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H.-G. Tiselius, D. Ackermann, P. Alken, C. Buck, P. Conort, M. Gallucci, T. Knoll
© European Association of Urology 2006
TABLE OF CONTENTS
1. Background 1.1 References Classification 2.1 Categories of stone formers 2.2 Specific risk factors for stone formation 2.3 References Diagnostic procedures 3.1 Diagnostic imaging 3.1.1 Allergy to contrast medium 3.1.2 Metformin 3.1.3 Reduced renal function Risk factors for the development of reduced renal function Dosage of iodine 3.1.4 Untreated hyperthyroidism 3.1.5 References 3.2 Analysis of stone composition 3.2.1 References 3.3 Biochemical investigations 3.3.1 Analytical work-up in the acute phase 3.3.2 Analysis of urine in search for risk factors of stone formation 3.3.3 Comments on the analytical work-up 3.3.4 References Stone burden 4.1 References Treatment of patients with renal colic 5.1 Pain relief 5.1.1 Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) 5.1.2 Prevention of recurrent episodes of renal colic 5.1.3 Effects of diclofenac on renal function 5.2 References Indications for active stone removal 6.1 References Active removal of stones in the kidney 7.1 Extracorporeal shock wave lithotripsy (ESWL) for stone removal 7.1.2 ESWL for removal of large renal stones 22.214.171.124 Location of the stone mass 126.96.36.199 Stone burden 188.8.131.52 Composition and hardness of the stone 184.108.40.206 References 7.2 Percutaneous removal of renal stones 7.2.1 Complications 7.2.2 References 7.3 Aspects on staghorn stone treatment and importance of stone burden 7.3.1 ESWL 7.3.2 Percutaneous nephrolithotomy (PNL) 7.3.3 ESWL and PNL 7.3.4 Percutaneous surgery versus ESWL for removal of renal stones 7.3.5 References 7.4 Open surgery for removal of renal stones 7.4.1 Indications for open surgery 7.4.2 Operative procedures 7.4.3 References
5 6 6 6 6 7 8 8 8 8 9 9 9 10 10 11 12 12 12 13 15 16 19 19 19 19 19 20 20 20 21 21 22 22 23 23 24 24 25 30 30 30 31 31 31 31 32 32 33 33 33 34
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Chemolytic possibilities 7.5.1 Infection stones 7.5.2 Brushite stones 7.5.3 Cystine stones 7.5.4 Uric acid stones 7.5.5 Calcium oxalate and ammonium urate stones 7.5.6 References Recommendations for removal of renal stones
35 35 35 35 35 36 36 37 38 38 39 42 42 42 43 43 44 44 44 44 45 45 45 45 45 46 49 49 50 52 52 53 53 53 53 53 53 54 55 55 58 59 61 61 61 61 62 63 64 64 65 65 66
Active removal of stones in the ureter 8.1 ESWL for removal of ureteral stones 8.1.1 References 8.2 Retrograde manipulation of stones 8.2.1 Stenting 8.2.2 References 8.3 Ureteroscopy for removal of ureteral stones 8.3.1 Standard endoscopic technique 8.3.2 Anaesthesia 8.3.3 Assessment of different devices 220.127.116.11 Ureteroscopes 18.104.22.168 Disintegration devices 22.214.171.124 Baskets 126.96.36.199 Dilatation and stenting 188.8.131.52 Clinical results 184.108.40.206 Complications 220.127.116.11 Conclusion 8.3.4 References 8.4 Should ESWL or ureteroscopy (URS) be used for stone removal? 8.4.1 References 8.5 Recommendations for active removal of ureteral stones: all sizes General recommendations and precautions for stone removal 9.1 Infections 9.2 Bleeding 9.3 Pregnancy 9.4 Pacemaker 9.5 Hard stones 9.6 Radiolucent stones 9.7 References Complete or partial staghorn stones Managing special problems 11.1 References Residual fragments 12.1 References Steinstrasse 13.1 References Preventive treatment in calcium stone disease 14.1 General recommendations 14.1.1 References 14.2 Pharmacological agents in prevention of recurrent calcium stone formation 14.2.1 Thiazides and thiazide-like agents 14.2.2 Alkaline citrate 14.2.3 Orthophosphate 14.2.4 Magnesium 14.2.5 Allopurinol
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7 Pyridoxine 14.2.4 14.2.3 18.104.22.168 References Pharmacological treatment of uric acid stone disease 14. ACKNOWLEDGEMENTS ABBREVIATIONS USED IN THE TEXT APPENDICES A1 Approximate stone surface area with known diameters of the stone A2 Devices for endoscopic disintegration of stones A3 References 4 UPDATE JUNE 2005 .6 Cellulose phosphate 14.8 Recommendations 14.1 References Pharmacological treatment of cystine stone disease 14. 17.1 References 66 66 66 67 72 73 74 74 74 75 75 76 77 77 78 78 15.1 References Pharmacological treatment of infection stone disease 14.2.5 14. 22.214.171.124.
5) have been allocated to the procedures according to the consensus reached. According to the principles set by the European Association of Urology (EAU) Guidelines Office. whereas other statements rely on a substantial clinical experience. However. 24 & 26). UPDATE JUNE 2005 5 . when a certain form of therapy is not recommended.1. Some of the therapeutic principles are the result of evidence obtained from randomized or controlled studies. the scientific basis for the various recommendations or statements has been classified in terms of level of evidence and grade of recommendation when appropriate. 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. the whole field of treatment of patients with urolithiasis has been characterized by changes that are attributable to pronounced technical achievements. When two procedures were considered equally useful they have been given the same number. 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 guidelines and recommendations given below are based on results presented in the modern literature. 16. however. It needs to be emphasized. 2. this has been specifically stated. The first alternative always has the number 1. The optimal clinical management of this disease requires knowledge of the diagnostic procedures. 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.due to the extensive geographical diversity and variability between the financial systems in the health care sector . BACKGROUND Patients with urolithiasis constitute an important part of everyday urological practice. since discussing associated economic issues may be . as such a step was beyond the possibilities of our work. The abbreviations LE and GR are used in the tables and recommendations given in these guidelines. During the past few decades. 18. We are very well aware of the different treatment and technical facilities available geographically. The criteria for level of evidence (LE) (Table 1) and grades of recommendation (GR) (Table 2) are shown below (1). we focused mainly on medical aspects. 22. 3. 4.3). that no attempt has been made to cover the literature completely. 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. an increased understanding of the mechanisms of stone formation and advancements in pharmacological treatment of the various aspects of stone disease. This does not mean that other methods are not applicable. 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. 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. The current edition of Guidelines on Urolithiasis published here is an update of our previously published document (2. such as comparative studies. Numbers (1. When recommendations were formulated.beyond the scope of a European guideline document. the rational treatment of acute stone colic and the modern principles of stone removal. 19. 20.
pdf Tiselius HG. http://www. Edition presented at the 16th EAU Congress. Alken P. REFERENCES US Department of Health and Human Services. 6 UPDATE JUNE 2005 .2. Gallucci M.gov/entrez/query. Alken P. 2. Buck C.2 Specific risk factors for stone formation Risk factors for stone formation are listed in Table 4. Public Health Service.org/files/uploaded_files/urolithiasis.nih. Guidelines on urolithiasis. Ackermann D.40:362-371. http://www.gov/ Tiselius HG. 2. These different categories are useful when making decisions regarding the need for metabolic evaluation and medical treatment (1.ahcpr.ncbi. pp 115-127. Geneva.nlm. 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. Ackermann D. Buck C.3). In: EAU guidelines. 1992.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11713390 2. Eur Urol 2001. Guidelines on urolithiasis. Switzerland 2001 (ISBN 90-806179-3-9).1 CLASSIFICATION Categories of stone formers A system for subgrouping stone-forming patients into different categories is shown in Table 3. Conort P.uroweb. Gallucci M. http://www. Conort P. Agency for Health Care Policy and Research.1 1. 3.1.
i. Epidemiology and medical management of stone disease.33:1-7. BJU Int 2003. Buck C. Conort P.91:758-767.nlm.Table 4: Risk factors for recurrent stone formation • Onset of disease early in life.gov/entrez/query.nih.nlm. 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..3 1.nih.e. Eur Urol 1998.40:362-371. Eur Urol 2001. Ackermann D. Gallucci M. 2. below 25 years of age • Stones containing brushite (calcium hydrogen phosphate. http://www. CaHPO4.gov/entrez/query. Alken P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11713390 3.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12709088 Tiselius HG. UPDATE JUNE 2005 7 .ncbi.ncbi. Guidelines on urolithiasis. Tiselius HG. REFERENCES Tiselius HG. Curriculum in Urology. http://www. caliceal cyst ■ ureteral stricture ■ vesico-ureteral reflux ■ horseshoe kidney ■ ureterocele 2.2H2O) • Strong family history of stone formation • Only one functioning kidney (only one kidney does not mean an increased risk of stone formation. Etiology and investigation of stone disease.
11). In randomized prospective studies. Many urologists also take responsibility for the diagnostic radiological work-up of patients with stone problems.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). 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. 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. given 1 hour before contrast administration. According to the recommendations given by the European Society of Urogenital Radiology (12. Unfortunately. This is an unusual complication caused by retention of dimethylbiguanide. clemastine 2 mg). US = ultrasound.5.1 Unenhanced helical CT A/1 1-10 3. • This medication might be combined with an intramuscular injection of an anti-histamine agent (e.1 Excretory urography Standard 3. contrast medium can be administered. This will immediately help to decide if a conservative approach is justified or if another treatment should be considered. additional information regarding renal function may be obtained by combining CT with contrast infusion. and when the diagnosis of stone is in doubt. Another advantage is the ability of CT to detect alternative diagnoses (7.1 DIAGNOSTIC PROCEDURES Diagnostic imaging Stone disease very often presents as an episode of acute stone colic. which are radiolucent on plain films. the specificity and sensitivity of this method for patients with acute flank pain was found to be similar to that obtained with urography (4. LE = level of evidence. KUB = kidney. • In metformin-treated patients with a normal serum creatinine. However. prednisolone 30 mg) between 12 and 2 hours before the contrast medium is injected. Patients with renal stone colic usually have characteristic loin pain.10). In case of an acute stone colic. It is therefore essential to have a basic understanding of the risks associated with the use of contrast medium and the necessary precautions. Although the intravascular administration of contrast medium is usually a concern for the radiologist. excretory urography (intravenous pyelography.13) the serum creatinine level should be measured in every patient with diabetes being treated with metformin.1 Allergy to contrast medium Where there is a need for administration of contrast medium to patients who have reported allergic reactions (Table 7).. serum creatinine > 130 µmol/L). or in those who are at such a risk.3. lactic acidosis is associated with high mortality and great care needs to be taken when using contrast medium in patients taking metformin. ureters and bladder (KUB) combined with ultrasonography (US). 3.g. Special examinations carried out in selected cases include retrograde pyelography. ureters and bladder urography. 3.3).2.g. particularly in the presence of reduced renal function (i.5-9).. 8 UPDATE JUNE 2005 .. The diagnostic work-up of all patients with symptoms of urinary tract stones requires a reliable imaging technique (Table 5). During recent years. CT = computed tomography. vomiting and mild fever. antegrade pyelography and scintigraphy.e.13): • Always use low-molecular non-ionic contrast medium.1. One great advantage of CT is the demonstration of uric acid and xanthine stones. • Give a corticosteroid (e. the following precautions should be taken (12. 3. 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. An alternative and commonly applied method for evaluating patients with acute flank pain is a plain film of kidneys. and they may have a history of stone disease. 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. In selected cases. IVP) has been established as a gold standard. Imaging is imperative in patients with fever or a solitary kidney. unenhanced helical computed tomography (CT) examinations have been introduced as a quick and contrast-free alternative (1. The clinical diagnosis should be supported by an appropriate imaging procedure. contrast medium is occasionally used as an auxiliary procedure for stone localization during shock wave lithotripsy.1.1 GR = grade of recommendation.
such as non-steroidal anti-inflammatory agents (NSAIDs) and aminoglycosides (the latter should be stopped for at least 24 hours).5 x height(cm)/serum creatinine) x (kg/70)0. the administered dose of iodine should not exceed 80-90 g. or with a reduced renal function.07 GFR = creatinine clearance x 1. Serum creatinine.) .13). without information on the renal function. epigastric pain. UPDATE JUNE 2005 9 .age) x kg/(0. anorexia. diarrhoea and thirst. lactic acid and blood pH should be monitored. Patients with multiple myeloma should either be examined with an alternative method or after adequate hydration. 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).725 x 0. somnolence.007184 In patients with a serum/plasma-creatinine level exceeding 140 µmol/L (1.85 x (140 . lethargy. Table 6: Formulae for calculating glomerular filtration rate (GFR) and body surface area (17) Men: GFR = (140 . medication with metformin should be stopped and administration of contrast medium delayed until 48 hours have passed after the last intake of metformin.73m2 body surface area (12. Treatment with metformin may resume 48 hours after the examination provided that serum creatinine remains at the pre-examination level.82 x serum creatinine) For patients < 20 years. For a patient with a GFR of 80-120 mL/min. The vasoconstriction of glomerular afferent arterioles causes a reduced glomerular filtration rate (GFR) and an increased renal vascular resistance.1.25 and serum lactic acid concentration > 5 mmol/L (14. 3. hyperpnoea.72 hours.• • • In patients with reduced renal function. Symptoms of lactic acidosis are vomiting.age) x kg/(0. When the GFR is reduced to a level between 50-80 mL/min. the dose of iodine should be limited to the same amount as the GFR expressed in mL/min/1.6 mg/100 mL) hydration before and after the use of contrast medium may be beneficial in order to prevent nephropathy. 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.16). 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.73m2 Body surface area = kg0.82 x serum creatinine) Women: GFR = (0. The investigative findings are a blood pH < 7. Table 6 lists useful formulae for calculating GFR and body surface area (17). administration of metformin should be stopped immediately and the patient should be hydrated so that diuresis is > 100 ml/h during 24 hours.2. alternative imaging techniques should be used. In a situation when contrast medium has been administered to a patient on metformin treatment.1.425 x height(cm)0. In a situation where no information on renal function is available.3 Reduced renal function Intravenous administration of contrast medium can bring about a reduced renal perfusion and toxic effect on tubular cells. Dosage of iodine Reduced renal function means that the serum creatinine > 140 µmol/L or that the GFR is < 70 ml/min. Avoid repeated injections of contrast medium at intervals less than 48 (see section 3. the following formula should be used: Creatinine clearance = (42.
nlm. 4.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11930053 Homer JA.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12913701 Sudah M. REFERENCES Smith RC. Ogura K. Abdulmaaboud M.13 13 13-16 13 Comment 3. Verga M. J Urol 2002.165:1082-1084.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9836541 Dalrymple NC.nih. Donovan MS.168:2457-2460.1. Sears ST.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12441939 Miller OF.ncbi. http://www.1. Partanen K. Graham IR.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11531750 Shokeir AA. Choe KA. Contrast medium should not be given unless these patients are appropriately treated.1 3. http://www. http://www.223:98-105. Aus Radiol 2001.nlm. J Urol 1998. Covey AM. Glickman MG.nlm. Acute flank pain: Comparison of non-contrast-enhanced CT and intravenous urography. 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. J Urol 2001. Prospective comparison of unenhanced computed tomography and intravenous urogram in the evaluation of acute flank pain.1. Malinen A. 9.gov/entrez/query.ncbi.1.52:982-987. Smith RC.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7862980 Smith RC. Prospective comparison of computerized tomography and excretory urography in the initial evaluation of asymptomatic microhematuria.nih.4 Untreated hyperthyroidism For patients in whom hyperthyroidism is suspected the TSH (thyroid stimulating hormone) level should be assessed before use of contrast medium. Vanninen RL. Peddinti BS. McCarthy S. 8. Essenmacher KR.ncbi.nih. The value of unenhanced helical computerized tomography in the management of acute flank pain. Kane CJ.nih.194:789-794. Nishizawa K. 7. Patients with acute flank pain: comparison of MR urography with unenhanced helical CT. Ward JF.gov/entrez/query. 3.gov/entrez/query. 10 UPDATE JUNE 2005 . Clinical characteristics of ureteral calculi detected by non-enhanced computerized tomography after unclear results of plain radiography and ultrasonography.gov/entrez/query. Verga M. Kane CJ. http://www.nih. Rineer SK. Diagnosis of acute flank pain: value of unenhanced helical CT.159:735-740 http://www. http://www.3. Lange RC.ncbi.ncbi. Radiol 2002.ncbi. Table 7: Considerations regarding excretory urography LE 4 3 3 Selected references 12.170:799-802.1. Rosenfield AT. Amling CL.nih. Anderson KR. Rosenfield AT. Bove P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8571915 Kobayashi T. Urology 1998.gov/entrez/query.nlm. Prospective comparison of non-enhanced helical computerized tomography and Doppler ultrasonography for the diagnosis of renal colic.ncbi. Am J Roentgenol 1996. Goff WB. Heino A. Puckett MF. 6. Ala-Opas M.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11257642 Gray Sears CL.ncbi.166:97-101.nih. Verga M.5 1. http://www.nlm.nlm.2 3.gov/entrez/query.nlm. Davies-Payne DL. Buckley RG. Watanabe J.nlm. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9474137 2. Randomized prospective comparison of non-contrast enhanced helical computed tomography and intravenous urography in the diagnosis of acute ureteric colic.3 Contrast medium should not be given to. http://www.45:285-290. Reichard SR.nih. Rosenfield AT.1.gov/entrez/query.gov/entrez/query.gov/entrez/query.1 3. Radiol 1995. 5. J Urol 2003. Kainulainen S.
ncbi. http://www.gov/entrez/query.11:1720-1728.gov/entrez/query. Unenhanced helical CT evaluating acute abdominal pain: a little more cost.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1244564 Tepel M.343:180-184. An appropriate quantitative or semi-quantitative analysis of the stone material should enable conclusions to be drawn regarding the main constituent or constituents. 14. McHardy K. ask for urease-producing microorganisms). http://www. Gilbert FJ. All patients should have at least one stone analyzed. http://www. N Eng J Med 2000. can be expected to have influenced the stone composition. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9915507 Thompson NW. BJU Int 2000.ncbi.ncbi. Thomsen HS. Contrast Media Safety Committee of the European Society of Urogenital Radiolology. When stone(s) or stone material have not been retrieved. or any other cystine test). 13. http://www. Nephron 1976.85:219-221. high in patients with infection stones). Cleveland T. Prediction of creatinine clearance from serum creatinine. Br J Radiol 2003. Love MH. Schwarzfeld C. Radiol 1997.nlm. Metformin and contrast media . 16. Contrast media and the kidney: European Society of Urogenital Radiology (ESUR) guidelines. J Urol 2003. Editorial: Choosing imaging modality in 2003. • Serum urate (in cases where a uric acid or urate stone is a possible alternative).nih.nih. The preferred analytical procedures are X-ray crystallography and infrared spectroscopy.fcgi?cmd=Retrieve&db=pubmed&dopt Abstract&list_uids= 10671870 Cockcroft DW. Morcos SK.nih. 18.a dangerous combination? Clin Radiol 1999.gov/entrez/query. Laufer U. Thompson TJ. Drugs and intravenous contrast media. Webb JA. or excreted as fragments following disintegration.nlm. http://www.nlm.nlm.170:803.2 Analysis of stone composition Stones that pass spontaneously.nlm. 12.nih..gov/entrez/query. • Urine pH (low in patients with uric acid stones. Prevention of radiographiccontrast-agent-induced reductions in renal function by acetylcysteine.nlm. Mindelzun RE. Prevention of generalized reactions to contrast media: a consensus report and guidelines.nih. Jeffrey RB.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9314959 Shinokara K. dietary habits. Van der Giet M. Gaines PA.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10900277 3. http://www.53:342-344. 11.ncbi. 15.g.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9630271 McCartney MM. Chan P. Eur Radiol 2001. Clin Radiol 1998. Pearson D. 17. are removed surgically.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12893691 Nawaz S.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12913702 Morcos SK. Clinical risk associated with contrast angiography in metformine treated patients: a clinical review. Zidek W.54: 29-33.nih. http://www. Repeated analysis is indicated when any changes in urine composition.10. Brand’s test (6). • Radiographical characteristics of the stone. a lot more information.ncbi.ncbi.gov/entrez/query.nih. UPDATE JUNE 2005 11 . sodium nitroprusside test.ncbi.gov/entrez/query.gov/entrez/query.nih.gov/entrez/query. due to medical treatment. should be subjected to stone analysis to determine their composition (1-5). conclusions on stone composition may be based on the following observations: • Qualitative cystine test (e. • Demonstration of crystals of struvite or cystine upon microscopic examination of the urinary sediment. http://www. environment or diseases. Gault MH. Liermann D.76:513-518.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11511894 Thomsen HS.ncbi. Murchinson LE. Young MR.gov/entrez/query. Murray AD.nlm. • Bacteriuria/urine culture (in the case of a positive culture.16:31-41.ncbi.205:43-45.nlm.
nih. Scand J Urol Nephrol 1983. J Clin Chem 1980.ncbi. Observations on the analysis of ten thousand urinary calculi. J Urol 1962. 3. Urol Res 1990. • White cells and bacteria (nitrite).98:31-36.nlm. Infection stones have the following typical constituents: • Magnesium ammonium phosphate • Carbonate apatite. Biloon S.fcgi?cmd=Retrieve&db=PubMed&list_uids=13954078& dopt=Abstract Daudon M..nih. 6.fcgi?cmd=Retrieve&db=PubMed&list_uids=6867630&dopt= Abstract Leusmann DB.ncbi. http://www.nih.gov/entrez/query. xanthine and various drug metabolites (e. 2004.1 Analytical work-up in the acute phase For patients with an acute stone episode.1 1. Crystalline composition of urinary stones in Norwegian patients.nlm.3.2. Blaschke R. Cystinuria: Excretion of cystine complex which decomposes in the urine with the liberation of cystine.gov/entrez/query.g.ncbi. 2. REFERENCES Asper R.3 Biochemical investigations 3.18(Suppl):9-12.fcgi?cmd=Retrieve&db=PubMed&list_uids=2237297&dopt= Abstract Brand E.nih.ncbi. Nephron Physiol.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.8-dihydroxyadenine.88 545-562. http://www.nlm.nlm. and a blood white cell count and urine culture carried out.ncbi. Clinical value of crystalluria and quantitative morphoconstitutional analysis of urinary calculi.nlm. 5. Scand J Urol Nephrol 1990. uric acid/urate stones and cystine stones associated with infection are referred to as ‘stones with infection’. Calcium stones.gov/entrez/query. • Approximate pH level. C-reactive protein (CRP) should be assessed.24:205-210. 3. Less common stone constituents include 2.nih. http://www. the routine laboratory investigations should include: • Urinary sediment/dipstick test for demonstration of red cells. Stone analysis. 3. Harris MH. Jungers P.fcgi?cmd=Retrieve&db=PubMed&list_uids=2291252&dopt= Abstract Herring LC.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15499212 Otnes B. 12 UPDATE JUNE 2005 . indinavir). 4. In cases of fever. The following stones not associated with infection are referred to as uric acid/urate stones: • Uric acid • Ammonium urate • Sodium urate.gov/entrez/query.035 stone analyses: a contribution to epidemiology of urinary stone disease. Results of 5. • Serum creatinine should be analyzed as a measure of the renal function.gov/entrez/query.17:85-92. http://www. http://www.86:315. sulphonamide. Schwandt W.
