lingeman JE. Russo R.2. Leveillee RJ.40:619-24. it can be stated that. Eur Urol 2001. Teichman J. Stone surface area determination techniques: a unifying concept of staghorn stone burden http://www.151:1648-51.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11805407 Jackman SV. 7. Steele RE.nlm. Kumar A. Efficacy of extracorporeal shock wave lithotripsy for solitary lower caliceal stone: a statistical model.7. 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. 3. Woods JR. PNL is associated with more severe complications than ESWL.nlm.nih.ncbi. Mandhani Nakada SY. 5.nih.52:697-701. Lingeman JE. Kahn RI.3.fcgi?cmd=Retrieve&db=PubMed&list_uids=8189589&dopt= Abstract Lam HS.1.nlm. the indication for PNL can also be extended to include so-called ‘easy cases’ when ESWL is not available.166:2072-80.nih.148:1026-29. Hubmer G. Clayman RV. Patel S.1 Location of the stone mass). 9. BJU Int 2004.ncbi. http://www. Urol Int 2003. and the best treatment for stones in the lower calices is still controversial. 32 UPDATE JUNE 2005 .nlm.nih. Bapat S.1) while percutaneous procedures result in a stone-free rate of up to 97% (4-11).gov/entrez/query. Gotz T. Pearle MS.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14646431 Srivastava A. Preminger GM. although PNL has a higher. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis . Hedican SP. Principally. Bichler KH. Strohmaier WL.nih.e. Mosbaugh http://www.ncbi.ncbi. particularly for patients with an obstructed lower calix or when the stone burden is considerable (i. Hebel P. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. A percutaneous approach might therefore be preferable. J Urol 2001. Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy. Gutierrez-Aceves J.nlm.

Poulakis V.ureteroneocystotomy. Witzsch U. BMC Urol 2003. contractures and fixed deformities of hips and legs.ncbi. expertize and experience in the surgical treatment of renal tract stones report a need for open surgery in 1-5. Dahm P. • Stone in a transplanted kidney where there may be a risk of damage to the overlying bowel. especially if these calices are obstructed so that either several percutaneous accesses and several. Remplik J. Khawaja K.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12546707 7. It is now accepted that. UPDATE JUNE 2005 33 . Becht E.12) and renal surgery under hypothermia.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12629337 Ather MH. • Treatment failure with ESWL and/or PNL or failed ureteroscopic procedure. 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.nih. • Pyeloplasty. Since most of these cases will usually involve difficult stone situations. • Pyelonephrolithotomy. • Cystolithotomy for giant bladder calculus. the indications for open stone surgery have markedly diminished.nlm.10.2 Operative procedures Operative procedures that can be carried out include: • Simple and extended pyelolithotomy. • Concomitant open surgery. obstruction of the ureteropelvic junction. With today’s limited experience with open stone surgery in many hospitals. there is a place for open surgical removal of calculi. 7. Prediction of lower pole stone clearance after shock wave lithotripsy using an artificial neural network. it is important that urologists maintain proficiency. shockwave sessions will be necessary for complete stone removal. • Skeletal deformity. skills and expertize in open renal and ureteral surgical techniques. http://www. with the various modalities of treatment that are now available for the surgical management of stones. 11. stricture. • Ureterolithotomy. in some circumstances. • Removal of calculus with reimplantation of the ureter . J Urol 2003. de Vries R. • Morbid obesity. Akhtar S. non-functioning kidney (nephrectomy). appropriate. multiple radial nephrotomy (11. • Patient choice following failed minimally invasive procedures .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. • A large stone burden in children because of easy surgical access and the need for only one anaesthetic procedure. The latest progress in this area has been the introduction of intra-operative B-mode scanning and Doppler sonography (13. Thus. • Non-functioning lower pole (partial nephrectomy). • Stone in an ectopic kidney where percutaneous access and ESWL may be difficult or impossible.4% of cases (1-5). anatrophic nephrolithotomy (7-10). Whenever the major stone volume is located peripherally in the calices.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. • Co-morbid medical disease. http://www.1 Indications for open surgery Indications for open surgery for stone removal include: • Complex stone burden. an open surgical procedure should be preferred. there will inevitably be some controversy as to when open operation in a particular case is. Abid F. 7. Centres with the equipment. • Anatrophic nephrolithotomy.4. • Radial nephrolithotomy. stone in the caliceal diverticulum (particularly in an anterior calix). 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).the controversy continues. • Partial nephrectomy and nephrectomy.169:1250-1256.single procedure in preference to possibly more than one PNL procedure. • Intrarenal anatomical abnormalities: infundibular stenosis.nlm. Stone clearance in lower pole nephrolithiasis after extra corporeal shock wave lithotripsy .4. probably unsuccessful. or is not.3:1.

http://www. 5. 13. Spirnak P.nih. Weems WL.ncbi. New surgical concepts in removing renal calculi.ncbi. Current surgical approaches to nephrolithiasis.123:604. Reidy C. Gower RL. Anatrophic nephrolithotomy: Update 1978. http://www. while a large stone burden in association with abnormal anatomy limiting endoscopic access in 31% of the cases. Endocrinol Metab Clin North Am McCullough DL. Boyce WH. Thüroff S. Another report mentions 25 open surgical procedures in 799 treatments for renal stones. Alken P. Boyce WH.ncbi.651 stone procedures carried out in Singapore (16). http://www. Urol Int 1965. Resnick A 2% need for open surgery was recorded in 2.nih. Smith ER. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9649242 Gil-Vernet J. Current indications for open stone surgery in the treatment of renal and ureteral calculi.nih. Cohen AS. 11. 7. 1978. Anatrophic nephrotomy and plastic calyrhaphy. Hutschenreiter G. particularly for stones located in a ventral caliceal diverticulum (17).59:102-108. Donohue JP (eds). Letter to the editor.15:475-477.ncbi. In: AUA courses in urology. Laparoscopic surgery is also an option.fcgi?cmd=Retrieve&db=PubMed&list_uids=4436892&dopt= Abstract&itool=iconnoabstr Sleight MW. Smith MJV. Surgical anatomy of the human kidney and its application. Commission on Dietetic Registration Dietetics Practice Audit.nih. Lewis C.fcgi?cmd=Retrieve&db=PubMed&list_uids=7365912&dopt= Abstract Resnick MI. J Urol J Urol 1980. http://www.nlm. J Urol 1982. Wainstein MA. Pounds DM.nih. Coe N. 20:255-288.159:374-37.nih.142:263-267.fcgi?cmd=Retrieve&db=PubMed&list_uids=8948396&dopt= Abstract Bichler KH.ncbi. anatomical abnormalities in 24%.4. Vol 1. pp 1-23.ncbi. Euro Urol 1975.1292-1301. failed low invasive surgery in 29%. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=6064524&dopt= Abstract Harrison LH. Boyce WH. Trans Am Assoc Genitourinary Surg 1967.nih. http://www. Ward JP. J Am Diet Assoc 1996. Bonney WW.fcgi?cmd=Retrieve&db=PubMed&list_uids=2746742&dopt= Abstract Segura JW. The role of open surgery since extracorporeal shock wave lithotripsy. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=7052711&dopt= Abstract Thüroff Abstract Paik ML. Frohneberg D. 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). One hundred cases of nephrolithotomy under hyporthermia. Strohmaier WL.fcgi?cmd=Retrieve&db=PubMed&list_uids=7086985&dopt= Abstract 2. 9.nlm.nih.nlm. Localization of segmental arteries in renal surgery by Doppler sonography.nlm.ncbi.nih.nlm.3 1. 34 UPDATE JUNE 2005 . J Urol Indications for open stone removal of urinary calculi. Urol Int 1997. 10. http://www. 6.nlm. http://www. 12. Kroonvand RL. http://www. Harrison LH.17:367-369.127:863-866.ncbi. In one recent report reasons given to perform open surgery were a complex stone burden in 55%. REFERENCES Assimos DG. Lahme Riedmiller R. Wickham JE. Williams and Wilkins: Baltimore. but (as yet) there are no comparative studies available (LE:4). 19:912-925.ncbi. Urology 1981. Intrarenal superiority of open surgery over less invasive therapy in terms of stone-free rates is based on considerable historical experience. 8. morbid obesity in 10% and co-morbid medical diseases in 7% of cases (5).fcgi?cmd=Retrieve&db=PubMed&list_uids=5863978&dopt= Abstract Boyce WH. Urology 1980.1:71-74.fcgi?cmd=Retrieve&db=PubMed&list_uids=2081519&dopt= Abstract Kane Hample N. Wickham JEA. Hohenfellner R. 3.ncbi.nih.ncbi.

This is a particularly interesting treatment approach in view of the very high recurrence rate of brushite stones. URS or open surgery for a more complete elimination of stone fragments or residual fragments. 0. Thüroff JW. Current indications for open stone surgery in an endourological centre. 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.nlm.ncbi.1. the most attractive alternative. which is an acid solution with a pH between Meria P. Another useful agent is Suby’s solution. 16.fcgi?cmd=Retrieve&db=PubMed&list_uids=6719663&dopt= Abstract Kane CJ. Riedmiller H. http://www.2). Percutaneous chemolysis is a useful method for complete stone clearance in combination with other stone-removing techniques (14-18). 7.23:455-460. http://www.14. This section provides a summary of chemolytic treatment options. This method involves lowering urate concentration using allopurinol and a high fluid intake.5-9. Bolton DM. and increasing the pH to alkali (19-21). Urology 1984. The pH of these solutions is in the range 8. Alken P. Urology 1995. BJU Int.6 mol/L trihydroxymethyl aminomethan (THAM) solution can be the ureter should be protected by a double-J stent during the procedure (1.nlm. 15. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7855969 Sy FY. Hohenfellner R. Another option is acetylcysteine.nlm. For this purpose. 17. 7. 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. but several weeks will be necessary to dissolve a complete staghorn stone using chemolysis combined with ESWL.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11119107 7. Wong MYC.5 Chemolytic possibilities Chemolytic dissolution of stones or stone fragments is a useful adjunct to ESWL. Current indications for open stone surgery in Singapore. 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. Mahe P. The combined treatment of ESWL and chemolysis is a particularly low-invasive option for selected patients with partially or completely infected staghorn stones. The time required for dissolution depends on the stone burden. however. PNL.28:241-244.Stoller ML. Danjou P. 7. This option should be considered in patients with residual brushite fragments after other stone-removing procedures. Oral chemolytic treatment is also a very attractive therapeutic alternative for the removal of uric acid stones.86:1088-1089. 7. the patient should have at least two nephrostomy catheters.nih. 2000.4 Uric acid stones A high concentration of urate and a low (acidic) pH are the determinants of uric acid stone formation. Laparoscopically-assisted percutaneous nephrolithotomy for the treatment of anterior calyceal diverticula. In the case of a large stone burden. The surface area of the stone or the stone remnants is increased by ESWL.1 Infection stones Stones composed of magnesium ammonium phosphate and carbonate apatite can be dissolved with a 10% solution of hemiacidrin. Doppler sonography and B-mode ultrasound scanning in renal stone surgery.5 and 4. For percutaneous chemolysis.45:218-221. Foo KT. During appropriate antibiotic treatment the chemolytic solution is allowed to flow in through one nephrostomy catheter and out through another.nih. Percutaneous dissolution can be accomplished with THAM solutions. UPDATE JUNE 2005 35 . Ann Acad Med Singapore 1999.ncbi.nlm.5.3 or 0.nih.3 Cystine stones Cystine is soluble in an alkaline environment.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10497675 Brunet P.5. The two solutions can also be used in combination.2 Brushite stones Brushite is also soluble in the acid solutions mentioned above in section 7.5.0. Oral chemolysis is.ncbi. It should be noted that Hemiacidirin and Suby G solutions carry a serious risk of mortality (cardiac arrest) from

Scand J Urol Neprol 1999.5 Calcium oxalate and ammonium urate stones There is currently no physiologically useful chemolytic agents for dissolving stones composed of calcium oxalate or ammonium urate (22).9:121-130. pp 281-310. Harrison LH. [German] 2. Reckler JM. Plenum Press: New York.ncbi. Urol Clin North Am 1993. http://www. Primary dissolution therapy of struvite Israel Chemolysis of calculi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7080280&dopt= Abstract Griffith DP.fcgi?cmd=Retrieve&db=PubMed&list_uids=1003633&dopt= Abstract Burns JR. Eur Urol 1988.5.ncbi. Otting Kandel B. Talwalkar YB. http://www. Bick C. Riedmiller H.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215233&dopt= Abstract Rodman JSA. Cattolica EV. Larsson L.nih.a useful component in the treatment of infection renal stones. Kandel B.ncbi. http://www. [Perkutane Chemolyse von Struvit-Steinen bei Nierenbecken-und Kelchhalsobstruktion] Akt Urol 1982. In: State of the art extracorporeal shock wave lithotripsy. Eriksson L. Ureteral calculi.nlm.nlm. [German] Klein RS.7. Hemiacidrin renal irrigation: Complications and successful management. http://www.nih.ncbi. 7. http://www. Joseph DB. Resnick MI.13:256-258. Andersson A. Rossier AB. Hemiacidrin . J Urol 1991. 11. 8. Alken P. [Lokale Chemolitholyse von Harnsteinen] Zeitschrift fur Klinische Medizin 1989. Smith AD.fcgi?cmd=Retrieve&db=PubMed&list_uids=6708214&dopt= Abstract Fam B. Vijan SR.fcgi?cmd=Retrieve&db=PubMed&list_uids=10572989&dopt =Abstract Fahlenkamp C. Brien G. http://www. 15.fcgi?cmd=Retrieve&db=PubMed&list_uids=7269011&dopt= Abstract Weirich W. [Auflösung von Cystin-Steinen mit N-Acetylcystein nach perkutaner Nephrostomie] Akt Urol 1981.fcgi?cmd=Retrieve&db=PubMed&list_uids=8351769&dopt= Abstract Kachel TA. http://www.nlm. McCullough DL (eds). Combination therapy for a partial staghorn calculus in an infant. J Urol 1976. Harrison In: State of the art extracorporeal shock wave lithotripsy. The role of hemiacidrin in the management of renal stones in spinal cord injury patients. The presence of calcium oxalate in an infection stone markedly reduces the solubility in hemiacidrin (6).fcgi?cmd=Retrieve&db=PubMed&list_uids=7109081&dopt= Abstract Dretler SP. http://www.20:435-442. 6. J Endourol 1993.nih. Urology 1981. REFERENCES Tiselius HG. Suckow B. McCullough DL (eds). http://www. http://www. Hellgren E. Hatch T.116:696-698.145:25-28. Tiselius HG. Dissolution of cystine calculi by pelvocaliceal irrigation with tromethamine-E. 7. Berg S.nih. Alken Rankin KN. Urol Clin North Am 1982. 9. Alexander SR.fcgi?cmd=Retrieve&db=PubMed&list_uids=7154186&dopt= Abstract Weirich W.nlm. De Temple R. Ackermann D. 4. Haas 1987.nlm. J Urol 1984.ncbi.128:1281-1284. Dretler SP. J Urol 1982. Yalla S.ncbi. Tank ES.ncbi. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis. 16. Hemiacidrin irrigations to dissolve stone remnants after nephrolithotomy. pp 311-353.nih.7:469-471.nlm. http://www. Schöpke W.18:127-130.ncbi. 33:286-290.ncbi.nih. Plenum Press: New York. 36 UPDATE JUNE 2005 . Staghorn calculi. 13. Borrud-Ohlsson J Urol Abstract Tseng CH.nlm.nih.nlm. 12. Endourological experience with cystine calculi and a treatment algorithm.6 1. 3. Lingeman JE.nlm.131:861-863. [German] Sheldon CA.fcgi?cmd=Retrieve&db=PubMed&list_uids=8124339&dopt= Abstract Levy DA. Pfister RC. 1987. 10. Wall I. 14. Management of urinary stones in the patient with spinal cord injury.

