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PREVENTION OF RECURRENT UROLITHIASIS; PROBABLE OR CERTAIN BENEFIT FROM DIFFERENT METHODS ?.
Dr. HIWA OMER AHMAD. CABS CONSULTANT SURUEON SULAIMANI – IRAQ

SUMMARY
One hundred patients with urolithiasis were studied to evaluate the benefit of different diets & medical programs in the prevention of the recurrence. The most common type of the urinary stones was triphosphate (56%) followed by calcium oxalate (44%). Female: male ratio was 34/66. The urolithiasis which may affect all age groups were more common in forth decade of the life. Stones from all the patients were analyzed chemically and then diet & medical programs applied accordingly. It seems to be possible to prevent high number of recurrent urolithiasis by these easy, non -costly and tolerate methods.

INTRODUCTION
While the lithotomy is the first goal of the treatment of urinary tract stones, the prevention of recurrence is the second & vital goal of the management. Recurrent urolithiasis after surgery is considered as on of the global problems, which may be as high as 50% within a year(1). In some articles, studies have shown that single stone formers have same incidence & severity of metabolic derangement as patients with recurrent stone disease(1), so every patient with urolithiasis may has a risk for recurrence. The need for repeated stone removal may be dramatically reduced by prophylactic medical program & dieting of the patients, to implement these preventive measures, we need identification of the specific risk factors and composition of the stone an each case(2). A study on recurrent urolithiasin was done in south Iraq(3), but none in our region, which have different weather, style of life & composition of drinking water. The present work done in Sulaimani Teaching Hospital (STH), which covers more than million populations in Sulaimani & keruk governates. The aim of the study was to evaluate the role of different medical programs & diets in the prevention of the recurrence of urinary tract stones.

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Patients & Methods
This is prospective study of 100 patients having urolithiasis, conducted in STH over a period of 3 years from 1st Jan. 1994 to 31st dec.1996. Data were collected regarding age (Figure I), sex, type of the stones (Table I), history of previous urolithiasis (Table II), familial history, type of work, presence of urinary tract infection (UTI) & other predisposing factors (Table III), the water supply project, calcium content of drinking water for each patient (Table IV), investigations including GUE, ultrasonography, KUB, serum calcium, and IVU in selected cases. All stones after surgical removal or when passed by medical treatment were sent for chemical analysis, then accordingly each patient received a list of dieting & medical advice’s (Table V), Each patient was asked to be reported regularly every 6 month for evaluation; clinically and by GUE, ultrasonography each for 5 years (Table VI). All the recurrences (5%) were recorded and the patient labeled as recurrence. Each patient investigated for the main factors of the recurrence (table VII).

Differemt Age Groups

No. of Patients

40 35 30 25 20 15 10 5 0

38

21 14 10 8 6 3

1
Age Years

Figure I: Showing different age groups of the patients with urolithiasis.

Type of stone Triphosphate Calcium oxalate Uric acid Cystin

% 56 44 00 00

Table I: showing percentage of the different types of stones.

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No. of patient 2 2 4 6 6

Frequency of recurrence 04 17 05 02 10

Table II: showing history of recurrences before the present work in the patients.

ASSOCIATED CONDITIONS BPH Stricture Hypercalcaemia UTI Horseshoe kidneys

% 02 04 08 16 02

Table III: showing predisposing factors for urine stasis.

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Amount of calcium in water AREA PPM Part per million Sulemani city Water project of : Aziz aga Hagi bag Girdi jow New dokan Serchenar Sulemani governate Kefri Saidsadiq Penjwen Arbat Old halabja Mawat Rania Bazian Dokan 187 100 89.0 73.6 68.0 66.0 65.6 57.0 36.0 93.9 50.0 44.5 36.5 34.0 33.0 32.5 28.5 18.0 08 08 02 02 08 08 07 02 03 76.0 67.0 50.0 46.6 44.5 38.0 33.5 25.0 23.2 22.2 06 00 14 04 28 mEq/L No. of patients

Table IV: showing amount of calcium in different water project in the area.

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@ Fluid INTAKE ↑

TYPE OF STONE 1. Calcium Oxalate

FOOD RESTRICTIONS Not to take diary products, unless with oxalate containing foods like: spinach, tomato, lemon .etc, & vice versa.