HCl also counteracts the oxidation of ascorbate to oxalate. 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. Two urine collections for each set of analyses are recommended. In this respect. Urate can be analyzed in samples collected with sodium azide. The stone. A number of alternative collection options are feasible. 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. a sample collected with sodium azide is useful.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. serum sodium and serum potassium levels should be measured. pH Cystine.2 Analysis of urine in search for risk factors of stone formation For an identification of metabolic risk factors of stone formation. with a few examples listed in Table 8. A collection of urine without HCl is necessary for pH measurement.00 and 22. uric acid precipitates and has to be dissolved by alkalinization if urate excretion is of interest. UPDATE JUNE 2005 13 . In order to avoid the need for future repeated blood analyses in the search for metabolic risk factors.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. 3. The urine collections are repeated when necessary (1-3). Rmo. plasma) and urine analyses recommended for such patients are shown in Table 10. an analytical programme for the different categories of stone formers is shown in Table 9. blood (serum.00 hours in a bottle containing 10 mL of 0. 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 Creatinine Yes (see Table 10) Yes (see Table 11) Yes (see Table 10) Yes (see Table 11) Yes (see Table 11) Urine analysis Culture.In cases of vomiting. Table 3). 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 06.3. In acidified samples.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. pH Urate. it might be helpful to assess levels of serum calcium and serum urate at this point in time.
Urine culture in case of bacteriuria.5 Urea2. phosphate. Optional analysis. First-time stone formers with residual fragments may also be considered in this respect (categories: Rs.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. blood and urine analyses recommended for these patients are shown in Table 11 (4-12). with or without residual fragments or stones in the kidney or specific risk factors. Urea. the remaining 8 hours of the 24-hour period can be used to collect urine with sodium azide for analysis of urate. helpful in suspected uric acid/urate stone disease. Blood analysis Calcium Albumin1 Creatinine Urate2 1 2 3 4 A patient with complicated stone disease has a history of frequent recurrences.5 Sodium2. or has not been. Sres. Cystine test if cystinuria cannot be. sodium and potassium measurements are used to assess the dietary habits of the patient. urate has to be analyzed in a sample that has not been acidified or following alkalinization to dissolve uric acid. As uric acid precipitates in acid solutions. When a 16-hour urine sample has been collected in a bottle with an acid preservative. 24-hour urine.5 Potassium2. 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. The stone.4. Blood analysis Calcium Albumin1 Creatinine Urate2 1 2 3 4 5 6 14 UPDATE JUNE 2005 . Table 3). 16-hour + 8-hour urine or any other collection period can be chosen provided normal excretion data are available (4-7). excluded by other means. or direct analysis of ionized (free) calcium. Rm-res. A spot urine sample can be used with creatinine-related variables (7).4 Phosphate2. such as AP(CaOx) index and AP(CaP) index (8-12). 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). Optional analysis. 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. 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 Magnesium2.5 Creatinine Volume Either analysis of calcium + albumin to correct for differences in calcium concentration attributable to the albumin binding.
9 is specific for the 24-hour period. A relationship between abnormalities in urine composition and severity of calcium stone formation has been demonstrated (38-44). this factor is 2. A pH above 5.12 x V-1. A fasting morning urine sample (or a spot morning urine sample) should be used to measure pH (25). 4 hours or even spot urine samples.9 x Ca0. Various collection periods.29). the reader should consult reference 5. phosphate. For a 16-hour urine sample. • To prevent the in-vitro oxidation of ascorbate to oxalate (28. 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.4. The following urine variables can be analyzed in the acidified sample: calcium. In this regard it needs to be emphasized that whereas a uric acid stone is usually invisible on a plain film (KUB). citrate and phosphate has to be acidified. the diagnosis of HPT should be established or excluded by repeated calcium analyses and assessment of the parathyroid hormone level (19-24). In those patients in whom a stone analysis has not been carried out.8 x Cit-0. Ox.20 x V-1. but this test is not often used clinically today (13). magnesium. It should be noted that although individual abnormal urine variables might indicate a risk of stone formation. The reasons for this acidification are: • To maintain calcium.84 x Ox x Cit-0. it is the concerted action of the various urine constituents which result in supersaturation and crystallization of the stone. In the case of a high calcium concentration (> 2.3 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.3.3. 8 The AP[CaOx] index approximately corresponds to 10 x APCaOx (where APCaOx is the ion-activity product of calcium oxalate). during and after the collection period. a high serum urate level together with a radiolucent stone support the suspicion of a uric acid stone. oxalate. bacteriuria and cystinuria can be excluded or confirmed by an appropriate test (27). 12 hours. 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. It might occasionally be useful to carry out a calcium loading test. the urine volume (V) is expressed in litres and the urine variables (Ca. The additional analytical work-up in patients with calcium stone disease is summarized in Table 12. citrate.8 in fasting morning urine raises the suspicion of incomplete or complete renal tubular acidosis (RTA) (26). chloride and potassium.22 x Mg-0. Factors for other collection periods can be found in reference 5.60 mmol/L). The protein intake can be derived from the urea excretion (Uurea. oxalate. Although the creatinine concentration might be slightly affected. In the same fasting morning or spot urine sample. Cit.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. Mg. The recommendation to collect two urine samples is based on observations that such an approach will increase the likelihood of detecting urine abnormalities.07 x P0. urea. The factor 1.70 x (pH . such as for 24 hours. oxalate.31 The AP[CaP] index approximately corresponds to 10 x APCaP (where APCaP is the ion-activity product of calcium phosphate). preferably with HCl.03 In this formula. sodium. calcium. The AP[CaP] index for a 24-hour urine sample is calculated in the following way: AP[CaP] index = 2. 17 hours. The aim of adding serum potassium to the analytical programme is to obtain further support for a diagnosis of suspected RTA. magnesium) in mmol excreted during the collection period. are useful for this purpose provided a set of normal values is available for the collection period (4-7). • To prevent bacterial growth and the associated alteration of urine composition.3. It must be emphasized that the urine sample used for analysis of calcium. For other collection periods. 15 UPDATE JUNE 2005 15 . oxalate and phosphate in solution.5)6. The optional analysis of urea. 16 hours. phosphate and sodium helps to reflect dietary factors of therapeutic significance.7 x 10-3 x Ca1. citrate. it is clearly demonstrated with a CT examination. Hypokalaemic hypocitraturia may be one reason for therapeutic failures in patients treated with thiazides. mmol/L) and urine volume in litres (V) as follows (30): Intake of protein (gram) during the 24h period = (Uurea x 0.
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fcgi?cmd=Retrieve&db=PubMed&list_uids=8126804&dopt= Abstract Mitch WE. Am J Med 1982.86:315.155:1186-1190.158:352-355. Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. Guarneri A.nlm. A prospective study.nih. Lunz C. Kladensky J.nlm. http://www. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis patients.nlm.nih.41:159-162.nlm. Liedl B.nlm. Lacour B. http://www.nlm. J Urol 1994. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy. Effectiveness of ESWL for lowerpole caliceal nephrolithiasis: evaluation of 452 cases.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8254832&dopt= Abstract Fine JK.315:970-971.gov/entrez/query. J Urol 1995. http://www.ncbi.gov/entrez/query.26.nih.nih.gov/entrez/query. Streem SB. Jelinek P. Pak YC. 41.gov/entrez/query.gov/entrez/query. Seveso M. Walser M. Bildon S. 29. http://www.nih. J Urol 1997.ncbi.gov/entrez/query. Metabolic abnormalities in patients with caliceal diverticular calculi. 31. Bub P.nlm. Turjanica M. Factors influencing the course of calcium oxalate stone disease. J Biol Chem 1930. Gambaro G.nlm.72:17-24. Nutritional therapy of the uremic patient.fcgi?cmd=Retrieve&db=PubMed&list_uids=9355942&dopt= Abstract Tiselius HG. http://www. Gault MH. Kidney Int 2005. J Urol 1996. Deutsch L. http://www. http://www.ncbi. J Endourol 1997.gov/entrez/query. 36. 3rd ed.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7058820&query_hl=5 Hsu TH.nih.ncbi.67:1934-1943.nih. http://www. Urol Res 1988.nlm. http://www.11:305-307.nih.6:217-218.16:256. Trinchieri A. Merlo F. 37.nih.153:27-32. http://www. Eur Urol 1999. pp 1759-1790.fcgi?cmd=Retrieve&db=PubMed&list_uids=3762602&dopt= Abstract Wandzilak TR. Serial crystalluria determination and the risk of recurrence in calcium stone formers. McWhinney BC. 35. Kumstat P. First morning urine pH in the diagnosis on renal tubular acidosis with nephrolithiasis. 33. Mascha E.gov/entrez/query. Abstract. Eisenberger F.nlm. 32. 34.gov/entrez/query. Williams HE. Chalmers AH.nlm. 27. 30.gov/entrez/query. J Urol 1998. D’Andre SD. Schmidt A. Hanak T.fcgi?cmd=Retrieve&db=PubMed&list_uids=8187359& dopt=Abstract Brand E. In: The kidney. Jungers P.nih. Saunders: Philadelphia. 28. Anselmo G. Schuster C.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9783922&query_hl=7 Daudon M. http://www.151:834-837.151:5-9.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15840041&query_hl=10 18 UPDATE JUNE 2005 . Renal stone fragments following shock wave lithotripsy. Cystinuria: excretion of a cystine complex which decomposes in the urine with the liberation of free cystine. http://www. 39.fcgi?cmd=Retrieve&db=PubMed&list_uids=7966783&dopt= Abstract Streem SB. Del Nero A. Clin Nephrol 1994. Cicerello E. Yost A.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224301&dopt= Abstract Pacik D. Factors that predict the relapse of calcium nephrolithiasis during treatment. http://www. 40.ncbi. Hennequin C. J Endourol 1992. Harris MM. 38. Coxley DM.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516443&query_hl=1 Robertson WG.ncbi.36:363-370. Nespoli R. Vol II. Parks JH.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12957848&query_hl=3 Strauss AL. Front Biosci 2003.nih. 1986. Baggio B. Brenner BM. Long-term results in ESWL-treated urinary stone patients.ncbi.ncbi. Maccatrozzo L. Davis PA. 42.nlm. Rector FC Jr (eds).ncbi. Chafe L. Montanari E. Coe FL. J Urol 1994.nih. The fate of residual fragments after extracorporeal shock wave lithotripsy. Boujelben G. Brown JM. Preminger GM. Fandella A.8:1330-1338.nih.32:2073-2074 and 1986. Effect of high dose vitamin C on urinary oxalate levels.ncbi. Enteric hyperoxaluria and urolithiasis.gov/entrez/query. A risk factor model of stone formation.gov/entrez/query. 160:1640-1642.ncbi. Jocham D.fcgi?cmd=Retrieve&db=PubMed&list_uids=8632527&dopt= Abstract Zanetti G. N Engl J Med 1986.
the stone volume can be calculated by the formula below (2): Volume = 0. 5. 5. With knowledge of the surface area. 5. A notation of the largest diameter is the most common way of expressing size in the literature. Calculation of stone volume and urinary stone staging with computer assistance.nlm.nih.25 For a quick estimate of the stone surface area. Dunthorn M. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7637098&query_hl=12 Raj GV. J Endourol 2004.ncbi.nlm. 2.1 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.1 TREATMENT OF PATIENTS WITH RENAL COLIC Pain relief The relief of pain is usually the most urgent therapeutic step in patients with an acute stone episode. Crystallization properties in urine from calcium oxalate stone formers. Griffith DP. 43:275-281.nih. J Urol 1995.18:157-161. REFERENCES Tiselius HG.gov/entrez/query.e.3:355-359. With knowledge of the length (l) and the width (w). Tiselius HG. 4.1. Preminger GM. 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. placebo-controlled study. J Endourol 1989. Andersson A. we have based our recommendations on the stone surface area as well as on the largest stone diameter.1 1.6 x SA1.. 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.nih. Auge BK. The surface area can also be measured using computerized systems and from CT scans. i. an appropriate estimate of the stone surface area (SA) can be obtained for most stones (1): SA = l x w x π x 0. 44. Finlayson B.ncbi. please refer to Table A1 (Appendix). http://www. Bek-Jensen H.27 In this guideline document.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12600431 Ackermann D.gov/entrez/query. UPDATE JUNE 2005 19 .nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15072623&query_hl=15 4. Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys.gov/entrez/query. but these are not always easy procedures. STONE BURDEN The size of a concrement (stone burden) can be expressed in different ways.154:940-946. Nilsson MA.43. Fornander AM. the length of the stone as measured on the plain film. Assimos D.ncbi. the efficacy of diclofenac (2) was clearly demonstrated. http://www. In another double-blind. Newman RC.
double-blind. Passage of the stone and normalization of renal function should be confirmed using appropriate methods. Kral LG. Treatment of ureteral colic by prostaglandin-synthetase inhibition with diclofenac sodium. Prostaglandin-synthetase inhibition of diclofenac sodium in the treatment of renal colic: comparison with use of a narcotic analgesic.1. Oral diclofenac in the prophylactic treatment of recurrent renal colic. taking account of the side-effects. Fagertun HE. Wåhlander LA.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6122892 Lundstam SO. Comment: In France. ketoprofen is the only drug approved for the treatment of renal colic. no differences were recorded between the two substances (3).ncbi. Lancet 1982. 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. Moreover.3 with normal renal function Diclofenac sodium is recommended as a method to counteract recurrent pain after 1b/A 5 5.nlm.1. Analgesic effect and tolerance of ketoprofen and diclofenac in acute ureteral colic. The effect was most pronounced in the first 4 treatment days (5).fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8529732 Lundstam SO. Scand J Urol Nephrol 1993. Eur Urol 1995. When pain relief cannot be obtained by medical means.nih. Hydromorphone and other opiates without simultaneous administration of atropine should be avoided because of the increased risk of vomiting. 50 mg administered twice daily over 3-10 days. Ommundsen OE. but not in patients 2a 6 5.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8290910 2. GFR = glomerular filtration rate. http://www.1.28:355-358. 4. A double-blind comparison with placebo. morphine chlorhydrate (with titration) is indicated.gov/entrez/query.28:108-111. For patients with ureteral stones that are expected to pass spontaneously. Gronseth JE. The patient should be instructed to sieve the urine in order to retrieve a concrement for analysis. 1096-1097. REFERENCES Laerum E.nih. comparative study. http://www. Leissner KH. Kral JG.1 Diclofenac sodium affects GFR in patients with reduced renal function. 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.When diclofenac was compared with ketoprofen in a randomized. NSAID = non-steroidal anti-inflammatory drug. might therefore be useful in reducing the inflammatory process and the risk of recurrent pain.nih.gov/entrez/query.ncbi.gov/entrez/query. Lahtinen J. 20 UPDATE JUNE 2005 .2 an episode of ureteral colic LE = level of evidence. GR = grade of recommendation.2 Prevention of recurrent episodes of renal colic In a double-blind.nlm. drainage by stenting or percutaneous nephrostomy (PN) or by stone removal should be carried out. 5. the resistant index was reduced in patients with renal colic when NSAID treatment was given (4). Curr Ther Res 1980. this is not the case for normally functioning kidneys (6).ncbi. http://www. placebo-controlled trial. Wåhlander LA.27:323-325. Elvander E. suppositories or tablets of diclofenac sodium. In case of contraindication (pregnancy) or allergy to non-steroidal anti-inflammatory drugs. 5. Walden M.2 1.1. The recommendation is to start with diclofenac whenever possible (Table 13) and change to an alternative drug if the pain persists.1. 5. Christiansen A. 3.nlm.3 Effects of diclofenac on renal function Although the renal function can be affected in patients with an already reduced function.
ncbi. A narrow caliceal neck may require dilatation.nlm. Awad RM. Fadilla M. http://www. site and shape of the stone at the initial presentation are factors that influence the decision to remove the stone (Table 14).fcgi?cmd=Retrieve&db=PubMed&list_uids=13394022&dopt =Abstract Morse RM.gov/entrez/query.ncbi.nih. GR = grade of recommendation 6.145:263-265. 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. Kane CJ. http://www. 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 mm.nlm. Spontaneous stone passage can be expected in up to 80% in patients with stones < 4 mm in diameter.nih. Hafner R. Resistive index in renal colic: the effect of nonsteroidal anti-inflammatory drugs. REFERENCES Sandegard E. http://www. Patel KP.nih.gov/entrez/query. Shelty SD. http://www. It should also be observed that small stones (< 6-7 mm) residing in a calix can cause considerable pain or discomfort (6-12). Garty M. Ureteral calculi: natural history and treatment in an era of advanced technology.(Suppl 219):1-67. UPDATE JUNE 2005 21 . Resnick MI. INDICATIONS FOR ACTIVE STONE REMOVAL The size. BJU Int 1999. http://www. Comparison of ketorolac and diclofenac in the treatment of renal colic.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10468715 6. Abdulmaaboud M.84:249-251.nih. 4.nlm.gov/entrez/query. Acta Chir Scand 1956. Rotenberg Z. 6. • Distal ureteral stones: 70%. For stones with a diameter > 7 mm. The likelihood of spontaneous passage must also be evaluated. Eur J Clin Pharmacol 1998. http://www. Prognostic factors in the conservative treatment of ureteric stones.gov/entrez/query.gov/entrez/query.nlm. 3.162:688-691.67:358-361.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9776434&dopt= Abstract Shokeir AA. Br J Urol 1991.ncbi. LE = level of evidence.1 1.fcgi?cmd=Retrieve&db=PubMed&list_uids=1988715&dopt= Abstract Ibrahim AI.54:455-458. Mutabagani H. J Urol 1999. Farage Y. Time to stone passage for observed ureteral calculi: a guide for patient education.nih. Cohen E. J Urol 1991.fcgi?cmd=Retrieve&db=PubMed&list_uids=2032074&dopt= Abstract Miller OF. Such stones should be removed with a technique that is as little invasive as possible.5. • Mid-ureteral stones: 45%.fcgi?cmd=Retrieve&db=PubMed&list_uids=10458343&dopt =Abstract 2. Prognosis of stone in the ureter.ncbi. The overall passage rate of ureteral stones is: • Proximal ureteral stones: 25%.ncbi.nlm. the chance of spontaneous passage is very low (1-4).nih.nlm.ncbi.
