17 Urolithiasis

March 24, 2018 | Author: Marie Carmelli Cuyugan | Category: Renal Function, Creatinine, Clinical Medicine, Medical Specialties, Medicine


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Guidelines onUrolithiasis H-G. Tiselius, P. Alken, C. Buck, M. Gallucci, T. Knoll, K. Sarica, Chr. Türk © European Association of Urology 2009 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 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 a simplified overview of the principles of analytical work-up in patients 3.3.5 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 Spontaneous passage of stones 5.3 Medical expulsive treatment (MET) 5.4 references IndIcaTIonS For acTIVE STonE rEMoVaL 6.1 references pAgE 6 7 7 7 8 9 9 9 10 10 10 11 11 12 13 13 13 14 15 17 18 20 21 21 21 21 21 22 22 22 22 23 23 24 24 25 26 26 26 27 32 32 33 33 34 34 34 34 34 35 35 35 2. 3. 4. 5. 6. 7. acTIVE rEMoVaL oF STonES In THE kIdnEY 7.1 Extracorporeal shock-wave lithotripsy (ESWL) for removal of stones in the kidney 7.1.2 Factors of importance for the outcome of ESWL 7.1.2.1 Location of the stone mass 7.1.2.2 Stone burden 7.1.2.3 composition and hardness of the stone 7.1.2.4 references 7.2 Percutaneous removal of renal stones 7.2.1 complications 7.2.2 references 7.3 retrograde removal of ureteral and renal stones (retrograde intrarenal surgery [rIrS]) 7.3.1 Standard endoscopic technique 7.3.2 anaesthesia 7.3.3 assessment of different devices 7.3.3.1 ureteroscopes 7.3.3.2 disintegration devices 7.3.3.3 Baskets and forceps 7.3.3.4 dilatation, ureteral access sheaths and stenting 7.3.4 clinical results 2 uPdaTE MarcH 2008 7.4 7.5 7.6 8. 9. 7.3.4.1 renal calculi 7.3.5. complications 7.3.6. conclusions 7.3.7 references open and laparoscopic surgery for removal of renal stones 7.4.1 Indications for open and laparoscopic surgery 7.4.2 operative procedures 7.4.3 references chemolytic possibilities by percutaneous irrigation 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 36 36 37 42 42 42 43 45 45 45 45 45 46 46 47 49 STagHorn STonES ManagEMEnT oF PaTIEnTS WITH STonES In THE urETEr. Eau/aua 2007 guIdELInE For THE ManagEMEnT oF urETEraL caLcuLI 9.1 Introduction 9.2 Methodology 9.3 results of the outcomes analysis 9.3.1 observation and Medical Therapies Stone passage rates 9.3.1.1 Shock-wave Lithotripsy and ureteroscopy 9.3.1.2 Efficacy outcomes Stone-free rates 9.3.1.3 Procedure counts 9.3.1.4 complications 9.3.1.5 other Surgical Interventions 9.4 The Index Patient 9.5 Treatment guidelines for the Index Patient 9.5.1 For all Index Patients 9.5.2 For ureteral Stones <10 mm 9.5.3 For ureteral Stones >10 mm 9.5.4 For Patients requiring Stone removal 9.6 recommendations for the Pediatric Patient 9.7 recommendations for the nonindex Patient 9.8 discussion 9.8.1 Medical Expulsive Therapy 9.8.2 Shock-wave Lithotripsy 9.8.3 ureteroscopy 9.8.4 Percutaneous antegrade ureteroscopy 9.8.5 Laparoscopic and open Stone Surgery 9.8.6 Special considerations 9.8.6.1 Pregnancy 9.8.6.2 Pediatrics 9.8.6.3 cystine Stones 9.8.6.4 uric acid Stones 9.9 research and Future directions 9.10 acknowledgements and disclaimers 9.11 references gEnEraL rEcoMMEndaTIonS and PrEcauTIonS For STonE rEMoVaL 10.1 Infections 10.2 aspects of anticoagulation and stone treatment 10.3 Pacemaker 10.4 Hard stones 50 52 52 54 55 55 55 55 55 58 60 62 62 63 63 63 64 64 65 65 65 65 66 67 67 68 68 68 68 69 69 69 70 70 75 75 75 76 76 10. uPdaTE MarcH 2008 3 6 references rEcurrEncE PrEVEnTIVE TrEaTMEnT 17.2 Stone removal 13.1.1.4 conclusions 12. Management of the stone problem 12.1.2.1.1 references InTErnaL STEnTIng – WHEn and WHY 16.5 Magnetic resonance urography (Mru) 13.1 Imaging 13.4 Magnesium 76 76 76 77 77 79 79 80 80 81 81 81 81 81 82 82 83 84 84 84 84 84 85 85 85 85 85 86 86 87 87 87 89 91 93 93 93 93 94 94 94 94 95 95 96 96 97 97 98 98 99 100 100 12.5 10.2.2 Temporary urinary diversion 12.1 references STEInSTraSSE 15.2.3 references rESIduaL FragMEnTS 14.1 Indications for stenting for urgent relief of obstruction 16.1.1.2 Stents in the management of kidney stones 16.3 Pharmacological treatment 17.1 recurrence preventive treatment of patients with calcium stone disease 17.2.1.1. 13.3.3 ureteroscopy (urS) 12.1.10.1 Percutaneous nephrostomy catheter 12.2.3 conclusions 13.1.3.6 nuclear imaging 13.1.2 alkaline citrate 17.1 Symptoms 12.1.3 The use of stents in the ureter 16.2 diagnostic evaluation 12.1. 14.2. 4 uPdaTE MarcH 2008 .1.3.1 drinking recommendations 17.2 dietary recommendations 17.1.3.1.2 Metaphylactic investigations 13.4 Helical computed tomogram (cT) 13.2 Internal ureteral stent 12.3.2 Plain films (kuB) 13.3 orthophosphate 17.4 open or laparoscopic surgery 13.2.1 ultrasound 13.1 Introduction 16. 15.3.6 10.1.3. 16.1 Endourological procedures 13.5 Stents in conjunction with ureteroscopy (urS) 16.5 references ManagEMEnT oF STonE ProBLEMS In cHILdrEn 13. 17.3.3.1 Thiazides and thiazide-like agents 17.3.1.1 Investigations 13.1.7 11.4 Stents in conjunction with ESWL therapy for ureteral stones 16.1.1. radiolucent stones recommendations for special considerations in the removal of stones references ManagIng SPEcIaL ProBLEMS In STonE rEMoVaL 11.3.1 Surgical management 12.1 references ManagEMEnT oF STonE ProBLEMS durIng PrEgnancY 12.2 ESWL 13.3 Intravenous urography (IVu) 13. 2 drinking advice 17.1 drinking an dietary recommendations 17. 19.2 references 101 101 101 102 103 108 108 108 109 110 110 110 110 111 111 111 112 113 114 114 115 18.4.17.3 references Medical treatment of cystine stone disease 17.5 references Medical treatment of patients with uric acid stone disease 17.3.7 Management of patients with enteric hyperoxaluria 17.2 17.2.3 Pharmacological treatment 17.4.1.3.1 Pharmacological treatment of infection stone disease 17.3.2.1. aBBrEVIaTIonS uSEd In THE TEXT aPPEndIcES appendix 1: appendix 2: devices for endoscopic disintegration of stones approximate stone surface area with known diameters of the stone uPdaTE MarcH 2008 5 .1.3 17.2 Pharmacological treatment 17.6 Pyridoxine 17.1.3.1 dietary recommendations 17.3.3.4 recommendations 17.2.3.4 17.1.5 allopurinol 17.4 references Management of patients with infection stones 17. stone expulsion treatment. a document resulting from collaboration between the american urological association (aua) and the Eau (2. and ‘option’ allows for the greatest flexibility. 3. 2. we refer to the 2007 guideline for the Management of ureteral calculi. (1) Table 2: grade of recommendation (gR)* grade Nature of recommendations a Based on clinical studies of good quality and consistency addressing the specific recommendations and including at least one randomized trial B Based on well-conducted clinical studies. according to the literature or consensus reached.1. a basic understanding of the aetiology of stone formation and of metabolic risk evaluation are also essential. 1. uroweb. The criteria for LE and gr are given in Tables 1 and 2 (1).org/professional-resources/guidelines). BACKgROUND The management of patients with urolithiasis is an important part of everyday urological practice. improved understanding of the mechanisms of stone formation and advances in pharmacological treatment. ‘Standard’ is the most rigid treatment policy. an ‘index patient’ has been defined to describe the typical individual with a ureteral stone The index patient is a non-pregnant adult with a unilateral non-cystine/non-uric acid radiopaque ureteral stone without renal calculi requiring therapy whose contralateral kidney functions normally and whose medical condition. during the past few decades. such as comparative studies. statements are graded as ‘standard’. 1. body habitus. as they provide a sound basis on which to select appropriate measures to prevent stone recurrence. Table 1: Level of evidence (LE)* Level 1a 1b 2a 2b 3 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 scientific basis for recommendations or statements has been classified by level of evidence (LE) and grade of recommendation (gr) when appropriate. etc. 3. ‘recommendation’ has significantly less rigidity. STANDARD: the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions.org/guidelines and http://www. http://www. The preferred treatment alternative always has the preference number 1 For the management of patients with stones in the ureter (see chapter 9). according to the principles of the European association of urology (Eau) guidelines office. the methods considered have been assigned preference numbers. Some of the therapeutic principles are based on evidence from randomized or controlled studies. the rational treatment of acute stone colic. The optimal clinical management of urolithiasis requires knowledge of the diagnostic procedures. to indicate which treatment alternative was considered most appropriate or was preferred. the same preference number is given.auanet. and there is virtual unanimity about which intervention is preferred. some statements are based on other types of study or on substantial clinical experience. correlation studies and case reports 4 Evidence obtained from expert committee reports or opinions or clinical experience of respected authorities modified from Sackett et al. and the latest methods of stone removal. and anatomy allow any one of the treatment options to be undertaken. but without randomized clinical trials c Made despite the absence of directly applicable clinical studies of good quality modified from Sackett et al. Whenever possible. (1) In several statements. These guidelines are based on published results. 