Peterson CM. The approximate estimates of surface area corresponding to oval stone projections with certain diameters are given in Appendix A. 18. An overview of treatment recommendations according to size and stone type is shown in Tables 15 and 16. J Urol 1984. Reinke DB.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1317980&dopt= Abstract Rodman JS. it is logical to select a method with low invasiveness and low morbidity.48:81-86.ncbi.nih. 19. Indudhara R. http://www. http://www. Residual fragments of infection stones. as well as video-endoscopic retroperitoneal and open surgery.nlm. 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.fcgi?cmd=Retrieve&db=PubMed&list_uids=8249225&dopt= Abstract&itool=iconabstr Oosterlinck W.ncbi.ncbi. Schmiedt E.nih.ncbi.nlm. Lange PH. For small stones (up to a maximum diameter of 20 mm or a surface area of 300 mm2).nlm.51:147-151. 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.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. http://www. Although larger stones can also be treated successfully with ESWL. there is an ongoing debate as to whether large renal stones are best treated with ESWL or with PNL. Kersting H. It needs to be emphasized. but such a routine is indicated also because of the inherent tendency to new stone formation that characterizes patients with stone disease. Chem MT.fcgi?cmd=Retrieve&db=PubMed&list_uids=6726897&dopt= Abstract Lee YH. Although residual fragments can develop into new stones. Chemodissolution of urinary uric acid stones by alkali therapy. However. Chaussy C. associated with the most pronounced risk of recurrences can be eliminated with percutaneous chemolysis. PNL. Local chemolysis of obstructive uric acid stones with 0.nih. Urol Int 1993. Schüller J. 20.02% chlorhexidine.ncbi.17. A follow-up programme for patients with residual fragments appears necessary. http://www. ESWL has been established as the standard procedure because it is non-invasive. J Urol 1984. flexible URS. Combination of chemolysis and shock wave lithotripsy in the treatment of cystine renal calculi. The available options are All these methods are applicable. Rationale for local toxicity of calcium has a low rate of complications and there is no need for regional or general anaesthesia. several reports have shown that risk to be reasonably low. Huang JK. The drawbacks of ESWL are a frequent need for repeated treatments and the relatively common occurrence of residual fragments. Urol Res 1992. but for any given stone situation. http://www. Verbeeck R. Urology 1979. For uric acid stones. 21. Chang LS. Miller RP.fcgi?cmd=Retrieve&db=PubMed&list_uids=1736482&dopt= Abstract 7. it is important to note that unless percutaneous surgery is carried out with a meticulous Abstract Schmeller NT.8:422-423. percutaneous stone removal might be preferable for faster debulking of the stone.131:1039-1044. Dissolution of cystine calculi by irrigation with acetylcysteine through percutaneous nephrostomy.fcgi?cmd=Retrieve&db=PubMed&list_uids=6699980&dopt= Abstract Sharma SK. residual fragments of stone may be left behind in these patients. oral chemolysis is the first choice of treatment for stone disintegration.1 M THAM and 0. Dissolution of uric acid calculi. Urol Int 1992. though it is advantageous in some types of reconstructive surgery. For large renal stones. Such a step might also be used as an auxiliary procedure in the treatment of cystine stones. http://www. Williams JJ. Smith AD. Vergauwe D.nlm. Video-endoscopic retroperitoneal surgery has no place as standard procedure for removal of stones from the kidney. that complete clearance of stones from the caliceal system by a percutaneous technique requires considerable expertize and experience. However.nih. 22.20:19-21.nlm. UPDATE JUNE 2005 37 . Cuvelier C.

. PNL + ESWL 2a B 3. 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. Oral chemolysis 2a B 2. 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. 8. also including piezolithotripsy. * Numbers (1. The first alternative always has the number 1. PNL 2a B 2. PNL = percutaneous nephrolithotomy. also including piezolithotripsy. assumed that ureteral stones generally require higher shock wave energy and a greater number of shock waves.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. GR = grade of recommendation. 3. PNL 1b B 2. Uric acid/urate stones 1.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. Open or video-endoscopic retroperitoneal surgery LE = level of evidence. 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. by stenting or urethral catheters). Open or video-endoscopic retroperitoneal surgery LE= level of evidence.g. When two procedures were considered equally useful they have been given the same number. degree of impaction and extent to which repeated shock waves sessions are 38 UPDATE JUNE 2005 . Stent + ESWL + oral chemolysis 2a B Cystine stones 1. Uric acid/urate stones 1. Stent + ESWL + oral chemolysis 2a B Cystine stones 1. The first alternative always has the number 1. PNL 2a B 3. It has been shown clearly that. PNL + flexible nephroscopy 2a B 4. 3) have been allocated to the procedures according to the consensus reached. 2. Oral chemolysis 2a B 2. PNL = percutaneous nephrolithotomy. GR = grade of recommendation. ESWL = extracorporeal shock wave lithotripsy. 2. in most cases. 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. however. this technique has been extensively used and a considerable experience has demonstrated that ESWL is very useful for stone removal from the ureter. ESWL 2a B 2. 8. The literature comprises numerous reports with a variable success rate. 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. Improved results in complicated cases can be achieved by combining ESWL with low-invasive auxiliary procedures (e. ESWL = extracorporeal shock wave lithotripsy. ESWL with or without stenting 2a B 3. This lack of consistency is obviously related to the type of lithotripter. It is. ESWL 1b A 2. * Numbers (1. size and composition of the stone.

Nakada SY. are summarized in Table 17.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446792 2. Dunn M. A 10-year experience of managing ureteric calculi: changing trends towards endourological intervention . Mearini Vögeli T.4 8.1 Re-ESWL % 10.896 Stone free % (range) 77. J Urol 2001. Paryani J. the vast majority of ureteral stones are successfully treated in situ without auxiliary procedures and using only analgesics and sedation.nih.nlm. Vespasiani G. In a report comprising 18.ncbi. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11547053 Virgili C.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10360494 Pearle Mutz J.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10569535 Pardalidis NP.nlm. J Endourol 1999. Kapotis CG. http://www. Figenshau S. The re-treatment rate in these patients was 12%. Shalhav Endoscopy vs. Sundaram C. Micali S.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10597122 Ather MH. Chen C. Stone treatment can also be completed following retrograde manipulation of the stone to the kidney (‘push and bang’ procedure).000 patients with ureteral stones a stone-free state was achieved in 81% (1-40).13:161-164.nih. Stones at different levels of the ureter present with different degrees of difficulty. http://www. 6. of patients 8.3 11. there a role for open surgery? BJU Int 2001.0 4. extracorporeal shock wave lithotripsy in the treatment of distal ureteral stones: ten years’ experience. Table 17: Literature results of ESWL-treated ureteral stones Level of stone in the ureter Proximal (30 reports) Mid (24 reports) Distal (38 reports) No. Auxiliary procedures were used in 17% and regional or general anaesthesia in 26%.88:173-177. Miano R. Ackermann R. Clayman RV.3 4. as presented in a number of reports.nlm. J Endourol 1999. Out of approximately 20. J Urol 1999. 84% became stone free. by passing the stone with the catheter or by placing a catheter below the stone. Sulaiman MN.162:1909-1912. UPDATE JUNE 2005 39 .1 1. Bartsch G. 4.acceptable. Janetschek G. Primary treatment of ureteral stones by new multiline lithotripter.166:1255-1260. http://www. Extracorporeal piezoelectric shockwave lithotripsy of ureteral stones: are second-generation lithotripters obsolete? J Endourol 1999.4 (63-100) 80.ncbi. Bercowsky E. Wolf JS.ncbi. Another important and probably neglected factor is the experience and ambition of the operator.3 12. Memon A. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral Grimm MC. REFERENCES Peschel R. The results of ESWLtreatment of stones in the proximal-. McDoughall EM. Nadler R. 5.ncbi.1.3 (60-98) 77.2 9. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study.13:543-547. http://www.13:339-342.0 8.9 (59-100) Auxiliary procedures % 13. Hoenig DM.nlm. and distal ureter.nih.825 429 6. 3. The re-treatment rate in the latter series of patients was 11% (41).fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11488723 Bendhack ML.825 patients treated with ESWL for ureteral stones in the United Anaesthesia % 11. Porena M. Kosmaoglou EV. mid-. Stones in the ureters can be treated in situ with or without a catheter or stent.

Perrig M.nlm. Two-year experience with ureteral stones: Extracorporeal shockwave lithotripsy v ureteroscopic Wong MYC.nih. http://www. Park M. Karaoglan Ü.169:878-880. http://www.84:770-774. Coury T. Experience with extracorporeal shock wave lithotripsy in children.ncbi. BJU Int 1999.039 urinary calculi with the Storz Modulith SL 20 lithotripter at the Singapore General Hospital. Thomas Ramsden PDR. San Francisco I.nlm. Extracorporeal shock wave lithotripsy in children: experience with the multifunctional lithotripter MFL 5000.ncbi.nlm. Bozkirli I.nlm.ncbi. 18. Extracorporeal shock wave lithotripsy for distal ureteral calculi: what a powerful machine can achieve. Comparison of first-generation (Dornier HM3) and second-generation (Medstone STS) lithotripters: treatment results with 145 renal and ureteral calculi in children.136:238240.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9895251 Cass AS. J Endourol 2000. 9.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10213099 Turk TMT. Lyng Scand J Urol 2002.ncbi. Treatment of lower ureteral stones: extracorporeal shockwave lithotripsy or intracorporeal lithotripsy? J Endourol 1999.nih. Ather MH. 10:493-499.nlm. Park T.36:363-367. J Endourol 1998. Kohle R.nih.14:181-183. Murthy LSN. J Urol 1999. 14. Sinik the first 150 ureteral http://www. Mobley TB.ncbi. Memon A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the treatment of distal ureteral calculi. http://www. J Urol 2003. Isen K. Smith G. Jenkins JM.ncbi.ncbi. Kunit G. http://www. Jenkins AD. Mosbaugh PG. J Endourol 2000.nlm. Moussa SA.ncbi. J Urol Hinrichs A. http://www.16:645-648. Küpeli B.ncbi. http://www.14:239-246.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7815618 Lin CM. Yip SK.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12490016 Gnanapragasam VJ.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8972780 Newman DM.161:45-47. The Dornier Compact Delta lithotripter. 16. http://www. Grine WB.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3723671 Frick J.7. 13. Paediatric low energy lithotripsy with the Lithostar. Zhonghua 1992. 19. J Endourol 1996. Studer UE. Lingeman JE.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12576804 Coz 10. Jordan WR.nih.nlm.nlm. 8.nlm. http://www. Orvieto Foo KT. http://www.nih.12:501-504. Extracorporeal shock wave lithotripsy experience in children. Steele RE. Tolley DA. J Urol 12. Stein C. Knapp PM. Therapeutic efficacy of Dornier MPL 9000 for prevesical calculi as judged by efficiency quotient.153:453.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10037364 Park H.ncbi. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12487741 Lalak NJ. Primary in situ extracorporeal shock wave lithotripsy in the management of ureteric calculi: results with a third-generation Cheng C.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3383928 Myers DA. 15.14:551-553. http://www.nih. J Urol 1996. Extracorporeal shockwave lithotripsy of 2000 urinary calculi with the Modulith SL-20: Success and failure according to size and location of stones.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11030534 Tan YM. Eur Urol 1988. http://www.13:77-81.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10795612 Biri H.ncbi.nih. Bustos M.nlm. Clinical experience and results of ESWL treatment for 3.ncbi. 17.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1296446 40 UPDATE JUNE 2005 10532969 Hochreiter WW.33:357-362. http://www. Chong TW. Danuser H. Mertz JH.nih.

http://www. Sanchez C.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516445 Lam JS. De La Rosette JJ. 26. Treatment of proximal ureteral calculi: Holmium: YAG laser ureterolithotripsy versus extracorporeal shock wave http://www.nih. Gabilonda F.nih. Andreoni C. Rao PN. Isen K.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11956420 Küpeli B. 32.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10149148 Strohmaier J Lithotr Stone Dis 1991. Newman DM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9831788 Bierkens AF. Br J Urol 1998. http://www. 22.167:1972-1976. Management of upper ureteral calculi with extracorporeal shock wave lithotripsy.864 renal and ureteral 28. Alkibay T.36:376-379.84:264-269.nih. Extracorporeal shock wave lithotripsy in situ treatment for ureteral stones. Kasep 588-592.nih. Schubert G. http://www. Claro JF. ureteroscopy.ncbi.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2733105 D’Hallewin. Biri H.ncbi. 25. http://www. Rao PN.nlm. Gupta M. http://www. J Urol 2003.ncbi. Woods Extracorporeal shock wave lithotripsy for distal ureteral stones. Beerlage HP. BJU Int 1999.nih. Comparison of first generation (Dornier HM3) and second generation (Medstone STS) lithotripter: treatment results with 13.ncbi. Clayman RV. 33. Steele RE. A comparative analysis of nephrostomy. http://www. 34. http://www. Mendoza A. Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: A prospective study.and lower-ureteric calculi: extracorporeal shock wave lithotripsy vs.149:1425-1426. Hendrikx AJ. Abstract 239.ncbi. 29. http://www. 27.ncbi.142:37-39.21. Rosenkranz. Stultiens GN.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3656518 Cass AS. J Urol 1990.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2374188 Holden D.nlm. Mosbaugh PG. Debruyne http://www. 34:474-479. Shirrell WL. Yan Y. 31.nlm. http://www.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9467473 Joshi HB.ncbi. Rodrigues Netto Jr N. Baert L. J Urol A comparison of Herrman E.nih.ncbi. Onaran M. Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives.nlm. J Urol 2002. Greene TD.ncbi.nih. 30. Extracorporeal shock wave lithotripsy for ureteral calculi. Weigl A. Matched pair analysis of shock wave lithotripsy effectiveness for comparison of lithotripters. Eur Urol 1999. 24.169:58-62.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7861488 Cass AS. Karaogan Ü.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1593673 Erturk E. Moore R. Obadeyi OO.nlm. morbidity and effectiveness. Arends AJ.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501780 Feria G. JJ stent and urgent in situ extracorporeal shock wave lithotripsy for obstructing ureteric stones.nlm. In situ extracorporeal shock wave lithotripsy for ureteral calculi. Lingeman JE. J Urol 1990.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12478102 UPDATE JUNE 2005 41 .3:45-47. http://www. J Urol J Urol 1989. J Urol Treatment of mid. Cockett ATK. Ureteral stones: the results of primary in situ extracorporeal shock wave http://www.nih. J Urol 1987. Pattaras JG.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10468719 Portis AJ. Bozkirli I. Lemos GC.nih.nlm. In situ treatment of ureteral calculi with extracorporeal shock-wave lithotripsy using electromagnetic Eur Urol 1998.