Small renal caliceal calculi as a cause of pain. Even the indications for stone removal were modified when shock wave lithotripsy was introduced. Management of painful caliceal stones by extracorporeal shock wave lithotripsy. Sylven M.gov/entrez/query. All these factors give an efficacy that is the same as. Porpaczy P. however. 8. 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. 6. but also of all the diagnostic and ancillary procedures associated with ESWL treatment.nih. http://www. There are no clearly established rules on how often ESWL sessions can be repeated.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2261935 Hübner W. in the vast majority of cases. in comparison with the Dornier HM3-lithotripter. 7. severe skeletal malformations. because of their smaller focal volumes.ncbi. severe obesity and aortic and/or renal artery aneurysms (1. the contraindications to ESWL treatment are restricted to pregnancy. 22 UPDATE JUNE 2005 . the development of lithotripters. The latter factor probably has become more important with later generations of lithotripters. Treatment of painful caliceal stones. Lee YH. Painful caliceal calculi. Kvist Kristensen J.ncbi. part of a uroradiological table which allows the application of not only ESWL treatment.27:75-76.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2393803 Streem SB.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8493473 7. the intrarenal position and chemical composition of the stone are determinants of the treatment results.ncbi. http://www. When repeated treatments are necessary. Eur Urol 1990. Chang LS.nlm. Currently.ncbi.66:9-11.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1507327 Brandt B. J Urol 1992.ncbi.nih.nlm. Dretler SP. Lingeman JE. 11. In addition to the size of the stone.nih. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended followup. 9. Lange P.138:707-711.nlm. In the case of infected stones or bacteriuria.nih. Yost A. J Urol 1987.nlm. Andersson L. A pacemaker is.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3116280 Coury TA. Ostri P. http://www. Kahnoski RJ.gov/entrez/query.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. Modern lithotripters are smaller and.gov/entrez/query. Chen MT. antibiotic therapy should be given before ESWL treatment and continued for at least 4 days after the treatment.18:211-214. ESWL should not be carried out in patients with uncontrolled blood coagulation or uncontrolled urinary tract infection.gov/entrez/query.gov/entrez/query. It is reasonable to assume.nlm. not a contraindication.nlm. 7. that the interval between two successive sessions must be longer for electrohydraulic and electromagnetic lithotripsy than for treatments with piezoelectric equipment. 10. http://www. as well as modified indications and principles for treatment. 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. Br J Urol 1990.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6887409 Psihramis KE. Treatment of caliceal calculi.32:119-123.nih.nih.2). Numerous authors have addressed this issue in recent years (3-12). Sonda LP.130:752-753. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. Huang JK. http://www.gov/entrez/query. 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 recommended that the number of ESWL sessions should not exceed three to five (dependent on the lithotripter used).ncbi. Generally. have changed the type and rate of complications.gov/entrez/query. otherwise a percutaneous lithotripsy might be considered as a more rational option. but at a lower cost and with greater versatility. Scand J Urol Nephrol 1993.5.148:1043-1046.nih. J Urol 1983. for example.ncbi.nlm. This has led to the conclusion that large stones are better treated with a percutaneous approach (see below). http://www. Urology 1988. however. or superior to. http://www. Moreover. that of the first lithotripters on the market.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3400135 Lee MH. The treatment of small nonobstructing caliceal calculi in patients with symptoms.
however. It has been observed that the lower calices are insufficiently cleared of disintegrated stone material in up to 35% of ESWL-treated patients. 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. 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. There are some reports indicating that ESWL is also useful in patients with medullary sponge kidneys (tubular ectasia) and nephrocalcinosis (18. In the horseshoe kidney.2 ESWL for removal of large renal stones ESWL for the treatment of large renal stones often causes problems. 7. In case of fever lasting for a few days. Moreover. There is no consensus on the maximum number of shock waves that can be delivered at each session. 7.2.5% (2152). A faster clearance of upper pole stones has been observed.1. In a series of 35. the risk of damage is most pronounced with treatments directed towards stones in the kidney. leading to a risk of obstructive pyelonephritis. The success rate depends mainly on the lithotripter used and varies between 53% and 60%. It might. Almost since the introduction of ESWL. In ectopic kidneys. without any particular side-effects (20). This usually prevents obstruction with loss of ureteral contraction.55). In one treatment series the incidence of auxiliary procedures was reported to be 24% and the re-treatment rate 27% (15). Such fragments either emerge from stones originally found in this part of the kidney or from stones at other locations. and shorter intervals between treatment sessions are usually acceptable for stones in the ureter. This number again depends on the type of lithotripter and the shock wave power used. • Composition and hardness of the stone (53). the efficacy of ESWL is strictly related to the position of the kidney. it is well recognized that most residual fragments are lodged in the lower caliceal system. the obstructive and infective complications after ESWL due to large renal stones are reduced. Sometimes. Stone particles may pass easily along stents while urine flows in and around the stent. Some authors claim that percutaneous surgery is the treatment of choice for these patients (16. however.255 cases. In view of the numerous lithotripters presently in use it is not possible to give a general recommendation in this regard. the incidence of stones is around 20%.19). satisfactory disintegration was recorded in 32. Insertion of the stent before ESWL is advocated for stones with a diameter > 20 mm (54.17). which is 92%. Frequent complications are pain. even when ultrasonography does not reveal any dilatation. One factor that might affect the result of ESWL treatment is the presence of anatomical abnormalities. hydronephrosis. UPDATE JUNE 2005 23 . a PN tube is necessary.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. the efficacy of ESWL is similar to that in normal kidneys and well tolerated.100 patients treated for kidney stones with ESWL. It is still unknown why stones preferentially develop in the lower pole calices. although the accumulation of fragments in this position is most probably due to the effect of gravity.1. fever. The need of auxiliary procedures in these patients is high. with one study showing that only 50% of the patients were stone-free at 3-months follow-up (14). This is an important issue because a large number of kidney stones are located in this part of the kidney.Moreover. It stands to reason. and occasional urosepsis due to difficulties in passage of stone particles especially in case of insufficient disintegration (53-58). there has been a continuous debate on the best way to treat stones in the lower calix. The following factors are crucial with respect to treatment success: • Location of the stone mass (pelvic or caliceal). stents are not efficient in draining purulent or mucoid material. By using a double-J stent. • Total stone burden. Clinical experience supports this view. 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. 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. • State of contralateral kidney: nephrectomy or functionless kidney on the other side. In transplanted kidneys. The stone-free rate in these patients was 70% with re-treatments in 10. that the interval should be determined by the energy level used and the number of shock waves given.
It might be relevant to note that a previous percutaneous procedure in one study (69) was considered as a negative determinant of fragment clearance. ESWL can still be considered an option for treatment. with success rates of 71-96% and acceptable morbidity and complications. For larger stones. The invariance and morbidity of PNL undoubtedly needs to be taken into account.63) have a negative influence on fragment clearance. With ESWL monotherapy (only stent).or struvite-containing stones provides reasonable results in terms of stone removal and complications (58). and in one report the authors even noted that the clearance of fragments was better with an infundibulopelvic angle below.69). The latter is much more susceptible to shockwaves than the first one (72). Today most authors consider a largest stone diameter of 20 mm as a practical upper limit for ESWL. Stones composed of uric acid and calcium oxalate dihydrate have a better coefficient of fragmentation than those composed of calcium oxalate monohydrate and cystine. a long calix neck or a narrow calix can undoubtedly counteract elimination of fragments. 7. The success rate for larger stones was only 43% after 3 months with ESWL monotherapy.2 Stone burden Although the problems associated with removal of stones from the kidney increases with the volume of the stone. as well as the infundibulum length and width. For cystine stones with a diameter less than 15 mm. ESWL should be considered to be the first choice for treatment. It is important to note that there are two types of cystine stone morphology: smooth and rough. the size of the stones has been found to be the most important determining factor (64. possibly combined with ESWL. About 1% of all patients treated for urinary tract stones by ESWL have cystine stones.3 Composition and hardness of the stone ESWL monotherapy of large calcium.1. The recommended upper size limit for ESWL in this document is 20 mm (300 mm2). it is difficult to formulate specific guidelines on how to remove stones from the kidney. the results are contradictory and there is no strong evidence that these variables can be used to predict the outcome of ESWL. Although an acute angle. ESWL as monotherapy is currently not recommended. no such relationship has been demonstrated (64-69). It appears that an area of 40 x 30 mm (940 mm2) could represent an upper limit for ESWL alone. despite the lower clearance of fragments. 7. respectively (8). that the risk of complications of the combined treatment or PNL alone is higher than for ESWL monotherapy.69). It is of note. but larger stones are also successfully treated with ESWL in some centres. 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.67. In the case of a solitary kidney. ESWL monotherapy provided satisfactory results only in patients with pelvic stones smaller than 1 cm. several authors have concluded that an acute infundibulum angle (59-63). This conclusion was based both on observations in a randomised prospective study comparing ESWL and PNL (66) and in a multivariate analysis (64). is an effective treatment for all other patients with cystine stones (70. ESWL after PNL seems to be more effective than PNL after ESWL.2. 70° (68). a figure that dropped to 40% when the diameter exceeded 20 mm (9). however. At least for stones with a largest diameter of 20 mm (surface area ~ 300 mm2).1. even if the stone has an area larger than 40 x 30 mm (57). for cystine stones with a diameter greater than 15 mm.56).71). Success rates for these two groups of stones were shown to be 38-81% and 60-63%.63) and/or a narrow infundibulum (59-61. ESWL is the recommended treatment. The indication for open stone surgery has become extremely rare because of the invasiveness of this approach (55.66. Below this size. 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. 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). 24 UPDATE JUNE 2005 . however. the problem might be more rationally solved using PNL.By taking measurements of the infundibulopelvic angle. Thus. Another factor that most certainly is of great importance is the less well-understood caliceal physiology (63. Patients with large cystine stones need up to 66% more ESWL sessions and shock waves to reach satisfactory results in comparison with other stone patients (70). rather than above. Instead of multiple ESWL sessions. In other studies. the combination of PNL and ESWL (sandwich approach) has emerged as a solution. provided the pros and cons are clear.2. Stone composition can be an important factor in the disintegration and subsequent elimination of fragments. a long infundibulum (59. In the absence of a geometrical explanation. However. it might be feasible to try ESWL monotherapy first. In the treatment of stones with an area larger than 40 x 30 mm. there is no clear cut-off for a critical stone size. a stonefree rate of about 71% was reported. PNL. particularly when the stones become larger. Several authors have shown that a better stone-free rate can be obtained with PNL.
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To reduce the number of residual fragments.2 Percutaneous removal of renal stones Principally. While the value of mini-perc in adults has not been determined. 13:235-41. The most frequently used access site is the dorsal calix of the lower pole. dilatation and instrumentation. calcium monohydrate. Bleeding is generally avoided by an anatomically oriented access. large bowel. However. 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). Prien EL Jr. Lingeman JE.2. CT-guided renal access may be an option (3). calcium oxalate. Venous bleeding stops in most cases when the nephrostomy tube is clamped for some hours. treatment time increases with stone size. However.2). 7. electrohydraulic. liver. it is still a surgical procedure and thus it is necessary to carefully consider the patient’s anatomy in order to avoid complications. such as stones in diverticulae or stones completely filling the target calix. Curr Opin Urol 2003. if ESWL is available. Sepsis and ‘transurethral resection syndrome’ indicate a poor technique with high pressure within the collecting system during manipulation. balloon dilators or metallic dilators. This can be avoided by puncture under ultrasound guidance. In the least traumatic access. clinically significant. However.nlm. While standard nephroscopes have shaft calibres of 2430 F.ncbi.2 1. These problems can be avoided by using continuous flow instruments or an Amplatz sheath (1. REFERENCES Kim SC. Furthermore. There are no major vessels in this region and there is only minimal bleeding. http://www.nih. the indications for PNL should be limited to cases in which a less favourable outcome is expected after ESWL. Dilatation of the tract is possible with the Amplatz system. bleeding results from an arterial injury and can be managed by angiographic superselective embolization.72.142:937-940.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2795746 7. a self-retaining balloon nephrostomy tube is the best choice to secure tamponading of the tract and access to the collecting system. Bhatta KM. Dretler SP. such a catheter will prevent fragments from falling into the ureter. Although PNL is minimally invasive. 7. http://www. in selected patients. In selected cases with anatomical anomalities. Cystine calculi-rough and smooth: a new clinical distinction.gov/entrez/query. A difficult procedure is indicated by anatomical conditions that offer only limited space for the initial puncture.ncbi.nlm. tubeless percutaneous nephrolithotomy may be a safe alternative (7). After completion of the procedure. It is also the safest point of access because it uses the infundibulum as a conduit to the pelvis. Kuo RL. These small-calibre instruments possibly have a lower rate of tract dilation-related complications such as bleeding or renal trauma. pleura and lungs) are not within the planned percutaneous path (1. placement of a nephrostomy tube and secondary intervention at a later date. The puncture can be performed under combined ultrasound and X-ray control or under biplanar fluoroscopy.2. As with open surgery. and to ensure that organs adjacent to the kidney (such as the spleen. Stones can be extracted straightaway or following disintegration by ultrasound.1 Complications Major complications are lesions to adjacent organs. so-called ‘mini-perc’ instruments have smaller dimensions with 12-20 F. Pre-procedural KUB and intravenous urography or uroCTscan are used to plan access. brushite) or if fragments are unlikely to pass (large stones. as described above. the majority of renal stones can be removed by percutaneous surgery.8). Percutaneus nephrolithotomy: an update. laser or hydropneumatic probes. These images will also give some indication as to whether the stones will respond poorly to ESWL (such as stones composed of cystine. The choice is a matter of experience. J Urol 1989. The procedure should only be carried out by experienced surgeons in these cases. availability and costs. caliceal diverticula).nih. continuous removal of small fragments by suction or extraction is preferred. The use of ultrasound allows easy identification of neighbouring organs and therefore lowers the risk of injuries to adjacent organs. The percutaneous puncture may be facilitated by the preliminary placement of a balloon ureteral catheter to dilate and opacify the collecting system. Major bleeding during the procedure requires termination of the operation. Persistent. 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. percutaneous procedures have different degrees of difficulty. which is why this method is recommended only for stones with a diameter < 20 mm (4). it is the method of choice for percutaneous stone removal in children (5-7).fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12692448 30 UPDATE JUNE 2005 .gov/entrez/query.
If the global kidney function is reduced or if there is bilateral stone disease. surgery and partial or complete nephrectomy .13:359-64. Percutaneous management. Urol Clin North Am 2000.gov/entrez/query. Urology 2001. there is no dilatation of the collecting system and the stone has a small volume (2). Eur Urol 2001. http://www. Tamaddon K.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11098760 Matlaga BR. 5. Patel S. http://www. J Urol 2002. Bapat S.nlm.3 ESWL and PNL A combined procedure should be planned in such a way that each single step is successful in itself. Renal calculi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11805407 Jackman SV.ncbi.52:697-701. 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. Renal intrapelvic pressure during percutaneous neprolithotomy and its correlation with the development of postoperative fever.nih. Ramakumar S.3. Shah OD. Prospective randomized study of various techniques of percutaneous nephrolithotomy.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11549477 Troxel SA. These are stones with a large. Urology 1998. 7. http://www.168:1348-51. Mikhail A.nlm.gov/entrez/query.170:45-7. Bichler KH. Stones with large volume extensions into the calices. Seguea JW. Strohmaier WL. every effort must be made to preserve functioning nephrons.nlm. Ridhorkar V. as well as in their secondary effects on renal anatomy and function.e.ncbi.ncbi. with obstruction of the collecting system. Assimos DG.ncbi.58:345-50.nih. stone volume. i. http://www.nih.3 Aspects on staghorn stone treatment and importance of stone burden Staghorn stones may significantly vary in size. http://www.ESWL. composition and distribution within the collecting system. Desai M.nih. Kaptein JS.3. Minimally invasive PCNL in patients with renal pelvic and caliceal stones. the use of flexible nephroscopes can reduce the need for multiple accesses (4). UPDATE JUNE 2005 31 .3.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12796641 Lahme S.ncbi. Docimo SG.nlm. PNL. Computerized tomography guided access for percutaneous nephrolithotomy. 3. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique.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. http://www. 8. all techniques . 6. Low RK.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446796 Feng MI. Hedican SP.nih.gov/entrez/query.nih.nih. Although multi-tract PNL only moderately increases morbidity. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. There is no generally accepted classification system that allows for determination of success and complication rates of single or combined procedures. J Endourol 1999.gov/entrez/query. 7. Thus. Gotz T. J Urol 2003. 4.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9763096 Desai M.nlm. http://www.are included in the treatment strategy (1).gov/entrez/query. are not suitable for this approach. Dyer RB. Peters CA. Bellman GC.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. Zagoria RJ.ncbi. Streem SB. 27:617-22.40:619-24. 7. without obstruction of these calices.2.nlm. 7.. The use of two or more percutaneous accesses should follow the same rules (3). are good indications for a combined procedure. centrally located.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12352390 7.nlm.
Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy.3.nlm. A percutaneous approach might therefore be preferable.nih.gov/entrez/query. Kumar A. Zaman W. Knapp PM. http://www.1.52:697-701.1) while percutaneous procedures result in a stone-free rate of up to 97% (4-11). 5. The American Urological Association Nephrolithiasis Clinical Guidelines Panel. and the best treatment for stones in the lower calices is still controversial.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9763096 Desai M. Lingeman JE. Scott JW.gov/entrez/query. REFERENCES Segura JW.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14764139 2.nih. Newman DM.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507330&dopt= Abstract Lahme S. http://www. The clearance of stone fragments from the lower pole calices varies between different studies but is generally considered as poor.ncbi. initial.71:350-354. 7.nih. Stones > 2 cm in diameter in the renal pelvis or the upper and middle caliceal group without obstruction and dilatation of the collecting system are generally accepted as ideal indications for ESWL.gov/entrez/query. with overall stone-free rates between 37% and 67% (see section 7. Kahn RI.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14646431 Srivastava A.nlm. it can be stated that.148:1026-29. Dretler SP. although PNL has a higher. Neprolithiasis Clinical Guidelines Panel summary report on the management of staghorn calculi. Russo R. http://www. Leveillee RJ. Bapat S.nlm. Docimo SG. 3. Mandhani A. Hubmer G. Efficacy of extracorporeal shock wave lithotripsy for solitary lower caliceal stone: a statistical model.1.ncbi. Lingeman JE.gov/entrez/query. Macaluso JN Jr. http://www. J Urol 1992.ncbi.nlm. However. Preminger GM. there is no consensus on the usefulness of measuring the infundibulopelvic angle and the length and width of the calix (see above section 7.ncbi.nih. Stone surface area determination techniques: a unifying concept of staghorn stone burden assessment. Outcome and safety of extracorporeal shock wave lithotripsy as first-line therapy of lower pole nephrolithiasis. Eur Urol 2001.148:1058-62. J Urol 1994.2.nih.gov/entrez/query. Hebel P.nlm.e. Nakada SY. 7. Minimally invasive PCNL in patients with renal pelvic and caliceal stones. PNL is associated with more severe complications than ESWL. Ridhorkar V.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11696709 Riedler I. the indication for PNL can also be extended to include so-called ‘easy cases’ when ESWL is not available. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis . J Endourol 1999. Preminger GM.nlm. http://www.ncbi. http://www.nih.nlm.3. Hedican SP. J Urol 2001. Peters CA. particularly for patients with an obstructed lower calix or when the stone burden is considerable (i. Clayman RV.initial results.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11805407 Jackman SV. McCullough DL. Desai M..ncbi.40:619-24.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507322&dopt= Abstract Lam HS. Pearle MS.7.151:1648-51. Strohmaier WL. Teichman J.fcgi?cmd=Retrieve&db=PubMed&list_uids=8189589&dopt= Abstract Lam HS.2.nih. http://www. http://www.5 1. Macaluso JN Jr. Chua GT. Assimos DG.13:359-64.gov/entrez/query. Munch LC.nih. stonefree rate.nlm. BJU Int 2004. 6. Urol Int 2003. Kahn RI. 9. http://www. Lingeman JE. Mosbaugh PG. Evolution of the technique of combination therapy for staghorn calculi: a decreasing role for extracorporeal shock wave lithotripsy. Assimos DG. 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. Denstedt JD. diameter exceeding 20 mm or stone surface area more than 300 mm2).gov/entrez/query. Trummer H. Principally. Gutierrez-Aceves J.ncbi. Newman RC.166:2072-80. Urology 1998. 32 UPDATE JUNE 2005 .ncbi.nlm. Woods JR.4 Percutaneous surgery versus ESWL for removal of renal stones PNL and ESWL are complementary rather than competing procedures. Steele RE. Singh U. 4. Grasso M. Currently.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10446796 Alabala DM.1 Location of the stone mass). Bichler KH.ncbi. Lingeman JE. J Urol 1992. Patel S.gov/entrez/query. Singh V.nih.93:364-368. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique. Gotz T. 8.