6 uPdaTE MarcH 2008 . the treatment of urolithiasis has been characterized by changes resulting from major technical achievements. If two procedures were considered equally useful. ‘recommendation’ or ‘option’ to reflect the degree of flexibility in application. Tiselius Hg. 4. Brian Haynes. When a certain form of therapy is not recommended. Berlin. http://www. different financial systems in the European healthcare sector.nlm. Sharon Straus. However. Wolf JS Jr.org/nc/professional-resources/guidelines/online/ 2. Edition presented at the 22nd Eau congress. our intention has been to highlight the alternatives that appear most convenient for the patient in terms of low invasiveness and risk of complications. no attempt was made to perform a structural analysis of the available literature. 3.nih. gallucci M. by panel opinion. alken P. gallucci M. It is not possible to translate these levels of grading to the grade of recommendations currently used by the Eau. and an appreciable. Eur urol 2001. REFERENCES oxford centre for Evidence-based Medicine Levels of Evidence (May 2001).52(6):1610-31. For all clinical problems. This edition of guidelines on urolithiasis is an update of previously published documents (4–6). guidelines on urolithiasis. conort P. Buck c. Sarica k. http://www. http://www. Inc. when data from the literature are contradictory or lacking. germany.nlm. this does not mean that other methods are not applicable. Lingeman JE. 2. ISBn-13:978-90-70244-59-0. In: Eau guidelines. ackermann d. gallucci M. 6. Pearle MS. chris Ball. Wolf JS Jr.cebm. Buck ac.nih.178(6):2418-34. or preferences are unknown or equivocal. Switzerland. knoll T. Martin dawes since november 1998. nakada SY. 1. Produced by Bob Phillips. Pearle MS. In: Eau guidelines.1 CLASSIFICATION Categories of stone-forming patients a system for categorizing stone-forming patients according to type of stone and severity of disease is shown in Table 3.1 1. http://www. These categories are useful when making decisions regarding the need for metabolic evaluation and medical treatment (1–4). geneva. uPdaTE MarcH 2008 7 . american urological association Education and research. Buck c. Türk c. European association of urology. conort P. majority agrees on which intervention is preferred. alken P. knoll T. alken P.2. ackermann d. guidelines on urolithiasis. doug Badenoch. assimos dg. ISBn 90-806179-3-9. J urol 2007. 2007 guideline for the management of ureteral calculi. Where recommendations are made. However. the statements made in chapter 9 will correspond. Lingeman JE. to the preference numbers used in the other fields of urolithiasis discussed in this guideline. Buck c.org/nc/professional-resources/guidelines/online/?no_cache=1&view=archive Tiselius Hg.uroweb. the main focus is on medical aspects. at least partly. Türk c. however.ncbi.nlm. 2007. a discussion of the associated economic issues is beyond the scope of a European guideline document because of the wide geographical diversity of. 3.gov/pubmed/17993340 Tiselius Hg. ackermann d. conort P. alken P. 2001. 2. but not unanimous. and variation between. assimos dg.nih. Eur urol 2007. this has been specifically stated. 5.gov/pubmed/11713390 Tiselius Hg. gallucci M.gov/pubmed/18074433 Preminger gM. guidelines on urolithiasis. Preminger gM. Buck c. Edition presented at the 16th Eau congress.net/index. RECOMMENDATION: the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions. http://www. Tiselius Hg. Sarica k. gallucci M. http://www. 2007 guideline for the management of ureteral calculi. alken P. OpTION: the health outcomes of the interventions are not sufficiently well known to permit meaningful decisions.uroweb. dave Sackett. nakada SY. The Panel is aware of the different treatment and technical facilities available geographically.aspx?o=1025 [access date February 2009].40(4):362-71. the recommendations in this guideline are supported by comments based on the most important publications or.ncbi.ncbi. Eau/aua nephrolithiasis guideline Panel. calcium supplements . CaHPO4.hyperparathyroidism .pelvo-ureteral junction obstruction .sulphonamides . caliceal cyst .renal tubular acidosis (partial/complete) .caliceal diverticulum. Table 4: Risk factors for recurrent stone formation • Onset of urolithiasis early in life ( i.2 Specific risk factors for stone formation risk factors for stone formation are listed in Table 4.triamterene .ureteral stricture 8 uPdaTE MarcH 2008 .vitamin d supplements .primary hyperoxaluria .sarcoidosis • Medication associated with stone formation .cystinuria . 2.intestinal resection . carbonate apatite or ammonium uratea uric acid/ammonium uratea/sodium urate stone cystine stone caLcIuM STonES 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 Category InF ur cY So Sres rmo rm-res recurrent stone former with severe disease with or without rs residual stone(s) or fragments or with specific risk factors irrespective of otherwise defined category (Table 4) a Ammonium urate stones form when a urease-producing infection occurs in patients with urine that is supersaturated with uric acid/urate.indinavir • Anatomical abnormalities associated with stone formation .acetazolamide .crohn’s disease .malabsorptive conditions .2H2o) • Strong family history of stone formation • Only one functioning kidney (although only one kidney does not mean an increased risk of stone formation.e.ascorbic acid in megadoses (> 4 g/day) .jejuno-ileal bypass .Table 3: Categories of stone-forming patients Definition non-caLcIuM STonES Infection stone: magnesium ammonium phosphate. below 25 years of age) • Stones containing brushite (calcium hydrogen phosphate. these patients should be particularly considered for measures to prevent stone recurrence) • Diseases associated with stone formation .tubular ectasia (medullary sponge kidney) . GR = grade of recommendation. eds.40(4):362-71. ureters and bladder (kuB) combined with ultrasonography (uS). excretory urography (intravenous pyelography. GR = grade of recommendation LE = 4 gR = C The diagnostic work-up of all patients with symptoms of urinary tract stones requires a reliable imaging technique (Table 5).1 3. In selected cases. Buck c. Extensive experience shows that in a large proportion of patients these methods are sufficient for the diagnosis of a ureteral stone. which are radiolucent on plain films.gov/pubmed/11713390 2. Many urologists also take responsibility for the diagnostic radiological work-up uPdaTE MarcH 2008 9 .nih. conort P. ackermann d. Etiology and investigation of stone disease.horseshoe kidney . an alternative.ncbi. 3. 4. IVP) has been the gold standard however. 3. alken P. In randomized prospective studies.33:1-7. 12). gallucci M.nih. Furthermore. Winearls cg. the specificity and sensitivity of unenhanced helical cT was found to be similar (4.1 DIAgNOSTIC pROCEDURES Diagnostic imaging Stone disease often presents as an episode of acute stone colic. 3rd edn. The clinical diagnosis should be supported by an appropriate imaging procedure. 3. guidelines on urolithiasis.vesico-ureteral reflux . antegrade pyelography and scintigraphy. ureters and bladder. oxford: oxford university Press. CT = computed tomography. 5. Imaging is imperative in patients with fever or a solitary kidney. REFERENCES Tiselius Hg. ritz E. injection of contrast medium is occasionally used as an auxiliary procedure for stone localization during shock-wave lithotripsy. and the ability to detect alternative diagnoses (7. In: davison aM. cT is less suited for follow-up after treatment of radiopaque stones.. unenhanced helical computed tomography (cT) has been introduced as a quick and contrast-free alternative (1-3). and when the diagnosis of stone is in doubt LE = level of evidence.91(8):758-67. and possibly a history of stone disease. method for evaluating patients with acute flank pain is a plain film of the kidneys. curriculum in urology. Patients with renal stone colic usually have characteristic loin pain. the advantage of a non-contrast imaging modality must be balanced against the higher radiation dose given to the patient during cT investigation (3. Eur urol 1998.3 1.1 3. KUB = plain film of kidneys. although intravascular administration of contrast medium is usually the responsibility of the radiologist. Epidemiology and medical management of stone disease. However.1 LE = level of evidence. Eur urol 2001. 5–9) or superior (10–11) to that obtained with urography.gov/pubmed/12709088 Tiselius Hg. additional information regarding renal function may be obtained by combining cT with contrast infusion. Oxford textbook of clinical nephrology. For an acute stone colic. 2005. in recent years. http://www. aetiological factors in stone formation. for patients with acute flank pain. pp. Special examinations carried out in selected cases include retrograde pyelography. commonly used. 1201-1223. BJu Int 2003.ncbi. Tiselius Hg. cameron JS.ureterocele 2. 13). grunfeld J-P. kerr dn. http://www. Table 5: Imaging modalities in the diagnostic work-up of patients with acute flank pain preference number 1 1 2 Examination non-contrast cT Excretory urography kuB + uS LE 1 Standard procedure 2a B 6 gR a References 1–12 Comment 3. which will immediately inform the decision to take a conservative approach or consider another treatment.nlm. advantages of cT are the demonstration of uric acid and xanthine stones. ch 8. vomiting and mild fever.nlm. US = ultrasonography. Tiselius Hg. serum creatinine level should be measured in every patient with diabetes being treated with metformin. contrast medium can be administered. For a patient with gFr 80–120 mL/min. 30 mg) between 12 hours and 2 hours before the contrast medium is injected. a basic understanding of the risks associated with the use of contrast medium and the precautions needed is therefore essential (Table 6).2. 