Medical Treatment and Prevention of Urinary Stone Disease.

The pathophysiology underlying urinary stone formation remains an area of active investigation. There are many pharmacotherapies aimed at optimizing metabolic factors and reducing urinary supersaturation of stone components that play an important role in urinary stone prevention. In addition, medical expulsive therapy for ureteral stones and medical dissolution therapy for uric acid-based urinary stones are helpful treatment tools and are used alongside surgical treatments in the management of urinary stones.

Renal and ureteric stones: assessment and management

This guideline covers assessing and managing renal and ureteric stones. It aims to improve the detection, clearance and prevention of stones, so reducing pain and anxiety, and improving quality of life.

NTrap in prevention of stone migration during ureteroscopic lithotripsy for proximal ureteral stones: a meta-analysis.

PURPOSE: To evaluate the effectiveness of NTrap in the prevention of stone migration during ureteroscopic lithotripsy for proximal ureteral stones. METHODS: Eligible studies were identified from electronic databases (PubMed, Embase, the Cochrane Library, ISI - Science Citation Index, and Chinese biomedicine literature database). The database search, quality assessment, and data extraction were independently performed by two reviewers. Our primary outcomes were the stone-free (SF) and incidence of stone migration. Secondary outcomes were operative time and the rate of auxiliary procedures. The outcomes were explored by using Review Manager 5.0. Sensitivity analysis was performed to explore the influence of low-quality studies. RESULTS: Two randomized controlled trials and one case-control study including 456 patients met the inclusion criteria. Meta-analysis of extractable data showed that patients who underwent ureteroscopic lithotripsy with the use of the NTrap demonstrated a significant advantage over without the use of the NTrap in terms of the stone-free rate (odds ratio [OR]=3.08, 95% confidence interval [CI] [1.45-6.53], P=0.003); the incidence of stone migration was significantly lower in NTrap treatment than without NTrap (OR=0.23, 95% CI: 0.10-0.53, P=0.0006, while there was no significant difference in operative time between NTrap and control (mean difference=-3.25, 95% CI: -16.11-9.62, P=0.62). Our pooled meta-analysis showed that the incidence of auxiliary shockwave lithotripsy was significantly lower in NTrap treatment than control (OR=0.29, 95% CI: 0.12-0.70, P=0.006). CONCLUSION: The results of this meta-analysis suggested that the NTrap stone occlusion device is efficient at preventing stone retropulsion during ureteroscopic lithotripsy of proximal ureteral calculi. The findings of this review highlight the need for more efficient performance of higher quality, more rigorous, large sample, long-term randomized controlled trials where outcomes are detailed in description.

Does ureteral stenting prior to shock wave lithotripsy influence the need for intervention in steinstrasse and related complications?

OBJECTIVE: To analyze factors affecting steinstrasse (SS) and study the impact of pre-shock wave lithotripsy (SWL) stenting in the prevention of SS and related complications. PATIENTS AND METHODS: The cohort included 4,644 patients with renal stones treated by SWL. Three hundred and twenty-six (7%) developed SS. Initially, all patients were managed conservatively (group 1); interventions were reserved for those in whom conservative treatment failed (group 2). The 2 groups were further analyzed to identify factors influencing the need for intervention. The impact of pre-SWL stenting on the development of SS and the need for intervention was also assessed. RESULTS: Expectant management was successful in 176 (54%) patients, while 150 (46%) required intervention for SS. The size of the stones had a significant association with the number of sessions required (p < 0.01) and the development of SS. The placement of a stent prior to SWL decreased neither the sessions of SWL (p < 0.01) nor the interventions required for SS and related complications. CONCLUSIONS: SWL for larger stones is a potentially significant complication of SWL and is associated with significant morbidity. Ureteral stents decrease the acute presentations of patients with SS; however, it does not decrease the ultimate need for intervention in the management of SS.

[Phytotherapy in the treatment of ureteral calculi].

Phytotherapy with prolit was given to 95 patients with ureteroliths (size of the concrrements 0.4-0.6 cm). A 40-day treatment resulted in elimination of the concrements from the ureter in 89 (93.7%) patients. Prolit had a positive action on metabolism in urolithiasis patients: lowered hypercalciuria, uric acid in the blood, oxalates and uric acid in urine. This is important for prevention of recurrent lithogenesis which for 3 years after the treatment occurred only in 4 (4.2%) patients.

[Economic aspects of evidence-based metaphylaxis]. / Okonomische Aspekte der evidenzbasierten Harnsteinmetaphylaxe.