• Ureterolithotomy. the indications for open stone surgery have markedly diminished. Thus. Since most of these cases will usually involve difficult stone situations. However. • Stone in a transplanted kidney where there may be a risk of damage to the overlying bowel.gov/entrez/query.gov/entrez/query.ncbi. Witzsch U. Akhtar S. appropriate. Poulakis V. • Anatrophic nephrolithotomy.4. • Stone in an ectopic kidney where percutaneous access and ESWL may be difficult or impossible. • Skeletal deformity. • Patient choice following failed minimally invasive procedures . • Intrarenal anatomical abnormalities: infundibular stenosis. stricture.single procedure in preference to possibly more than one PNL procedure. • Morbid obesity. • Removal of calculus with reimplantation of the ureter . • Partial nephrectomy and nephrectomy.nlm. skills and expertize in open renal and ureteral surgical techniques. Whenever the major stone volume is located peripherally in the calices. • Co-morbid medical disease. • Concomitant open surgery.ureteroneocystotomy. Abid F.4.nih. 7. there will inevitably be some controversy as to when open operation in a particular case is. 7. an open surgical procedure should be preferred. non-functioning kidney (nephrectomy). it is important that urologists maintain proficiency. J Urol 2003.1 Indications for open surgery Indications for open surgery for stone removal include: • Complex stone burden. Prediction of lower pole stone clearance after shock wave lithotripsy using an artificial neural network. in some circumstances.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12546707 7. • Cystolithotomy for giant bladder calculus. • Pyeloplasty. 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). • Treatment failure with ESWL and/or PNL or failed ureteroscopic procedure. 11.10. de Vries R. 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. With today’s limited experience with open stone surgery in many hospitals. Dahm P. with the various modalities of treatment that are now available for the surgical management of stones. The latest progress in this area has been the introduction of intra-operative B-mode scanning and Doppler sonography (13. probably unsuccessful.nih. multiple radial nephrotomy (11. • Radial nephrolithotomy. stone in the caliceal diverticulum (particularly in an anterior calix).12) and renal surgery under hypothermia. shockwave sessions will be necessary for complete stone removal. there is a place for open surgical removal of calculi. Becht E. It is now accepted that. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12629337 Ather MH. anatrophic nephrolithotomy (7-10). expertize and experience in the surgical treatment of renal tract stones report a need for open surgery in 1-5.ncbi.nlm. Khawaja K. • Pyelonephrolithotomy.169:1250-1256. Centres with the equipment. UPDATE JUNE 2005 33 . obstruction of the ureteropelvic junction.3:1. or is not. • A large stone burden in children because of easy surgical access and the need for only one anaesthetic procedure.the controversy continues. contractures and fixed deformities of hips and legs. BMC Urol 2003. Remplik J.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.2 Operative procedures Operative procedures that can be carried out include: • Simple and extended pyelolithotomy.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. • Non-functioning lower pole (partial nephrectomy). http://www. especially if these calices are obstructed so that either several percutaneous accesses and several. Stone clearance in lower pole nephrolithiasis after extra corporeal shock wave lithotripsy .4% of cases (1-5).
Vol 1. Urol Int 1965. http://www.nih. failed low invasive surgery in 29%. Current indications for open stone surgery in the treatment of renal and ureteral calculi.nlm. Smith ER. Endocrinol Metab Clin North Am 1990.nih.nlm.ncbi. Harrison LH. McCullough DL. http://www.ncbi.nih. Smith MJV.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=7052711&dopt= Abstract Thüroff JW.nlm.ncbi. The role of open surgery since extracorporeal shock wave lithotripsy. Reidy C. http://www. One hundred cases of nephrolithotomy under hyporthermia. 7. http://www.nlm. pp 1-23.gov/entrez/query.nlm. In one recent report reasons given to perform open surgery were a complex stone burden in 55%. http://www. J Urol 1989. Williams and Wilkins: Baltimore. 7.142:263-267. http://www.123:604.gov/entrez/query.nih.gov/entrez/query. Lahme S. Boyce WH.nih. Euro Urol 1975. 13.gov/entrez/query. REFERENCES Assimos DG.fcgi?cmd=Retrieve&db=PubMed&list_uids=8948396&dopt= Abstract Bichler KH.ncbi. Weems WL.The superiority of open surgery over less invasive therapy in terms of stone-free rates is based on considerable historical experience. 3. Donohue JP (eds).gov/entrez/query. Hutschenreiter G.4.ncbi. http://www. Alken P. 10.ncbi. http://www. 5. Wickham JEA.fcgi?cmd=Retrieve&db=PubMed&list_uids=2081519&dopt= Abstract Kane MT.59:18-24. Wickham JE. Thüroff S.nlm. J Am Diet Assoc 1996.fcgi?cmd=Retrieve&db=PubMed&list_uids=9392057&dopt= Abstract Paik ML. anatomical abnormalities in 24%. J Urol 1980.17:367-369. http://www. Boyce WH. Letter to the editor. Hample N. Resnick MI.1292-1301.nih. 9. 19:912-925.nlm. http://www. Frohneberg D. but (as yet) there are no comparative studies available (LE:4). Cohen AS. Strohmaier WL.ncbi. morbid obesity in 10% and co-morbid medical diseases in 7% of cases (5).gov/entrez/query. New surgical concepts in removing renal calculi. Anatrophic nephrolithotomy: Update 1978. Another report mentions 25 open surgical procedures in 799 treatments for renal stones.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2746742&dopt= Abstract Segura JW. Lewis C.fcgi?cmd=Retrieve&db=PubMed&list_uids=6064524&dopt= Abstract Harrison LH. Current surgical approaches to nephrolithiasis. 34 UPDATE JUNE 2005 . 12.651 stone procedures carried out in Singapore (16).ncbi.gov/entrez/query.159:374-37. Urology 1980. Trans Am Assoc Genitourinary Surg 1967. Surgical anatomy of the human kidney and its application. Indications for open stone removal of urinary calculi. 4. 20:255-288. particularly for stones located in a ventral caliceal diverticulum (17).fcgi?cmd=Retrieve&db=PubMed&list_uids=7365912&dopt= Abstract Resnick MI. A 2% need for open surgery was recorded in 2. Boyce WH. Urol Int 1997. 8.1:71-74.nih.gov/entrez/query.127:863-866.nih. Gower RL. Ward JP. Urology 1981. Hohenfellner R.ncbi. Localization of segmental arteries in renal surgery by Doppler sonography. Anatrophic nephrotomy and plastic calyrhaphy.nih. 6. Laparoscopic surgery is also an option.ncbi.nlm. 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).fcgi?cmd=Retrieve&db=PubMed&list_uids=5863978&dopt= Abstract Boyce WH. Pounds DM. Bonney WW. J Urol 1998. Riedmiller R. 11.gov/entrez/query. Kroonvand RL.59:102-108.nlm. http://www. 1978.nih. J Urol 1982. Wainstein MA.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9649242 Gil-Vernet J.fcgi?cmd=Retrieve&db=PubMed&list_uids=4436892&dopt= Abstract&itool=iconnoabstr Sleight MW.nlm. while a large stone burden in association with abnormal anatomy limiting endoscopic access in 31% of the cases. Spirnak P.3 1. Coe N. In: AUA courses in urology. Intrarenal access.15:475-477.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7086985&dopt= Abstract 2. Commission on Dietetic Registration Dietetics Practice Audit.gov/entrez/query.
Alken P.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11119107 7.nlm.4 Uric acid stones A high concentration of urate and a low (acidic) pH are the determinants of uric acid stone formation.2). 0. In the case of a large stone burden. 7. URS or open surgery for a more complete elimination of stone fragments or residual fragments.nih. Percutaneous chemolysis is a useful method for complete stone clearance in combination with other stone-removing techniques (14-18). PNL. Foo KT.ncbi.5. The pH of these solutions is in the range 8.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10497675 Brunet P. Danjou P. the most attractive alternative.28:241-244. Oral chemolysis is. http://www. however. but several weeks will be necessary to dissolve a complete staghorn stone using chemolysis combined with ESWL.5-9. The two solutions can also be used in combination. UPDATE JUNE 2005 35 .nlm. For this purpose. http://www.3 Cystine stones Cystine is soluble in an alkaline environment. http://www.gov/entrez/query.5. This option should be considered in patients with residual brushite fragments after other stone-removing procedures.gov/entrez/query. 15. Another useful agent is Suby’s solution. Urology 1984.gov/entrez/query.45:218-221. 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. Percutaneous dissolution can be accomplished with THAM solutions. This is a particularly interesting treatment approach in view of the very high recurrence rate of brushite stones.1.fcgi?cmd=Retrieve&db=PubMed&list_uids=6719663&dopt= Abstract Kane CJ. The time required for dissolution depends on the stone burden. and increasing the pH to alkali (19-21). Wong MYC. Oral chemolytic treatment is also a very attractive therapeutic alternative for the removal of uric acid stones. 16. The combined treatment of ESWL and chemolysis is a particularly low-invasive option for selected patients with partially or completely infected staghorn stones. the ureter should be protected by a double-J stent during the procedure (1.6 mol/L trihydroxymethyl aminomethan (THAM) solution can be used.5. This section provides a summary of chemolytic treatment options.5 Chemolytic possibilities Chemolytic dissolution of stones or stone fragments is a useful adjunct to ESWL.gov/entrez/query. 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).5 and 4.nlm. BJU Int.5. This method involves lowering urate concentration using allopurinol and a high fluid intake. Urology 1995. For percutaneous chemolysis.nih. Laparoscopically-assisted percutaneous nephrolithotomy for the treatment of anterior calyceal diverticula. Ann Acad Med Singapore 1999.nih.23:455-460. the patient should have at least two nephrostomy catheters. It should be noted that Hemiacidirin and Suby G solutions carry a serious risk of mortality (cardiac arrest) from hypermagnesemia. 2000. 17. Current indications for open stone surgery in Singapore.0. http://www. During appropriate antibiotic treatment the chemolytic solution is allowed to flow in through one nephrostomy catheter and out through another. Another option is acetylcysteine. 7. Thüroff JW.ncbi.nlm. Meria P.ncbi.Stoller ML. Doppler sonography and B-mode ultrasound scanning in renal stone surgery.14. which is an acid solution with a pH between 3. The surface area of the stone or the stone remnants is increased by ESWL. Bolton DM. Mahe P.1 Infection stones Stones composed of magnesium ammonium phosphate and carbonate apatite can be dissolved with a 10% solution of hemiacidrin. Riedmiller H.nih.86:1088-1089. Hohenfellner R.5.2 Brushite stones Brushite is also soluble in the acid solutions mentioned above in section 7. Current indications for open stone surgery in an endourological centre. 7.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 7855969 Sy FY.3 or 0. 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. 7.
McCullough DL (eds).ncbi. Israel AR.6 1.131:861-863.gov/entrez/query. McCullough DL (eds).12:224-226. J Urol 1982.nih.ncbi. http://www.gov/entrez/query.gov/entrez/query.44:913-916. Larsson L. 6. Tiselius HG.nlm. Hatch T. Andersson A.ncbi. Reckler JM.fcgi?cmd=Retrieve&db=PubMed&list_uids=1984093&dopt= Abstract Tseng CH. http://www. 3. Alken P. 9. Kandel B. Cattolica EV. Minimally invasive treatment of infection staghorn stones with shock wave lithotripsy and chemolysis.nih. 13.fcgi?cmd=Retrieve&db=PubMed&list_uids=7154186&dopt= Abstract Weirich W.fcgi?cmd=Retrieve&db=PubMed&list_uids=1003633&dopt= Abstract Burns JR. Plenum Press: New York.nih.ncbi. 36 UPDATE JUNE 2005 .nih.gov/entrez/query. J Urol 1982. [Lokale Chemolitholyse von Harnsteinen] Zeitschrift fur Klinische Medizin 1989. http://www. 10.nlm.nih.ncbi.128:241-242. Eriksson L. Staghorn calculi. Eur Urol 1988.nih. Chemolysis of calculi. Hemiacidrin renal irrigation: Complications and successful management. REFERENCES Tiselius HG.gov/entrez/query.20:435-442.nlm. Bick C. 12.a useful component in the treatment of infection renal stones. Lingeman JE.145:25-28.nih. Hemiacidrin .nlm. Riedmiller H. Tank ES. [German] Klein RS.nih.nlm. Ureteral calculi. In: State of the art extracorporeal shock wave lithotripsy. 15.gov/entrez/query. J Endourol 1993. http://www. J Urol 1976. Primary dissolution therapy of struvite calculi.ncbi. Urol Clin North Am 1982. 8. Wall I.gov/entrez/query. Urol Clin North Am 1993. http://www.nih. Management of urinary stones in the patient with spinal cord injury. pp 311-353.ncbi. http://www. [German] 2.fcgi?cmd=Retrieve&db=PubMed&list_uids=6708214&dopt= Abstract Fam B. [German] Sheldon CA. [Auflösung von Cystin-Steinen mit N-Acetylcystein nach perkutaner Nephrostomie] Akt Urol 1981.ncbi.nih. 7. 33:286-290.nlm. Alken P. Plenum Press: New York. http://www. Ackermann D. Rossier AB.7.9:121-130. J Urol 1991. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=10572989&dopt =Abstract Fahlenkamp C.5.gov/entrez/query. http://www. Berg S. Urology 1981. http://www. Resnick MI. Pfister RC. [Perkutane Chemolyse von Struvit-Steinen bei Nierenbecken-und Kelchhalsobstruktion] Akt Urol 1982.nlm.ncbi. Borrud-Ohlsson A.fcgi?cmd=Retrieve&db=PubMed&list_uids=8351769&dopt= Abstract Kachel TA. Combination therapy for a partial staghorn calculus in an infant. Hemiacidrin irrigations to dissolve stone remnants after nephrolithotomy. Endourological experience with cystine calculi and a treatment algorithm.fcgi?cmd=Retrieve&db=PubMed&list_uids=7080280&dopt= Abstract Griffith DP.gov/entrez/query. Scand J Urol Neprol 1999.18:127-130. http://www. 11.15:26-30.5 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). Harrison LH. 16.fcgi?cmd=Retrieve&db=PubMed&list_uids=8124339&dopt= Abstract Levy DA. 7.ncbi. In: State of the art extracorporeal shock wave lithotripsy. Dissolution of cystine calculi by pelvocaliceal irrigation with tromethamine-E. Rankin KN.nlm. Vijan SR. Yalla S.ncbi. Harrison LH.nlm. The role of hemiacidrin in the management of renal stones in spinal cord injury patients.fcgi?cmd=Retrieve&db=PubMed&list_uids=7109081&dopt= Abstract Dretler SP. Alexander SR.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215233&dopt= Abstract Rodman JSA. Haas H.nlm. Kandel B. 1987.5. Talwalkar YB. 14. Smith AD. J Urol 1984. The presence of calcium oxalate in an infection stone markedly reduces the solubility in hemiacidrin (6). 1987. Schöpke W.13:256-258.fcgi?cmd=Retrieve&db=PubMed&list_uids=7269011&dopt= Abstract Weirich W. Dretler SP. Otting U. Joseph DB.128:1281-1284. pp 281-310.nlm. 5. Brien G.gov/entrez/query. Suckow B.gov/entrez/query. Hellgren E. http://www.nih.116:696-698.7:469-471. De Temple R.
gov/entrez/query. Such a step might also be used as an auxiliary procedure in the treatment of cystine stones. Dissolution of uric acid calculi. Huang JK. though it is advantageous in some types of reconstructive surgery. 22.ncbi.gov/entrez/query.nih. it is logical to select a method with low invasiveness and low morbidity. Vergauwe D. oral chemolysis is the first choice of treatment for stone disintegration. 21. However.nih. Urology 1979. For uric acid stones.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1317980&dopt= Abstract Rodman JS. it is important to note that unless percutaneous surgery is carried out with a meticulous technique. an increased rate of dissolution can be obtained following stone disintegration and treatment in this order may be considered for removing large uric acid stones.nlm.20:19-21. 19. Residual fragments of infection stones. Video-endoscopic retroperitoneal surgery has no place as standard procedure for removal of stones from the kidney.17. but for any given stone situation.131:434-438. 18. Chang LS. Chemodissolution of urinary uric acid stones by alkali therapy. http://www.nlm.gov/entrez/query. Schmiedt E. there is an ongoing debate as to whether large renal stones are best treated with ESWL or with PNL.8:422-423. Lange PH. Local chemolysis of obstructive uric acid stones with 0.48:81-86. associated with the most pronounced risk of recurrences can be eliminated with percutaneous chemolysis.gov/entrez/query. J Urol 1984. 20. For large renal stones.gov/entrez/query.ncbi.ncbi. Urol Int 1992. Chem MT.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. Reinke DB. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8249225&dopt= Abstract&itool=iconabstr Oosterlinck W. that complete clearance of stones from the caliceal system by a percutaneous technique requires considerable expertize and experience. Schüller J. An overview of treatment recommendations according to size and stone type is shown in Tables 15 and 16. Chaussy C. J Urol 1984. flexible URS. Williams JJ. 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=433056&dopt= Abstract Schmeller NT.nlm. It needs to be emphasized. Indudhara R.nih. Peterson CM.ncbi. The available options are ESWL. Combination of chemolysis and shock wave lithotripsy in the treatment of cystine renal calculi. Rationale for local toxicity of calcium chelators.fcgi?cmd=Retrieve&db=PubMed&list_uids=6699980&dopt= Abstract Sharma SK. PNL.nih.nih.51:147-151. Kersting H. Although residual fragments can develop into new stones. residual fragments of stone may be left behind in these patients. http://www.ncbi. but such a routine is indicated also because of the inherent tendency to new stone formation that characterizes patients with stone disease. Verbeeck R. ESWL has been established as the standard procedure because it is non-invasive.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6726897&dopt= Abstract Lee YH. http://www. Cuvelier C. Urol Res 1992. A follow-up programme for patients with residual fragments appears necessary. has a low rate of complications and there is no need for regional or general anaesthesia. http://www. http://www. However. Urol Int 1993. UPDATE JUNE 2005 37 . Although larger stones can also be treated successfully with ESWL. The drawbacks of ESWL are a frequent need for repeated treatments and the relatively common occurrence of residual fragments.nlm.nlm. Dissolution of cystine calculi by irrigation with acetylcysteine through percutaneous nephrostomy. several reports have shown that risk to be reasonably low.nlm. For small stones (up to a maximum diameter of 20 mm or a surface area of 300 mm2).ncbi.02% chlorhexidine. as well as video-endoscopic retroperitoneal and open surgery. The approximate estimates of surface area corresponding to oval stone projections with certain diameters are given in Appendix A. Miller RP. however. All these methods are applicable.131:1039-1044.fcgi?cmd=Retrieve&db=PubMed&list_uids=1736482&dopt= Abstract 7. percutaneous stone removal might be preferable for faster debulking of the stone.1 M THAM and 0. Smith AD.
Stent + ESWL + oral chemolysis 2a B Cystine stones 1. 8. 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. PNL 1b B 2. however. The first alternative always has the number 1. degree of impaction and extent to which repeated shock waves sessions are 38 UPDATE JUNE 2005 . ESWL = extracorporeal shock wave lithotripsy. When two procedures were considered equally useful they have been given the same number.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. 3.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. GR = grade of recommendation. Uric acid/urate stones 1. PNL = percutaneous nephrolithotomy.. PNL = percutaneous nephrolithotomy. PNL 2a B 2. 2. It has been shown clearly that. assumed that ureteral stones generally require higher shock wave energy and a greater number of shock waves. 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. ESWL = extracorporeal shock wave lithotripsy. also including piezolithotripsy. Oral chemolysis 2a B 2. this technique has been extensively used and a considerable experience has demonstrated that ESWL is very useful for stone removal from the ureter. When two procedures were considered equally useful they have been given the same number. Improved results in complicated cases can be achieved by combining ESWL with low-invasive auxiliary procedures (e. 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.g. This lack of consistency is obviously related to the type of lithotripter. size and composition of the stone. PNL + ESWL 2a B 3. ESWL with or without stenting 2a B 3. PNL 2a B 3. 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. GR = grade of recommendation. PNL + flexible nephroscopy 2a B 4. ESWL 1b A 2. 3) have been allocated to the procedures according to the consensus reached. also including piezolithotripsy. Open or video-endoscopic retroperitoneal surgery LE = level of evidence. * Numbers (1. Uric acid/urate stones 1. Open or video-endoscopic retroperitoneal surgery LE= level of evidence. It is. ESWL 2a B 2. in most cases. * Numbers (1. 2. 4) have been allocated to the procedures according to the consensus reached. Stent + ESWL + oral chemolysis 2a B Cystine stones 1. Oral chemolysis 2a B 2. by stenting or urethral catheters). The first alternative always has the number 1.