3. Vasoconstriction of glomerular afferent arterioles causes a reduced glomerular filtration rate (gFr) and increased renal vascular resistance. the following precautions must be taken (14. This unusual complication is caused by retention of dimethylbiguanide. 15): • always use low-molecular non-ionic contrast medium • give a corticosteroid (e. The investigative findings are a blood pH < 7. when there is no alternative explanation. for example non-steroidal anti-inflammatory agents (nSaIds) • aminoglycosides should be stopped for at least 24 hours before contrast medium is injected. Symptoms of lactic acidosis are vomiting. nephrotoxicity caused by contrast medium is diagnosed by an increase of 25%. diarrhoea and thirst. the following should be considered.2 Metformin Metformin.50 mg/100 mL). lactic acid and blood pH should be monitored. metformin must be stopped immediately and the patient hydrated so that diuresis is ≥ 100 ml/h during 24 hours. may give rise to lactic acidosis in case of contrast-induced anuria (16–18).25 and serum lactic acid concentration > 5 mmol/L (16. • When contrast medium has been given to a patient on metformin. the dose of iodine should not exceed 80–90 g. • In patients who are being treated with metformin and have a normal serum creatinine.1 Allergy to contrast medium When contrast medium needs to be adminstered to a patient who has had or who may be at risk of an allergic reaction to the medium. but the intake of metformin should be stopped for 48 hours from the time of the radiological examination and until the serum creatinine remains normal. or at least 44 μmol/L.g.) to 72 hours. for whom no information on the renal function is available. clemastine. according to the recommendations given by the European Society of urogenital radiology (14. avoid repeated injections of contrast medium at intervals less than 48 hours (see Section 3. lactic acidosis is associated with high mortality and great care needs to be taken when using contrast medium in patients taking metformin. epigastric pain.e.1. In addition. 3. in the level of serum creatinine during the 3 days following intravascular administration of the agent. somnolence. unfortunately. 3. or who has reduced renal function. Risk factors for 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 years • diabetes • congestive heart failure • concurrent treatment with nephrotoxic drugs. 15).g.3 Reduced renal function Intravenous administration of contrast medium might result in a reduced renal perfusion and toxic effect on tubular cells. serum creatinine level > 130 μmol/L or > 1. which is used to treat diabetes type II. • In patients with reduced renal function. 2 mg) given 1 hour prior to administration of the contrast medium. prednisolone. Dosage of iodine reduced renal function is defined as serum creatinine ≥ 140 μmol/L or gFr ≤ 70 mL/min. • When no information on renal function is available. Treatment with metformin may resume 48 hours after the examination provided that serum creatinine remains at the pre-examination level. alternative imaging techniques should be used. particularly when renal function is reduced (i. Patients with multiple myeloma should be examined either after adequate hydration or using an alternative method.1. hyperpnoea.17).1. lethargy.1.of patients with stone problems. metformin should be stopped and administration of contrast medium delayed until 48 hours have passed after the last intake of metformin. Serum creatinine. • combine corticosteroid with an intramuscular injection of an antihistamine agent (e. anorexia. When the gFr is 10 uPdaTE MarcH 2008 . Vanninen rL.1. Lange rc. choe ka. hydration. clinical characteristics of ureteral calculi detected by non-enhanced computerized tomography after unclear results of plain radiography and ultrasonography.5 1. 1. ogura k. 0.82 .85 x (140 – age) . abdulmaaboud M. randomized prospective comparison of non-contrast enhanced helical computed tomography and intravenous urography in the diagnosis of acute ureteric colic. 3.ncbi.1.nlm.gov/pubmed/11531750 Shokeir aa. aMJ am J roentgenol 1996. 600 mg twice on the day before injection of contrast medium has been recommended to prevent renal failure caused by contrast medium (21). (kg/70)0.1.nlm. Verga M.5 .nih. serum creatinine) Body surface area = kg0. http://www. Mccarthy S.4 3. http://www.07 2. ala-opas M. serum creatinine) gFr = (0.1.nlm. 5. In patients with a serum or plasma creatinine ≥ 140 μmol/L (1. 13).nih. the dose of iodine should not exceed the same amount as the gFr expressed in mL/min/1.nih. acute flank pain: comparison of non-contrast-enhanced cT and intravenous urography. J urol 2003. nishizawa k.ncbi.gov/pubmed/7862980 Smith rc.ncbi.gov/pubmed/8571915 kobayashi T. useful formulae for calculating gFr and body surface area are given in Table 7 (19). radiol 1995. rosenfield aT.ncbi.725 .45(3):285-90.15 15 15–18 – 15 Comment 3.ncbi. glickman Mg.gov/pubmed/11257642 uPdaTE MarcH 2008 11 . diagnosis of acute flank pain: value of unenhanced helical cT.194(3): 789-94.1.gov/pubmed/12913701 Sudah M.170(3):799-802. kg/(0. the level of thyroid-stimulating hormone should be assessed before use of contrast medium.1 3. Patients with acute flank pain: comparison of Mr urography with unenhanced helical cT. height(cm)/serum creatinine) . height(cm)0.223(1): 98-105. 6. before and after use of contrast medium. http://www. 4.2 3. Verga M. Essenmacher kr. radiol 2002.nlm. Malinen a.reduced to 50–80 mL/min.1. Table 6: general considerations regarding the use of contrast medium Contrast medium should not be given. kg/(0.nih. Peddinti BS.73 m2 body surface area (12. gFr = (140 – age) . davies-Payne dL.165(4):1082-4.3 Table 7: Formulae for calculating glomerular filtration rate (gFR) and body surface area (19) Men Women For patients < 20 years.nlm. see the guidelines presented by the radiological Society (20). australas radiol 2001. may be beneficial in order to prevent nephropathy.73m2 creatinine clearance= (42.007184 gFr = creatinine clearance . http://www.6 mg/100 mL).nlm. or should be avoided. Partanen k. J urol 2001.nih.ncbi. http://www. kainulainen S.1. References Smith rc. GR = grade of recommendation LE – 4 3 3 3 gR – c B B B Selected references 14.82 .166(1):97-101. For further advice regarding the appropriate dose of contrast medium. 3. Heino a. http://www. rosenfield aT. the following formula should be used: 3.gov/pubmed/11930053 Homer Ja. Watanabe J. contrast medium should not be given unless these patients are appropriately treated for hyperthyroidism. in the following circumstances • Patients with an allergy to contrast media • Serum or plasma creatinine > 150 μmol/L • Patients receiving metformin • Untreated hyperthyroidism • Patients with myelomatosis LE = level of evidence. Prospective comparison of non-enhanced helical computerized tomography and doppler ultrasonography for the diagnosis of renal colic.nih.425 .1 3. administration of n-acetylcysteine.4 Untreated hyperthyroidism For patients in whom hyperthyroidism is suspected. contrast media and the kidney: European Society of urogenital radiology (ESur) guidelines. European Society of urogenital radiology. 12.ncbi. The preferred analytical procedures are X-ray crystallography and infrared spectroscopy. Love MH. 17. gault MH. Editorial: choosing imaging modality in 2003.gov/pubmed/10671870 cockcroft dW. http://www.ncbi. nephron 1976. Br J radiol 2003.nih.nih.343(3): 180-4. 14. 10. goff WB.gov/pubmed/9630271 Mccartney MM.gov/pubmed/10900277 3.ncbi.gov/pubmed/17786506 Mindelzun rE. http://www.52(6):982-7.nlm.170(3):803. BJu Int 2000. The accuracy of noncontrast helical computed tomography versus intravenous pyelography in the diagnosis of suspected acute urolithiasis: a meta-analysis. n Engl J Med 2000.ncbi. Pearson d. http://www. Laufer u. Prospective comparison of computerized tomography and excretory urography in the initial evaluation of asymptomatic microhematuria. Brand’s test (6). Prospective comparison of unenhanced spiral computed tomography and intravenous urogram in the evaluation of acute flank pain.nih.html Tepel M. urinary calculus: IVu vs cT renal stone? a critically appraised topic. 11.ncbi.nih. as a result of medical treatment.ncbi. Prediction of creatinine clearance from serum creatinine.2 Analysis of stone composition Stones that pass spontaneously. contrast Media Safety committee of the European Society of urogenital radiolology. Prevention of generalized reactions to contrast media: a consensus report and guidelines. Haines T. 21. 8. http://www.gov/pubmed/9314959 Shinokara k. Smith rc. Weaver B. Liermann d. Van der giet M.gov/pubmed/9915507 Thompson nW.0.53(5):342-4.gov/pubmed/12913702 Morcos Sk. Preyra I. http://www. Eur radiol 2001. 16.40(3):280-6. Puckett MF. or any other cystine test) 12 uPdaTE MarcH 2008 . might have influenced stone composition.g. graham Ir. Ward JF. http://www.ncbi. 9.ncbi. gray Sears cL.nlm.nih.gov/pubmed/11511894 Thomsen HS. rosenfield aT. clin radiol 1998. cleveland T.205(1):43-5. gaines Pa. Bove P. Webb Ja. http://www.nih.gov/pubmed/9474137 Worster a.54(1):29-33. kane cJ. or excreted as fragments following disintegration.7. 13. environment or diseases.nlm. http://www. http://www. http://www. J urol 2002.nih.nlm. Morcos Sk. repeated analysis is indicated when any changes in urine composition. 19. 