Jenkins JM. J Urol 2000. Eur Urol 1998. as well as to fill the collecting system with contrast medium for detecting radiolucent Jenkins JM.7.2 Retrograde manipulation of stones The push-back technique has been applied in order to avoid problems with insufficient disintegration of ureteral stones.2.nlm.149:1427-1430. Grine WB. Soble JJ. Myers DA.nih. 8.nih. Low success rate of repeat shock wave lithotripsy for ureteral stones after failed initial treatment.9. 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. Shock wave treatment of ureteric stones in situ with second generation lithotriptor.nlm. Myers DA. Although slightly better results have been reported with this procedure.nlm.nih. Salvatore FT. Grine WB. Mattei A.nih. experience with 165 patients.ncbi. Pearle MS. J Urol 1994. J Urol 1993.nlm.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12131285 Mobley TB.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8201687&query_hl=19 8.fcgi?cmd=Retrieve&db=PubMed&list_uids=7495114&dopt= Abstract Simon J. 8.nih.152:66-67. http://www. Clayman RV.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. Burkhard FC.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2351188&query_hl=6 Mobley TB. Studer 9693242 Jermini FR.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501779 Thomas R. Jenkins JM. 39. Another reason for stenting might be to aid in the location of small and less radio-opaque stones.nih. Taroq N.825 calculi using the Lithostar lithotriptor. http://www.nih.164:1905-1907. Vandenberg T.2. Jordan 36.ncbi. stentless ventral technique.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11061877 Ghobish Macaluso JN. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18.46:649-652. Gardner SM.nlm. http://www. 40. the retreatment rate was usually not significantly lower (3. Soble JJ.46:649-652. It needs to be emphasized.149:1419-1424. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501781 Mobley TB. 3.ncbi. Nakada SY. J Urol 1994. 42 UPDATE JUNE 2005 .gov/entrez/query. Grine WB. but it is difficult to find definite evidence for this assumption in the literature.35.nlm.2 1. Jordan WR. 37. McClennan BL.ncbi. It might. Clayman RV. however. Gardner SM.fcgi?cmd=Retrieve&db=PubMed&list_uids=8201687&dopt= Abstract 2. Eur Urol 1990. Vanden Bosshe M. REFERENCES Nakada SY.11).ncbi.ncbi. Weir MJ.ncbi. Danuser H. Pearle http://www. http://www. McClennan BL.962 renal and ureteral calculi. retrograde manipulation resulted in stone-free rates of 73-100% (5. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18.fcgi?cmd=Retrieve&db=PubMed&list_uids=7495114&dopt= Abstract Pace KT. http://www. 41. Extracorporeal shock wave lithotripsy of middle ureteral stones: are ureteral stents necessary? Urology 1995. Jordan WR.825 calculi using the Lithostar lithotripter.168:446-449. An innovative approach to management of lower third ureteral calculi. be of some help to use a ureteral catheter when treating large and impacted ureteral stones.ncbi. In situ extracorporeal shock wave lithotripsy of middle and lower ureteral stones: A boosted.nih. J Urol 1993. 38. Non-invasive anaesthesia.152:53-56. Myers DA. When compared with stone-free rates of 62-97% following in situ treatment (1-10). Low energy lithotripsy with the Lithostar: treatment results with Schulmann CC. J Urol 2002. Extracorporeal shock wave lithotripsy of middle ureteral stones: are ureteral stents necessary? Urology 1995.nlm.8-14). analgesia and radiation-free extracorporeal shock wave lithotripsy for stones in the most distal ureter. http://www.ncbi. Honey RJ.

Hasun R. Under general spinal anaesthesia or intravenous sedation. Tuerk Höbarth K.nih.ncbi. 8. 9. Extracorporeal shock wave lithotripsy of ureteric stones with the Modulith SL 20.ncbi.nlm. New ureteroscopes (semi-rigid and flexible) and lithotripsy devices have recently become available. Treatment of ureteral stones by extracorporeal shock wave lithotripsy: with ureteral catheter or in situ? J Endourol 1994.fcgi?cmd=Retrieve&db=PubMed&list_uids=8490668&dopt= Abstract Cass AS.nlm. Manning M.fcgi?cmd=Retrieve&db=PubMed&list_uids=8252017&dopt= Abstract Hendriks AJM. Inaba Y. Antibiotic prophylaxis should be administered before the procedure to ensure sterile urine. Br J Urol 1992.fcgi?cmd=Retrieve&db=PubMed&list_uids=1486384&dopt= Abstract Danuser H. 13. Are obstructing ureteral stones more difficult to treat with extracorporeal electromagnetic shock wave lithotripsy? J Endourol 1993. http://www.nlm.72:683-687. the patient is placed in the lithotomy position. Intramural ureteral dilatation is not indicated Ackermann DK.nlm.ncbi.nlm. URS is extensively used in many urological centres all over the world.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=3656518&dopt= Abstract Watson RB. 8.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281394&dopt= Abstract&itool=iconabstr Cass AS.fcgi?cmd=Retrieve&db=PubMed&list_uids=8116112&dopt= Abstract Harada M.43:178-181. Debruyne FMJ.ncbi.nih. Do upper ureteral stones need to be manipulated (pushed back) into the kidneys before extracorporeal shock wave lithotripsy? J Urol 1992.ncbi. However.nlm. Treatment of proximal and midureteral calculi: a randomized trial of in situ and push back extracorporeal lithotripsy. http://www.ncbi. Kirkali Z. Mosbaugh PG. http://www.1 Standard endoscopic technique The basic endoscopic technique has been well standardized for many years ( Abstract Hofbauer J. Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. 14.4:353359.8:9-11.nih.2).nlm. Bierkens AF. Alken P.150:824826.ncbi. Woods JR. URS has dramatically changed the management of ureteral calculi. 10.fcgi?cmd=Retrieve&db=PubMed&list_uids=1732591&dopt= Abstract Lingeman JE.nih.11:54-58. James AN.146:8-12. and the treatment of choice for ureteral stones with diameters of 1 mm or larger is still controversial.nlm. J Urol 5. Newman D.147:349-251. Oosterhof GON.3. A pre-operative plain film of the urinary tract is obtained to confirm the location of the stone. http://www. Okamoto M. Steele RE. Esen A. Zingg E. Urology 1993. http://www. Köhrmann KU. and secured to the drapes. Joyce AD. Marberger M. http://www. J Urol 1991. Rassweiler J.nih. The operating room must have fluoroscopic equipment. J Urol 1987. Shirrell Extracorporeal shock wave lithotripsy in situ or after push up for upper ureteral calculi: a prospective randomized trial. http://www. Henkel TO. Nonstent or noncatheter extracorporeal shock-wave lithotripsy for ureteral stones. ESWL in situ or ureteroscopy for ureteric stones? World J Urol 1993. Marth DC. 6.ncbi.ncbi. Extracorporeal shock wave lithotripsy for ureteric calculi with the Dornier MFL 5000 lithotriptor at a multi-user http://www. it is an invasive technique compared to ESWL.7:277-279.4. Br J Urol 1993. The procedure starts with rigid or flexible cystoscopy.3 Ureteroscopy for removal of ureteral stones During the past two decades. Celebi I. A guide wire is introduced under endoscopic and fluoroscopic control.fcgi?cmd=Retrieve&db=PubMed&list_uids=8345592&dopt= Abstract Tiselius HG. J Endourol 1990.70:594-599. but UPDATE JUNE 2005 43 . 7. Güler C. Anaesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones.ncbi. Studer UE. 12.fcgi?cmd=Retrieve&db=PubMed&list_uids=7514472&dopt= Abstract 8.

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. Retrograde access to the upper urinary tract is usually obtained under video-guidance with a rigid ureteroscope (9. The operating time is generally between 10 and 60 minutes.20).4).2 Disintegration devices Laser lithotripsy is a reliable method for the treatment of ureteral stones. The use of flexible ureteroscopes (7-7. Its cost-effectiveness is three times that of laser lithotripsy (9.depends on the size of the ureteroscope and width of the ureter.5 F) allows easier progression of the ureteroscope up to the proximal ureter. The recently developed (semi-)flexible ureterorenoscopes (Storz) with enhanced maximal deflection provide particular advantages for ureteroscopic surgery (36-39). laser lithotripsy will require a longer operating time than the electrohydraulic technique (5) but because of the greater risk of tissue damage. electrohydraulic lithotripsy.4 F probe in a semi-rigid ureteroscope provide excellent fragmentation rates (90-96%).0-7. Miniaturization avoids dilatation of the intramural ureter (with associated complications) in more than 50% of cases (8-10). Ballistic lithotriptors (pneumatic or electropneumatic) using a 2. 8. If the stone is impacted.3). It is the only applicable method when performing flexible URS (12. as minimal deflection is required to access the stone.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. It is dependent on the injury to the ureteral mucosa due to the stone or the ureteroscope. but provides a sufficiently efficient alternative for most stone compositions. The small diameter (6.17. electrohydraulic devices should not be used as a standard procedure.11-15). is not recommended (1. Patients should be followed up by plain abdominal film. Nevertheless.19).14.22-24).6. but may be substantially longer for flexible URS. The stent will usually remain in place for about 1 week. The stone may be fragmented by ultrasonic lithotripsy. because of its tendency to fall back into the bladder. Flushing of large fragments or the stone itself up to the renal pelvis or calices or perforation of the ureteral wall may occur. 8. If manipulated with care.0 J and 5-10 Hz.035-inch safety guide wire with a floppy tip or in a 10-13 F sheath.1 Ureteroscopes Semi-rigid and thin ureteroscopes are available.0-8. Ho:YAG lithotripsy seems to give better stone-free results at 3 months than electrohydraulic lithotripsy (97% versus 87%) for distal ureteral stones (5). An operating time for laser lithotripsy of between 7 minutes and 45 minutes is acceptable (18).5-11 F). the laser does not damage the ureteral mucosa (16. without dilating the intramural ureter in over 75% of cases. 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.3.3 Assessment of different devices 8.5).3.5 F). a flexible ureteroscope. However.18).3. 44 UPDATE JUNE 2005 . This technique is particularly useful for removal of distal ureteral stones in women (2. Laser lithotripsy using pulsed dye laser has shown similar results to those obtained using the Ho:YAG laser (21). for ureteral calculi < 15 mm in diameter. regardless of the hardness of the stone (16). 8. A 365 µm holmium:yttrium aluminium garnet (Ho:YAG) laser fibre is the best choice for ureteral stones. Stent placement at the end of the procedure is optional and a matter of debate (2).3. The ideal energy and frequency settings are less than 1. In the lower ureter. the best approach is to insert a ureteral stent for several days prior to the URS (2).7). This device offers an excellent cost-performance ratio (40). Small stones and fragments < 5 mm in diameter are best retrieved with a basket or a grasper (3. migration of stones towards the renal pelvis from the mid. Endoscopic lithotripsy is based on the use of different devices in order to break the stone into dust or fragments with diameters < 2 mm. Irrigation facilitated with a piston syringe or a flow control unit is needed to ensure good direct vision. The safety guide wire prevents the risk of false passage in case of perforation.18. Dilatation of the intramural ureter and use of a laser usually requires the insertion of a single/double pigtail stent under fluoroscopic guidance.3.or proximal ureter might be a limiting factor of ballistic lithotripsy (25). They are suitable for access to the upper part of the ureter and renal collecting system. A flexible ureteroscope is inserted either alongside a second 0. a semi-rigid ureteroscope (6.2. ultrasonography or intravenous urography after 2-12 weeks (2. A low capital cost and simple and safe handling are major advantages of this type of device.3.5 F) has been evaluated (1. laser lithotripsy or ballistic (or pneumatic) lithotripsy.