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fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11061877 Ghobish A. Soble JJ. Jordan WR. but it is difficult to find definite evidence for this assumption in the literature.nih. Honey RJ.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9693242 Jermini FR.ncbi. Danuser H. It needs to be emphasized. Weir MJ.152:53-56.fcgi?cmd=Retrieve&db=PubMed&list_uids=7495114&dopt= Abstract Pace KT.34:93-98. J Urol 1993. 3. as well as to fill the collecting system with contrast medium for detecting radiolucent stones. however.nlm. J Urol 1994. Pearle MS. Vandenberg T. 40.gov/entrez/query. Clayman RV. 36. 42 UPDATE JUNE 2005 . Jenkins JM.gov/entrez/query. stentless ventral technique.ncbi.nlm. Studer UE. the retreatment rate was usually not significantly lower (3.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501781 Mobley TB. Clayman RV. Jordan WR. Nakada SY. 41.nih. Eur Urol 1990.2. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18. Jordan WR.152:66-67. http://www. experience with 165 patients. Grine WB. Mattei A.gov/entrez/query.ncbi.gov/entrez/query.nlm. REFERENCES Nakada SY. Although slightly better results have been reported with this procedure.11). J Urol 2000.gov/entrez/query. J Urol 1994.ncbi. Macaluso JN.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12131285 Mobley TB.ncbi. Shock wave treatment of ureteric stones in situ with second generation lithotriptor.35.8-14). An innovative approach to management of lower third ureteral calculi. Low success rate of repeat shock wave lithotripsy for ureteral stones after failed initial treatment.825 calculi using the Lithostar lithotriptor. http://www. Grine WB. Myers DA.168:446-449.825 calculi using the Lithostar lithotripter. 37. Effects of stents on lithotripsy of ureteral calculi: treatment results with 18. When compared with stone-free rates of 62-97% following in situ treatment (1-10). 39. analgesia and radiation-free extracorporeal shock wave lithotripsy for stones in the most distal ureter. J Urol 1993.962 renal and ureteral calculi.fcgi?cmd=Retrieve&db=PubMed&list_uids=8201687&dopt= Abstract 2. Vanden Bosshe M. 8.7.nih.149:1419-1424. http://www.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 2351188&query_hl=6 Mobley TB. 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. Taroq N. http://www. http://www.46:649-652.9. In situ extracorporeal shock wave lithotripsy of middle and lower ureteral stones: A boosted. http://www. Low energy lithotripsy with the Lithostar: treatment results with 19. http://www. http://www. Myers DA.nlm. http://www.gov/entrez/query.149:1427-1430.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=7495114&dopt= Abstract Simon J.17:200-202. Extracorporeal shock wave lithotripsy of middle ureteral stones: are ureteral stents necessary? Urology 1995.nlm. Soble JJ. Pearle MS. retrograde manipulation resulted in stone-free rates of 73-100% (5.nih.gov/entrez/query.nih.nih.gov/entrez/query.nlm.nlm.2 Retrograde manipulation of stones The push-back technique has been applied in order to avoid problems with insufficient disintegration of ureteral stones.nih. Myers DA. however.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8201687&query_hl=19 8. Jenkins JM.ncbi. Another reason for stenting might be to aid in the location of small and less radio-opaque stones. be of some help to use a ureteral catheter when treating large and impacted ureteral stones. McClennan BL. It might. 8. 38. Burkhard FC.nlm. Extracorporeal shock wave lithotripsy of middle ureteral stones: are ureteral stents necessary? Urology 1995. McClennan BL.ncbi. Jenkins JM. J Urol 2002.nih.164:1905-1907.ncbi. http://www.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. Salvatore FT.2 1.46:649-652. Non-invasive anaesthesia.2. Eur Urol 1998. Gardner SM. Grine WB.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8501779 Thomas R.nlm. Gardner SM.nlm. Schulmann CC.gov/entrez/query.gov/entrez/query.nih.nih.
nlm.gov/entrez/query.ncbi. Tuerk C. J Endourol 1990.nlm. http://www. Güler C. 13.fcgi?cmd=Retrieve&db=PubMed&list_uids=8490668&dopt= Abstract Cass AS.8:9-11.gov/entrez/query. Celebi I.fcgi?cmd=Retrieve&db=PubMed&list_uids=7514472&dopt= Abstract 8. J Urol 1987.ncbi. Manning M. URS has dramatically changed the management of ureteral calculi. Höbarth K. Debruyne FMJ.fcgi?cmd=Retrieve&db=PubMed&list_uids=1732591&dopt= Abstract Lingeman JE. 6.nih. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8116112&dopt= Abstract Harada M.1 Standard endoscopic technique The basic endoscopic technique has been well standardized for many years (1.nih.nlm. Marberger M. New ureteroscopes (semi-rigid and flexible) and lithotripsy devices have recently become available.fcgi?cmd=Retrieve&db=PubMed&list_uids=8252017&dopt= Abstract Hendriks AJM.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1486384&dopt= Abstract Danuser H. Bierkens AF. ESWL in situ or ureteroscopy for ureteric stones? World J Urol 1993.nih. Are obstructing ureteral stones more difficult to treat with extracorporeal electromagnetic shock wave lithotripsy? J Endourol 1993. Intramural ureteral dilatation is not indicated routinely. http://www. James AN. Rassweiler J.ncbi. http://www. but UPDATE JUNE 2005 43 . A guide wire is introduced under endoscopic and fluoroscopic control.nih. 7. 9.nih. Esen A. However. 14.11:54-58. the patient is placed in the lithotomy position.gov/entrez/query. Woods JR. Steele RE. Br J Urol 1992. http://www. Köhrmann KU.gov/entrez/query.nlm. Nonstent or noncatheter extracorporeal shock-wave lithotripsy for ureteral stones.146:8-12.ncbi. Shirrell WL.nlm.4:353359.ncbi.147:349-251.ncbi. Under general spinal anaesthesia or intravenous sedation. Extracorporeal shock wave lithotripsy of ureteric stones with the Modulith SL 20. Ackermann DK.7:277-279.nih.nlm. Extracorporeal shock wave lithotripsy for ureteric calculi with the Dornier MFL 5000 lithotriptor at a multi-user centre. Marth DC. Anaesthesia-free in situ extracorporeal shock wave lithotripsy of ureteral stones. Studer UE. URS is extensively used in many urological centres all over the world.gov/entrez/query.nih. Alken P. J Urol 1993. 8.2). it is an invasive technique compared to ESWL.nlm.gov/entrez/query. Inaba Y. A pre-operative plain film of the urinary tract is obtained to confirm the location of the stone. Kirkali Z.43:178-181.fcgi?cmd=Retrieve&db=PubMed&list_uids=8345592&dopt= Abstract Tiselius HG.138:720-723. J Urol 1991.nlm.nlm. Zingg E.ncbi.150:824826. Henkel TO.fcgi?cmd=Retrieve&db=PubMed&list_uids=2056608&dopt= Abstract Hofbauer J.ncbi. Joyce AD. Treatment of proximal and midureteral calculi: a randomized trial of in situ and push back extracorporeal lithotripsy. Newman D.3 Ureteroscopy for removal of ureteral stones During the past two decades. and secured to the drapes. http://www.72:683-687. 8.gov/entrez/query. Nowadays. http://www. Antibiotic prophylaxis should be administered before the procedure to ensure sterile urine.gov/entrez/query. 11.ncbi. Br J Urol 1993. Okamoto M. Extracorporeal shock wave lithotripsy in situ or after push up for upper ureteral calculi: a prospective randomized trial.3.nih. http://www.70:594-599. and the treatment of choice for ureteral stones with diameters of 1 mm or larger is still controversial.gov/entrez/query.nlm. 5. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281394&dopt= Abstract&itool=iconabstr Cass AS. Treatment of ureteral stones by extracorporeal shock wave lithotripsy: with ureteral catheter or in situ? J Endourol 1994. The procedure starts with rigid or flexible cystoscopy. 12. Management of upper ureteral calculi with extracorporeal shock wave lithotripsy. Mosbaugh PG. 10. The operating room must have fluoroscopic equipment. Hasun R.ncbi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=3656518&dopt= Abstract Watson RB. Oosterhof GON. Do upper ureteral stones need to be manipulated (pushed back) into the kidneys before extracorporeal shock wave lithotripsy? J Urol 1992. Urology 1993.4. http://www.gov/entrez/query.
The stent will usually remain in place for about 1 week. Retrograde access to the upper urinary tract is usually obtained under video-guidance with a rigid ureteroscope (9.3. Small stones and fragments < 5 mm in diameter are best retrieved with a basket or a grasper (3. electrohydraulic devices should not be used as a standard procedure. If manipulated with care. Irrigation facilitated with a piston syringe or a flow control unit is needed to ensure good direct vision. It is dependent on the injury to the ureteral mucosa due to the stone or the ureteroscope.17.22-24). regardless of the hardness of the stone (16).3. migration of stones towards the renal pelvis from the mid.11-15).4 F probe in a semi-rigid ureteroscope provide excellent fragmentation rates (90-96%). Ballistic lithotriptors (pneumatic or electropneumatic) using a 2.5 F) has been evaluated (1. for ureteral calculi < 15 mm in diameter. Miniaturization avoids dilatation of the intramural ureter (with associated complications) in more than 50% of cases (8-10). The ideal energy and frequency settings are less than 1. 8. However. A 365 µm holmium:yttrium aluminium garnet (Ho:YAG) laser fibre is the best choice for ureteral stones. 8. 8. This device offers an excellent cost-performance ratio (40).3.2 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.1 Ureteroscopes Semi-rigid and thin ureteroscopes are available.20). because of its tendency to fall back into the bladder. The stone may be fragmented by ultrasonic lithotripsy. a semi-rigid ureteroscope (6. laser lithotripsy or ballistic (or pneumatic) lithotripsy. In the lower ureter. 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. The use of flexible ureteroscopes (7-7.3 Assessment of different devices 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).5 F). Endoscopic lithotripsy is based on the use of different devices in order to break the stone into dust or fragments with diameters < 2 mm. but may be substantially longer for flexible URS.0-7.7). but provides a sufficiently efficient alternative for most stone compositions.18.4).0 J and 5-10 Hz. ultrasonography or intravenous urography after 2-12 weeks (2. electrohydraulic lithotripsy.18). The small diameter (6.3.5-11 F).035-inch safety guide wire with a floppy tip or in a 10-13 F sheath. Dilatation of the intramural ureter and use of a laser usually requires the insertion of a single/double pigtail stent under fluoroscopic guidance. The recently developed (semi-)flexible ureterorenoscopes (Storz) with enhanced maximal deflection provide particular advantages for ureteroscopic surgery (36-39). Its cost-effectiveness is three times that of laser lithotripsy (9.2. They are suitable for access to the upper part of the ureter and renal collecting system. The operating time is generally between 10 and 60 minutes. as minimal deflection is required to access the stone.6. the laser does not damage the ureteral mucosa (16. laser lithotripsy will require a longer operating time than the electrohydraulic technique (5) but because of the greater risk of tissue damage. Patients should be followed up by plain abdominal film.or proximal ureter might be a limiting factor of ballistic lithotripsy (25). Stent placement at the end of the procedure is optional and a matter of debate (2).5 F) allows easier progression of the ureteroscope up to the proximal ureter.14. Laser lithotripsy using pulsed dye laser has shown similar results to those obtained using the Ho:YAG laser (21). An operating time for laser lithotripsy of between 7 minutes and 45 minutes is acceptable (18). is not recommended (1.19). A flexible ureteroscope is inserted either alongside a second 0. This technique is particularly useful for removal of distal ureteral stones in women (2. 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. without dilating the intramural ureter in over 75% of cases.0-8.depends on the size of the ureteroscope and width of the ureter. the best approach is to insert a ureteral stent for several days prior to the URS (2). a flexible ureteroscope. 44 UPDATE JUNE 2005 .3.3.2 Disintegration devices Laser lithotripsy is a reliable method for the treatment of ureteral stones.5). If the stone is impacted. Nevertheless. Flushing of large fragments or the stone itself up to the renal pelvis or calices or perforation of the ureteral wall may occur.3). It is the only applicable method when performing flexible URS (12. The safety guide wire prevents the risk of false passage in case of perforation. A low capital cost and simple and safe handling are major advantages of this type of device.
20. 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.3.13. with a 1% rate of significant complications (3. 8. Similar results were observed in children and in obese patients (11.5 Clinical results The Ureteral Clinical Guidelines Panel of the American Urological Association have conducted a meta-analysis of relevant studies between 1966 and 1996.4).3. 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. be carried out without an access sheath (42). particularly when the ureter has to be re-entered several times. 8.3. Analysis of the literature for the past 3 years indicates an improvement in stone-free rates.3. An access sheath of a suitable dimension can be introduced over a guide wire. An access sheath may faciltate URS.3. Reduced need for dilatation (0-40%).3 Baskets Ureteroscopic removal of small ureteral stones with a basket is a relatively quick procedure with a lower morbidity rate than lithotripsy (3. The basket technique should be attempted first for small distal ureteral calculi. The major acute complication remains ureteral avulsion (9.32). Small ureteral stones or fragments can be removed fast and safely with forceps which can be better controlled than a basket. 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.30). the overall stone-free rates were 72% and 90%. Most procedures can.32-35). Laser or electrohydraulic lithotripsy may break the wires of the basket (16). especially in the proximal ureter (5). The nitinol tipless basket is more effective than a flat-wire basket because of its greater flexibility (4.26). Ureteral strictures were the only long-term complication reported. Members produced a report for guidelines in August 1997.29). 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). the stone-free rates were 56% and 89% for proximal and distal stones.11).3. respectively (27). respectively. 23). The best results were reported with Ho:YAG laser lithotripsy. particularly when the stone diameter < 10 mm.12. When the material was stratified into results for proximal and distal ureteral stones. Most perforations seen during the procedure are successfully treated with approximately 2 weeks of stenting (8). both ESWL and URS can be considered acceptable treatment alternatives for stones in these positions.3. Thus.7 Conclusion Improvements in the design of ureteroscopes. The cost-effectiveness of ureteroscopic treatment has not been assessed. A total of 95% of patients were successfully treated with only one endoscopic procedure. The overall complication rates reported in recent literature are 5-9%.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. UPDATE JUNE 2005 45 . This latter technique might be a good alternative to ESWL. which was published in the Journal of Urology (27).6 Complications Significant acute complication rates of 11% and 9% have been reported for the proximal and distal ureters. Randomized and prospective studies are needed in order to compare all forms of stone removal from the ureter. operating time and post-operative ureteral stenting have resulted from the use of thin ureteroscopes Routine stent placement following uncomplicated URS may be unnecessary. Autologous transplantation or uretero-ileoplasty are the methods of choice in cases of avulsion (33). 8. in obese patients or in those with less visible stones (9. Several new designs of endoscopic stone retrieval baskets are available.8-10. respectively. New requirements for endoscopic sterilization could dramatically increase the cost of the procedures.28. For ureteral stones with a diameter < 10 mm.3. however. There is a strong relationship between the complication rate and the equipment used and/or the expertize of the urologist (31. for example. with the estimated rate being 1%. 126.96.36.199. even with a parallel decrease in operating time and complication rate. This last result is considerably better than the results reviewed before 1997 (25. Patient discomfort is modest and satisfactorily controlled by oral analgesics (21.33). The tipless nitinol basket is non-traumatic and allows excellent control inside calices.
10.gov/entrez/query.12:241-246.ncbi.gov/entrez/query. J Endourol 1999.nih. http://www.nlm.8. Clayman RV. Bagley DH. http://www. A new generation of semirigid fiberoptic ureteroscopes. A review of 378 cases.fcgi?cmd=Retrieve&db=PubMed&list_uids=9886583&dopt= Abstract Honey RJ. J Urol 1997. Retrograde flexible ureterorenoscopic holmium-YAG laser lithotripsy: the new gold standard. Ricciotti G.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9146583&dopt= Abstract Harmon WJ.nlm. 12.12:33-35. Ozmen E.gov/entrez/query.nlm. Is general anaesthesia necessary for URS in women? Int Urol Nephrol 1996. http://www.gov/entrez/query.gov/entrez/query. Cohen TD.fcgi?cmd=Retrieve&db=PubMed&list_uids=9531148&dopt= Abstract Tawfiek ER. 4.ncbi. Urology 1999. Blute ML. 8.nih. Lee CW. Elbahnasy AM. J Urol 1996.28:153-156.ncbi. Sershon PD. Introini C.fcgi?cmd=Retrieve&db=PubMed&list_uids=8976208&dopt= Abstract Netto NR Jr.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9679874&dopt= Abstract Elashry OM. 7.36:48-52.gov/entrez/query.nlm.nih.ncbi. http://www. Belis JA. J Endourol 1998. Preminger GM. Rogenes VJ.ncbi.nlm. http://www.nlm.ncbi. http://www.gov/entrez/query.156:899-902.nlm.gov/entrez/query. http://www.ncbi. Patterson DE.3.53:25-23.gov/entrez/query. http://www. 46 UPDATE JUNE 2005 .fcgi?cmd=Retrieve&db=PubMed&list_uids=9895257&dopt= Abstract Gould DL.160:346-351.157:2074-2080. 13. Bagley D.fcgi?cmd=Retrieve&db=PubMed&list_uids=8836781&dopt= Abstract Ferraro RF.gov/entrez/query. J Urol 1998. 9. Nakada SY.nlm.158:1358-1361. http://www. Retrograde ureteropyeloscopic treatment of 2 cm or greater upper urinary tract and minor staghorn calculi.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=9658294&dopt= Abstract Nguyen TA. Assessment of a new tipless nitinol stone basket and comparison with an existing flat-wire basket. Tam PC. Topaloglu H. Ureteroscopy with intravenous sedation for treatment of distal ureteral calculi: a safe and effective alternative to shock wave lithotripsy.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=9146584&dopt= Abstract Teichman JM. J Urol 1997.13:35-40. Flexible ureteroscopy: Washington University experience with the 9.nih.157:28-32. 6. J Urol 1997.fcgi?cmd=Retrieve&db=PubMed&list_uids=8709358&dopt= Abstract Yalcinkaya F.nih.nlm.ncbi. 11.nih.157:2081-2083. Tech Urol 1998.fcgi?cmd=Retrieve&db=PubMed&list_uids=10102126&dopt =Abstract Puppo P.gov/entrez/query. Abraham VE.gov/entrez/query.4 1.nih.ncbi.4:22-24. Ureteroscopic stone removal in the distal ureter. Holmium laser lithotripsy for ureteral calculi: an outpatient procedure.gov/entrez/query.nlm. Bozzo W.nlm.nlm. 14. Conlin M. Harris JM.ncbi. 5. Rao RD.nih. Management of upper urinary tract calculi with ureteroscopic techniques.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=10364655&dopt =Abstract Yip KH.fcgi?cmd=Retrieve&db=PubMed&list_uids=9568772&dopt= Abstract 2.nih. Andrade EFM. Eur Urol 1999.nih. Bard RJ. 3. Primary endoscopic treatment of ureteric calculi.3F and 7. http://www. Unal S. REFERENCES Grasso M. http://www. Endoscopic management of urolithiasis in the morbidly obese patient. Rao GS. http://www. Esteves SC. J Endourol 1998. Ureteroscopic management of ureteral calculi: electrohydraulic versus holmium:YAG lithotripsy. http://www.5F flexible ureteroscopes.nih.gov/entrez/query.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9302119&dopt= Abstract Hosking DH.ncbi. http://www.12:529-523. J Endourol 1998.nih.ncbi. Why change? J Urol 1997. Segura JW. de Almeida Claro J. Ureteroscopy: current practice and long-term complications.
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The urologist’s experience. Sundaram C. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi.nih. Several comparative studies between URS and ESWL can be found in the literature. access to adequate equipment and specific circumstances are probably the best determinants of which method will be most appropriate for a particular patient. Mutz J.ncbi. or even more so. Urol Clin North Am 2004. 4. Nakada SY. Park M.ncbi. The size of ureteral stones has also been considered a limiting factor for ESWL.161:45-47.31:83-87.4 Should ESWL or URS be used for stone removal? This is indeed a controversial issue for which there is a lack of consensus. A comparison of ureteroscopy to in situ extracorporeal shock wave lithotripsy for the treatment of distal ureteral calculi. Shalhav AL. On the other hand. little information is available on how the ureter reacts to repeated ureteroscopic procedures. Sinik Z. Janetschek G. 5.nih. http://www. 3.nlm. Bozkirli I. http://www.gov/entrez/query.gov/entrez/query. Furthermore.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10213099 Pardalidis NP. J Urol 2001. than the HM3 machine. http://www. Even with the addition of auxiliary procedures. Arguments have been presented for and against both these procedures. have contributed to a less favourable attitude to ESWL from urologists. J Endourol 1998.12:501-504. REFERENCES Peschel R. McDougall EM.nlm.nih. The argument against the routine use of ureteral access sheaths.gov/entrez/query.and distal ureter ureteroscopically. Treatment of lower ureteral stones: extracorporeal shockwave lithotripsy or intracorporeal lithotripsy? J Endourol 1999.gov/entrez/query.13:77-81.16:1255-1260. J Endourol 1999. http://www.nih. Although these studies demonstrate what has been mentioned above. J Urol 1999. Park T. In conclusion. Bercowsky E. 6. the advantages of ESWL are non-invasiveness and no need for regional or general anaesthesia. but most focus on stones in the distal ureter (1-10).nlm.gov/entrez/query.gov/entrez/query. Nadler R. Although the access to flexible ureteroscopes and efficient laser devices has made it more attractive to treat stones in the mid.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9895251 2. UPDATE JUNE 2005 49 . However.ncbi. it is difficult or impossible to give priority to either of these procedures. Kosmaoglou EV. Hoenig DM. Bartsch G.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10037364 Park H. 8. It can be assumed that the production and marketing of lithotripters. Two-year experience with ureteral stones: extracorporeal shockwave lithotripsy v ureteroscopic manipulation.ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10569535 Pearle MS.42. Küpeli B.nlm. several groups concluded that ESWL is preferable in view of its lower degree of invasiveness. J Urol 1999. http://www.13:161-164.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10360494 Turk TMT. Figenshau S. Abrahams HM. Stoller ML.nih.4. URS is considered to be a one-step procedure that in the majority of studies has been carried out under anaesthesia. ESWL can be considered a low-invasive and gentle procedure.nih. http://www.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15040404 8. Jenkins AD. Karaoglan Ü. the need for anaesthesia is unchanged. Dunn M.nlm. Isen K. which obviously were inferior to the initial HM3-device. Extracorporeal shock wave lithotripsy versus ureteroscopy for distal ureteral calculi: a prospective randomized study. a remarkable improvement has been noticed in recent years with lithotripters that have the capacity to disintegrate ureteral stones as efficiently as.1 1.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11547053 Biri H. Clayman RV. Kapotis CG. Chen C. Wolf JS. Endoscopy vs extracorporeal shock wave lithotripsy in the treatment of distal ureteral stones: ten years’ experience.nlm.ncbi. http://www. Although the need for re-treatment is definitely greater with ESWL than with URS.ncbi.ncbi. but URS-disintegrated stones also require elimination of residual fragments.nlm.162:1909-1912.