The calculation model which we developed for the cost of stone therapy and metaphylaxis in Germany some years ago with a social health insurance company is based on estimates of stone incidence, types and recurrence rates, actual costs for stone removal, and metaphylaxis (based on data from a district of the social health care system). There are 200,000 stone recurrences per year in Germany. Costs for treatment of these stones amount to $687,000,000. Stone metaphylaxis reduces the recurrence rate by some 40%. The annual cost for stone removal could be lowered by $275,300,000. Metabolic evaluation/metaphylaxis amount to $70,100,000 per year, resulting in a net saving of $205,200,000. In 1997, there were 96 days off work per stone patient resulting in 5,800,000 days off work in Germany per year. Metaphylaxis is not only medically effective in stone formers but also can lower health care cost significantly. Although health care conditions may vary from country to country, in principle this calculation model is applicable also to other countries.

[Rational therapy of urolithiasis in every-day practice]. / Rationale Therapie der Urolithiasis in der täglichen Praxis.

Patients with renal colic are usually treated in emergency care units or by their family doctors and require immediate diagnosis and treatment. The life-time risk is up to 10 %. The prevalence amounts to 4.7 % in Germany. In addition to confirming the diagnosis and inducing an adequate pain therapy it's very important for patients to be directed correctly and, above all, prevention is important, too. Without treatment the recurrence rate ranges between 50 and 100 %. Particularly, these principals should give useful advice, wherever patients are treated without urological department.

Steinstrasse after extracorporeal shockwave lithotripsy: aetiology, prevention and management.

OBJECTIVE: To determine the causes of steinstrasse, methods of prevention and treatment strategies. PATIENTS AND METHODS: Fifty-two patients with steinstrasse were identified and treated: all patients were initially treated conservatively but when there was obstruction, infection or no progression of the stone fragments, further treatment was used, ranging from repeated extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrostomy (PCN), endoscopic manipulations and finally open surgery, depending on the degree of obstruction, infection, renal function and response to each kind of therapy. RESULTS: Conservative management was successful in 25 patients (48%), repeated ESWL in 12 (23%), PCN in 10 (19%), ureteroscopy in three (6%) and open surgery in two (4%). CONCLUSION: As many patients, and particularly those with larger stones, are treated by ESWL, the risk of developing steinstrasse will increase, with associated patient discomfort, infection or impaired renal function. The optimum selection of cases (aiming to pulverize the stones rather than fragment them) and accurate stone targeting are essential to minimise the development of steinstrasse. The meticulous follow-up of patients with steinstrasse should prevent any loss of renal function. When there is obstruction and/or infection or renal damage, active treatment is indicated, of which ESWL and PCN are the most effective, with ureteroscopy and open surgery reserved for difficult cases.

Stone recurrence after endopyelotomy.

OBJECTIVES: The purpose of this study was to evaluate whether repair of the ureteropelvic junction (UPJ) obstruction reduces the incidence of stones in stone-forming patients with concurrent UPJ obstruction. METHODS: We performed a retrospective study evaluating 90 patients with UPJ obstruction who underwent endopyelotomy and simultaneous stone extraction (group A) and 80 patients without UPJ obstruction who underwent only stone extraction (group B). Group A consisted of 52 men and 38 women with an average age of 54.4 years (range 15 to 82), and group B of 46 men and 34 women with an average age of 53.5 years (range 8 to 94). Metabolic evaluation was available in 47 patients of group A and 42 patients of group B. RESULTS: We achieved a stone-free state in all patients of both groups. Stone recurrence was observed in 7 patients (8%) in group A and in 32 patients (40%) in group B. Nine of 47 patients (19%) in group A showed metabolic abnormalities. In group B we found 30 of 42 patients (71.4%) with metabolic abnormalities. CONCLUSIONS: Our results suggest that correction of the anatomic obstruction facilitates the drainage of the previously entrapped urine, and thus decreases the incidence of recurrent urinary stone formation.

The efficacy of potassium citrate based medical prophylaxis for preventing upper urinary tract calculi: a midterm followup study.