3.4 Dilatation and stenting Over recent years it has been attempted to modify the standard technique of dilatation and stenting. Ureteral perforation at the site of the stone is the primary risk factor for stricture.11). Reduced need for dilatation (0-40%). respectively.4). particularly when the ureter has to be re-entered several times.3 Baskets Ureteroscopic removal of small ureteral stones with a basket is a relatively quick procedure with a lower morbidity rate than lithotripsy (3.33).3. for example. The major acute complication remains ureteral avulsion (9. Small ureteral stones or fragments can be removed fast and safely with forceps which can be better controlled than a basket. Several new designs of endoscopic stone retrieval baskets are available. Most procedures can. Thus. An access sheath of a suitable dimension can be introduced over a guide wire. There is a strong relationship between the complication rate and the equipment used and/or the expertize of the urologist (31.30). Most perforations seen during the procedure are successfully treated with approximately 2 weeks of stenting (8). 8. Randomized and prospective studies are needed in order to compare all forms of stone removal from the ureter.3.5 Clinical results The Ureteral Clinical Guidelines Panel of the American Urological Association have conducted a meta-analysis of relevant studies between 1966 and 1996. even with a parallel decrease in operating time and complication rate.3. The overall complication rates reported in recent literature are 5-9%. The tipless nitinol basket is non-traumatic and allows excellent control inside calices.3. UPDATE JUNE 2005 45 . especially in the proximal ureter (5). respectively (27). New requirements for endoscopic sterilization could dramatically increase the cost of the procedures. Laser or electrohydraulic lithotripsy may break the wires of the basket (16). in obese patients or in those with less visible stones (9. Ureteral strictures were the only long-term complication reported. with the estimated rate being 1%. particularly when the stone diameter < 10 mm.3. which was published in the Journal of Urology (27). the overall stone-free rates were 72% and 90%. however. operating time and post-operative ureteral stenting have resulted from the use of thin ureteroscopes Routine stent placement following uncomplicated URS may be unnecessary.29. respectively. 23). 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. Members produced a report for guidelines in August 1997.3. 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).29). be carried out without an access sheath (42). The cost-effectiveness of ureteroscopic treatment has not been assessed.3.6 Complications Significant acute complication rates of 11% and 9% have been reported for the proximal and distal ureters.28.26). 8.32).12. A total of 95% of patients were successfully treated with only one endoscopic procedure. 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. 8. The best results were reported with Ho:YAG laser lithotripsy.13.3. This latter technique might be a good alternative to ESWL. the stone-free rates were 56% and 89% for proximal and distal stones. 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. Autologous transplantation or uretero-ileoplasty are the methods of choice in cases of avulsion (33).3.8. The basket technique should be attempted first for small distal ureteral calculi. This last result is considerably better than the results reviewed before 1997 (25. Similar results were observed in children and in obese patients (11. Patient discomfort is modest and satisfactorily controlled by oral analgesics (21. 8. Analysis of the literature for the past 3 years indicates an improvement in stone-free rates. The nitinol tipless basket is more effective than a flat-wire basket because of its greater flexibility (4.32-35).7 Conclusion Improvements in the design of ureteroscopes. An access sheath may faciltate URS.20. For ureteral stones with a diameter < 10 mm. both ESWL and URS can be considered acceptable treatment alternatives for stones in these positions. When the material was stratified into results for proximal and distal ureteral stones.8-10. with a 1% rate of significant complications (3.

gov/entrez/query.nih.53:25-23.156:899-902. Tech Urol 1998. J Endourol 1998. Ureteroscopy with intravenous sedation for treatment of distal ureteral calculi: a safe and effective alternative to shock wave lithotripsy.fcgi?cmd=Retrieve&db=PubMed&list_uids=8976208&dopt= Abstract Netto NR Jr. Belis JA.nlm. http://www.ncbi.5F flexible ureteroscopes. Ureteroscopy: current practice and long-term complications. http://www.13:35-40. Elbahnasy AM. Rogenes VJ. Blute ML. Flexible ureteroscopy: Washington University experience with the 9.nih. J Endourol 1998. Bagley DH. Nakada SY.fcgi?cmd=Retrieve&db=PubMed&list_uids=9531148&dopt= Abstract Tawfiek ER. Bard RJ. de Almeida Claro J.nlm. Esteves SC.3F and 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=9895257&dopt= Abstract Gould J Urol 1997. Holmium laser lithotripsy for ureteral calculi: an outpatient Eur Urol 1999.157:28-32. J Urol 1998.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9886583&dopt= Abstract Honey RJ. Patterson DE. J Endourol 1999. Andrade EFM.fcgi?cmd=Retrieve&db=PubMed&list_uids=8836781&dopt= Abstract Ferraro RF.nih. Bozzo W.nih.3. Ureteroscopic stone removal in the distal J Urol 1997. 10. 3. http://www.nih.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8709358&dopt= Abstract Yalcinkaya F.nlm. Abraham VE. 5.ncbi. 8. Retrograde ureteropyeloscopic treatment of 2 cm or greater upper urinary tract and minor staghorn calculi.nlm.nlm. Ozmen E. http://www.nih. Ricciotti G. Conlin M.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9146584&dopt= Abstract Teichman JM. Rao Clayman Unal S. Cohen TD.157:2074-2080.fcgi?cmd=Retrieve&db=PubMed&list_uids=10364655&dopt =Abstract Yip KH.ncbi.12:241-246. Why change? J Urol 4.nlm. Ureteroscopic management of ureteral calculi: electrohydraulic versus holmium:YAG lithotripsy.nlm. Management of upper urinary tract calculi with ureteroscopic techniques.158:1358-1361. 11. 13. A review of 378 cases. Harris JM.4 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=9302119&dopt= Abstract Hosking DH. J Endourol 1998. Introini C.fcgi?cmd=Retrieve&db=PubMed&list_uids=9658294&dopt= Abstract Nguyen TA. J Urol http://www.ncbi.nlm. Tam Retrograde flexible ureterorenoscopic holmium-YAG laser lithotripsy: the new gold standard.8. Bagley D.36:48-52.fcgi?cmd=Retrieve&db=PubMed&list_uids=10102126&dopt =Abstract Puppo P. http://www.nih.nih. Primary endoscopic treatment of ureteric calculi. http://www.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9146583&dopt= Abstract Harmon WJ. 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=9568772&dopt= Abstract 2.nlm.4:22-24. Lee CW.ncbi.157:2081-2083. Is general anaesthesia necessary for URS in women? Int Urol Nephrol 1996.28:153-156.ncbi. http://www.ncbi. 46 UPDATE JUNE 2005 .nih. 9. http://www.nih.nih. 14. Segura JW. Endoscopic management of urolithiasis in the morbidly obese patient.nih. http://www. J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=9679874&dopt= Abstract Elashry OM. Sershon PD. Rao GS.nlm.nlm.12:529-523. Topaloglu H. http://www. http://www. A new generation of semirigid fiberoptic ureteroscopes.ncbi. 6. REFERENCES Grasso M. Preminger GM.160:346-351. Assessment of a new tipless nitinol stone basket and comparison with an existing flat-wire basket.ncbi. Urology 1999.

fcgi?cmd=Retrieve&db=PubMed&list_uids=9334635&dopt= Abstract UPDATE JUNE 2005 47 .gov/entrez/query. http://www. Preminger GM. http://www.nih. Pneumatic lithotripsy applied through deflected working channel of miniureteroscope: results in 143 patients. J Urol 1997. Lingeman JE. laser ureteroscopy. Ureteral stones clinical guidelines panel summary report on the management of ureteral calculi. Zhong P. Mugiya S. J Endourol 1998.nlm. http://www. Assimos DG. Holmium:YAG laser and its use in the treatment of urolithiasis: our first 160 cases.fcgi?cmd=Retrieve&db=PubMed&list_uids=8837001&dopt= Abstract Razvi HA.fcgi?cmd=Retrieve&db=PubMed&list_uids=10072626&dopt =Abstract Kuo RL. morbidity and effectiveness.161:48-50. Lasers Surg Med 1996. J Endourol 1998.nlm.nih. Bagley 21.nih.nlm.nlm. De Lisa A.fcgi?cmd=Retrieve&db=PubMed&list_uids=9895256&dopt= Abstract Gould DL. J Endourol 1999. Hendrikx AJM. Macluso JN Jr. Liu PL.and lower ureteric calculi: extracorporeal shock-wave lithotripsy vs. 16. Abstract El Gabry EA. 24. Fujita K. 25.fcgi?cmd=Retrieve&db=PubMed&list_uids=9531146&dopt= Abstract Bierkens AF.13:305-307. http://www.ncbi. Heicappell R.ncbi. Alvarez JL.19:103-106. Suzuki K. Ureteroscopic lithoclast lithotripsy: a cost-effective J Endourol 1998. Un-No T.158:1915-1921.nlm.nlm.nih. Consigliere D.nih. Retrieval capabilities of different stone basket designs in vitro.ncbi.nlm.ncbi. Klan R. Beerlage HP. Holmium:YAG laser ureterolithotripsy.nlm. Intracorporeal lithotripsy with the holmium:YAG laser.15.nlm. http://www. Sales JL.ncbi.] Arch Esp Urol 1996.12:341-344.fcgi?cmd=Retrieve&db=PubMed&list_uids=9886589&dopt= Abstract Yiu MK. Torrent Quer N. Smith WF. Chan AYT.fcgi?cmd=Retrieve&db=PubMed&list_uids=8709362&dopt= Abstract Scarpa RM.nih.53:60-64. Eur Urol 1999. Aslan Abstract Montserrat Orri V. Arends AJ. Tan SM.nih. J Urol 27.ncbi. Chun SS. McColm SE. Urology 1999. http://www.ncbi. Impact of holmium laser settings and fiber diameter on stone fragmentation and endoscope deflection.ncbi. Usai E.fcgi?cmd=Retrieve&db=PubMed&list_uids=10405911&dopt =Abstract Tan PK. 20.ncbi. Stultiens GN.ncbi.nlm. Dretler SP. Yiu TF.fcgi?cmd=Retrieve&db=PubMed&list_uids=9895254&dopt= Abstract Hosking DH. Porru D. Debruyne FM.nih.nih. Br J Urol 1998. http://www. http://www. Denstedt JD. [Spanish] http://www. Is stenting following ureteroscopy for removal of distal ureteral calculi necessary? J Urol 1999. Ordis Dalmau M.fcgi?cmd=Retrieve&db=PubMed&list_uids=10037365&dopt =Abstract Segura De La Rosette Valiente Amarilla CR. Ohhira T.81:31-35. 19.12:523-527. http://www. http://www. Clinical experience with holmium:YAG laser lithotripsy of ureteral calculi. 17.nih.156:912-914. Preminger GM.nih. 18.ncbi. http://www. A comparison of costs. Takayama T. Treatment of mid. Miller K.35: 233-238.fcgi?cmd=Retrieve&db=PubMed&list_uids=9726400&dopt= Abstract Knispel HH.nlm. 22. Endoscopic management of upper urinary tract disease using a 200-microm holmium laser fiber: initial experience in Japan. Kahn RI.12:513-515.49:751-754.12:23-26.nih. J Endourol 1998. 23.nlm. [Treatment of ureteral lithiasis with lithoclast: analysis of our experience.nlm.

33. Feitosa Tajra LC. 2004. [Ureteroscopy for ureteral calculi. Dubosq 41. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9410318&dopt= Abstract Martin X. Prog Urol Smith AD. Marcovich R.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12803991 Vanlangendonck R. Preminger GM. Micali S. 32.] Prog Urol 1997.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15040403 48 UPDATE JUNE 2005 .ncbi. Abram F. http://www. Nakada SY. 379 cases.ncbi. 31.nih. Impact on active scope deflection and irrigation flow of all endoscopic working tools during flexible ureteroscopy.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15351558 User HM. Slovick RW.fcgi?cmd=Retrieve&db=PubMed&list_uids=9428436&dopt= Abstract Du Fosse W. Medhat M. Munoz del Rio A.ncbi. Are new-generation flexible ureteroscopes better than their predecessors? BJU Int.ncbi. http://www. Mauffette Thibault P.18:735-738. Perreault http://www.ncbi. Blunt LW.nlm. Mattelaer J.nlm.nlm. 37. Urology 2004. In vitro analysis of stone fragmentation ability of the FREDDY laser. http://www. Acta Urol Belg 1998. Weizer AZ. http://www.nih.nlm.nlm. Jenkins AD.fcgi?cmd=Retrieve&db=PubMed&list_uids=9689667&dopt= Abstract Turk 36. Paquin JM. Hazards of lumbar ureteroscopy: apropos of 4 cases of avulsion of the ureter.nlm. Jacqmin D. Performance and durability of leading flexible ureteroscopes.159:723-726. Ureteroscopic treatment of ureteric 59:177-181.fcgi?cmd=Retrieve&db=PubMed&list_uids=10037364&dopt =Abstract Roberts WW.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14667517 Delveccio 39.nlm. Tlingui M.fcgi?cmd=Retrieve&db=PubMed&list_uids=8924928&dopt= Abstract Delepaul B. Clinical utility of dual active deflection flexible ureteroscope during upper tract ureteropyeloscopy. Osti AH. J Urol 1998. Ureteral access strategies: pro-access sheath.nih. J Urol 1999. Saussine C. 29.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9474134&dopt= Abstract Chiu Ureteral stricture formation after removal of impacted calculi.161:45-47. Frohmüller H. Kavoussi LR. Ureteroscopy versus in situ extracorporeal shockwave lithotripsy in the treatment of calculi of the distal ureter. Hua V. 35. [French] http://www.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9393306&dopt= Abstract Leblanc B. Zong P. 34.64:430-434.nih.nlm. Cadeddu JA. Dawahra M. Auge BK. Faucher R.8:358-362. Bernard F.ncbi. 40. Lang H.80:797-801.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15659893 Pasqui F. http://www. Prem AR. Hofmockel G. Wambi C.71-81. Moore RG.45:58-64. Gonzalez CM.ncbi. http://www.nlm. 30.nih.nlm.ncbi. J Endourol 2004. Eur Urol 2004.ncbi. Paediatric ureteroscopy for ureteric calculi: a 4 year experience. Dubernard JM. Lowry PS. Gattegno Prog Urol 1996. Landman J. Valiquette L.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14678381 Ankem MK. Tchala K. Gelet A.fcgi?cmd=Retrieve&db=PubMed&list_uids=9864877&dopt= Abstract Al Busaidy SS. A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the treatment of distal ureteral calculi. Lee BR. Brizuela RM.nih. J Endourol 2003.ncbi. Konan PG.nih. http://www. Cai Y.nih.28. Billiet I. Nadler RB. Ureteroscopic treatment of ureteral stones: only an auxiliary measure of extracorporeal shockwave lithotripsy or a primary therapeutic option? Urol Int 1997.nlm. http://www. http://www. Traxer O. Urol Clin North Am 2004:31. Ndoye A. Br J Urol 1997. Analysis of 354 URS procedures in a community hospital.