18.ncbi.esur.11(9):1720-8.nih.gov/pubmed/12192351 Shine S.org/ESur_guidelines_nEW.nih.nlm. 20. amling cL. urology 1998. should be analysed to determine their composition (1–5). Zidek W. rineer Sk. covey aM.159(3):735-40.168(6):2457-60. clinical risk associated with contrast angiography in metformine treated patients: a clinical review.nlm. http://www.nih. [access date February 2009]. Schwarzfeld c. Murray ad. sodium nitroprusside test. radiology 1997.nlm.ncbi. all patients should have at least one stone analysed. gilbert FJ. abdom Imaging 2008.gov/pubmed/12441939 Miller oF.nih. Murchinson LE. a lot more information. Sears ST. drugs and intravenous contrast media. J urol 1998. http://www.gov/pubmed/1244564 ESur guidelines on contrast Media. When stone(s) or stone material have not been retrieved. reichard Sr. Verga M. http://www.nih.76(908):513-8. kane cJ.nlm. Buckley rg.nlm. Prevention of radiographiccontrast-agent-induced reductions in renal function by acetylcysteine. Young Mr.ncbi. dietary habits.ncbi.nih. are removed surgically.ncbi. 15. Metformin and contrast media–a dangerous combination? clin radiol 1999. The value of unenhanced helical computerized tomography in the management of acute flank pain. ann Emerg Med 2002. Thomsen HS. unenhanced helical cT evaluating acute abdominal pain: a little more cost. donovan MS. chan P. McHardy k. Jeffrey rB.gov/pubmed/12893691 nawaz S. http://www. anderson kr.nlm.gov/pubmed/9836541 dalrymple nc.ncbi.nlm.nlm.85(3):219-21. J urol 2003.nlm.6. http://www. stone composition may be assessed using the following: • qualitative cystine tests (e.nlm. Thompson TJ.nih.16(1):31-41.33(1):41-3. nephron Physiol 2004.1 1. 6. are referred to as uric acid/urate stones: • uric acid • sodium urate.8-dihydroxyadenine. http://www.brushite . Scand J urol nephrol 1983.86:315. uric acid/urate stones. Biloon S.ncbi. http://www.3. 3. xanthine and various drug metabolites (e. http://www.• • • • • bacteriuria/urine culture (in the case of a positive culture. Infection stones have the following typical constituents: • magnesium ammonium phosphate • carbonate apatite. which are not associated with infection. cystinuria: Excretion of cystine complex which decomposes in the urine with the liberation of cystine.nlm. http://www.ncbi. calcium stones. observations on the analysis of ten thousand urinary calculi. crystalline composition of urinary stones in norwegian patients. Blaschke r.nlm.gov/pubmed/2291252 Herring Lc.18(Suppl):S9-S12. J clin chem 1980.17(1):85-92. 3. 3. cystine stones and ammonium urate stones associated with infection are referred to as ‘stones with infection’. sulphonamide.nih. an appropriate quantitative or semi-quantitative analysis of stone material should enable the main constituent(s) to be determined.calcium oxalate monohydrate .035 stone analyses: a contribution to epidemiology of urinary stone disease. Schmandt W. The following stones. test for bacteriuria (nitrite) and urine culture in case of a positive reaction Serum creatinine to measure renal function c-reactive protein and blood cell count Serum/plasma sodium Serum/plasma potassium Patients with fever Patients who vomit uPdaTE MarcH 2008 13 .gov/pubmed/13954078 daudon M.whitlockite.octacalcium phosphate . are referred to as radiopaque stones: • calcium oxalate .hydroxyapatite . Scand J urol nephrol 1990.gov/pubmed/2237297 Brand E.88:545-62.ncbi.calcium oxalate dihydrate • calcium phosphate . indinavir).2.nlm. Harris MH.carbonate apatite . results of 5.g. clinical value of crystalluria and quantitative morphoconstitutional analysis of urinary calculi. high in patients with infection stones) radiographic characteristics of the stone.gov/pubmed/6867630 Leusmann dB.nlm.nih.nih.1 Biochemical investigations Analytical work-up in the acute phase (Table 8) Table 8: Biochemical analyses recommended for patients with an acute stone episode all patients urinary sediment/dipstick test for: red cells White cells.ncbi.nih. ask for urease-producing micro-organisms) microscopic examination of the urinary sediment to detect crystals of struvite or cystine serum urate (in cases where a uric acid or urate stone is a possible alternative) urine pH (low in patients with uric acid stones. 5. References asper r. J urol 1962.3 3. Less common stone constituents include 2.98(2):31-6. Stone analysis. http://www.gov/pubmed/15499212 otnes B.ncbi. which are not associated with infection.24(3):205-10. The following calcium stones. urol res 1990.nih.nlm. 2. 4. Jungers P. pH cystine. In addition. Table 3).3 mol/L sodium azide Excretion of each urine variable is related to creatinine level 2 3 one 24-hour collection one 16-hour urine collection and one 8-hour urine collection 4 Spot urine sample Hydrochloric acid (Hcl) prevents precipitation of calcium oxalate and calcium phosphate in the container during storage. 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 Yes Yes Yes no Yes no Yes Yes Table 3 in Chapter 2 for an explanation of the categories of stone formers. a sample collected with sodium azide is useful. pH urate.00 and 22. The stone.2 Analysis of urine in search for risk factors for stone formation For an identification of metabolic risk factors for stone formation.3. For each set of analyses. This might be the only occasion on which patients with hypercalcaemia are identified. For pH measurement.00 and 06. urate creatinine2 Yes (see Table 11) Yes (see Table 11) Yes (see Table 11) Yes (see Table 11) Yes (see Table 11) Urine analysis follow-up culture. 3. Table 10: Some alternatives for urine collection Alternative Timing of collection 1 Two 24-hour collections Description of collection 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. urate can be analysed in samples collected with sodium azide as preservative. a night-time sample in which pH is measured soon after urine collection is useful. uric acid precipitates and must be dissolved by alkalinization if urate excretion is of interest.00 hours in a bottle containing 10 mL of 0.optional useful information a b approximate pH levela Serum/plasma calciumb all other examinations that might be necessary in case of intervention Knowledge of pH might reflect the type of stone. Hcl counteracts oxidation of ascorbate to oxalate.3 mol/L sodium azide Sample collected in a bottle containing 30 mL of 6 mol/L hydrochloric acid Sample 1 collected between 06. 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. two urine collections are recommended. as urinary pH may alter during storage. Table 9: Analytical programme for patients with stone disease Category of stone former1 INF UR CY So Sres Rmo Rm-res Rs 1See 2The Blood analysis (serum/plasma) creatinine creatinine. collection of urine without Hcl is needed. The urine collections are repeated when necessary (1–3). 14 uPdaTE MarcH 2008 . Several alternative collection options are feasible (Table 10). rmo. In acidified samples. type of medical treatment being received by these patients will determine which other blood variables need to be included in the follow-up analysis.00 hours in a bottle containing 20 mL of 6 mol/L hydrochloric acid Sample 2 collected between 22. blood (serum or plasma) and urine analyses recommended for these patients are shown in Table 11. an analytical programme for the different categories of stone formers is available (Table 9). a spot urine sample can provide a rough guide to the need of further analyses. When a 16-hour urine sample has been collected in a bottle with an acid preservative.6 Analysis of calcium + albumin to correct for differences in calcium concentration attributable to albumin binding. When a stone analysis has not been carried out. a patient with complicated stone disease has a history of frequent recurrences. In the same fasting morning or spot urine sample. Formulae are given below. phosphate.8 in fasting morning urine raises the suspicion of incomplete or complete renal tubular acidosis (rTa) (26). As uric acid precipitates in acid solutions. uPdaTE MarcH 2008 15 .60 mmol/L). a high serum urate level together with a radiolucent stone support the suspicion of a uric acid stone. 3. the remaining 8 hours of the 24-hour period can be used to collect urine in a bottle with sodium azide for urate analysis. Analysis of magnesium and phosphate is necessary to calculate estimates of supersaturation with calcium oxalate (CaOx) and calcium phosphate (CaP).3. 6. as it is not always easy to obtain this sample during routine clinical work. First-time stone formers with residual fragments may also be considered in this category (categories: rs. For special tests that might be required see Table 12 (13–18).6 Sodium 4. with or without residual fragments or stones in the kidney. The stone. Stone In every patient one stone should be analysed. Urea. 4. rm-res. 5.6 urea 5. for example AP(CaOx) index and AP(CaP) index (8–12). Optional 3. However.3 Comments on the analytical work-up The purpose of analysing serum or plasma calcium is to identify patients with hyperparathyroidism or other conditions associated with hypercalcaemia. blood and urine analyses recommended for these patients are shown in Table 11 (4–12). 16-hour + 8-hour urine or any other collection period can be chosen provided normal excretion data are available (4–7). a pH above 5. In the case of a high calcium concentration (> 2. the diagnosis of hyperparathyroidism should be established or excluded by repeated calcium analyses and assessment of the parathyroid hormone level (19–24).Ideally.6 Potassium 4. urate 4 Magnesium 5 Phosphate 5. sodium and potassium measurements are useful for assessing the patient’s dietary habits. 