DRUGS Thiazid VB6 Monthly

2.Triphosphate

↑ ↑

Treatment & control of UTI
(9)

Antibiotics Acidification of the urine

3.Cystin

Eggs , meat , fish

D-penicillamin Soluble alkaline; K+ citrate orally

4.Uric acid

Red meat ,(offal , fish)(9)

Alkalization of the urine Allupurinol

Table V: Different diets in applied for prevention of recurrence of the stones (1,4,6)

Duration of follow up One year Two years Three years Four years More than 4 years

% 30 14 38 10 08

Table VI: period of follow-up in the study.

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@ Drinking water project Dieting & medical program Hypercalcacemia Type of the stone

Side of the stone

Family history

Time of the Recurrence

RESULTS
Most of the patients were in the fourth decade of life (figure I). Most were male (M: F = 66/34). Majority of the stones were triphsphate, the rest was calcium oxalate (table I). With history of recurrence in (20%) of the patients before entering the study (table II). There was family history of urolithiasis in (32%) of the patients. Thirty-two patients have associated predisposing factors of stone formation (table III) .The patients were from different areas in the Sulaimani and Karkuk governates, were drinking water from different water projects with various amounts of calcium contents (table IV).

Age (years) 36 25 26 28 6

Residency

work Housewi fe Housewi fe Military officer Farmer child

UTI

Table VII: showing the main common factors in the patients with the recurrence

sex + + +

Calcium oxalate calciumo xalate calciumo xalate calciumo xalate triphosph at

Sulaimani, Karezawishk

New dokan

3rd visit 18 months

-

-

+

Omitted by the patient

Left

Sulaimani Mamostayan

New dokan

4th visit 24 months

+

+

+

Omitted by the patient

left

Sulaimani Malkandi

New dokan

3rd months

-

-

-

Omitted by the patient

left

Sulaimani Mama yara

Aziz aga

2nd visit 12 months

left

-

-

-

Continued

Sulaimani Malkendi

Grdig ow

1st visit 6 months

+

-

+

Omitted by the patient

left

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DISCUSSION
Majorities of the stones were triphosphate types (56%) while in other studies it is ranging between 10-20% (3). The cause may be due to the high incidence of UTI in our locality, predisposing to formation of triphosphate stones. The acceptable daily intake of calcium from the drinking water is 40 - 50 mEq /L. While our patients were drinking water containing calcium from (18-93.9mEq/L)(5) . We found no any relation between the level of the calcium in the drinking water and the incidence of calcium oxalate stones or their recurrence, for example the highest level of calcium in the drinking water was in Kifri water (187ppm=93.9mEq/L) followed by SaidSadiq (100 PPM = 50 mEq/L), but no patients from these two places (16%) had recurrence. While all the recurrences were from Sulaimani City, with a level of calcium in drinking water much lower (Table IV). While the recurrent UTI appeared as an important factor in the predisposition for recurrence of the stones, even in the recurrence of the calcium oxalate stones. The incidence of recurrent urolithiasis without dieting & medical programs is 40 - 50 % in 5 years(6). But in the present work the incidence was (5%) .The main factors were omitting of the diet & medical programs by the patients themselves, recurrent UTI & left sided stones (Table VII). We found dieting & medical programs to be effective in reducing the incidence of recurrence by 10 folds (from 40-50(6) to 5% in 5years). While in other studies they found a remission rate of greater than 30% over all reduction in individual stone formation rate of greater than 90% (1).

CONCLUSION
The diet & medical programs is a non-costly, effective, acceptable method to decrease the number of recurrent urolithiasis, but needs best doctor-patient cooperation.

ACKNOWLEDGMENT
Technical assistance received from staff in the 16th surgical unit, laboratory in STH and administration of Sulaimani water projects thankfully acknowledged.

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REFERENCES

1. 2. 3.

Shwartz, Shire, and Spenser, Principles of Surgery, 6th edition, and 1994: 1750-1754. Francesco P. cappucio, BMJ, Kidney stone and hypertension, 1990 - 1234-6. Lamia M al Naama, Saudia MJ, The incidence & composition of urinary stones in south

Iraq, Sept. 1987, Vol. 8 No 5 , 456-457 . 4. 5. 6. Kambal et al., British J of Urology, Urolithiasis in Sudan, 1981, 52, 7 - 12 . From Sulemani water project Archive . Edmund R Yendt, International Medicine, Renal calculi, Dec.1982,Vol. 94, No.24,

1110-1112 . 7. M.S abomelha, Saudia MJ, ESWL first experience in the mid east, Nov. 1986, Vol. 17

No.6, 89-90. 8. Jay Y Gillen water, year book of Urology, London,1994-29 .

9.

RCU - Russell , Bailey & loves short practice of Surgery-London - 23rd

edition, 2000, 1188.

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