http://www. J Endourol 1998.nlm. Although the access to flexible ureteroscopes and efficient laser devices has made it more attractive to treat stones in the mid.nih. Endoscopy vs extracorporeal shock wave lithotripsy in the treatment of distal ureteral stones: ten years’ experience. Küpeli B. which obviously were inferior to the initial HM3-device. Urol Clin North Am 2004. than the HM3 machine. http://www.nih. Several comparative studies between URS and ESWL can be found in the literature. 5. It can be assumed that the production and marketing of lithotripters. 4. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study. 8.nih. Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation. the advantages of ESWL are non-invasiveness and no need for regional or general anaesthesia. A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the treatment of distal ureteral calculi. The urologist’s Isen K.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10569535 Pearle MS. The size of ureteral stones has also been considered a limiting factor for 11547053 Biri H. Hoenig DM. Sundaram C. http://www. or even more REFERENCES Peschel R.nih. The argument against the routine use of ureteral access sheaths. J Urol Kapotis CG.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15040404 8.nlm.13:161-164. http://www. Mutz J. several groups concluded that ESWL is preferable in view of its lower degree of invasiveness.16:1255-1260. Furthermore. the need for anaesthesia is unchanged.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10360494 Turk TMT. In conclusion. J Urol 2001. have contributed to a less favourable attitude to ESWL from urologists. McDougall Janetschek G. Treatment of lower ureteral stones: extracorporeal shockwave lithotripsy or intracorporeal lithotripsy? J Endourol 1999. Dunn M.ncbi.4 Should ESWL or URS be used for stone removal? This is indeed a controversial issue for which there is a lack of consensus.162:1909-1912. Abrahams HM.ncbi. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10037364 Park H.161:45-47.nih. Even with the addition of auxiliary procedures. but most focus on stones in the distal ureter (1-10).gov/entrez/query. Park T. 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. Chen C. Bozkirli I. On the other hand. Jenkins AD.nih. Shalhav AL. Karaoglan Ü. http://www. Although the need for re-treatment is definitely greater with ESWL than with URS. Sinik Z. 6. ESWL can be considered a low-invasive and gentle procedure.12:501-504.nlm. Stoller ML. Clayman RV. Bartsch G. 3. http://www.42. 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. Park M.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9895251 2. access to adequate equipment and specific circumstances are probably the best determinants of which method will be most appropriate for a particular patient.4. Nadler R. J Endourol 1999.nlm.1 1. Although these studies demonstrate what has been mentioned above. UPDATE JUNE 2005 49 . J Urol 1999. Kosmaoglou EV. Arguments have been presented for and against both these procedures. Nakada SY.ncbi.and distal ureter ureteroscopically. Figenshau S. Wolf JS. URS is considered to be a one-step procedure that in the majority of studies has been carried out under anaesthesia.ncbi.nlm.nlm.13:77-81. However. Bercowsky E. but URS-disintegrated stones also require elimination of residual fragments.ncbi.

fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11956420 Küpeli B. percutaneous chemolytic irrigation can be used to increase the clearance rate of stone fragments. These techniques also have to be applied when there are contraindications for ESWL and URS.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15540749 8.nlm. Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with Holmium-YAG laser lithotripsy for treating large proximal ureteral stones. Eur Urol 1999. Eur Urol Recommendations for active removal of ureteral stones: all sizes In case of failure with minimally invasive techniques. Treatment of proximal ureteral calculi: Holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy. In selected cases with infection stones. Shee JJ. in patients with a stone proximal to a ureteral stricture. 10. 9. Isen K.nih.5).nih. an open surgical procedure might be required to remove the stone.nih. J Urol 2004.36:376-379. the location can be facilitated by means of a ureteral catheter or a double-J stent.172:1899-1902. in our opinion they are considered equally useful for the removal of distal ureteral stones. not those composed of ammonium urate or sodium urate. Although retreatments are necessary in a substantial fraction of ESWL-treated patients. Schubert G.nlm.ncbi.7. For stones with a low radiodensity. Gupta but ESWL usually can be carried out without anaesthesia and has a low morbidity. can be dissolved by oral chemolytic treatment.ncbi. The principles of chemolytic treatment are outlined above (see section 7. Chen CS. Weigl A. There are advantages and disadvantages of both these procedures. Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study. Biri H. 50 UPDATE JUNE 2005 . 8. There is controversy as to whether ESWL or URS is the best method for removal of ureteral stones. e. Lin WY.167:1972-1976. cystine stones and pure calcium phosphate stones.ncbi. http://www. Alkibay T. It is of note that only uric acid stones. Lin CL. Onaran M. particularly for those situated in the lower ureter.. Strohmaier J Urol 2002.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516445 Lam JS.ncbi. Karaogan Ü. Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9831788 Wu CF. http://www. uric acid stones.nlm. Video-endoscopic retroperitoneal surgery is a minimally invasive alternative to open surgery. http://www. Greene TD. Rosenkranz T.nih.nlm. Bozkirli I.

3. URS = ureteroscopy. URS + contact disintegration: . PNL = percutaneous nephrolithotomy with or without lithotripsy. Percutaneous URS in antegrade direction Cystine stones 1. Ureteral catheter or intravenous contrast + ESWL 2. prone positiona 1. 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. Stent + oral chemolysis 2b B 2. Table 19: Principles of active stone removal (all sizes) in the mid ureter* Procedure 1.semi-rigid or flexible URS 4. prone positiona 1. 2. ESWL following retrograde manipulation of B the stone (‘push up’) 3. URS + contact disintegration: . ESWL in situ 1a A 2. 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. When two procedures were considered equally useful they have been given the same number. ESWL following retrograde manipulation of the stone (‘push up’) 3. URS + contact disintegration: .semi-rigid or flexible URS 4. ESWL in situ. or retrograde contrast ) + oral chemolysis 3. also including piezolithotripsy.semi-rigid or flexible URS 2. The first alternative always has the number 1. URS + contact disintegration: . 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 .Table 18: Principles of active stone removal (all sizes) in the proximal ureter* Type of stone Radio-opaque stones Procedure LE GR 1. GR = grade of recommendation. * Numbers (1. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 2. ESWL in situ (with i. URS + contact disintegration: . PNL + URS in antegrade direction LE = level of evidence. ESWL = extracorporeal shock wave lithotripsy. Stent + oral chemolysis 3.semi-rigid or flexible URS 2.v. 4) have been allocated to the procedures according to the consensus reached. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 3. Ureteral catheter or intravenous contrast + ESWL 2. ESWL in situ 2a B 2.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. ESWL in situ.

URS with lithotripsy: 2a B . Percutaneous antegrade URS LE = level of evidence. laser or electrohydraulic disintegration . Type of stone Radio-opaque stones 9. contrast medium) 3 B 1. ESWL = extracorporeal shock wave lithotripsy. 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. * Numbers (1. When two procedures were considered equally useful they have been given the same number. 3) have been allocated to the procedures according to the consensus reached. urine culture is necessary. 3) have been allocated to the procedures according to the consensus reached. URS + contact disintegration: 1b A . Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 3. URS = ureteroscopy. Ureteral catheter (+ contrast medium) + ESWL 3. also including piezolithotripsy.rigid URS + US. 2. URS + contact disintegration 3 B . GR = grade of recommendation. When two procedures were considered equally useful they have been given the same number. 9.1. PN + antegrade contrast + ESWL in situ Cystine stones 1. US = ultrasound. GR = grade of recommendation.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. PN = percutaneous nephrostomy. also including piezolithotripsy. In others. prone positiona 2a B 1. The first alternative always has the number 1. a For lithotripters with the shock wave source below the patient. several days of drainage procedures by a stent or a percutaneous nephrostomy should precede the active intervention for stone removal.rigid URS + US. ESWL = extracorporeal shock wave lithotripsy. Cystine stones Table 20: Principles of active stone removal (all sizes) in the distal ureter* Procedure LE GR 1.semi-rigid or flexible ureteroscopy 2. URS + contact disintegration 3 B 2. ESWL in situ 3 B 1. laser or ballistic/ pneumatic disintegration . ESWL in situ (i. 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. Ureteral catheter + ESWL LE = level of evidence.semi-rigid URS 2. 2.v.semi-rigid URS 2. URS = ureteroscopy. ESWL in situ 1b A 1. * Numbers (1. In cases with clinically significant infection and obstruction. The first alternative always has the number 1. 52 UPDATE JUNE 2005 . Ureteral catheter + ESWL 2. ESWL in situ. Screening with dipsticks might be sufficient in uncomplicated cases.

PNL is the best alternative for efficient removal. Hofbauer J. particularly if they are large. 9. a double-J stent or a ureteral catheter (1-7). Problems and complications in stone disease. 4. J Urol 1992.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1507336 Marberger These patients should be referred to an internist for appropriate therapeutic measures during the stone-removing procedure. Curr Opin Urol 1994.5 Hard stones Stones composed of brushite or calcium oxalate monohydrate are characterized by particular hardness.148:1076-1078.2 Bleeding Bleeding disorders and anticoagulant treatment should be considered.ncbi.77:17-20.3 Pregnancy In pregnant women.4:234238. http://www. In patients with coagulation disorders. 9. http://www. percutaneous nephrolithotomy (PNL) with or without lithotripsy. it is recommended that the patient’s cardiologist is consulted before undertaking ESWL treatment.4 Pacemaker Although the rule is that patients with a pacemaker can be treated with ESWL. UPDATE JUNE 2005 53 . Swartz R.9.ncbi. Carringer M. This may mitigate in favour of percutaneous removal of such stones. 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.6 Radiolucent stones Uric acid concrements can be localized with ultrasound. either with a percutaneous nephrostomy catheter.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6698085 Kroovand RL. PNL and URS are contraindicated.nlm.nih. Stones in pregnancy and in children. 3. not sodium urate or ammonium urate stones. Management of ureteric calculi during pregnancy by ureteroscopy and laser The possibility of chemolytic treatment of brushite stone fragments is noteworthy in view of the high recurrence rate seen with this type of stone.7 1. http://www. PCNL = percutaneous nephrolithotripsy. Eur Urol 1984. the following treatments are contraindicated: extracorporeal shock wave lithotripsy (ESWL). thereby avoiding too much shock wave energy to the renal tissue.4 9. Johansson JE. B Comment 9. ureteroscopy (URS) and open surgery. Urolithiasis in pregnancy. ESWL = extracorporeal shock wave lithotripsy.those responding well to ESWL and those responding poorly (8).nlm. Homsy It is of note that only uric acid stones. URS has been successfully used to remove ureteral stones during pregnancy. In expert hands. 9.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8653305 2. but it must be emphasized that complications of this procedure might be difficult to manage. can be dissolved by oral chemolytic treatment.nih. 9.ncbi. REFERENCES O’Regan S. For large ESWL-resistant stones.10:40-42.3 9. the preferred treatment is drainage.2 9. Laberge I.nlm. In such women.1 B C C 9. ESWL. Table 21: Special considerations GR Treatment with antibiotics should precede stone-removing procedures in case of a positive urine culture. or with intravenous or retrograde administration of contrast medium. Br J Urol 1996. Cystine stones are of two types .

ncbi. 159:365-368.nih. J Urol 1987. Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes. PNL 2a B 2. 1989. 54 UPDATE JUNE 2005 . Wollin MR. PNL + ESWL 2a B 3.ncbi.ncbi. COMPLETE OR PARTIAL STAGHORN STONES A staghorn stone is defined as a stone with a central body and at least one caliceal branch. In selected cases with infection. Newman DM. Lal A. Table 22: Active removal of complete and partial staghorn stones* Type of stone Radio-opaque stones Procedure LE GR 1.. ESWL + PNL 1b A 4. Cystine calculi: two types. Woods http://www. Scarpa RM. ESWL + PNL 1b B Cystine stones 1. Open surgery standard Infection stones and 1. 2. Newman DM (eds). Antibiotics + ESWL + local chemolysis 2a B 5. The principles of chemolytic treatment are discussed in Section 7. Antibiotics + PNL 1b A stones with infection 2. In: Shock Wave Lithotripsy 2.nlm. Antibiotics + PNL + ESWL 1b A 3. Plenum Press: New York. Mosbaugh PG. PNL = percutaneous Mertz JH. a complete staghorn stone fills all calices and the renal pelvis.nlm. *Numbers (1. repeated ESWL sessions with a stent can be a reasonable treatment alternative. PNL + ESWL 1b A 3. J Urol 1998. 3. Prien EL Jr. http://www. http://www.nih.nlm.nih.155:875-877. J Urol 1996.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9649240 Lingeman JE. De Lisa A. Kahnoski RJ. Antibiotics + ESWL + PNL 1b A 4. 4. Renal colic during pregnancy: a case for conservative treatment. ESWL + PNL 2a B LE = level of evidence. Howard PJ Jr. 7. Coury TA. Treatment of both types of staghorn stone is detailed in Table 22. Lingeman JE. Hopkins TB. PNL + ESWL 1b A 2. Dretler SP. cystine. In patients with small staghorn stones and a non-dilated system. PNL/ESWL + oral chemolysis 1b A 3. Nephrectomy should be considered in the case of a non-functioning kidney. PNL 1b A 2. ESWL = extracorporeal shock wave lithotripsy. GR = grade of recommendation. PNL 1b A 2. 10. Steele RE. 6.5.138:485-490. Usai E. The first alternative always has the number 1. also including piezolithotripsy. pp 55-59. Antibiotics + open surgery standard Uric acid/urate stones 1. 5) have been allocated to the procedures according to the consensus reached.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8583596 Parulkar BG.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3625845 Bhatta KM. uric acid and calcium phosphate stones. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. Whereas a partial staghorn stone fills up only part of the collecting system. the combined use of ESWL and chemolysis may be 8. When two procedures were considered equally useful they have been given the same number.5.