8. It is of note that only uric acid stones..34:474-479. 50 UPDATE JUNE 2005 . Greene TD.36:376-379. Strohmaier WL. Gupta M. Eur Urol 1998.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10516445 Lam JS. Comparison between extracorporeal shock wave lithotripsy and semirigid ureterorenoscope with Holmium-YAG laser lithotripsy for treating large proximal ureteral stones.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9831788 Wu CF.nih.nlm.nih. Isen K. an open surgical procedure might be required to remove the stone. J Urol 2002.ncbi.gov/entrez/query.ncbi. Alkibay T. Although retreatments are necessary in a substantial fraction of ESWL-treated patients. Biri H. the location can be facilitated by means of a ureteral catheter or a double-J stent. not those composed of ammonium urate or sodium urate.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15540749 8.7. in our opinion they are considered equally useful for the removal of distal ureteral stones.gov/entrez/query. Comparison of extracorporeal shock wave lithotripsy and ureteroscopy in the treatment of ureteral calculi: a prospective study. http://www.5 Recommendations for active removal of ureteral stones: all sizes In case of failure with minimally invasive techniques.ncbi. http://www. 10. Weigl A.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11956420 Küpeli B. http://www. Lin CL. J Urol 2004.nih. http://www. Treatment of ureteral stones: comparison of extracorporeal shock wave lithotripsy and endourologic alternatives.gov/entrez/query. Treatment of proximal ureteral calculi: Holmium:YAG laser ureterolithotripsy versus extracorporeal shock wave lithotripsy. These techniques also have to be applied when there are contraindications for ESWL and URS. cystine stones and pure calcium phosphate stones. but ESWL usually can be carried out without anaesthesia and has a low morbidity.ncbi.5). Rosenkranz T. There is controversy as to whether ESWL or URS is the best method for removal of ureteral stones. Karaogan Ü. uric acid stones.nlm.g. in patients with a stone proximal to a ureteral stricture. Chen CS. e. 9.gov/entrez/query. For stones with a low radiodensity. Bozkirli I. Eur Urol 1999. particularly for those situated in the lower ureter. Video-endoscopic retroperitoneal surgery is a minimally invasive alternative to open surgery.nlm.167:1972-1976. Lin WY. percutaneous chemolytic irrigation can be used to increase the clearance rate of stone fragments. can be dissolved by oral chemolytic treatment.nih. There are advantages and disadvantages of both these procedures. Shee JJ. In selected cases with infection stones. The principles of chemolytic treatment are outlined above (see section 7. Onaran M.172:1899-1902. Schubert G.
When two procedures were considered equally useful they have been given the same number. Ureteral catheter or intravenous contrast + ESWL 2. ESWL = extracorporeal shock wave lithotripsy. Stent + oral chemolysis 3. Ureteral catheter or intravenous contrast + ESWL 2. Percutaneous antegrade URS LE 2a 2a GR B B Type of stone Radio-opaque stones Infection stones and stones with infection 2a B Uric acid/urate stones 2a 2a B B UPDATE JUNE 2005 51 .semi-rigid or flexible URS 4. GR = grade of recommendation. or retrograde contrast ) + oral chemolysis 3. ESWL in situ.v. ESWL in situ (with i.Table 18: Principles of active stone removal (all sizes) in the proximal ureter* Type of stone Radio-opaque stones Procedure LE GR 1. 2. 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.semi-rigid or flexible URS 4. ESWL following retrograde manipulation of the stone (‘push up’) 3.semi-rigid or flexible URS 2. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 2. ESWL following retrograde manipulation of B the stone (‘push up’) 3. prone positiona 1. PNL = percutaneous nephrolithotomy with or without lithotripsy. prone positiona 1. URS + contact disintegration: . URS + contact disintegration: . ESWL in situ 1a A 2.semi-rigid or flexible URS 4. URS = ureteroscopy. Percutaneous URS in antegrade direction Cystine stones 1. ESWL in situ 2a B 2. 3. PNL + URS in antegrade direction LE = level of evidence. Ureteral catheter with retrograde manipulation (‘push up’) + ESWL 3. Table 19: Principles of active stone removal (all sizes) in the mid ureter* Procedure 1. URS + contact disintegration: . The first alternative always has the number 1. ESWL in situ. * Numbers (1. also including piezolithotripsy. Stent + oral chemolysis 2b B 2. 4) have been allocated to the procedures according to the consensus reached. URS + contact disintegration: . 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.semi-rigid or flexible URS 2. URS + contact disintegration: . 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.
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.rigid URS + US.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. ESWL in situ (i. 9. URS + contact disintegration 3 B .v. Ureteral catheter + ESWL LE = level of evidence. ESWL in situ. 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 with retrograde manipulation (‘push up’) + ESWL 3. laser or ballistic/ pneumatic disintegration . URS = ureteroscopy. GR = grade of recommendation. 2. When two procedures were considered equally useful they have been given the same number. Ureteral catheter + ESWL 2. urine culture is necessary. The first alternative always has the number 1. Type of stone Radio-opaque stones 9. Ureteral catheter (+ contrast medium) + ESWL 3. laser or electrohydraulic disintegration . also including piezolithotripsy. In cases with clinically significant infection and obstruction. contrast medium) 3 B 1.rigid URS + US. In others. ESWL = extracorporeal shock wave lithotripsy. ESWL in situ 3 B 1. URS + contact disintegration 3 B 2. 3) have been allocated to the procedures according to the consensus reached. URS = ureteroscopy. ESWL = extracorporeal shock wave lithotripsy. also including piezolithotripsy. * Numbers (1. The first alternative always has the number 1. 52 UPDATE JUNE 2005 . several days of drainage procedures by a stent or a percutaneous nephrostomy should precede the active intervention for stone removal. URS with lithotripsy: 2a B . URS + contact disintegration: 1b A .semi-rigid or flexible ureteroscopy 2. prone positiona 2a B 1. Screening with dipsticks might be sufficient in uncomplicated cases. ESWL in situ 1b A 1. 2. PN + antegrade contrast + ESWL in situ Cystine stones 1. PN = percutaneous nephrostomy. Cystine stones Table 20: Principles of active stone removal (all sizes) in the distal ureter* Procedure LE GR 1. GR = grade of recommendation. When two procedures were considered equally useful they have been given the same number. * Numbers (1. Percutaneous antegrade URS LE = level of evidence. 3) have been allocated to the procedures according to the consensus reached. a For lithotripters with the shock wave source below the patient.semi-rigid URS 2.semi-rigid URS 2. US = ultrasound.1.
ncbi. Problems and complications in stone disease. URS has been successfully used to remove ureteral stones during pregnancy.148:1076-1078. Johansson JE. 9.4 Pacemaker Although the rule is that patients with a pacemaker can be treated with ESWL. 9. ureteroscopy (URS) and open surgery. 9. Hofbauer J. but it must be emphasized that complications of this procedure might be difficult to manage. either with a percutaneous nephrostomy catheter. Stones in pregnancy and in children.7 1. it is recommended that the patient’s cardiologist is consulted before undertaking ESWL treatment. The possibility of chemolytic treatment of brushite stone fragments is noteworthy in view of the high recurrence rate seen with this type of stone.nih. 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.77:17-20. 4.3 Pregnancy In pregnant women. Eur Urol 1984. a double-J stent or a ureteral catheter (1-7). Table 21: Special considerations GR Treatment with antibiotics should precede stone-removing procedures in case of a positive urine culture. For large ESWL-resistant stones. Homsy Y. In expert hands. REFERENCES O’Regan S. These patients should be referred to an internist for appropriate therapeutic measures during the stone-removing procedure.nlm. thereby avoiding too much shock wave energy to the renal tissue.gov/entrez/query.those responding well to ESWL and those responding poorly (8). particularly if they are large.nih.9.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1507336 Marberger M. Urolithiasis in pregnancy.2 Bleeding Bleeding disorders and anticoagulant treatment should be considered.2 9. PNL and URS are contraindicated. In patients with coagulation disorders. Laberge I. 3.10:40-42. percutaneous nephrolithotomy (PNL) with or without lithotripsy.4:234238. not sodium urate or ammonium urate stones. ESWL.3 9. Cystine stones are of two types .ncbi.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 6698085 Kroovand RL.nlm. This may mitigate in favour of percutaneous removal of such stones. 9. PNL is the best alternative for efficient removal. or with intravenous or retrograde administration of contrast medium. In such women. B Comment 9. Management of ureteric calculi during pregnancy by ureteroscopy and laser lithotripsy. J Urol 1992. Carringer M.5 Hard stones Stones composed of brushite or calcium oxalate monohydrate are characterized by particular hardness.nlm. the following treatments are contraindicated: extracorporeal shock wave lithotripsy (ESWL). It is of note that only uric acid stones. can be dissolved by oral chemolytic treatment.4 9.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8653305 2. ESWL = extracorporeal shock wave lithotripsy.6 Radiolucent stones Uric acid concrements can be localized with ultrasound. http://www. Swartz R. UPDATE JUNE 2005 53 . Br J Urol 1996.gov/entrez/query. http://www.1 B C C 9.ncbi. the preferred treatment is drainage. Curr Opin Urol 1994. http://www. PCNL = percutaneous nephrolithotripsy.gov/entrez/query.
gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9649240 Lingeman JE.138:485-490.nlm. 4. Table 22: Active removal of complete and partial staghorn stones* Type of stone Radio-opaque stones Procedure LE GR 1. PNL 2a B 2. pp 55-59. Newman DM (eds). The first alternative always has the number 1. Cystine calculi: two types. 159:365-368. Renal colic during pregnancy: a case for conservative treatment. Usai E. Treatment of both types of staghorn stone is detailed in Table 22. PNL 1b A 2. Whereas a partial staghorn stone fills up only part of the collecting system. Open surgery standard Infection stones and 1.ncbi. Dretler SP. Lingeman JE. ESWL + PNL 1b A 4. a complete staghorn stone fills all calices and the renal pelvis. Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes. J Urol 1998. Lal A. ESWL = extracorporeal shock wave lithotripsy. Howard PJ Jr. Scarpa RM.nih. Antibiotics + ESWL + local chemolysis 2a B 5. Kahnoski RJ. Prien EL Jr.. 2. Antibiotics + ESWL + PNL 1b A 4. Plenum Press: New York. Steele RE. cystine. Antibiotics + PNL + ESWL 1b A 3.gov/entrez/query.5.ncbi.nih.nlm. 1989. De Lisa A. 8. GR = grade of recommendation. http://www.nih. http://www. Nephrectomy should be considered in the case of a non-functioning kidney. J Urol 1996.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3625845 Bhatta KM. Hopkins TB. repeated ESWL sessions with a stent can be a reasonable treatment alternative. also including piezolithotripsy. Newman DM. PNL = percutaneous surgery.5.ncbi. J Urol 1987. PNL/ESWL + oral chemolysis 1b A 3. 10. ESWL + PNL 1b B Cystine stones 1. the combined use of ESWL and chemolysis may be useful. 3. In selected cases with infection. In: Shock Wave Lithotripsy 2. Coury TA. 54 UPDATE JUNE 2005 . ESWL + PNL 2a B LE = level of evidence. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy.nlm. PNL 1b A 2. The principles of chemolytic treatment are discussed in Section 7. Wollin MR. PNL + ESWL 1b A 2. Antibiotics + PNL 1b A stones with infection 2. PNL + ESWL 1b A 3. Mertz JH. Mosbaugh PG. 7. When two procedures were considered equally useful they have been given the same number. 5) have been allocated to the procedures according to the consensus reached. http://www. Antibiotics + open surgery standard Uric acid/urate stones 1. In patients with small staghorn stones and a non-dilated system. uric acid and calcium phosphate stones. Woods JR. *Numbers (1.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8583596 Parulkar BG. PNL + ESWL 2a B 3.155:875-877. COMPLETE OR PARTIAL STAGHORN STONES A staghorn stone is defined as a stone with a central body and at least one caliceal branch. 6.
nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2336770&dopt= Abstract Chen KK.ncbi.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8239742&dopt= Abstract Locke DR. Finlayson B. Each stone problem has to be considered and treated individually.nih. Rey Pacheco M. Recommended procedures for the removal of stones in transplanted kidneys are ESWL and PNL.ncbi. 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. It needs to be emphasized. Retroperitoneal laparoscopic pyelolithotomy. Horseshoe kidneys may be treated according to the principles of stone treatment presented above (6).ncbi. These patients may become asymptomatic as a result of stone disintegration only.nlm.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507351&dopt= Abstract 2. Eur Urol 1989.nlm. PNL or open surgery are the options in obese patients. Retroperitoneal endoscopic ureterolithotomy: our experience in 12 patients. J Urol 1994.35:407-411. Chen MT.gov/entrez/query.ncbi.] Arch Esp Urol 1993. Rodriguez Cordero M. World J Urol 1993. Agarwal DK. Urology 1990. [Spanish] http://www. Webster GD. 3. REFERENCES Raboy A. Lopez Escalante JR. General directions for the management of this problem cannot be given.46:633637. however. Pollack MS. Khatri VP.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2714327&dopt= Abstract Weinerth JL. Newman RC. Cuervo R.ncbi. In the case of a narrow communication between the diverticulum and the renal collecting system. Gonzalez Zerpa RD. Multiple large calculi in a continent urinary reservoir: a case report. 9. that according to the anterior position of the kidney. http://www.gov/entrez/query.gov/entrez/query. The principles of videoendoscopic surgery are outlined elsewhere (1-5). In patients with obstruction of the ureteropelvic junction. well-disintegrated stone material will remain in the original position.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126827&dopt= Abstract Escovar Diaz P.151:927-929. http://www.nih. Walden T.. J Endourol 1990. J Endourol 1993. An optional method for removal of diverticular stones is video-endoscopic retroperitoneal surgery. 8.1 1. Ferzli GS. Lee YH.ncbi. [Ureterolitotomia laparoscopia. la Riva Rodriguez F.148:1129-1130. For pelvic kidneys.39:223-225. Albert PS. Experience with management of stones formed within Kock pouch continent urinary diversions.7:501-503.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=8124346&dopt= Abstract Gaur DD.ncbi. Purohit KC.fcgi?cmd=Retrieve&db=PubMed&list_uids=8401638&dopt= Abstract Gaur DD. Laparoscopic ureterolithotomy. Darshane AS.11.e. J−ζUrol 1992. http://www.nlm. http://www.nlm. Electrohydraulic lithotripsy for stones in Kock pouch.16:110-113. it is commonly necessary to carry out ESWL treatment with the patient in the prone position (i. http://www. Transureteral endopyelotomy with Ho:YAG laser endopyelotomy is another alternative to correct such an abnormality. UPDATE JUNE 2005 55 . ESWL.nlm. Retroperitoneal laparoscopic ureterolithotomy.nlm.11:175-177. Steinbock GS.nlm. 7. MANAGING SPECIAL PROBLEMS Caliceal diverticulum stones are treated using ESWL. 5. Extracorporeal shock wave lithotripsy in horseshoe kidney.gov/entrez/query. 4. 11. ESWL or video-endoscopic laparoscopic surgery is recommended. Chang LS.gov/entrez/query.nih. Garcia JL. 6.nih.gov/entrez/query. Loffreda R. The stones formed in a continent reservoir present a varied and often difficult problem (7-14).4:149-154. Urology 1992. http://www.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=1532102&dopt= Abstract Gaur DD. PNL (if possible) or retrograde URS.gov/entrez/query. 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). with shock wave entrance from the abdominal side).nih.
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cystine and brushite. In a 2. However. After 6.0% and 41. there is no data in the literature demonstrating the clinical value of being able to detect small tiny concretions visible only on CT scan. 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. For a kidney with stones or fragments in the lower caliceal system and with no functioning parenchyma in that part. CT scans cannot be carried out everywhere. 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.4% after 1 year. Most studies on the long-term course of the disease in patients with residual fragments are restricted to periods between 1 and 6 years.2 year follow-up of 53 patients.6 years. URS with contact disintegration is another treatment option. During a follow-up of between 7 and 96 months. In a Japanese report. carbonate apatite. necessary therapeutic steps need to be taken to eliminate symptoms. the recurrence rates were 6. In a follow-up of patients with < 4 mm residual fragments during a 4-year period. Identification of biochemical risk factors and appropriate stone prevention may be particularly indicated in patients with residual fragments or stones. However. known as a Steinstrasse (see Section 13) (22-34). A new stoneremoving procedure was undertaken in 22% of patients (15). The greatest risk was seen in patients with stones containing a high content of calcium phosphate (20). the term ‘clinically insignificant residual fragments’ (CIRF) was introduced. 6. In other cases. which are otherwise radiolucent. stones (largest diameter) < 4-5 mm > 6-7 mm 58 UPDATE JUNE 2005 . a CT or topographic examination both demonstrate small fragments better than a standard film (KUB). 28. treatment should be applied according to the relevant stone situation.4 years. 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. For calcium stones. Moreover. uric acid. a 20% risk of recurrent stone formation was recorded during the first 4 years after ESWL.3 years. residual fragments may occur following ESWL for all sizes of stones. 40% showed decreased disease or remained stable. with further intervention necessary in 9. it is important to rule out obstruction and to treat this problem if present. Residuals with a diameter of 5 mm or more should be termed residual stones.12. A CT scan also has the capacity to demonstrate uric acid concrements. The role of CIRF has been a matter of debate and concern for some time (2-13). the residual fragments increased in size in 37% of patients. For a group of Swedish patients with calcium stones.7% after 3. The risk of recurrence in patients with residual fragments after treatment of infection stones is well recognized. Stone residuals with a largest diameter of 4 mm should be termed residual fragments. 3 and 5 years. 20% after 3. Table 23 summarizes the recommendations for the treatment of residual fragments.5 years and 7% after 3. there was obvious increase in size in 37% and a need for retreatment in 12% (17). Patients with residual fragments or stones should be regularly followed up to monitor the course of their disease.3% of patients by 2 years of follow-up. In symptomatic patients. In data on 104 patients with residual fragments. Different imaging techniques have variable degrees of sensitivity.6 years (18).2 years (16). most frequently presenting in the lower calix following disintegration of large stones. For stones in the upper and middle calices. with an average follow-up of 3. In asymptomatic patients where the stone is unlikely to pass. The clinical problem of asymptomatic stone residuals in the kidney is related to the risk of developing new stones from such nidi. 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.7%. Reports on residual fragments therefore vary from one institution to another depending on which imaging method is used. 9.2% after 1. 25% of patients with infection stones had formed new stones after 2 years. The corresponding stone-free rate was 20% (1). Thus. Percutaneous chemolysis is an alternative treatment for stone fragments composed of magnesium ammonium phosphate. stone growth was observed in 26% of patients and recurrent stone formation in 15%. 78% of the patients with stone fragments 3 months after treatment experienced stone progression. while 5% progressed during a mean follow-up of 1.3 years. The longest follow-up period was reported by Yu and co-workers (14).8% after 1. lower pole resection is an alternative treatment to be considered (21). respectively (19). Stone recurrences were thus reported to be 8. RESIDUAL FRAGMENTS Residual fragments are commonly seen after ESWL.