24-hour urine. For all patients Blood Urine calcium Fasting morning spot urine or spot urine sample: albumin1 pH creatinine Leucocytes / Bacteria urate2 cystine test (when necessary) Additional analyses for patients with complicated calcium stone disease Urine collection during a defined period of time3 Preference urine variable 1 calcium 1 oxalate 1 citrate 1 creatinine 1 Volume 2 2 2 2 2 2 1. Table 11. A spot urine sample can be used with creatinine-related variables (7). although a uric acid stone is usually invisible on a plain film (kuB). urate has to be analysed in a sample that has not been acidified or following alkalinization to dissolve uric acid. or direct analysis of ionized (free) calcium 2. Table 3). a spot morning urine sample should be used to measure pH (25). it is clearly demonstrated with a cT examination. Sres. or the patient presents specific risk factors. Analyses in patients with uncomplicated and complicated stone disease. urine collection should be postponed until at least 4 weeks after stone removal or after an episode of obstruction and should never be carried out in the presence of infection or haematuria. a fasting morning urine sample should be analysed. bacteriuria and cystinuria can be excluded or confirmed (27). ox (oxalate). V-1. to: • maintain calcium. mmol/L) and urine volume in litres (V) as follows (30): Intake of protein (g) during the 24 h period = (Uurea (mmol/24 h) . oxalate. citrate and phosphate must be acidified. provided a set of normal values is available for the collection period (4–7). occasionally.5)6.18) + 13 an estimate of the ion-activity products of calcium oxalate (aP[caox] index) and calcium phosphate.12 . The following urine variables can be analysed in the acidified sample: calcium. 24 hours.70 . 16 hours. it may be necessary to measure pH variation during the day or to make an acid loading for identification of disturbances in urine acidification. aPcaP (where aPcaP is the ion-activity product of calcium phosphate). The aP[caP] index for a 24-hour urine sample is calculated as follows: Ap[Cap] index = 2.20 . and Mg (magnesium) are expressed in millimoles (mmol) excreted during the collection period.4. preferably with Hcl. although the creatinine concentration might be slightly altered. Mg-0. sodium. 10-3 . analytical findings in patients with incomplete and complete rTa are summarized in Table 13. phosphate. The aP[caox] index corresponds approximately to 108 . Ca1.The aim of adding serum potassium to the analytical programme is to obtain further support for a diagnosis of suspected rTa. oxalate. 4 hours. (pH .7 . urate forms uric acid in the acidified urine and must therefore be analysed either following complete dissolution with alkali or in a urine sample that has not been acidified. can be calculated as follows (31–37): Ap[CaOx] index = 1.22 . 16 uPdaTE MarcH 2008 . The factor 1. The protein intake can be derived from the urea excretion (uurea. although individual abnormal urine variables might indicate a risk of stone formation. optional analysis of urea. V-1. aPcaox (where aPcaox is the ion-activity product of calcium oxalate). chloride and potassium.9 is specific for the 24-hour period. 0. cit (citrate). For other collection periods. Cit-0. Hypokalaemic hypocitraturia might be one reason for therapeutic failures in patients treated with thiazides.03 In this formula. it is the concerted action of the various urine constituents that produces supersaturation and crystallization of the stone.8 . urea. phosphate and sodium helps to assess dietary factors of therapeutic significance. 29). The urine sample used for analysis of calcium.9 . citrate. known as the aP[caP] index. The urine variables ca (calcium). for a 16-hour urine sample. oxalate and phosphate in solution. Ox . 17 hours. magnesium. P is used for phosphate. or even spot urine samples) are useful for this purpose. it must be assessed in the same sample when creatinine-related variables are used and also for conclusions on the completeness of the collection. Various collection periods (e.84 . Factors for other collection periods can be found in reference 5. the urine volume (V) is expressed in litres (L).3. The principles for such a work-up are summarized in Table 12. Ca0. p0. The recommendation to collect two urine samples is based on observations that this approach will increase the likelihood of detecting urine abnormalities.g. 12 hours. a relationship between abnormalities in urine composition and severity of calcium stone formation has been demonstrated (38–44). consult reference 5. this factor is 2. Cit-0.07 .31 The aP[caP] index corresponds approximately to 1015 . during and after the collection period • prevent bacterial growth and the associated alteration of urine composition • prevent the in-vitro oxidation of ascorbate to oxalate (28. 3. uPdaTE MarcH 2008 17 . drink 150 mL • 13.00 Collect urine and measure pH.Table 12: Additional analytical work-up in patients with calcium stone disease pH profile (13) repeated measurements of pH during the 24-hour period • Frequent samples should be collected for immediate measurement of pH with pH paper or a glass electrode • Sampling every second hour or otherwise as appropriate Acid loading (14–18) This test is carried out together with blood sampling to show whether or not the patient has a complete or an incomplete acidification defect • Breakfast + ammonium chloride tablets (0. If this assumption is not possible. drink 150 mL • 10. If a reasonable assumption regarding the patient’s category can be made. drink 150 mL • 12. drink 150 mL • 11.00 Collect urine and measure pH. an alternative analytical approach must be used until more data have been collected.1 g/kg body weight). lunch Interpretation pH of 5.00 Collect urine and measure pH.00 Collect urine and measure pH. the principles shown in Figure 1 can be applied to all patients. drink 150 mL • 09.4 A simplified overview of the principles of analytical work-up in patients correct categorization of patients requires both information on the stone composition and an actual imaging procedure.4 or lower indicates no renal tubular acidosis (rTa) Table 13: Analytical findings in patients with complete or incomplete distal renal tubular acidosis (RTA) (13) Test • Blood (pH) • Plasma bicarbonate • Plasma/serum potassium • Plasma/serum chloride • Urinary calcium • Urinary phosphate • Urinary citrate RTA = renal tubular acidosis Incomplete RTA Low Low Low High High High Low Complete RTA Normal Normal Normal Normal High High Low 3.00 Collect urine and measure pH. Hoppe B. The composition of four-hour urine samples from patients with calcium oxalate stone disease. Solution chemistry of supersaturation. Hofbauer J.12(7):1362-8. Philadelphia: Lippincottraven. Hesse a.44(1):24-5. diagnosis and metaphylaxis of stone disease. Pak cYc. koehrmann ku. http://www.nih. Berg W. 5.gov/pubmed/8042263 Hess B.5 1.nih. http://www.nlm. Parks Hg. Schmidt M.3. Tiselius Hg. 1996. http://www.nlm.Figure 1.gov/pubmed/9249770 Straub M.nlm. 3. Favus MJ. Value of repeated analysis of 24-hour urine in recurrent calcium urolithiasis. blood and urine in different categories of stone forming patients 3. Hasler-Strub u. pp. Laube n. nephrol dial Transplant 1997. urology 1994. Strohmaier WL.nih. Beck B. consensus concept of the national Working committee on Stone disease for the upcoming german urolithiasis guideline. 4. Larsson L. eds. Jaeger P.ncbi. Metabolic evaluation of patients with recurrent idiopathic calcium nephrolithiasis. discussion 24-5.ncbi. 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Preminger gM. coe FL.nlm. Metabolic abnormalities associated with renal calculi in patients with horseshoe kidneys.gov/pubmed/9783922 daudon M.gov/pubmed/8632527 Zanetti g. J urol 1994. Factors that predict the relapse of calcium nephrolithiasis during treatment.36(5): 363-70. http://www. del nero a. 3:355-9. uPdaTE MarcH 2008 21 .4(3):275-81. π . d . Moreover. 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?. Finlayson B.nih. width (w) and depth (d): SV = l . see Table a1 (appendix 2). Is it recommended that pain relief should be initiated with diclofenac whenever possible (Table 15) and an alternative drug used if the pain persists. might be useful in reducing inflammation and the risk of recurrent pain. and should not be given without simultaneous administration of atropine. The effect was most pronounced in the first 4 treatment days (7). With the more common use of cT. we have based our statements on stone Sa in addition to largest stone diameter. dunthorn M. 5. diclofenac) provide effective relief in patients who have acute stone colic’ (1–5). stone volume SV can be calculated as follows (2): SV = 0. For patients who have ureteral stones that are expected to pass spontaneously. over 3–10 days. w . Table 14: pain relief for patients with acute stone colic preference 1 1 2 pharmacological agent diclophenac sodium Indomethacin Ibuprophen Hydromorphine hydrochloride+ atropine Methamizol Pentazocine Tramadol LE 1b gR a References 1–4 Comment 5. 