gov/entrez/query. The stones formed in a continent reservoir present a varied and often difficult problem (7-14). Eur Urol 1989.46:633637.ncbi. http://www.nlm. well-disintegrated stone material will remain in the original position. Each stone problem has to be considered and treated individually.fcgi?cmd=Retrieve&db=PubMed&list_uids=8401638&dopt= Abstract Gaur DD. Newman RC. Chang LS. Pollack MS. Purohit KC.7:501-503.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=1532102&dopt= Abstract Gaur http://www. 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507351&dopt= Abstract 2. Urology 1990. Retroperitoneal laparoscopic pyelolithotomy.nlm.nlm. 11. Rey Pacheco M. ESWL or video-endoscopic laparoscopic surgery is MANAGING SPECIAL PROBLEMS Caliceal diverticulum stones are treated using ESWL. Retroperitoneal laparoscopic ureterolithotomy. Transureteral endopyelotomy with Ho:YAG laser endopyelotomy is another alternative to correct such an abnormality.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2714327&dopt= Abstract Weinerth 9. It needs to be emphasized.nlm. Khatri VP. Lee YH. http://www.nlm. with shock wave entrance from the abdominal side). J Urol 1994. Lopez Escalante JR. ESWL. http://www. Agarwal DK. Chen MT. Darshane AS.4:149-154.nih. J Endourol 1990. In the case of a narrow communication between the diverticulum and the renal collecting system. 3. 5.nih.ncbi. J Endourol 1993. Webster GD. PNL (if possible) or retrograde URS. Rodriguez Cordero M. Extracorporeal shock wave lithotripsy in horseshoe kidney. [Ureterolitotomia laparoscopia.nih. Walden T.nih. Recommended procedures for the removal of stones in transplanted kidneys are ESWL and PNL.e. Gonzalez Zerpa RD. World J Urol 1993.ncbi. An optional method for removal of diverticular stones is video-endoscopic retroperitoneal surgery. la Riva Rodriguez F. PNL or open surgery are the options in obese patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=2336770&dopt= Abstract Chen KK. it is commonly necessary to carry out ESWL treatment with the patient in the prone position (i. Multiple large calculi in a continent urinary reservoir: a case report. J−ζUrol 1992.148:1129-1130.ncbi. In patients with obstruction of the ureteropelvic Horseshoe kidneys may be treated according to the principles of stone treatment presented above (6). The principles of videoendoscopic surgery are outlined elsewhere (1-5).11.nlm.35:407-411. Cuervo R. [Spanish] http://www. Garcia JL. Finlayson B. REFERENCES Raboy A.ncbi. Experience with management of stones formed within Kock pouch continent urinary diversions.nlm. For pelvic kidneys. 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. http://www. Ferzli GS. Urology 1992.1 1. that according to the anterior position of the kidney. UPDATE JUNE 2005 55 .fcgi?cmd=Retrieve&db=PubMed&list_uids=8239742&dopt= Abstract Locke DR. Retroperitoneal endoscopic ureterolithotomy: our experience in 12 patients. however.11:175-177.] Arch Esp Urol 1993.nih.16:110-113.ncbi. Laparoscopic ureterolithotomy.151:927-929. Steinbock GS. These patients may become asymptomatic as a result of stone disintegration Electrohydraulic lithotripsy for stones in Kock pouch. 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). Loffreda R. http://www. 6.nlm..fcgi?cmd=Retrieve&db=PubMed&list_uids=8126827&dopt= Abstract Escovar Diaz http://www.ncbi. Albert PS. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=8124346&dopt= Abstract Gaur DD. General directions for the management of this problem cannot be given.

nih. Correa RJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490901&dopt= Abstract Ramsay JW. http://www. 19.ncbi. Whitfield HN. Effect of urinary intestinal diversion on urinary risk factors for urolithiasis.ncbi.nlm. Martin X. 12.nlm. http://www. J Endourol J Urol 1991. Ureteropelvic invagination: reliable technique of endopyelotomy.fcgi?cmd=Retrieve&db=PubMed&list_uids=7951285&dopt= Abstract 56 UPDATE JUNE 2005 .fcgi?cmd=Retrieve&db=PubMed&list_uids=1942325&dopt= Abstract Motola JA. http://www.ncbi. Chin Badlani GH. Miller Arai Y. Endopylotomy in horseshoe Endopyelotomy for primary repair of ureteropelvic junction obstruction. Tazaki H. Dessouki T. 22. Smith Lewis GP. Gelet A. J Stone Dis 1992:4:323-327. Bush WH. Okada Y. Tazaki H. Yoshida O. Masuda T. Kawakita M. Terai A.7:395-398.56:586-588.nih. J Urol 1993. Yoshimura K. http://www. J Urol 1995. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8284881&dopt= Abstract Nakamura K. Effective intubation for percutaneous pyelolysis.149:453-456. 16. Urinary calculi as a late complication of the Indiana continent urinary diversion: comparison with the Kock pouch procedure. Denstedt JD.nih.nlm. 43:2-10. http://www. Streem SB.fcgi?cmd=Retrieve&db=PubMed&list_uids=3336099&dopt= Abstract Payne SR.nlm. 13.5:223-224.nih.14:477-481. Massive calculi formation in Indiana continent urinary reservoir: pathogenesis and management problems. J Endourol 1991. results and complications.fcgi?cmd=Retrieve&db=PubMed&list_uids=8345591&dopt= Abstract Gerber GS.fcgi?cmd=Retrieve&db=PubMed&list_uids=8298622&dopt= Abstract Motola JA.150:821-823.nlm. 24. http://www. Smith AD. 15. http://www.146:1492-1495. complications and Abstract Baba S. Ueda T. Okada Y. Baba S. Longterm incidence and risks for recurrent stones following contemporary management of upper tract calculi in patients with a urinary diversion. http://www.8:203-206. Clayman RV.nlm.renal effects and endosurgical relief. 25.139:29-32. Yoshida O.nlm.153:37-41. Eur Urol Badlani GH.ncbi.ncbi. http://www.ncbi. Fried R. Korth K.nlm. 21. J Urol 1996.nlm. Bush 155:62-65. Percutaneous transperitoneal endopyelotomy and ureteroplasty in pelvic kidney associated with ureteral calculus.nih. J Endourol 1994. Sugiura K. Br J Urol 1984. Nephrolithiasis in patients with urinary diversion. http://www. http://www.nih.nih.ncbi. Kellett MJ. Wickham JE. Lammert G.ncbi. J Urol 1996. Terachi Abstract Assimos DG. Ido Blackford HN.fcgi?cmd=Retrieve&db=PubMed&list_uids=7966785&dopt= Abstract Cohen Ohkuma K.ncbi. 26. 23. Endopyelotomy: patient selection. Percutaneous pyelolysis: indications. 18. Coptcoat MJ. J Urol 1996. J Urol 1993. Results of 212 consecutive endopyelotomies: an 8-year followup.nlm.10. Endopyelotomy: review of results and complications. Failed endopyelotomy: implications for future surgery on the ureteropelvic junction. Cassis AN. Lyon ES.fcgi?cmd=Retrieve&db=PubMed&list_uids=8437245&dopt= Abstract Klahr S. Kuenkel M. Editorial. J Urol 1988.nlm. Kakehi Y. 20. Arai J Endourol 1993.nih. 14. Kellett MJ.ncbi.4:109-116. 17. Review: obstructive uropathy . Chambers M. Wickham JE.ncbi. Brannen GE. Chandhoke P. Urology 1994.fcgi?cmd=Retrieve&db=PubMed&list_uids=7490899&dopt= Abstract Terai A. http://www. J Endourol 1990. Endopyelotomy: long term follow-up of 143 patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=6534471&dopt= Abstract Brannen GE.nih. 11.155:69-70.

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However.2 years (16).5 years and 7% after 3. it is important to rule out obstruction and to treat this problem if present. In data on 104 patients with residual fragments. stone growth was observed in 26% of patients and recurrent stone formation in 15%. a CT or topographic examination both demonstrate small fragments better than a standard film (KUB). known as a Steinstrasse (see Section 13) (22-34). For calcium stones. Different imaging techniques have variable degrees of sensitivity. For stones in the upper and middle calices.2 year follow-up of 53 patients. RESIDUAL FRAGMENTS Residual fragments are commonly seen after ESWL.7%. 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. Patients with residual fragments or stones should be regularly followed up to monitor the course of their disease. 40% showed decreased disease or remained stable. Thus.2% after 1. the term ‘clinically insignificant residual fragments’ (CIRF) was introduced. In a 2. 25% of patients with infection stones had formed new stones after 2 years. 78% of the patients with stone fragments 3 months after treatment experienced stone progression. CT scans cannot be carried out everywhere. Table 23 summarizes the recommendations for the treatment of residual fragments.8% after 1. necessary therapeutic steps need to be taken to eliminate symptoms. the residual fragments increased in size in 37% of patients. The corresponding stone-free rate was 20% (1). Residuals with a diameter of 5 mm or more should be termed residual stones. respectively (19). However.12. 28. For a group of Swedish patients with calcium stones. A new stoneremoving procedure was undertaken in 22% of patients (15). 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. For a kidney with stones or fragments in the lower caliceal system and with no functioning parenchyma in that part. In a follow-up of patients with < 4 mm residual fragments during a 4-year period. In asymptomatic patients where the stone is unlikely to pass. 3 and 5 years.6 years. most frequently presenting in the lower calix following disintegration of large stones. In a Japanese report. cystine and brushite. while 5% progressed during a mean follow-up of 1.3 years.0% and 41. Identification of biochemical risk factors and appropriate stone prevention may be particularly indicated in patients with residual fragments or stones. 9. In symptomatic patients.7% after 3. The greatest risk was seen in patients with stones containing a high content of calcium phosphate (20). Percutaneous chemolysis is an alternative treatment for stone fragments composed of magnesium ammonium phosphate. A CT scan also has the capacity to demonstrate uric acid concrements.4% after 1 year. The role of CIRF has been a matter of debate and concern for some time (2-13).4 years. The longest follow-up period was reported by Yu and co-workers (14). URS with contact disintegration is another treatment option. The clinical problem of asymptomatic stone residuals in the kidney is related to the risk of developing new stones from such nidi. 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 residuals with a largest diameter of 4 mm should be termed residual fragments. lower pole resection is an alternative treatment to be considered (21). Moreover. there was obvious increase in size in 37% and a need for retreatment in 12% (17). a 20% risk of recurrent stone formation was recorded during the first 4 years after ESWL. Stone recurrences were thus reported to be 8. 6. stones (largest diameter) < 4-5 mm > 6-7 mm 58 UPDATE JUNE 2005 . After 6. During a follow-up of between 7 and 96 months. 20% after 3. The risk of recurrence in patients with residual fragments after treatment of infection stones is well recognized. with an average follow-up of 3. 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 (18). treatment should be applied according to the relevant stone situation. uric acid. 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. the recurrence rates were 6. with further intervention necessary in 9. there is no data in the literature demonstrating the clinical value of being able to detect small tiny concretions visible only on CT scan. which are otherwise radiolucent. carbonate apatite. Reports on residual fragments therefore vary from one institution to another depending on which imaging method is used. In other cases.3 years. residual fragments may occur following ESWL for all sizes of stones.3% of patients by 2 years of follow-up.

http://www. Yost A. Extracorporeal shock wave lithotripsy for lower calyceal stones: can clearance be predicted? Br J Urol 1997. Br J Urol 1993. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=10148257&dopt =Abstract Sabnis RB.ncbi. Br J Urol 1993. http://www. Kumstat P.nlm. Dretler SP.ncbi.6:217-218. Extracorporeal shock wave lithotripsy retreatment (“stir-up”) promotes discharge of persistent caliceal stone fragments after primary extracorporeal shock wave lithotripsy.ncbi. Del Nero A. Marberger M. Mulley AG Jr.153:27-33. Arch Esp Urol 1991. Maccatrozzo L.nih.nlm. Gambaro G. The fate of residual fragments after extracorporeal shock wave lithotripsy monotherapy of infection stones. Anselmo G.fcgi?cmd=Retrieve&db=PubMed&list_uids=8632527&dopt= Abstract Zanetti G.nlm. Lang H. Kladensky http://www.nih. Montanari E. Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for urinary calculi: comparison of immediate and long-term effects.nih. 3. BE Hibbert. Long-term results in ESWL-treated urinary stone patients. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy.nlm.5:8-18.nlm. Lee YH. 16. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis J Urol 1997. Huang JK. pp 349-355.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224301&dopt= Abstract Pacik D. http://www. Lin AT. Schuster C. Fandella A. Cicerello E.fcgi?cmd=Retrieve&db=PubMed&list_uids=9355942&dopt= Abstract Segura JW.11:305-307.nih.ncbi. J Urol 1991. SR Khan. B Hess.nlm. http://www. J Urol 1992.44:1023-1024. Chen KK. Huang REFERENCES Beck EM. Chen MT. http://www. 15.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507326&dopt= Abstract Yu CC. Eur Urol 2000.nih. Jocham D. Chen KK. Abstract. 5.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10671779 Tiselius HG. Trinchieri A. 8. 2. J Stone Dis 1993. The definition of success.72:688-691. Lee YH. Jelinek P. Gladstone K. Hatziandreu E. J Endourol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=7966783&dopt= Abstract Streem SB. J Endourol 1992. Preminger GM.151:5-9.80:853-857. Hanak T.ncbi.nih. Baggio B. Jacqmin D. Comprehensive metabolic evaluation of stone formers is cost http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8254832&dopt= Abstract Fine JK. GM Preminger.148:1040-1041. Effectiveness of SWL for lower-pole caliceal nephrolithiasis: evaluation of 452 cases. Riehle RA Jr. Faure F.ncbi. Desai MR. Guarneri A.nlm. Lin AT.12. 6.nih. Krings F.155:1186-1190. J Urol Steinkogler I. Abstract Carlson KJ. Seveso M. Patel SH. Bapat Schmidt A. http://www. http://www. Lunz C. Chang LS. Tuerk C. Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. 9. In: Urolithiasis 2000.nih.nlm.nlm. J Urol 1995.ncbi. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy. Chen MT.ncbi. Merlo F.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1984100 Eisenberger F.ncbi. 12.nlm.nlm. Roth RA.158:352-355. Saussine C.nih. 11.nih. Bub P.ncbi.nlm. Turjanica M. Chang LS. Urol Res 1988.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281395 Candau C. 14. 10. Pak YC. Mascha Naik K. 13. UPDATE JUNE 2005 59 .ncbi. Roy C. Nespoli R. Renal stone fragments following shock wave lithotripsy. http://www. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy.nih. Liedl B. J Urol Editors: AL Rodgers. http://www. The fate of residual fragments after extracorporeal shock wave lithotripsy. Natural history of residual renal stone fragments after ESWL.fcgi?cmd=Retrieve&db=PubMed&list_uids=9439396&dopt= Abstract Yu CC.1 1. Cape Town: University of Cape 7.145:6-9.