PURPOSE: We examined the efficacy of potassium citrate based medical prophylaxis for preventing upper urinary calculous recurrence, and compared it with the stone recurrence rate in patients who only received intermittent or no medical prophylaxis. MATERIALS AND METHODS: We retrospectively reviewed the records of 493 patients with upper urinary calculi, of whom 237 men and 76 women with a mean age of 56.1 and 51.4 years, respectively, were enrolled in the study. Of the 313 participants 64 (group 1, 20.4%) received regular medical prophylaxis for 24 to 42 months (mean 27.8), 80 (group 2, 25.6%) received intermittent medical prophylaxis for 1.5 to 19 months (mean 7.9) and 169 (group 3, 54%) did not receive any medical prophylaxis. RESULTS: At midterm followup of 24 to 60 months 107 patients (34.2%) had stone recurrence. In group 1 the stone recurrence rate was 7.8%, which was significantly less (p <0.001) than in groups 2 (30%) and 3 (46.2%). Similarly new calculous events in patients with a history of multiple stone recurrence were less frequent in group 1 than in groups 2 and 3 (9.7, 47.4 and 52.2%, respectively, p <0.001). Multiple stone recurrence history, hypercalciuria, hyperuricosuria and calcium oxalate dihydrate calculi were independent risk factors for stone recurrence. CONCLUSIONS: Regular medical prophylaxis may effectively prevent stone recurrence regardless of previous treatment modalities, stone composition, metabolic abnormalities and stone-free status. Cost effectiveness, patient compliance and gastrointestinal upset may limit patient acceptability and clinical use of medical prophylaxis. However, patients with a history of multiple stone recurrence, calcium oxalate dihydrate stones, hypercalciuria and hyperuricosuria benefit from regular medical prophylaxis.

[Urinary calculi and indinavir sulfate in patients with HIV infection. Apropos of 4 cases]. / Lithiase urinaire et sulfate d'indinavir chez les patients infectés par le VIH. A propos de 4 cas.

We report on 4 cases of urinary stone observed in patients treated with the drug Crixivan (Indinavir Sulfate) and review the literature. Comments include stone composition, clinical aspects, treatment and prevention.

[Diclofenac in the short-term prevention of recurrent colic from ureteral calculi. A placebo controlled double-blind study]. / Korttidsprofylakse med diklofenak mot residiv av uretersteinskolikk. En placebokontrollert dobbeltblind undersøkelse.

We have conducted a double-blind randomised placebo controlled trial with oral diclofenac to study the prophylactic effect on recurrence of renal colic and rate of spontaneous stone expulsion. 41 patients were given 50 mg oral diclofenac three times a day for seven days after being discharged for a colic episode from Oslo Emergency Hospital and 39 patients were given matching placebo tablets. The number of new ureteral colic episodes per accumulated patient treatment days was 64/287 in the diclofenac group and 119/273 in the placebo group (p < 0.01). The difference was greatest during the first four days of treatment. A similar trend was found for pain intensity, with the greatest difference on day one. There was no difference in reported type or frequency of side effects in the two treatment groups. Stone expulsion rate was almost identical. The effect of the treatment was not affected by fluid intake. Re-admission rates to Oslo Emergency Hospital or other hospitals were 10 and 67% (p < 0.001).

[Citrate (CG-120) therapy for urolithiasis. 1. Clinical effects].

Urinary citrate is an important determinant for crystallization of calcium salts, and recently oral administration of citrate has been suggested to be clinically useful in the management of renal stone disease. The effect of CG-120, a citrate compound (potassium citrate, sodium citrate and citric acid) produced by Dr. Madaus (Germany), on upper urinary tract stones was investigated in 398 patients in this study group. The patients were treated with 3 or 4 g CG-120 daily. Two hundred thirty-one of them were treated accurately according to the protocol of the study for more than 32 weeks. The cumulative percentage of positive clinical effect for the stone (disappearance, passage or decrease in size) was 30.3% (70/231). There were no differences in the clinical effect between the group of 3 g/day and the group of 4 g/day. CG-120 seemed to be more effective in the cases of ureteral stone, young patients and females, but was less effective in the recurrent stone formers. Although there were 45 episodes of side effects in 38 patients in this study, no serious side effects attributed to CG-120 were experienced. CG-120 was proved as a useful drug in the treatment of upper urinary tract calculi as well as its prevention.

Cateterismo vesical intermitente / Intermittent bladder catheterization

Os autores apresentam a técnica de cateterismo vesical intermitente näo-estéril indicada nas situaçöes agudas ou crônicas que se acompanham de dificuldade no esvaziamento da bexiga. Este procedimento, a superdistensäo da bexiga, preserva o suprimento sanguíneo e o estado funcional da mesma. Os índices de infecçäo urinária, incontinência, litíase e deterioraçäo do aparelho urinário superior e inferior foram comparados com os outros métodos de esvaziamento vesical utilizados. A eficácia terapêutica a curto e longo prazo e a simplicidade da técnica proporcionou-lhe a grande aceitaçäo entre os profissionais de saúde e os pacientes