50 mg tds. andersson a. placebo-controlled trial. GR = grade of recommendation 5. Hydromorphone and other opiates are associated with an increased risk of vomiting. griffith dP. Eur urol 2003. http://www. improved estimates of SV can be obtained using length (l).1.27 In this guideline. the resistant index was reduced in patients with renal colic when nSaId treatment was given (6). suppositories or tablets of diclofenac sodium.gov/pubmed/12600431 ackermann d. 5. recurrent pain episodes of stone colic were significantly fewer in patients treated with diclofenac.1 Treatment using non-steroidal anti-inflammatory drugs (NSAIDs) clinical trials have shown that nSaIds (e. 5. Facilitation of Stone passage might be facilitated by administration of alpha-blocking agents or. newman rc.6 . The Sa can also be measured using computerized systems and from cT scans.ncbi. Sa1.For a quick estimate of the stone Sa.2 Prevention of recurrent episodes of renal colic In a double-blind. calculation of stone volume and urinary stone staging with computer assistance.1 TREATMENT OF pATIENTS WITH RENAL COLIC pain relief Pain relief is usually the therapeutic step that needs to be taken most urgently in patients with an acute stone episode (Table 14). REFERENCES Tiselius Hg.52 4. 0. 50 mg bid.1 1.g. during the first 7 days.1 4 c LE = level of evidence. using Sa. however these procedures are not necessarily easy and the software not always available. J Endourol 1989. 2.1.nlm. 4.nih.gov/pubmed/8529732 Lee a.gov/pubmed/366182 Lundstam So. Eur J clin Pharmacol 1998.ncbi.nih. The facilitation of ureteral stone passage is discussed in detail in chapter 9 (9.28(2):108-11.1. ommundsen oE. http://www. comparison of ketorolac and diclofenac in the treatment of renal colic.nih. Farage Y.3 Effects of diclofenac on renal function diclofenac can affect renal function in patients with an already reduced function.3 5. Mutabagani H. Treatment of ureteral colic with indomethacin. 7. gronseth JE.3 diclofenac sodium affects gFr in patients with reduced 2a renal function.nlm. 3. analgesic effect and tolerance of ketoprofen and diclofenac in acute ureteral colic.nlm. 22 uPdaTE MarcH 2008 . kral Lg. Spontaneous passage of stones Medical expulsive treatment (MET) REFERENCES Holmlund d. knight JF. Prostaglandin-synthetase inhibition of diclofenac sodium in the treatment of renal colic: comparison with use of a narcotic analgesic. Table 15: Recommendations and considerations regarding pain relief for the patient with renal colic Recommendations Treatment should be started with an nSaId LE 1b gR a 2a Selected references 1-4 8 Comment 5.nlm. 10). a double-blind comparison with placebo. there is no effect if the kidney are functioning normally (LE = 1b.gov/pubmed/17443518 Most ureteral stones pass spontaneously.nlm. Lahtinen J. LE = level of evidence. craig Jc. Fadilla M. please see chapter 6 and chapter 9 (9.nlm.nih. christiansen a.ncbi. Elvander E.possibly. curr Ther res 1980. Leissner kH.gov/pubmed/9776434 Shokeir aa.1(8281):1096-7.ncbi. For further details. When pain relief cannot be achieved by medical means. but not in patients with normal renal function diclofenac sodium is recommended to counteract 1b recurrent pain after an episode of ureteral colic a 7 5. 6.ncbi. however.gov/pubmed/8290910 cohen E. garty M. cochrane database Syst rev 2007. abdulmaaboud M. NSAID = non-steroidal anti-inflammatory drug. drainage using stenting or percutaneous nephrostomy or by stone removal should be carried out. http://www.27(3):323-5.nih.54(6):455-8.4 1. Treatment of ureteral colic by prostaglandin-synthetase inhibition with diclofenac sodium. http://www.1.ncbi. http://www. http://www. J urol 1978. gr = a) (8).nlm. Lancet 1982.gov/pubmed/10468715 Laerum E. Wåhlander La.nih. Walden M.120(6):676-7.gov/pubmed/6122892 Lundstam So. GR = grade of recommendation.ncbi. Passage of the stone and restoration of normal renal function should be confirmed using appropriate methods. Sjödin J-g. BJu Int 1999. 2. The patient should be instructed to sieve the urine to retrieve a concrement for analysis.1. alpha-receptor antagonists inhibit ureteral basal tone and peristaltic activity and dilate the lumen of the ureter. 5. resistive index in renal colic: the effect of nonsteroidal anti-inflammatory drugs.2 5. http://www. nifedipine (see chapter 9 fore futher details). Scand J urol nephrol 1993.18(2):cd002765. 8. kral Jg.nih.ncbi. 5. Eur urol 1995. Effects of nonsteroidal anti-inflammatory drugs on postoperative renal function in adults with normal renal function.28:355-8. 10). cooper Mg. rotenberg Z.1 5. http://www.84(3):249-51. 5. Hafner r. calcium channel blocking agents reduce ureteral spasm and inhibit the fast peristaltic activity whereas the slow peristaltic activity remains unaffected.2 GFR = glomerular filtration rate. oral diclofenac in the prophylactic treatment of recurrent renal colic.nlm. Wåhlander La. Fagertun HE.1. keneally JP. 219:1-67. Inc.162(3 Pt 1):688-90. In the stone interval 6-10 mm spontaneous passage is seen between 10 and 53% of patients (chapter 9).gov/pubmed/1988715 Ibrahim aI.gov/pubmed/13394022 Morse rM. alken P.nlm. Time to stone passage for observed ureteral calculi: a guide for patient education. Small renal caliceal calculi as a cause of pain. Shetty Sd. http://www.130(4):752-3. assimos dg. resnick MI. Br J urol 1991. nakada SY. removal is indicated.9. Studies have shown that asymptomatic stones in the kidney will eventually cause clinical problems (5).gov/pubmed/17993340 6. These stones should be removed using a minimally invasive technique.ncbi.gov/pubmed/2032074 Miller oF. J urol 1991.ncbi. The overall passage rate of ureteral stones is: • proximal ureteral stones: 25% • mid-ureteral stones: 45% • distal ureteral stones: 70%. 4. uPdaTE MarcH 2008 23 . GR = grade of recommendation. http://www.nlm. Tiselius Hg. gallucci M. LE = level of evidence. Table 16: Indications for active stone removal Indications for considering active stone removal • Stone diameter > 7 mm (because of the chance of spontaneous passage is very low) • Adequate pain relief cannot be achieved • Stone obstruction is associated with infection* • Risk of pyonephrosis or urosepsis* • Single kidneys with obstruction* • Bilateral obstruction* LE 2a 4 4 4 4 4 gR B B B B B B Selected references 1–5 * Diversion of urine with a percutaneous nephrostomy catheter or bypassing the stone with a stent are minimal requirements in these patients. European association of urology. ureteral calculi: natural history and treatment in an era of advanced technology. Tiselius Hg. J urol 1999.nih. Small stones (< 6–7 mm) in a calix can cause considerable pain or discomfort (6–12).ncbi. acta chir Scand Suppl 1956.nih.ncbi. awad rM. Prognosis of stone in the ureter. Eau/aua nephrolithiasis guideline Panel. Sarica k.nih. knoll T. Wolf JS Jr.ncbi. Pearle MS. Eur urol 2007. a narrow caliceal neck may require dilatation.gov/pubmed/6887409 3.145(2):263-5. Sylven M. 5. INDICATIONS FOR ACTIVE STONE REMOVAL The size. assimos dg. For stones with a diameter exceeding 6–7 mm.nlm. 2. http://www. Buck c.nlm. 2007 guideline for the management of ureteral calculi. 10.nih.nih. Buck c. http://www. Pearle MS. alken P. http://www.67(4):358-61. http://www. nakada SY.gov/pubmed/10458343 andersson L. http://www.52(6):1610-31. For stones with increasing diameters.gov/pubmed/18074433 Preminger gM. Türk c. Prognostic factors in the conservative treatment of ureteric stones. Lingeman JE.nlm. 2007 guideline for the management of ureteral calculi. Lingeman JE. J urol 2007. site and shape of the stone at the initial presentation influence the decision for operative intervention (Table 16). gallucci M.ncbi.nih.ncbi. Wolf JS Jr. Patel kP. REFERENCES Sandegard E. 6.1 1. J urol 1983.nlm. Türk c. The likelihood of spontaneous passage must also be evaluated. kane cJ. Sarica k. Spontaneous stone passage can be expected in up to 80% in patients with stones ≤ 4 mm in diameter.178(6):2418-34. knoll T. the chance for spontaneous passage is decreased (1-4). Preminger gM. american urological association Education and research.nih.nlm. nih. 11. It is important to limit the number of shock waves and the power used in repeat treatments to avoid causing renal tissue damage and bleeding complications (see below). Sonda LP. Repeat treatment sessions The disintegrating power of ESWL is generally very good. the interval between 24 uPdaTE MarcH 2008 . location and hardness of the stones • patient’s habitus • ambition and experience of the operator (6). but are much cheaper and have greater versatility.148(3 Pt 2):1043-6. urology 1988. Treatment of painful caliceal stones. kahnoski rJ. For more sessions. Scand J urol nephrol 1993.66(1):9-11. http://www.ncbi.ncbi. but include: • pregnancy • severe skeletal malformations • severe obesity • aortic and/or renal artery aneurysms • uncontrolled blood coagulation • uncontrolled urinary tract infections (1. modified indications and treatment principles have completely changed the treatment of kidney stones.32(2):119-23. Treatment of caliceal calculi. antibiotics should be given before ESWL and continued for at least 4 days after treatment. J urol 1987.7-17). Management of painful caliceal stones by extracorporeal shock wave lithotripsy.gov/pubmed/3116280 coury Ta.ncbi. 8.nlm. ostri P. kvist kristensen J. Each of these factors has an important influence on retreatment rate and final outcome of ESWL.nlm. However.nlm.nih. Lingeman JE. 10.gov/pubmed/8493473 7.6. contraindications to the use of ESWL are few. usually involving a percutaneous approach. 