http://www.nih. Extracorporeal shock wave lithotripsy retreatment (“stir-up”) promotes discharge of persistent caliceal stone fragments after primary extracorporeal shock wave lithotripsy. Krings F. 14. J Endourol 1992. Del Nero A. Maccatrozzo L. SR Khan.ncbi. pp 349-355.44:1023-1024.nlm.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1984100 Eisenberger F.80:853-857.nih.nih. Preminger GM. Huang JK.gov/entrez/query.ncbi. 2. Pak YC.151:5-9.fcgi?cmd=Retrieve&db=PubMed&list_uids=10148257&dopt =Abstract Sabnis RB. 10.ncbi.nih. 13. Eur Urol 2000.12. J Urol 1991. J Stone Dis 1993.nih.nlm. 11. http://www. Merlo F.1 1. http://www. 15. Chen KK.6:217-218. 6. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy.ncbi. Hanak T.fcgi?cmd=Retrieve&db=PubMed&list_uids=7966783&dopt= Abstract Streem SB. The fate of residual fragments after extracorporeal shock wave lithotripsy monotherapy of infection stones. Effect of alkaline citrate therapy on clearance of residual renal stone fragments after extracorporeal shock wave lithotripsy in sterile calcium and infection nephrolithiasis patients.148:1040-1041. Baggio B. http://www.gov/entrez/query. Jocham D. Riehle RA Jr. J Endourol 1997.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10671779 Tiselius HG. Comprehensive metabolic evaluation of stone formers is cost effective. Extracorporeal shock wave lithotripsy for lower calyceal stones: can clearance be predicted? Br J Urol 1997.ncbi. Liedl B. Bub P.ncbi.nlm. Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for urinary calculi: comparison of immediate and long-term effects. http://www. 16. Long-term results in ESWL-treated urinary stone patients. Jacqmin D. Yost A. http://www.gov/entrez/query. Trinchieri A.153:27-33.nih. Hatziandreu E. Steinkogler I.145:6-9. 5.16:256. J Urol 1995. http://www. Marberger M.nih.11:305-307. Arch Esp Urol 1991. J Urol 1994. Effectiveness of SWL for lower-pole caliceal nephrolithiasis: evaluation of 452 cases. REFERENCES Beck EM.gov/entrez/query. http://www. The definition of success. Lin AT. Effect of medical management and residual fragments on recurrent stone formation following shock wave lithotripsy. Lee YH. Br J Urol 1993. http://www. Renal stone fragments following shock wave lithotripsy.nlm.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281395&dopt= Abstract Carlson KJ.72:688-691.gov/entrez/query. Lang H.fcgi?cmd=Retrieve&db=PubMed&list_uids=1507326&dopt= Abstract Yu CC.nlm. B Hess. Clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy. http://www. Roy C.nlm. GM Preminger. BE Hibbert. J Urol 1997. 8. 4. Natural history of residual renal stone fragments after ESWL.72:688-691. Chen MT. http://www. Gambaro G. The fate of residual fragments after extracorporeal shock wave lithotripsy. Lee YH.fcgi?cmd=Retrieve&db=PubMed&list_uids=8281395 Candau C. Urol Res 1988. Lunz C.nlm. Mulley AG Jr.5:8-18. Fandella A.gov/entrez/query.nlm.ncbi. 37:18-22. J Urol 1992.158:352-355.fcgi?cmd=Retrieve&db=PubMed&list_uids=9439396&dopt= Abstract Yu CC.ncbi. Faure F. Br J Urol 1993.fcgi?cmd=Retrieve&db=PubMed&list_uids=8254832&dopt= Abstract Fine JK.ncbi. Gladstone K. Saussine C. Mascha E. Nespoli R.nlm.nih. Bapat SD. 9. Chang LS. Seveso M.nih. Chen KK. Montanari E. Tuerk C. Kladensky J.gov/entrez/query.gov/entrez/query.nlm. Roth RA. Naik K.ncbi. Guarneri A.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8632527&dopt= Abstract Zanetti G.nih. Schuster C.nih. J Urol 1996. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy. Jelinek P. Chen MT.gov/entrez/query. 7.fcgi?cmd=Retrieve&db=PubMed&list_uids=9224301&dopt= Abstract Pacik D. Lin AT. http://www. Patel SH.155:1186-1190.fcgi?cmd=Retrieve&db=PubMed&list_uids=9355942&dopt= Abstract Segura JW.nih. Editors: AL Rodgers. Chang LS. In: Urolithiasis 2000. UPDATE JUNE 2005 59 . Desai MR.gov/entrez/query. Schmidt A. Dretler SP. Cicerello E. Kumstat P.ncbi. 12. Anselmo G.ncbi. Cape Town: University of Cape Town. Turjanica M. Abstract.gov/entrez/query. 3. Huang JK.
http://www. J Urol 1996. Zehntner C.gov/entrez/query. Long-term stone recurrence rate after extracorporeal shock wave lithotripsy. J Endourol 1989.748-749.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8863540 Lahme S.nih.nlm. Use of internal polyethylene ureteral stents in extracorporeal shock wave lithotripsy of staghorn calculi.nlm.gov/entrez/query. Schneider M.17. 29.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215235&dopt= Abstract Cohen ES. Thornhill JA. J Stone Dis 1992. Extracorporeal shock wave lithotripsy for stones in solitary kidney. Curr Opin Urol 1994. http://www. Ono Y. Grainger R.fcgi?cmd=Retrieve&db=PubMed&list_uids=9032530&dopt= Abstract Ackermann D.gov/entrez/query. J Urol 1989.nih. http://www.28:152-157.nlm. Hauri D.ncbi. 24. To what size is extracorporeal shock wave lithotripsy alone feasible? Eur Urol 1988.3:31-36. Chen RN. Alund G. Bachor R.nlm. Problems and complications in stone disease.gov/entrez/query. Urolithiasis 2000. Follows OJ.ncbi.156:1572-1575. Recker F. 28.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 8808851 Tiselius HG. The benefits of stenting on a more-or-less routine basis prior to extracorporeal shock wave lithotripsy.15:481-491. Extracorporeal shock wave lithotripsy for large renal stones.ncbi. http://www. Recker F. 23. 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. Pode D. Streem SB.gov/entrez/query. http://www. Urol Clin North Am 1988. Saltzman B.gov/entrez/query. http://www.ncbi.nih.nih.gov/entrez/query. Urol Clin North Am 1988. Stent use with extracorporeal shock wave lithotripsy. Extracorporeal shock wave lithotripsy experience with large renal calculi. Claus R.nlm. Jaeger P.gov/entrez/query. 26. Lennon GM. Pfau A. Eur Urol 1987.ncbi. Knönagel H. 33.15:5-8.31:24-29. Griffith DP. http://www. Urology 1990. Konstantinidis K. 25. Fate of clinically insignificant residual fragment (CIRF) after ESWL. Schmidt JD. 3 years of experience. 21. Kamihira O.ncbi. Hautmann R. Partial nephrectomy for stone disease.7: 155-162.fcgi?cmd=Retrieve&db=PubMed&list_uids=3043868&dopt= Abstract Constantinides C.fcgi?cmd=Retrieve&db=PubMed&list_uids=597695&dopt= Abstract&itool=iconabstr Miller K. [German] http://www. Extracorporeal shock wave lithotripsy for lower pole calculi: long-term radiographic and clinical outcome. A report of over 6 years’ experience] Urologe A 1989. http://www. http://www.36:52-54. Br J Urol 1977. 4:234-238. Hauri D.gov/entrez/query. Norman RW. Hofbauer J. Scheiber K. 20. Double pigtail ureteric stent versus percutaneous nephrostomy: effects on stone transit and ureteric motility.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=2368232&dopt= Abstract Shabsigh R. Katoh N.fcgi?cmd=Retrieve&db=PubMed&list_uids=8518830&dopt= Abstract Marberger M.nih. 27.ncbi. Jaeger P.gov/entrez/query. J Urol 1996.ncbi.nlm. 31.ncbi.13:174-175. Mizutani K. Rose MB. 32. Yamada S.nih.nih.nlm. Awad SA. http://www. Ureteral stents. 18. 19.nlm. J Endourol 1993. 22. Eur Urol 1997. Bichler KH. 30.4:152-157.nlm.fcgi?cmd=Retrieve&db=PubMed&list_uids=3609094&dopt= Abstract 60 UPDATE JUNE 2005 .nlm.nih.142:1415-1418. http://www.gov/entrez/query.ncbi.2:131-135. Verstandig A. McDermott TE.nih.nlm.156:1267-1271.ncbi. Wilbert DM. Extracorporeal shock wave lithotripsy as monotherapy of staghorn renal calculi.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=3407040&dopt= Abstract Saltzman B. Gleeson MJ. variations and complications.nlm.49:605-610. J Endourol 1988.ncbi.fcgi?cmd=Retrieve&db=PubMed&list_uids=2585613&dopt= Abstract Anderson PAM.fcgi?cmd=Retrieve&db=PubMed&list_uids=2741262&dopt= Abstract Chen AS.15:493-497. Butler MR.nih. Indications. [The staghorn calculus: anatrophic nephrolithotomy versus percutaneous litholapxy and extracorporeal shockwave therapy versus extracorporeal shockwave lithotripsy monotherapy. Ohshima S. Recurrent stone formation in patients treated with extracorporal shock wave lithotripsy. Shapiro A.gov/entrez/query.
The fluid intake should be evenly distributed over a 24-hour period. however.fcgi?cmd=Retrieve&db=PubMed&list_uids=8490666&dopt= Abstract Griffith DP. but without excesses of any kind (2). The intake of fruits and vegetables should be encouraged because of the beneficial effects of fibre (3). 4) have been allocated to the procedures according to the consensus reached. Sulaiman MN. PREVENTIVE TREATMENT IN CALCIUM STONE DISEASE 14. * Numbers (1. Pharmacological treatment should be instituted only when the conservative regimen fails.gov/entrez/query.nih. Kandel LB. ESWL 1. For a normal adult.fcgi?cmd=Retrieve&db=PubMed&list_uids=10360492&dopt =Abstract 13. Ureteral calculi.000 mL. ESWL ESWL 1.gov/entrez/query. Wheat bran. For distally located accumulations of fragments. In all patients with signs of infection. pp. Diet should be of a ‘commonsense’ type . ESWL 3.ncbi. 3.1 General recommendations Preventive treatment in patients with calcium stone disease should be started with conservative measures. Stent 3. Futura Publishing Co. World J Urol 1993.nlm.11:37-42.a mixed balanced diet with contributions from all food groups. Patients should be encouraged to have a high fluid intake (1).nlm. Care must be taken. Stent 4. the UPDATE JUNE 2005 61 . 14. Buchholz NP. but the supersaturation level should be used as a guide to the necessary degree of urine dilution. Clark PB. for instance. also including piezolithotripsy. J Endourol 1999.ncbi. When two procedures were considered equally useful they have been given the same number. irrespective of stone composition. URS = ureteroscopy. Recommendations for treatment are summarized in Table 24. to avoid fruits and vegetables that are rich in oxalate. REFERENCES Tolley DA. 13. The first alternative always has the number 1. Mt Kisco. 2. ESWL 2. Consensus of lithotriptor terminology. http://www. URS 2.1 1. is rich in oxalate and in order to avoid an oxalate load. PN PN Distal Ureter 2. Harrison LH. The role of ureteral stent placement in the prevention of steinstrasse. In: State of the Art Extracorporeal Shock Wave Lithotripsy. ESWL 3. The frequency of this complication has decreased with the liberal insertion of double-J stents before ESWL of large renal stones. Table 24: Recommendations for treatment of Steinstrasse* Unobstructed Position of stone Obstructed and/or symptomatic 1. and particular attention should be paid to situations in which an unusual loss of fluid occurs. Insertion of a PN catheter usually results in passage of the fragments (2). URS ESWL = extracorporeal shock wave lithotripsy. PN PN Mid ureter 1. the 24-h urine volume should exceed 2. PN PN Proximal ureter 1. PN = percutaneous nephrotomy. McCullough DL (eds). New York 1987. 2. URS might be useful to remove the leading stone fragment by contact disintegration. it is necessary to give antibiotics and to provide adequate drainage as soon as possible.13:151-155.34. http://www. 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).nih. ESWL ESWL 1. This advice is valid. 281-310.
Jahnen A. • Cocoa 625 mg oxalate/100 g. Animal protein should not be ingested in excessive amounts (8-14). Williams HE.nlm. Effects of a ‘common sense diet’ on urinary composition and supersaturation in patients with idiopathic calcium urolithiasis. Tiselius HG. The intake of food particularly rich in urate should be restricted in patients with hyperuricosuric calcium oxalate stone disease (15-20).nih.nih. Umekawa T. Karger: New York. 7.nih. Iguchi M. Kodama M. sprats 260-500 mg urate/100 g.ncbi.1.ncbi. anchovies. Br J Urol 1991.excessive intake of products rich in oxalate should be limited or avoided. • Nuts 200-600 mg oxalate/100 g.nlm. http://www.fcgi?cmd=Retrieve&db=PubMed&list_uids=2342165&dopt= Abstract 2. Takada M. Dietary intake and habits of Japanese renal stone patients.Diagnosis. Effect of high dose vitamin C on urinary oxalate levels. 62. pp.36:143-147.1 REFERENCES 1. 14. Briganti A.ncbi. 36:136-143.nlm.gov/entrez/query. Eur Urol 1999. Kurita T.81(suppl):31-37. Meschi T. Nephron 1999. as well as in patients with uric acid stone disease. 6.gov/entrez/query. Schianchi T.ncbi. sardines. • Spinach 570 mg oxalate/100 g.gov/entrez/query. Miner Electrolyte Metab 1987. Davis PA. 4.fcgi?cmd=Retrieve&db=PubMed&list_uids=8126804&dopt= Abstract Sutton RA. Kataoka K. Calcium intake should not be restricted unless there are very strong reasons for such advice. Yasukawa S.fcgi?cmd=Retrieve&db=PubMed&list_uids=10420035&dopt =Abstract Ebisuno S. Katayama Y.twenty years later. Miner Electrolyte Metab 1994. Jaeger P. Kohri K.67:237-40.nlm. 8. http://www. 9. Wandzilak TR. The intake of urate should not exceed more than 500 mg/day. The minimum daily requirement for calcium is 800 mg and the general recommendation is 1000 mg/day. J Urol 1990. Vitamin C in doses up to 4 g/day can be taken without increasing the risk of stone formation (5-7).gov/entrez/query.20:352-360.gov/entrez/query.143:1093-1095.2:164-172.fcgi?cmd=Retrieve&db=PubMed&list_uids=7783697&dopt= Abstract Auer BL. Below are examples of food rich in urate (21): • Calf thymus 900 mg urate/100 g. Allegri F. Mauron H. Diet and calcium stones.ncbi. J Urol 1994. http://www. Morimoto S. http://www. This is of particular importance in patients in whom high excretion of oxalate has been demonstrated. 10. Ohkawa T.151:834-837.nih. Borghi L.nlm.nlm. Commentary: Renal calculi .nih. http://www.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1902388&dopt= Abstract Hesse A. • Tea leaves 375-1450 mg oxalate/100 g.fcgi?cmd=Retrieve&db=PubMed&list_uids=9873212&dopt= Abstract Hess B. Enteric and mild hyperoxaluria. and it is recommended that animal protein intake is limited to approximately 150 g/day. D’Andre SD. 62 UPDATE JUNE 2005 . Ackermann D. 3. Katoh Y.ncbi.ncbi. 1996. The effects of ascorbic acid ingestion on the biochemical and physicochemical risk factors associated with calcium oxalate kidney stone formation. • Liver 260-360 mg urate/100 g. treatment and prevention of recurrence. Rodger AL. Walker VR. Urine volume stone risk factor and preventive measure. Results of long-term rice bran treatment on stone recurrence in hypercalciuric patients. http://www.13:228-234.nih.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=9589801&dopt= Abstract Robertson WG.gov/entrez/query. The following products have a high content of oxalate (4): • Rhubarb 530 mg oxalate/100 g. J Lithotripsy Stone Dis 1990. • Kidneys 210-255 mg urate/100 g.nih. Guerra A. Novarini A. • Herring with skin.nlm. in which additional calcium should be ingested with meals.fcgi?cmd=Retrieve&db=PubMed&list_uids=3306314&dopt= Abstract Yendt ER. Clin Chem Lab Med 1998. Ishikawa Y. Auer D.nlm. http://www.gov/entrez/query. In: Urinary stones .ncbi. • Poultry skin 300 mg urate/100 g. Supplements of calcium are not recommended except in cases of enteric hyperoxaluria. http://www. 5.
Zechner O. Norman RW. UPDATE JUNE 2005 63 .fcgi?cmd=Retrieve&db=PubMed&list_uids=2401715&dopt= Abstract Goldfarb S. Pak CYC.ncbi. 285-293. 15. Churchill Livingstone: Edinburgh. 851-858.gov/entrez/query. Buck AC (eds). pp. http://www. should a pharmacological approach be considered in addition to the drinking and dietary recommendations.gov/entrez/query. Impact of allopurinol treatment on the prevention of hyperuricosuric calcium oxalate lithiasis.nih. 12. In: Renal tract stone. and in some situations pyridoxine and oxabsorb.13:251-256. cellulose phosphate.fcgi?cmd=Retrieve&db=PubMed&list_uids=2081512&dopt= Abstract Hughes J. Doorenbos CM.ncbi.nih. Hyperuricosuric calcium oxalate nephrolithiasis. it is essential to choose the most appropriate form of treatment.146:137-143.nlm. Papapoulos SE.fcgi?cmd=Retrieve&db=PubMed&list_uids=3215256&dopt= Abstract Sarig S.nlm.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. 21. Can Med Assoc J 1992. Hart LJ. Peterson R. Hyperuricosuric calcium oxalate lithiasis. The ideal pharmacological agent should halt the formation of calcium stones. In: Kidney stones: medical and surgical management. The hyperuricosuric calcium oxalate stone former. however.nih.diagnosis. Jahnen A (eds). The scientific basis of these forms of treatment is briefly summarized below. Hofbauer J.4:130-136. http://www. Britton F. 19.nlm. Karger: New York. In: Urinary stones . All these aspects are of utmost importance in order to achieve a reasonably good compliance.15:227-229. Kidney Int 1983. Only when such treatment turns out to be unsuccessful.gov/entrez/query. 16. pp. The role of diet in the pathogenesis and therapy of nephrolithiasis. Iestra JA. Preminger GM (eds). http://www. 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).ncbi. http://www. Coe FL.nih.fcgi?cmd=Retrieve&db=PubMed&list_uids=3306317&dopt= Abstract Zechner O. Germany in 1996 and form the basis for the abovementioned recommendations (1). The recommendations given in this guideline document are based on what has been published in this field. Miner Electrolyte Metab 1987.nih. Hyperuricosuric calcium stone disease. Ward D.ncbi.6).nlm. 88.gov/entrez/query. In the present edition of the Urolithiasis guideline document.fcgi?cmd=Retrieve&db=PubMed&list_uids=8377380&dopt= Abstract Coe FL. Crowther C. 13. Kidney Int 1993. 17. Wickham JEA. Miner Electrolyte Metab 1980. http://www. Lippincott-Raven Publishers: Philadelphia. An extensive review and interpretation of literature results were carried out by the European Urolithiasis Research group at a Consensus Conference in Mannheim. Assessment of pathogenetic roles of uric acid. Goodman HO. 1990.nlm. Diet and calcium stones. Ettinger B. 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. Kok DJ. 1996.3. magnesium. Holt K. Tiselius HG. information has been added on recent studies with special emphasis on data from randomized studies.44:366-372. monopotassium urate. treatment and prevention of recurrence. Favus MJ. http://www. Hesse A.nlm. http://www.ncbi.ncbi.nih. orthophosphate.gov/entrez/query.gov/entrez/query. 14. monoammonium urate and monosodium urate in hyperuricosuric calcium oxalate nephrolithiasis.fcgi?cmd=Retrieve&db=PubMed&list_uids=1310430&dopt= Abstract Holmes RP.gov/entrez/query.ncbi.4). We believe that the latter approach is theoretically most attractive but it needs to be emphasized.19:805-820. Eur Urol 1988. Parks JH. sodium cellulose phosphate.71:861-867. pp. The pharmacological agents most commonly used in patients with recurrent calcium stone formation are thiazides. In this respect.fcgi?cmd=Retrieve&db=PubMed&list_uids=7424690&dopt= Abstract Pak CY. Assimos DG. 14.11. allopurinol. that there is no absolute consensus on such a view (5. Relationship of protein intake to urinary oxalate and glycolate excretion.24:392-403. 18. J Clin Endocrinol Metab 1990. 1996.nih.nlm. The conclusions of the Consensus Conference have been published separately (2. Endocrinol Metab Clin North Am 1990. 20. be free of side effects and easy to administer.
32. Compliance is usually in the range of only 50-70%. with only a small fraction of the administered citrate being excreted in urine. four of which included placebo-treated patients. 14. There is more than 30 years’ clinical experience with thiazides as a method for stone prevention.8). Although the general principle is to give citrate preparations. This observation is also supported by the different effects of potassium citrate and sodium citrate on urine composition (43).2.28). sodium potassium in one (33) and sodium magnesium citrate in another (34). most of which support a positive effect of recurrence prevention. 64 UPDATE JUNE 2005 . potassium citrate. development of diabetes and gout.02) (29). Due to the frequent occurrence of hypercalciuria also in an unselected group of stoneformers. the overall impression is that potassium citrate (31.32). 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). possibly by a reduced intestinal absorption of calcium (911). The unmasking of normocalcaemic HPT. a thiazide-induced reduction in urinary oxalate is not a consistent finding in the clinical studies. Whether or not thiazide treatment should be reserved only for patients with hypercalciuria. sodium citrate. The role of calcium is important because citrate chelates calcium and thereby reduces the ion-activity products of both calcium oxalate and calcium phosphate. trichlorothiazide and indapamide have been used for recurrence prevention in patients with calcium stone disease. Although two short-term placebo-controlled studies (13. The major drawback of thiazide treatment is the occurrence of side-effects. There are also reports of favourable clearance of residual fragments during treatment with alkaline citrate (see below). As in all situations when pharmacological treatment is considered. however.33. The alkalinizing agents used to prevent recurrent calcium stone formation are sodium potassium citrate. it is the alkalinization of the tubular cells that is the most important factor affecting increased citrate excretion. the results were less convincing (27. A significantly reduced rate of stone formation was also noted when a thiazide was given intermittently to recurrent stoneformers (22). been suggested that thiazides might decrease the excretion of oxalate. as well as erectile dysfunction. However.1 Thiazides and thiazide-like agents Hydrochlorothiazide.35-40) has a greater potential for preventing recurrence than sodium potassium citrate (2. but it has been stated that calcium reduction is also seen in patients with normocalciuria (7). In the two studies with potassium citrate.14. contribute to a low tolerance and a high drop-out rate. It has.3 and 4. potassium bicarbonate and sodium bicarbonate. Suffice it to mention that of the randomized studies. A favourable effect was also reported with potassium magnesium citrate. Moreover.2 Alkaline citrate Treatment with alkaline citrate is commonly used as a method to increase urinary citrate in patients with hypocitraturia. moreover. The clinical effect of thiazide treatment has accordingly been evaluated in 10 randomized studies. It is our opinion.2. a large number of reports have been published. whereas no effect was noted with sodium potassium citrate compared with an untreated group. a judgment must be made between the positive and the negative effects of the medication. A low citrate excretion is a frequent finding in patients with calcium stone disease. Potassium citrate was used in two (31. in which no selection was made. other forms of treatment may be more appropriate first-choice alternatives. three studies selected hypercalciuric patients (19-21) and all three showed a significantly positive effect of thiazides. In the absence of a high calcium excretion. cannot be definitely concluded from the various studies. there is no strong scientific basis for a recommendation in this regard. potassium magnesium citrate. a significantly reduced recurrence rate was recorded. Administration of an alkaline salt brings about an increased pH and an increased excretion of citrate.3 years in comparison with conservatively treated patients (19-21). a significant effect was reported in five.14) failed to confirm a positive effect of thiazides. A similar result was also obtained in three groups of patients treated with thiazides for 2. that the major indication for choosing a thiazide or a thiazide-like agent should be hypercalciuria. citrate is an inhibitor of growth and aggregation of these crystals (30). In the other seven randomized trials. or used also in patients without this abnormality. Following the initial report by Yendt in 1970 (12).41. However. Alkaline citrate has been used in four randomized studies. bendroflumethiazide. The purpose of thiazide treatment is to reduce the excretion of calcium in hypercalciuric patients.42). In several other studies. 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. a significantly reduced recurrence rate was recorded in three 3-year follow-up studies (15-18). 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. Other non-randomized studies with alkaline citrate have shown a variable outcome.