http://www. 26. McDermott TE.nih. http://www. Lennon GM. Norman RW.nlm.28:152-157.ncbi. Grainger R.nlm. [The staghorn calculus: anatrophic nephrolithotomy versus percutaneous litholapxy and extracorporeal shockwave therapy versus extracorporeal shockwave lithotripsy monotherapy. Alund G.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8863540 Lahme S. Extracorporeal shock wave lithotripsy as monotherapy of staghorn renal calculi. Hauri D.nih.nlm. J Urol 1989. Urol Clin North Am 1988. Knönagel H. http://www. http://www. Katoh N.36:52-54. Stent use with extracorporeal shock wave lithotripsy. Partial nephrectomy for stone disease. Urology http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=2585613&dopt= Abstract Anderson PAM. 28. Curr Opin Urol Hofbauer J.31:24-29. 23. 32. http://www. J Endourol 1993.nlm. 20. Pode D.ncbi.nih. Extracorporeal shock wave lithotripsy for large renal stones.nih. Wilbert DM. 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. http://www. Saltzman B. Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility. Butler MR. 30. J Endourol 1989.nih. Schneider M. Problems and complications in stone disease. Fate of clinically insignificant residual fragment (CIRF) after ESWL.ncbi.ncbi.3:31-36. Jaeger P. Hauri D.ncbi. Br J Urol 1977. J Urol 1996. Awad SA. 29.15:493-497. http://www. Ohshima S. Ono Y. Ureteral stents. http://www.ncbi. Mizutani K.156:1267-1271.13:174-175. Bachor R. Indications. 25. 3 years of experience. Urolithiasis 2000. Rose MB. 27.fcgi?cmd=Retrieve&db=PubMed&list_uids=3407040&dopt= Abstract Saltzman B.748-749.ncbi. Schmidt JD. Verstandig A. Long-term stone recurrence rate after extracorporeal shock wave lithotripsy. Pfau A.fcgi?cmd=Retrieve&db=PubMed&list_uids=8518830&dopt= Abstract Marberger M.49:605-610.4:152-157. J Urol 1996. Gleeson MJ.nlm. variations and complications. Claus R.142:1415-1418. 19.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215235&dopt= Abstract Cohen ES. Extracorporeal shock wave lithotripsy experience with large renal calculi.156:1572-1575.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=3043868&dopt= Abstract Constantinides http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=9032530&dopt= Abstract Ackermann D.17. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=2741262&dopt= Abstract Chen AS. Extracorporeal shock wave lithotripsy for stones in solitary kidney.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=3609094&dopt= Abstract 60 UPDATE JUNE 2005 .fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8808851 Tiselius HG. 24.nih. Recker F.ncbi. Kamihira O. Griffith DP.fcgi?cmd=Retrieve&db=PubMed&list_uids=597695&dopt= Abstract&itool=iconabstr Miller K. Thornhill 18. To what size is extracorporeal shock wave lithotripsy alone feasible? Eur Urol 1988. Jaeger P. The benefits of stenting on a more-or-less routine basis prior to extracorporeal shock wave lithotripsy.nlm. Hautmann R. Konstantinidis K.nlm. Chen Eur Urol 1987. Shapiro A. Recker F.ncbi. Recurrent stone formation in patients treated with extracorporal shock wave lithotripsy.15:5-8.ncbi. Follows OJ.nih.nih. Scheiber K. J Endourol 1988. Use of internal polyethylene ureteral stents in extracorporeal shock wave lithotripsy of staghorn calculi. Streem SB. Zehntner C. Bichler KH.7: 155-162. J Stone Dis 1992.15:481-491.fcgi?cmd=Retrieve&db=PubMed&list_uids=2368232&dopt= Abstract Shabsigh R. Yamada S. Urol Clin North Am 1988.nih. Extracorporeal shock wave lithotripsy for lower pole calculi: long-term radiographic and clinical outcome. Eur Urol 1997. [German] http://www. A report of over 6 years’ experience] Urologe A

In: State of the Art Extracorporeal Shock Wave Lithotripsy. For a normal adult. REFERENCES Tolley DA. for instance. and particular attention should be paid to situations in which an unusual loss of fluid occurs.ncbi. irrespective of stone composition. ESWL 3. The role of ureteral stent placement in the prevention of steinstrasse.nih. the 24-h urine volume should exceed 2. In all patients with signs of URS 2. 2. http://www. but without excesses of any kind (2). Sulaiman MN. Stent 4. Stent 3. 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). The fluid intake should be evenly distributed over a 24-hour period.11:37-42.nlm. Pharmacological treatment should be instituted only when the conservative regimen fails. but the supersaturation level should be used as a guide to the necessary degree of urine dilution. J Endourol 1999. PN = percutaneous nephrotomy. to avoid fruits and vegetables that are rich in oxalate.1 1. PN PN Proximal ureter 1. Futura Publishing Co. New York 1987.13:151-155. 2. 3. Care must be taken. pp.fcgi?cmd=Retrieve&db=PubMed&list_uids=8490666&dopt= Abstract Griffith DP. The intake of fruits and vegetables should be encouraged because of the beneficial effects of fibre (3). is rich in oxalate and in order to avoid an oxalate load.000 mL. Ureteral calculi. ESWL 3. The first alternative always has the number 1. Insertion of a PN catheter usually results in passage of the fragments (2). The frequency of this complication has decreased with the liberal insertion of double-J stents before ESWL of large renal stones. PN PN Mid ureter 1. ESWL ESWL 1. Buchholz NP. PN PN Distal Ureter 2. however.nlm. * Numbers (1.1 General recommendations Preventive treatment in patients with calcium stone disease should be started with conservative measures.ncbi. Clark PB. Wheat bran. PREVENTIVE TREATMENT IN CALCIUM STONE DISEASE 14.34. Diet should be of a ‘commonsense’ type . World J Urol 1993. ESWL 1. Patients should be encouraged to have a high fluid intake (1). 4) have been allocated to the procedures according to the consensus reached. For distally located accumulations of fragments.nih. URS ESWL = extracorporeal shock wave lithotripsy. 13. McCullough DL (eds).a mixed balanced diet with contributions from all food groups. URS might be useful to remove the leading stone fragment by contact disintegration. Consensus of lithotriptor terminology. the UPDATE JUNE 2005 61 . URS = ureteroscopy. http://www. 14. ESWL 2. it is necessary to give antibiotics and to provide adequate drainage as soon as possible. Harrison LH. This advice is valid. Kandel LB. also including piezolithotripsy. Mt Kisco. Recommendations for treatment are summarized in Table 24. Table 24: Recommendations for treatment of Steinstrasse* Unobstructed Position of stone Obstructed and/or symptomatic 1. When two procedures were considered equally useful they have been given the same number.fcgi?cmd=Retrieve&db=PubMed&list_uids=10360492&dopt =Abstract 13. ESWL ESWL 1.

Kohri K.nih.ncbi. 6. 14. Wandzilak TR. Calcium intake should not be restricted unless there are very strong reasons for such advice. • Spinach 570 mg oxalate/100 g. • Herring with skin. Morimoto Walker VR. • Tea leaves 375-1450 mg oxalate/100 g. Briganti A. http://www.ncbi. Ishikawa Abstract 2. Supplements of calcium are not recommended except in cases of enteric hyperoxaluria. Miner Electrolyte Metab 1994. Katoh Y. sprats 260-500 mg urate/100 g. 1996. Enteric and mild hyperoxaluria. http://www. Williams years later. Iguchi M. In: Urinary stones . Animal protein should not be ingested in excessive amounts (8-14). 9. Below are examples of food rich in urate (21): • Calf thymus 900 mg urate/100 g.nlm. • Liver 260-360 mg urate/100 g. http://www. Nephron 1999. Jahnen A.nlm. The intake of urate should not exceed more than 500 mg/day.nlm.nih.excessive intake of products rich in oxalate should be limited or avoided.nih. http://www. Kurita T. Results of long-term rice bran treatment on stone recurrence in hypercalciuric patients. Kodama M. and it is recommended that animal protein intake is limited to approximately 150 g/day.13:228-234. Novarini A. 62 UPDATE JUNE 2005 . 62.nlm.67:237-40. Allegri F.ncbi. • Kidneys 210-255 mg urate/100 g. Meschi T. in which additional calcium should be ingested with meals. Eur Urol 1999. Auer D.nlm. D’Andre SD. 36:136-143. 5. Commentary: Renal calculi . http://www. http://www.2:164-172.fcgi?cmd=Retrieve&db=PubMed&list_uids=10420035&dopt =Abstract Ebisuno S. This is of particular importance in patients in whom high excretion of oxalate has been demonstrated.20:352-360. Effects of a ‘common sense diet’ on urinary composition and supersaturation in patients with idiopathic calcium urolithiasis. Schianchi T. • Cocoa 625 mg oxalate/100 g. Karger: New York. The intake of food particularly rich in urate should be restricted in patients with hyperuricosuric calcium oxalate stone disease (15-20). Miner Electrolyte Metab 1987.fcgi?cmd=Retrieve&db=PubMed&list_uids=7783697&dopt= Abstract Auer BL. Rodger AL. 7. Borghi L. as well as in patients with uric acid stone disease.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126804&dopt= Abstract Sutton RA.1 REFERENCES 1.81(suppl) Abstract Hesse A. The following products have a high content of oxalate (4): • Rhubarb 530 mg oxalate/100 g.nlm. Yasukawa S. J Urol 1994. http://www. J Urol 1990. treatment and prevention of recurrence. • Poultry skin 300 mg urate/100 g. 8. Umekawa T. Clin Chem Lab Med 1998. Ackermann D.nih.nlm. Katayama Y. 3. Davis PA.151:834-837.ncbi. sardines.ncbi. Mauron H. • Nuts 200-600 mg oxalate/100 g.nih.ncbi.nih. Urine volume stone risk factor and preventive measure. The minimum daily requirement for calcium is 800 mg and the general recommendation is 1000 mg/day.fcgi?cmd=Retrieve&db=PubMed&list_uids=3306314&dopt= Abstract Yendt ER.Diagnosis.nlm. Br J Urol 1991. Kataoka K. Tiselius HG. The effects of ascorbic acid ingestion on the biochemical and physicochemical risk factors associated with calcium oxalate kidney stone formation. Dietary intake and habits of Japanese renal stone patients. Diet and calcium stones. Vitamin C in doses up to 4 g/day can be taken without increasing the risk of stone formation (5-7). J Lithotripsy Stone Dis 1990. Ohkawa T.fcgi?cmd=Retrieve&db=PubMed&list_uids=9589801&dopt= Abstract Robertson WG.36:143-147. Takada M.nih. 10.fcgi?cmd=Retrieve&db=PubMed&list_uids=9873212&dopt= Abstract Hess B.1. Guerra anchovies. Jaeger P. Effect of high dose vitamin C on urinary oxalate levels.nih.

14.nih.nlm. pp. In this respect. 285-293. Hart LJ.4:130-136.nlm. Buck AC (eds). Holt K. http://www. Diet and calcium stones. In: Urinary stones . allopurinol. pp.15:227-229.fcgi?cmd=Retrieve&db=PubMed&list_uids=1310430&dopt= Abstract Holmes RP. Miner Electrolyte Metab 1980. information has been added on recent studies with special emphasis on data from randomized studies. magnesium. http://www. The scientific basis of these forms of treatment is briefly summarized below. orthophosphate. Kidney Int 1993. sodium cellulose phosphate. Relationship of protein intake to urinary oxalate and glycolate excretion.4). Endocrinol Metab Clin North Am 1990.nih. Preminger GM (eds). Iestra JA.ncbi. Ward D.fcgi?cmd=Retrieve&db=PubMed&list_uids=7424690&dopt= Abstract Pak CY.146:137-143.ncbi. The recommendations given in this guideline document are based on what has been published in this field. Hofbauer J.fcgi?cmd=Retrieve&db=PubMed&list_uids=8377380&dopt= Abstract Coe FL. and in some situations pyridoxine and oxabsorb.71:861-867. http://www.ncbi. 13.nih.nlm. 20. The conclusions of the Consensus Conference have been published separately ( Pak CYC. pp. 15.11. Churchill Livingstone: Edinburgh.nlm. In the present edition of the Urolithiasis guideline document. The pharmacological agents most commonly used in patients with recurrent calcium stone formation are thiazides.ncbi. In: Renal tract stone.fcgi?cmd=Retrieve&db=PubMed&list_uids=3306317&dopt= Abstract Zechner O. 851-858.19:805-820. Tiselius HG.3. should a pharmacological approach be considered in addition to the drinking and dietary recommendations. Britton F. http://www. Favus MJ. Peterson R. cellulose phosphate. Germany in 1996 and form the basis for the abovementioned recommendations (1). Crowther C. Hyperuricosuric calcium oxalate lithiasis. Jahnen A (eds). http://www. 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. Doorenbos CM.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215256&dopt= Abstract Sarig monopotassium urate. 16. Wickham JEA. that there is no absolute consensus on such a view (5. We believe that the latter approach is theoretically most attractive but it needs to be emphasized. Can Med Assoc J 1992.nlm. Hyperuricosuric calcium stone disease.fcgi?cmd=Retrieve&db=PubMed&list_uids=2081512&dopt= Abstract Hughes J. 88. Kidney Int 1983. Assessment of pathogenetic roles of uric acid. Goodman HO. Papapoulos SE. 1990. 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).44:366-372.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=2401715&dopt= Abstract Goldfarb S. Assimos Norman RW.ncbi. J Clin Endocrinol Metab 1990. 1996.24:392-403. Only when such treatment turns out to be unsuccessful. Parks JH. In: Kidney stones: medical and surgical management.ncbi. Kok DJ. monoammonium urate and monosodium urate in hyperuricosuric calcium oxalate nephrolithiasis. UPDATE JUNE 2005 63 . Hyperuricosuric calcium oxalate nephrolithiasis. 14.diagnosis.nih. Karger: New York. The hyperuricosuric calcium oxalate stone former. be free of side effects and easy to administer. 1996.2 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. All these aspects are of utmost importance in order to achieve a reasonably good Ettinger B.6). An extensive review and interpretation of literature results were carried out by the European Urolithiasis Research group at a Consensus Conference in Mannheim.nih. treatment and prevention of recurrence. Hesse A. The role of diet in the pathogenesis and therapy of nephrolithiasis. it is essential to choose the most appropriate form of treatment. Miner Electrolyte Metab 1987. Eur Urol 1988. The ideal pharmacological agent should halt the formation of calcium stones. Coe FL. Zechner O. 17. Lippincott-Raven Publishers: Philadelphia. 12.ncbi. 19. 18. http://www. Impact of allopurinol treatment on the prevention of hyperuricosuric calcium oxalate lithiasis.