2).1 ACTIVE REMOVAL OF STONES IN THE KIDNEY Extracorporeal shock-wave lithotripsy (ESWL) for removal of kidney stones The introduction of ESWL during the early 1980s dramatically changed the management of urinary tract stones. Yost a. The number of ESWL sessions should not exceed three to five. 9. Modern lithotripters are smaller and usually included in uroradiological tables. Techniques other than ESWL. Br J urol 1990. Extracorporeal shock wave lithotripsy of caliceal diverticula calculi. The treatment of small nonobstructing caliceal calculi in patients with symptoms.nih. number. Painful caliceal calculi.18(3):211-4. Treatment of caliceal diverticular calculi with extracorporeal shock wave lithotripsy: patient selection and extended follow-up.ncbi. chang LS. http://www. Psihramis kE.nih. The development of new lithotripters. Lee YH. http://www. Lange P.nlm. Eur urol 1990. GR = grade of recommendation LE = 4 gR = C There are no rules on how frequently ESWL sessions can be repeated. http://www. chen MT. Huang Jk. LE = level of evidence. dretler SP.nih.27(1):75-6. should be used to treat large.gov/pubmed/2393803 Streem SB.138(4):707-11. Porpaczy P.gov/pubmed/1507327 Brandt B. which have smaller focal volumes. 7. In the case of infected stones or bacteriuria. The latest-generation lithotripters are at least as effective as the first lithotripters. ESWL can remove >90% of stones in adults (3-5). a percutaneous method might be a more rational option. http://www.nih.nlm.ncbi. particularly with later generations of lithotripters. allowing application of not only ESWL but other diagnostic and ancillary procedures associated with ESWL. 7. hard stones (see below) (3-5.gov/pubmed/3400135 Lee MH.nlm. http://www. J urol 1992. The success rate for ESWL depends on the efficacy of the lithotripter and upon: • size (volume). There is concern about using ESWL for large stones because residual fragments are common so repeat treatment may be necessary.ncbi.gov/pubmed/2261935 Hübner W. There is no consensus on the maximum number of shock waves.5 Hz (20). GR = grade of recommendation LE = 3 gR = B LE = 3 gR = C a recent randomised study reported that the routine use of internal stents before ESWL does not improve outcome in terms of stone-free rate (LE = 1b. LE = level of evidence.and the Lithostar Plus lithotripter. as the shock-wave frequency increases. GR = grade of recommendation Anatomical abnormalities anatomical abnormalities may affect the outcome of ESWL. However. In 35. the stone-free rates of 41. although the disintegrating capacity varies considerably between devices. In a prospective randomised trial comparing the dornier HM3. use of auxiliary procedures and the experience of the operator might explain the viriable outcome. Stents a double-J stent reduces the obstructive and infective complications that can follow the use ESWL for large renal stones. The stone-free rate in these patients was 70% with re-treatments in 10. respectively (32). gr = a) (78). Similar results were seen with the dornier HM3 lithotripter. shorter intervals between treatment sessions are usually acceptable. GR = grade of recommendation LE = 4 gR = C a variety of lithotripters are in use. as they alter the mechanism of urine elimination and thus impair the passage of stone fragments. stone location. This should be determined by the energy level used and the number of shock waves given (18). uPdaTE MarcH 2008 25 . Stone disintegration improves at lower frequencies. The number of shock waves that can be delivered at each session depends on the type of lithotripter and shock-wave power.two successive sessions must be longer for electrohydraulic and electromagnetic lithotripsy than for treatments using piezoelectric equipment.255 (92%) (40-70). The optimal shock wave frequency is 1. stone-free rates were 75-89% for stones with a diameter ≤ 20 mm versus 39-63% for stones with a diameter ≥ 20 mm (28).2 Factors influencing the outcome of ESWL Studies using ESWL to remove kidney stones have reported stone-free rates of 66-99% inpatients who had stones ≤ 20 mm in diameter and 45-60% for stones > 20 mm in diameter (29-31).0-1. Patient selection. especially when disintegration is not sufficient (71-76).100 patients treated for kidney stones using ESWL.1. tissue damage increases (19). frequency of repeated treatment sessions. late-generation lithotripters can treat kidney stones effectively.90% corresponded with those reported for the dornier HM3-lithotripter and for the second. the stone-free rates were 89% and 87%. Insertion of an internal stent before ESWL is recommended when stones with a diameter ≥ 20 mm (~300 mm2) are to be treated (77) LE = level of evidence. Complications When ESWL is used to treat large (diameter >20 mm or Sa > 300 mm2) renal stones. 7.and third-generation lithotripters. Malformations of the renal collecting system can cause stone formation. rather than in the kidney. satisfactory disintegration was recorded in 32. LE = level of evidence.5% (40-70) When results reported during the past 7 years were considered separately. For stones in the ureter. as a result of difficulties in the passage of stone particles. Clinical experience supports this view. it is not possible to make a general recommendation regarding the interval needed between two treatments. auxiliary procedures are often needed in anatomical abnormalities (21-27). The risk of damaging the renal tissue is greatest with treatments directed towards stones in the kidney. common complications can include: • pain • hydronephrosis • fever • occasional urosepsis. PnL could be considered. For stones with a diameter of ≤ 20 mm (surface area ~ 300 mm2). These guidelines recommend ESWL as the first choice of treatment for stones with a diameter ≤ 20 mm (300 mm2). It is still unknown why stones preferentially develop in the lower pole calices. stents do not efficiently draining purulent or mucoid material. For stones with an area > 40 x 30 mm (1200 mm2) the combination of PnL and ESWL (sandwich approach) carries success rates of 71-96% with acceptable morbidity and complications. The best way to treat these stones is debatable. occasionally. it might be possible to try ESWL monotherapy first. Comparison between ESWL and ureteroscopic removal of stones from the lower calix system failed to show a difference (91) LE = level of evidence. about 1% of patients treated for urinary tract stones by ESWL have cystine stones.2. even if the stone has an area > 40 x 30 mm (1200 mm2) (75). the discriminating power is not sufficiently strong to predict the outcome of ESWL or to selecting alternative methods for stone removal (35). These stones either originate in the lower pole calises or gravitate there from other locations.3 Composition and hardness of the stone ESWL monotherapy of large calcium. although the accumulation of fragments in this position is most probably due to the effect of gravity. though some centres treat larger stones successfully with ESWL (36. For stones with a diameter ≥20 mm (300 mm2). GR = grade of recommendation LE = 1b gR = A Stone particles may pass easily along stents while urine flows in and around the stent. there is no clear critical size.The morbidity associated with PnL undoubtedly need to be taken into account. gr = a).1 Location of stone mass The clearance rate for lower caliceal stones is less than that for stones located elsewhere in the kidney. The risk of complications for either combined treatment or PnL alone is higher than for ESWL monotherapy. weight or volume of stones) • state of contralateral kidney (e. In up to 35% of patients treated using ESWL. Most consider a stone diameter of 20 mm as the practical upper limit for ESWL. a total of 76% of cystine stones have a maximum diameter > 25 mm (only 29% of all patients with stones have stones of this size). up to 66% more ESWL sessions and shock waves are needed to achieve 26 uPdaTE MarcH 2008 .or struvite-containing stones provides reasonable results for stone removal and complications (76).2 Total stone burden although problems associated with stone removal increase with stone volume. attempts have been made to explain the incomplete clearance of fragments and to predict the outcome of ESWL treatments. although ESWL may still be an option. 7. while very large stones can be disintegrated using only one ESWL session. This usually prevents obstruction and loss of ureteral contraction. however.g. particularly when the stones are large (diameter >20 mm or Sa > 300 mm2).1. 85). even when ultrasound does not reveal any dilation. the lower calices are incompletely cleared of disintegrated stone material. although the geometry of the lower calix system is important in the clearance of fragments. 7. Many kidney stones are located in the lower calix. If fever lasts for a few days. The use of ESWL after PnL seems to be more effective than using PnL after ESWL. With a solitary kidney. a percutaneous nephrostomy tube is needed. a multi-centre randomised comparison between ESWL and ureteroscopic removal of stones from the lower calyceal system failed to show a significantly better result with uretoscopy (86) (LE = 1b. using geometrical observations of the anatomy of the lower calix. Several authors have shown that an increased stone-free rate can be obtained with percutaneous nephrolithotomy (PnL). The following factors all influence the outcome of treatment: • location of stone mass (pelvic or caliceal) • total stone burden (number. 87). In the absence of a geometrical explanation.2. the results are contradictory.1. It is difficult to provide specific guidelines on kidney stone removal. GR = grade of recommendation LE = 1b gR = A 7. the size of the stones has been found to be the most important factor (79-83).1. Most residual fragments are lodged in the lower caliceal system. thus leading to a risk of obstructive pyelonephritis. caliceal physiology is another important factor (84.2. The clearance rate for upper pole stones is faster than for stones in the lower pole. as residual fragments occur with stones less than 20 mm (300 mm2) wide. ESWL is recommended. despite the lower clearance rate of fragments.The routine use of internal stents before ESWL does not improve outcome in terms of stone-free rate (78) LE = level of evidence. is the other kidney absent or functionless • composition and hardness of the stone. 