Although potassium magnesium citrate appears efficient in prevention of recurrent stone formation, this agent is not yet generally available. Further studies are necessary to show whether this preparation is superior to potassium citrate. Whether or not alkaline citrate preparations should be reserved for patients with hypocitraturia or used in a non-selective way has not been appropriately addressed in any study. An attempt to compare literature data has suggested a trend towards selective treatment (44). In a meta-analysis of randomized trials it was not possible to adequately analyze the therapeutic outcome (29). The usefulness of alkaline citrate as a means to increase the stone clearance after shock wave lithotripsy has been studied by several groups and has recently been the subject of a European multicentre investigation (not yet finally analyzed). It was accordingly shown that sodium potassium citrate (45), as well as potassium citrate (40, 46), increased clearance of stone fragments. The frequency of side effects is fairly high and compliance with alkaline citrate administration was shown to be no better than approximately 50%. Because of the many effects on calcium oxalate and calcium phosphate crystallization and stone formation, treatment with alkaline citrate can be recommended as a treatment for preventing recurrent stones. The recommended agent is potassium citrate. Although it is likely that this form of treatment is most beneficial for patients with a low citrate excretion, so far there is no solid evidence in the literature to support this assumption and further studies are necessary. The risk of forming calcium phosphate stones as a result of the increased pH is theoretical, but there are no reports of this problem in the literature. 14.2.3 Orthophosphate The theoretical rationale for giving orthophosphate to patients with recurrent calcium oxalate stone formation is to reduce the excretion of calcium and increase the excretion of pyrophosphate. Pyrophosphate is an inhibitor of both calcium oxalate and calcium phosphate crystal growth. The effect on urinary calcium is assumed to be mediated by formation of 1,25 (OH)2-vitamin D with an associated decreased absorption of calcium and reduced bone resorption. Administration of orthophosphate (neutral) has been reported to also increase urinary citrate. There are only a few studies in the literature that deal with the effect of orthophosphate on stone formation. In a randomized, placebo-controlled study on potassium acid phosphate given during a period of 3 years, stone formation increased in the orthophosphate-treated group (47). The rate of stone formation during 3 years of treatment with phosphate was also studied in two randomized studies (16,17). The number of patients in each of these studies was small and there were no statistically significant differences between treated and untreated patients. In some, less well-controlled, studies (48,49), it was also not possible to confirm a reliable effect of phosphate treatment. A reduced rate of stone formation was, however, noted by others (50,51). In reviews of literature results, there is a lack of scientific evidence that phosphate is effective in preventing calcium stone formation (29,52). Although patient compliance with treatment is reported as good, side effects such as diarrhoea, abdominal cramps, nausea and vomiting are common. Moreover, a possible effect on PTH (parathyroid hormone) needs consideration. It is possible that the pattern of side effects is favourably affected by slowrelease potassium phosphate (53). The effect of phosphate administration on calcium stone phosphate formation has not been elucidated. In conclusion, there is only very weak evidence that orthophosphate significantly reduces calcium oxalate stone formation. Although this form of treatment may be a possible option in patients with absorptive hypercalciuria, so far there is insufficient evidence to recommend its use. 14.2.4 Magnesium An increased excretion of magnesium might reduce the ion-activity product of calcium oxalate and inhibit the growth of calcium phosphate crystals. There are also observations of an increased excretion of citrate (54). Magnesium is also considered important for the transformation between various calcium phosphate crystal phases. A high urinary concentration of magnesium is thus thought to decrease the risk of brushite formation. Magnesium oxide, magnesium hydroxide, potassium magnesium citrate and magnesium aspartate have been used. The effect of potassium magnesium citrate is discussed under Section 14.2.2 on alkaline citrate and will not be further discussed here. There are two randomized studies on the clinical effects of magnesium, one in which treatment with magnesium hydroxide was compared with a placebo control group (55) and one with magnesium oxide and untreated controls (16). None of them showed a statistically significant effect on stone formation despite followup periods of four and three years, respectively. The positive effects of magnesium administration that have been reported previously (56, 57) have not been confirmed by recent controlled studies (52,29). Thus, there is insufficient evidence to recommend magnesium as monotherapy in calcium stone prevention.
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14.2.5 Allopurinol Treatment with allopurinol in order to counteract the formation of calcium oxalate stones was introduced following demonstration of a relationship between hyperuricosuria and calcium oxalate stone formation (58). The effect of allopurinol on calcium oxalate stone formation may be mediated through a reduced salting-out effect, a decreased risk of uric acid or urate crystals as promoters of calcium oxalate precipitation, complex formation between colloidal urate and macromolecular inhibitors, and/or possibly by a reduced excretion of oxalate. It also needs to be mentioned that allopurinol may influence crystallization by its antioxidative properties. Allopurinol has been used clinically to treat patients both with, and without, hyperuricosuria. In a placebo-controlled randomized study of allopurinol-treated, hyperuricosuric, calcium-oxalate stone formers, 75% of patients given allopurinol were free of recurrent stone formation compared with 45% in the placebo group. This effect was statistically significant. Three other randomized studies compared treatment with allopurinol and placebo or no treatment (16,17,59) in patients not selected because of hyperuricosuria. No significant difference was found between treated and untreated patients in any of these studies. In a long-term follow-up of non-selected, calcium-oxalate stone formers treated with 300 mg of allopurinol daily, no effect was found on stone formation (60). A similar result was recorded in another Swedish study (61). These results are in contrast to those obtained in patients treated for hyperuricosuria (62,63). The tolerance to allopurinol is usually good, but severe side effects have been reported with high doses. There is no information on compliance. The results indicate that allopurinol might be useful for treating patients with hyperuricosuric calcium oxalate stone formation, but it cannot be recommended as treatment for patients with other biochemical abnormalities. 14.2.6 Cellulose phosphate Cellulose phosphate and sodium cellulose phosphate have been used to reduce calcium absorption in patients with absorptive hypercalciuria. Unfortunately, this complex formation may result in hyperoxaluria. Binding of magnesium causes hypomagnesuria and other ions may also be negatively affected by this form of treatment. Of nine studies in the literature, none were randomized (64-71). The overall results showed that 40% of the patients formed new stones. Cellulose phosphate and sodium cellulose phosphate cannot be recommended for prophylactic treatment against stone recurrence. 14.2.7 Pyridoxine Theoretically, administration of pyridoxine (vitamin B6) might favourably influence the endogenous production of oxalate. Such an effect can be explained by an increased transamination of glyoxylate due to the action of pyridoxal phosphate. Pyridoxine has successfully been used together with orthophosphate in the treatment of patients with primary hyperoxaluria (72), as well as patients with idiopathic hyperoxaluria (73,74). There are no controlled studies that presently support the use of pyridoxine in patients with idiopathic calcium oxalate stone disease. Due to the rarity, and severity, of primary hyperoxaluria, there are no randomized studies on the efficacy of pyridoxine. Several reports confirm, however, that a fraction of patients with Type 1 hyperoxaluria responds favourably to large doses of pyridoxine. Because of the lack of other effective forms of treatment, it is definitely worthwhile giving a therapeutic trial of pyridoxine in order to reduce the excretion of oxalate in patients with primary hyperoxaluria Type I. 14.2.8 Recommendations The following forms of treatment are discouraged: magnesium oxide and magnesium hydroxide as monotherapy. Magnesium salts might, however, be useful in combination with thiazides (74). Cellulose phosphate and sodium cellulose phosphate have no place in the prevention of stone recurrence in patients with calcium stone disease. Neither is there a place for synthetic or semisynthetic glycosaminoglycans (GAGs) (e.g., sodium pentosan polysulphate). There is no absolute consensus that a selective treatment is better than a non-selective treatment for recurrence prevention in idiopathic calcium stone disease. An analysis of data from the literature, however, has suggested a slight difference in favour of treatment directed towards individual biochemical abnormalities (6). Recommendations for a selective therapeutic approach are given in Table 25.
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Level of evidence and grade of recommendation for various forms of pharmacological treatment of patients with recurrent calcium stone disease Comment 14.2.1 14.2.2 14.2.5 14.2.3 14.2.4 14.2.7 14.2.6
Pharmacological agent LE GR Selected references Thiazides/thiazide-like agents 1a A 7-29 Alkaline citrate 1b A 2, 30-46 Allopurinol 1b A* 16,17, 58-63 Orthophosphate 3 16,17,29,47-53 Magnesium 3 16, 29, 54-57 Pyridoxine 2b B** 72-73 Cellulose phosphate Not recommended 64-71 Sodium cellulose phosphate * only for patients with hyperuricosuria; ** only for patients with hyperoxaluria. LE = level of evidence; GR = grade of recommendation
Suggested selective treatment of calcium stone formers with known abnormalities in urine composition*
Treatment Thiazides1 Thiazides + magnesium1
Treatment groups 1) Hypercalciuria 2) Brushite stone formation 3) Other abnormalities Alkaline citrate 1) Hypocitraturia 1) RTA 2) Enteric hyperoxaluria 3) Low inhibitory activity2 4) Other abnormalities Allopurinol 1) Hyperuricosuria Pyridoxine 1) Primary hyperoxaluria type 1 2) Mild hyperoxaluria Calcium supplements 1) Enteric hyperoxaluria Orthophosphate3 1) Hypercalciuria 1 Potassium supplements are necessary to avoid hypokalaemia and hypocitraturia caused by hypokalaemic intracellular acidosis. 2 In case the inhibition of crystal growth or crystal aggregation has been assessed. 3 Orthophosphate is not a first-line alternative, but it can be used in patients with hypercalciuria who do not tolerate thiazides. * Numbers (1, 2, 3, 4) have been allocated to the procedures according to the consensus reached. When two procedures were considered equally useful they have been given the same number. The first alternative always has the number 1.
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Karger.ncbi. Urol Clin North Am 1997. Tiselius HG. Arnold L. Parks JH and Preminger GM (eds). Philadelphia.Table 27: Objective Prevention Pharmacological treatment of uric acid stone disease GR B References 1-4 Therapeutic measures Urine dilution A high fluid intake. Diagnosis and treatment of uric acid calculi. Uric acid-related nephrolithiasis. 3. http://www.10:522-531. 5. Waters O. Fuller C. In: Kidney stones.ncbi. Low RK. Stoller ML.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 14173 Wilcox WR.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9048857 Shekarriz B.gov/entrez/query. http://www. 30:422-428.ncbi. J Clin Invest 1977. Khalaf A. Lippincott-Raven Publishers.nlm. Sakhaee K.nlm. Uric acid nephrolithiasis: current concepts and controversies.000 mL Alkalinization Potassium citrate 6-10 mmol x 2-3 Sodium potassium citrate 9-18 mmol x 2-3 Always reduce urate excretion Allopurinol 300 mg x 1 GR = grade of recommendation B 3-5 B B 1 1 B 1-4 B 1. Weinberger A.ncbi. Successful management of uric acid nephrolithiasis with potassium citrate.nlm.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 5074854 2. 1986. Pak CY. pp 73-91.168:1307-1314. Lopez ML. Solubility of uric acid and monosodium urate. 24-hour urine volume exceeding 2.59:426-431 http://www. UPDATE JUNE 2005 73 . 6. 24-hour urine volume exceeding 2.gov/entrez/query. Uric acid stones. Stoller ML.ncbi.nih.gov/entrez/query.3.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 3784284 Pak CY. http://www.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12352383 Hesse A.1 REFERENCES 1.000 mL Alkalinization Potassium citrate 3-7 mmol x 2-3 Sodium potassium citrate 9 mmol x 2-3 In patients with a high serum or urine level of urate Allopurinol 300 mg x 1 Medical dissolution Urine dilution of uric acid stones A high fluid intake. Med Biol Eng 1972. 2002. Mechanism for calcium urolithiasis among patients with hyperuricosuria: supersaturation of urine with respect to monosodium urate. Cox C. treatment and prevention of recurrence. Rodman JS. pp 973-989. Basel. Holt K. 7.24:135-148. Coe FL. Kidney Int. Pak CYC. Sosa E. In: Urinary stones diagnosis. http://www. medical and surgical management. Kippen I. J Urol 2002.nih.nih. 1996. 4.gov/entrez/query. Klinenberg JR.nlm. Favus MJ. Jahnen A. Barolla D.4 14.nih.
http://www.gov/entrez/query. Chow GK. J Urol 2000.163:1419-1423. Jungers P. The definition of infection stones is stones composed of magnesium ammonium phosphate and carbonate apatite and caused by urease producing micro-organisms.ncbi. 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.nlm.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 1113405 2.14. Méjean A.nih. The long-term outcome of cystinuria in Japan. To achieve this goal. The alternating use of an alkalizing salt and acetazolamide in the management of cystine and uric acid stones. Kotake T.000 mL. Ueda T. J Urol 1998.113:96-99.gov/entrez/query.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.ncbi. http://www.4 Pharmacological treatment of cystine stone disease The pharmacological treatment of patients with cystine stone disease is outlined in Table 28.5 74 UPDATE JUNE 2005 .gov/entrez/query.61:86-89.5. http://www.000 mg/day) or Captopril (75-150 mg) GR = grade of recommendation B 1-3 B 1-7 14. J Urol 1975. http://www. 4.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 10751848 Freed SZ.nlm.nlm.160:341-344. Streem SB. Rieu P. Nozumi K. 14. 3.nih.nih.1 REFERENCES 1. Daudon M.ncbi.4. Egoshi K. Table 28: Pharmacological treatment of cystine stone disease GR B References 1-3 Therapeutic measures Urine dilution A high fluid intake should be recommended so that the 24-h urine volume exceeds 3.gov/entrez/query. 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. Joly D.nih.ncbi. Ito H. treatment with acetohydroxamic acid (Lithostat) might be a therapeutic option GR = grade of recommendation B B 3 4.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9679873 Akakura K.nlm. Masai M. Medical treatment of cystinuria: critical reappraisal of long-term results. Contemporary urological intervention for cystinuric patients: immediate and long-term impact and implications.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9873246 Barbey F. Urol Int 1998.
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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 16.0 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. Width mm 1 0.6 19 25 31 38 94 100 107 113 119 126 132 138 144 151 157 9 7. The calculated surface area for any combination of stone diameters up to 25 mm is shown in Table A1.3 27 40 53 67 80 Approximate stone surface area with known diameters of the stone 18 14.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 A1.1 9 12 14 4 3.2 20.4 4.4 13 16 19 5 3.8 23.1 4.3 9.4 18.8 37.5 33.1 14.7 24 31 39 47 94 102 110 118 126 133 141 149 157 165 173 181 188 196 11 8.3 26 35 43 52 95 104 112 121 130 138 147 155 164 173 181 190 199 207 216 12 9.8 1.9 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 15.6 17.3 34.0 33 44 55 66 15 11.9 12 16 20 24 6 4. APPENDICES 7 5.1 21 28 35 42 99 106 113 120 127 134 141 148 155 162 170 177 10 7.5 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.6 25.0 16 22 27 33 99 104 110 115 121 126 132 137 8 6.6 3.7 9.1 28.1 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 18.0 22.1 6. 23 18. 22 17.8 28 38 47 57 94 104 113 122 132 141 151 160 170 179 188 198 207 217 226 236 13 10.9 15.4 3 4 5 UPDATE JUNE 2005 2 1.9 7.6 35 47 59 71 94 106 118 130 141 153 165 177 188 200 212 224 236 247 259 271 283 294 16 12.7 57 75 94 113 132 151 170 188 207 226 245 264 283 301 320 339 358 377 396 414 433 452 471 .7 6 8 9 3 2.7 31.5 11.1 36.6 2.3 42 57 71 85 19 14.1 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. Approximate stone surface area (mm2) calculated from the length and width of the stone.7 7.4 14 19 24 28 99 104 108 113 118 17.3 12.4 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.
fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 15072622 2.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9726400 Michel MS. 78 UPDATE JUNE 2005 . • Nd:YAG: frequency-doubled lasers (FREDDY. Kohrmann KU. In vitro assessment of lithoclast ultra intracorporeal lithotripter.5 mm results in reduced thermal injuries. 1. • Efficiency is low for hard stones like calcium oxalate-monohydrate stones. ULTRASOUND LITHOTRIPSY • Principle: ultrasound-based lithotripsy probes induce high-frequency oscillation which produces ultrasound waves (23. • Low cost of the Nd:YAG laser compared to the Ho:YAG laser makes this laser an interesting alternative.4 F probes are frequently used in semirigid URS with disintegration rates of more than 90%. 3.gov/entrez/query. • The resulting mobilization of fragments into more proximal parts of the urinary tract may decrease the stone-free rate (1).000-27. • Safe usage and excellent cost effectiveness are advantages of these systems (1).ncbi. http://www.nih. REFERENCES Tan PK.41:312-316. not be demonstrated (6).nih. • EHL is able to disintegrate stones of all chemical compositions. An increased incidence of strictures could. The insertion of stone baskets or special collecting tools like the ‘stone cone’ can prevent this loss of fragments (1). Consigliere D.A2. http://www. • The risk of stone migration is less than with ballistic probes. LASER-BASED LITHOTRIPSY • The neodymium:yttrium-aluminium-garnet (Nd:YAG) and the holmium:YAG (Ho:YAG) laser are mostly used for intracorporeal laser lithotripsy. Devices for endoscopic disintegration of stones ELECTROHYDRAULIC LITHOTRIPSY (EHL) • Principle: electric current generates a flash at the tip of the probe. Paterson RF.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12180234 Kuo RL. • In comparison with the Nd:YAG low tissue penetration of less than 0.12:341-344.nlm. • Currently the method of choice for stone treatment by flexible URS (5).gov/entrez/query. http://www.000 Hz). Alken P. • Several fibres are available for both lasers. leading to a vibration that disintegrates the calculi upon contact.18:153-156. Eur Uro 2002. • Ho:YAG: This laser type (2100 nm) can disintegrate stones of all chemical compositions. 532 and 1064 nm) are used for lithotripsy. 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. PNEUMATIC LITHOTRIPSY • Pneumatic or ballistic lithotripsy probes with 2.gov/entrez/query. • Laser probe must be in contact with the stone surface. Evan AP. • Flexible electrohydraulic probes (EHL) are available in different sizes for use in semirigid or flexible scopes. Lingeman JE.nlm. which accounts for the fact that EHL is not used as a standard procedure any more.ncbi. Williams JC Jr.nlm. Tan SM. Knoll T.ncbi.4). McAteer JA. 365 µm fibres are typically used in semirigid. the resulting heat produces a cavitation bubble leading to a spheric shock wave. The ultrasound is transmitted to the tip of the probe. Ptaschnyk T. Siqueira TM Jr. J Endourol 2004. • Cystine stones cannot be disintegrated with the Nd:YAG laser. 220µm fibres in flexible scopes (2). A3. • Flexible probes are available but they potentially impair the maximal tip deflection of the scope (2). Ureteroscopic lithoclast lithotripsy: a cost-effective option. • The undirected transmission of heat comes with a frequent risk of tissue injury.nih. • Perforation of the ureter or the pelvic wall is possible. J Endourol 1998. however. • Combined ultrasound/pneumatic probes are available and can be used for semirigid URS and PNL (3.
158:1357-1361.ncbi. In vitro comparison of standard ultrasound and pneumatic lithotrites with a new combination intracorporeal lithotripsy device. Watterson JD. Rogenes VJ. http://www. Lallas CD.nlm. J Urol 2002.gov/entrez/query.nih.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 9302119 UPDATE JUNE 2005 79 . Nott L. Preminger GM.nlm.nih. Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients.gov/entrez/query. J Urol 1997.4. Pietrow PK.nih.60:28-32. Ureteroscopic management of ureteral calculi: electrohydraulic versus holmium:YAG lithotripsy. Auge BK. Urology 2002. Zhong P.gov/entrez/query. 6.ncbi. Rao RD. Wollin TA. Razvi H.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 12100916 Sofer M.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids= 11743269 Teichman JM.ncbi.167:31-34. Denstedt JD. http://www.nlm. Harris JM. http://www. 5.
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