there is no strong scientific basis for a recommendation in this regard. most of which support a positive effect of recurrence prevention. Although two short-term placebo-controlled studies (13. bendroflumethiazide. potassium citrate.2 Alkaline citrate Treatment with alkaline citrate is commonly used as a method to increase urinary citrate in patients with hypocitraturia. A significantly reduced rate of stone formation was also noted when a thiazide was given intermittently to recurrent stoneformers (22). Following the initial report by Yendt in 1970 (12). Although the general principle is to give citrate preparations. potassium bicarbonate and sodium bicarbonate. possibly by a reduced intestinal absorption of calcium (911).8). It has. In several other studies. a judgment must be made between the positive and the negative effects of the medication.32). However. 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. In the other seven randomized trials. development of diabetes and gout. In the two studies with potassium citrate. cannot be definitely concluded from the various studies. moreover. it is the alkalinization of the tubular cells that is the most important factor affecting increased citrate excretion. The major drawback of thiazide treatment is the occurrence of side-effects. three studies selected hypercalciuric patients (19-21) and all three showed a significantly positive effect of thiazides. Alkaline citrate has been used in four randomized studies.32. however. Suffice it to mention that of the randomized studies. a significant effect was reported in five. citrate is an inhibitor of growth and aggregation of these crystals (30). that the major indication for choosing a thiazide or a thiazide-like agent should be hypercalciuria. However. contribute to a low tolerance and a high drop-out rate. as well as erectile dysfunction. whereas no effect was noted with sodium potassium citrate compared with an untreated group. trichlorothiazide and indapamide have been used for recurrence prevention in patients with calcium stone disease.33. a large number of reports have been published. This observation is also supported by the different effects of potassium citrate and sodium citrate on urine composition (43). In the absence of a high calcium excretion. the overall impression is that potassium citrate (31. A low citrate excretion is a frequent finding in patients with calcium stone disease. The clinical effect of thiazide treatment has accordingly been evaluated in 10 randomized studies. Moreover. other forms of treatment may be more appropriate first-choice alternatives. A similar result was also obtained in three groups of patients treated with thiazides for 2.28).14. a significantly reduced recurrence rate was recorded in three 3-year follow-up studies (15-18). The purpose of thiazide treatment is to reduce the excretion of calcium in hypercalciuric patients.42). As in all situations when pharmacological treatment is considered. or used also in patients without this abnormality. a thiazide-induced reduction in urinary oxalate is not a consistent finding in the clinical studies. The alkalinizing agents used to prevent recurrent calcium stone formation are sodium potassium citrate. sodium citrate. Potassium citrate was used in two (31.35-40) has a greater potential for preventing recurrence than sodium potassium citrate (2. A favourable effect was also reported with potassium magnesium citrate.14) failed to confirm a positive effect of thiazides. but it has been stated that calcium reduction is also seen in patients with normocalciuria (7). Other non-randomized studies with alkaline citrate have shown a variable outcome. 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. four of which included placebo-treated patients. The unmasking of normocalcaemic HPT. Due to the frequent occurrence of hypercalciuria also in an unselected group of stoneformers. Administration of an alkaline salt brings about an increased pH and an increased excretion of citrate. 64 UPDATE JUNE 2005 .41.02) (29). There is more than 30 years’ clinical experience with thiazides as a method for stone prevention. Compliance is usually in the range of only 50-70%. in which no selection was made.3 years in comparison with conservatively treated patients (19-21).2.1 Thiazides and thiazide-like agents Hydrochlorothiazide. The role of calcium is important because citrate chelates calcium and thereby reduces the ion-activity products of both calcium oxalate and calcium phosphate. It is our opinion. sodium potassium in one (33) and sodium magnesium citrate in another (34). been suggested that thiazides might decrease the excretion of oxalate.3 and 4. 14. Whether or not thiazide treatment should be reserved only for patients with hypercalciuria. There are also reports of favourable clearance of residual fragments during treatment with alkaline citrate (see below). with only a small fraction of the administered citrate being excreted in urine. a significantly reduced recurrence rate was recorded. potassium magnesium citrate. the results were less convincing (27. 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).2.

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.



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.



Table 25:

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

Table 26:

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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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 J Urol 1998. 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.000 mL.1 REFERENCES 1. J Urol 1975.4.nlm.ncbi.ncbi.ncbi.nlm. http://www.nlm. Joly D.nih. Streem SB. Méjean A.5 74 UPDATE JUNE 2005 . J Urol 2000. Nozumi 9873246 Barbey F.ncbi.4 Pharmacological treatment of cystine stone disease The pharmacological treatment of patients with cystine stone disease is outlined in Table 28. Jungers P.nih. Masai M. Medical treatment of cystinuria: critical reappraisal of long-term results. 3.160:341-344. To achieve this goal.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1113405 2. http://www. http://www. 4. Chow GK. Rieu P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10751848 Freed SZ.5 Pharmacological treatment of infection stone disease The pharmacological treatment of patients with infection stone disease is outlined in Table 29. Complex formation with cystine For patients with a cystine excretion above 3 mmol/24h: Tiopronin (α-mercapto-propionyl glycine) (250-2. Daudon M. Contemporary urological intervention for cystinuric patients: immediate and long-term impact and implications. Kotake T.113:96-99.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9679873 Akakura K. The definition of infection stones is stones composed of magnesium ammonium phosphate and carbonate apatite and caused by urease producing micro-organisms. Egoshi treatment with acetohydroxamic acid (Lithostat) might be a therapeutic option GR = grade of recommendation B B 3 4. http://www. The long-term outcome of cystinuria in Japan.61:86-89. Ito H.nih.5.163:1419-1423.000 mg/day) or Captopril (75-150 mg) GR = grade of recommendation B 1-3 B 1-7 14. Urol Int 1998. The alternating use of an alkalizing salt and acetazolamide in the management of cystine and uric acid stones. 14. 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. Ueda T.

Kok. http://www. Clinical and laboratory approaches for evaluation of nephrolithiasis. Jarrar K.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1726639&query_hl=23 Williams JJ. Longuet R.nlm.30:112-117. P. Gleeson MJ. Wilson DM.nih. D. 15.nlm.ncbi. B.nih.311:760-764. Parks JH. P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6472365&query_hl=25 2. Deman E. Griffith DP. 4. Jaeger. Hess. Alken. Lee H.H. Sarica. J Urol 1989.ncbi. pp. Leusmann. UPDATE JUNE 2005 75 . B.nlm.ncbi. A. Baumann. B.M. Weidner W.nih.20:243-247. A randomized double blind study of acetohydroxamic acid in struvite nephrolithiasis. Dussol. Schwille. Strohmaier. D.D.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2918617 Wong HY. Ann Urol (Paris) 1996.ncbi. Struvite stones: long term follow-up under metaphylaxis. http://www. Pak CYC. In: Kidney stones: medical and surgical management. Ph.nlm. K. 5.1 REFERENCES 1. Boedeker RH. http://www. Ackermann. Medical management and prevention of struvite stones. ACKNOWLEDGEMENTS Members of the Advisory Board of European Urolithiasis Research contributed to the section on metabolic evaluation and preventive treatment. N Eng J Med 1984.nih. Tiselius (President). Lippincott-Raven Publishers.L. Bichler. http://www. 941-950. Philadelphia 1996.O. Favus MJ. Rao (Vice-President). Achilles. Randomized double-blind trial of Lithostat (acetohydroxamic acid) in the palliative treatment of infection induced urinary calculi.-G. K. P. They include: W. Preminger GM (eds). Riedl CR. Rodman JS.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8766146&query_hl=21 Griffith DP. Caudarella. Coe J. Peterson 3.5. R.N. W. 141:770-774.J. Daudon. Eur Urol 1991. Earle N. M. Hesse.

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. 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.

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 16.3 12. 23 18.3 27 40 53 67 80 Approximate stone surface area with known diameters of the stone 18 14.1 6.4 3 4 5 UPDATE JUNE 2005 2 1.8 1.7 24 31 39 47 94 102 110 118 126 133 141 149 157 165 173 181 188 196 11 8.6 35 47 59 71 94 106 118 130 141 153 165 177 188 200 212 224 236 247 259 271 283 294 16 12.6 17.2 20.1 9 12 14 4 3.7 9.6 19 25 31 38 94 100 107 113 119 126 132 138 144 151 157 9 7.9 12 16 20 24 6 4.0 22. 22 17.1 28.6 2.3 42 57 71 85 19 14.9 7.1 14.5 33. Approximate stone surface area (mm2) calculated from the length and width of the stone.4 4.7 31.9 15.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 6 8 9 3 2. Width mm 1 0.0 33 44 55 66 15 11.3 26 35 43 52 95 104 112 121 130 138 147 155 164 173 181 190 199 207 216 12 9.8 23.1 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 13.7 7.8 37.4 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 11.4 14 19 24 28 99 104 108 113 118 17.1 4. APPENDICES 7 5. The calculated surface area for any combination of stone diameters up to 25 mm is shown in Table A1.6 25.5 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.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 18.3 9.0 16 22 27 33 99 104 110 115 121 126 132 137 8 6.5 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 15.1 36.3 34.6 3.4 18.8 28 38 47 57 94 104 113 122 132 141 151 160 170 179 188 198 207 217 226 236 13 10.1 21 28 35 42 99 106 113 120 127 134 141 148 155 162 170 177 10 7.0 49 66 82 99 115 132 148 165 181 198 214 231 247 264 280 297 313 330 346 363 379 396 412 Table A1.4 13 16 19 5 3.7 57 75 94 113 132 151 170 188 207 226 245 264 283 301 320 339 358 377 396 414 433 452 471 .

• Flexible probes are available but they potentially impair the maximal tip deflection of the scope (2). ULTRASOUND LITHOTRIPSY • Principle: ultrasound-based lithotripsy probes induce high-frequency oscillation which produces ultrasound waves (23. Paterson RF. • Safe usage and excellent cost effectiveness are advantages of these systems (1). • Cystine stones cannot be disintegrated with the Nd:YAG laser. Kohrmann KU.nlm. 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. REFERENCES Tan PK.nlm. • Flexible electrohydraulic probes (EHL) are available in different sizes for use in semirigid or flexible scopes. • Efficiency is low for hard stones like calcium oxalate-monohydrate stones. Williams JC Jr. • Low cost of the Nd:YAG laser compared to the Ho:YAG laser makes this laser an interesting alternative.ncbi. which accounts for the fact that EHL is not used as a standard procedure any more. Consigliere D.18:153-156. The ultrasound is transmitted to the tip of the probe. http://www. Ureteroscopic lithoclast lithotripsy: a cost-effective option.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12180234 Kuo RL.12:341-344. • Currently the method of choice for stone treatment by flexible URS (5). not be demonstrated (6).nih. LASER-BASED LITHOTRIPSY • The neodymium:yttrium-aluminium-garnet (Nd:YAG) and the holmium:YAG (Ho:YAG) laser are mostly used for intracorporeal laser lithotripsy. 78 UPDATE JUNE 2005 . Evan AP. http://www. 1. Siqueira TM Jr. Devices for endoscopic disintegration of stones ELECTROHYDRAULIC LITHOTRIPSY (EHL) • Principle: electric current generates a flash at the tip of the probe.nih. In vitro assessment of lithoclast ultra intracorporeal lithotripter. leading to a vibration that disintegrates the calculi upon contact. the resulting heat produces a cavitation bubble leading to a spheric shock wave. • EHL is able to disintegrate stones of all chemical compositions. Knoll T. Tan SM. The insertion of stone baskets or special collecting tools like the ‘stone cone’ can prevent this loss of fragments (1). PNEUMATIC LITHOTRIPSY • Pneumatic or ballistic lithotripsy probes with 2. • Combined ultrasound/pneumatic probes are available and can be used for semirigid URS and PNL (3.A2.ncbi.4). 3. however. 365 µm fibres are typically used in • Nd:YAG: frequency-doubled lasers (FREDDY.nih. • The undirected transmission of heat comes with a frequent risk of tissue injury.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9726400 Michel MS.5 mm results in reduced thermal injuries. • Laser probe must be in contact with the stone surface.4 F probes are frequently used in semirigid URS with disintegration rates of more than http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15072622 2.nlm. Lingeman JE. 220µm fibres in flexible scopes (2). McAteer JA. • Ho:YAG: This laser type (2100 nm) can disintegrate stones of all chemical • Several fibres are available for both lasers. • In comparison with the Nd:YAG low tissue penetration of less than 0. Ptaschnyk T. J Endourol 1998.000 Hz). • The risk of stone migration is less than with ballistic probes. • Perforation of the ureter or the pelvic wall is possible.000-27. Eur Uro 2002. An increased incidence of strictures could. Alken P. • The resulting mobilization of fragments into more proximal parts of the urinary tract may decrease the stone-free rate (1). A3. J Endourol 2004.ncbi. 532 and 1064 nm) are used for lithotripsy.

gov/entrez/query. http://www. Denstedt JD.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9302119 UPDATE JUNE 2005 79 .nih. Pietrow PK. J Urol 2002.60:28-32.nih.158:1357-1361.ncbi. Urology 2002.167:31-34. Lallas In vitro comparison of standard ultrasound and pneumatic lithotrites with a new combination intracorporeal lithotripsy device.nih. Razvi 12100916 Sofer M. 5. Rogenes VJ.ncbi. http://www. Zhong P.nlm. Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11743269 Teichman JM. http://www. Rao RD. Auge BK. Preminger GM. Watterson JD. J Urol 1997.4.nlm.nlm. Harris JM. Wollin TA. Nott L. 6. Ureteroscopic management of ureteral calculi: electrohydraulic versus holmium:YAG lithotripsy.

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