89). Woods Jr. http://www.65(5):449-52. in stones > 20 mm.334(7591):468-72.nlm. Politis g.gov/pubmed/17678990 5.7(Suppl 1):S105. Steele rE.ncbi.5:225-8. di Silverio F. kahnoski rJ. use of extracorporeal shock wave lithotripsy in a solitary kidney with renal artery aneurysm. Stones made of uric acid and calcium oxalate dihydrate have a better coefficient of fragmentation than those made of calcium oxalate monohydrate and cystine.138(3):485-90. the stone-free rate was approximately 71%. Treatment selection and outcomes: renal calculi.140(3):479-83. Luymes J.nih. diederichs W. 1989.nih.nlm. cassanelli a et al.nlm. In cystine stones <15 mm. Lam HS. Steele rE. 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Extracorporeal shock wave lithotripsy for lower pole nephrolithiasis: efficacy and variables that influence treatment outcome.nlm. chacko nk. use of double-J stents prior to shock wave lithotripsy is not beneficial: results of a prospective randomized study. albala dM. Pattaras J. nakada SY.nlm.93(3):364-8. 82. devasia a. Eur urol 1992. http://www. gopalarishnan g.ncbi. http://www. http://www.ncbi.34(2):96-9. nakada SY. kuo r. outcome of extracorporeal lithotripsy monotherapy for large renal calculi: effect of stone and collecting system surface areas and costeffectiveness of treatment. 15(1-2):5-8. Long-term follow-up after extracorporeal shock wave lithotripsy of large kidney stones. Efficacy of extracorporeal shock wave lithotripsy for solitary lower caliceal stone: a statistical model. J urol 2003. Mcdougall EM. 88. khawaja k. clayman rV. 86.ncbi.ncbi. radiographic anatomical factors do not predict clearance of lower caliceal calculus by SWL. Prospective. http://www. kekre nS.gov/pubmed/7788251 Baltaci S.gov/pubmed/9586604 Pearle MS. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrolithotomy for lower pole nephrolithiasis–initial results. denstedt Jd.nih.gov/pubmed/11696709 Sorensen cM. Mandhani a.nih.gov/pubmed/12441921 Sistla BW. remplik J.nlm.nlm. newman rc. http://www.9(1):9-13.nih. Berman cJ. http://www. assimos d.nih.nlm.nlm. chandoke PS. BJu Int 2004.166(6):2072-80. http://www. India. Macaluso Jn Jr.nih. http://www. 74.gov/pubmed/12546707 albala dM. Pode d.gov/pubmed/1478223 Michaels Ek. 87.gov/pubmed/3215235 Burns T. J Endourol 1995.gov/pubmed/7780436 ackermann d.gov/pubmed/2669309 Sulaiman Mn. http://www. Pearle MS.gov/pubmed/14764139 ather MH. Preminger gM. Schreiber k. caine M.gov/pubmed/17394095 Srivastava a. 78. chandoke PS. El Faqih Sr. auge B. Murray MJ. averch Td. Thürhoff S. 81. Buchholz nP. claus r. ESWL monotherapy for large volume renal calculi: efficacy and morbidity. Wolf JS Jr.36(2):124-8. Shapiro a. grasso M. Lingeman JE. dushinski J.nlm. 85. dahm P. köhle r. Witzsch u. Treatment of renal stones by extracorporeal shockwave lithotripsy: an update. Stein J. Sankey nE. kumar a. Watkins S.gov/pubmed/15879805 rassweiler JJ. Honey J.ncbi. Int urol nephrol. Woods Jr.nih. http://www. Macaluso J.nih. Leveillee rJ.ncbi. Stone clearance in lower pole nephrolithiasis after extracorporeal shock wave lithotrips–the controversy continues. de Vries r. 84.nlm. khan rI. ganavaj I. Extracorporeal shock wave lithotripsy for large renal stones. Fowler JE Jr. Pietrow P. gutierrez-aceves J.nlm. akhtar S. chaussy c.nih.75(4):435-40. Frick J.nlm. J urol 2001.nlm.72.22(2):106-11.ncbi. http://www. Poulakis V.nih. 75. http://www. abid F. 77. Munch Lc. Is lower pole caliceal anatomy predictive of extracorporeal shock wave lithotripsy success for primary lower pole kidney stones? J urol 2002.nlm. urol 1998.168(6):2377-82. or following disintegration by uS-. Livadas cE. pleura. continuous removal of small fragments by suction or extraction is preferred to reduce the number of residual fragments. GR = grade of recommendation LE = 1b gR = A Stones can be extracted straightaway. karayannis aa. the patient’s anatomy must be considered. is a safe alternative (8. 90.ncbi.gov/pubmed/2795746 7. with or without gR = A tract fulguration. ‘mini-perc’ instruments have smaller shaft calibres of 12-20 F and may therefore have a lower rate of tract dilation-related complications (e. LE = level of evidence. cystine calculi-rough and smooth: a new clinical distinction. ESWL. The catheter also prevents fragments falling into the ureter. this method is recommended only for stones with a diameter < 20 mm (5).g. pNL and flexible uretero-nephroscopy are competing procedures with different success and complication rates and patient acceptance (9-10). calcium oxalate monohydrate. Bleeding is generally avoided by an anatomically oriented access. as described above. cranidis aI.ncbi. 11). gr = a). small fragments should be continuously LE = 1b removed. ultrasound makes it easier to identify. a self-retaining balloon nephrostomy tube tamponading the tract and maintaining access to the collecting system is used at the end of the procedure. Pre-procedural sonography and fluoroscopy of the kidney and the surrounding structures are recommended: • to determine the optimal access site and stone position in the kidney (ventral or dorsal) • to ensure organs adjacent to the kidney (e.2. LE = level of evidence. and therefore avoid damage to. gr = a).nlm.56(3):180-3. http://www. In lower pole stones. large bowel. GR = grade of recommendation 7. The absence of major blood vessels results in only minimal bleeding. although PnL is minimally invasive. but mini-perc is the method of choice for percutaneous stone removal in children (6-8). In complicated cases or when a second intervention is necessary. In rare cases.2 percutaneous removal of renal stones Most renal stones can be removed using percutaneous surgery. cT-guided renal access may be an option (4). stones in caliceal diverticulae or horseshoe kidneys). In uncomplicated cases. In the least traumatic access.nih. whether stones will respond poorly to ESWL (e. with or without tract fulguration. The value of mini-perc in adults has not been determined. electrohydraulic-. stones made of cystine. urol Int 1996. J urol 1989. to avoid complications. dretler SP. balloon or metallic dilators.2). a subcostal or supracostal upper pole access has been used frequently with good success for the treatment of staghorn stones. To reduce the number of residual fragments. tubeless percutaneous nephrolithotomy.gov/pubmed/8860740 Bhatta kM.11) (LE = 1b. large stones. Sepsis and ‘transurethral resection syndrome’ indicate a poor technique that has resulted in high pressure within the 32 uPdaTE MarcH 2008 . if ESWL is available.nih. However. spleen. cystine stones: the efficacy of percutaneous and shock wave lithotripsy. with choice depending on experience. complications are lesions to adjacent organs. Pre-procedural kuB (plain abdominal film of the kidneys. The access site used most often is the dorsal calix of the lower pole. PnL should be used only when the outcome is likely to be less favourable after ESWL. bleeding or renal trauma). application of a sealant or double-J stenting. renal tract dilatation is possible using the amplatz system. availability and costs.89. http://www. but rare. In lower pole stones. is a safe alternative (8. delakas dS. where there are anatomical anomalies. which can be avoided by uS-guided puncture.nlm.142(4):937-40.g. laseror hydro-pneumatic probes. brushite) or if fragments are unlikely to pass (e.1 Complications Major. anezinis PE. as treatment time increases with stone size. Prien EL Jr. the puncture site on the skin lies in the extension of the long axis of the target calix and the puncture passes through the papilla. ESWL. PnL and flexible uretero-nephroscopy are competing procedures with different success and complication rates and patient acceptance (9-10) (LE = 1b.g. liver. lungs) are not within the planned percutaneous path (1. neighbouring organs (3). ureters and bladder) and intravenous urography (IVu) or computed tomography (cT) scans can be used to plan access and determine likely success.g. tubeless percutaneous nephrolithotomy. application of a sealant or double-J stenting. it is a surgical procedure and. For example. Percutaneous puncture may be easier if a ureteral balloon catheter is used to dilate and opacify the collecting system. This is the safest access point because it uses the infundibulum as a conduit to the pelvis. although standard nephroscopes have shaft calibres of 24-30 F. In uncomplicated cases. The puncture can be made under combined ultrasound (uS) and X-ray control or under biplanar fluoroscopy. nlm. averch Td. 7.nih. Heger k.nlm. Wendt-nordahl g. Percutaneous nephrolithotomy: the Mannheim technique. desai MM. 3. as with open surgery. Lower pole I: a prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. Pietrow P. These problems can be avoided by using continuous flow instruments or an amplatz system (1. urology 2001. Leveillee rJ. References kim Sc. Prospective randomized study of various techniques of percutaneous nephrolithotomy.ncbi. Major bleeding during the procedure requires termination of the operation. http://www.nlm. Low rk. J urol 2004. dilatation and instrumentation. nadler rB.40(6):619-24.nih. ureterorenoscopy (urS) has dramatically changed the management of ureteral calculi and is now used extensively in urology centres worldwide.nlm. Lingeman JE. http://www.58(3):345-50. Macaluso J. 5. alken P. desai M.gov/pubmed/11696709 desai Mr. Peters ca. Pattaras J. Percutaneus nephrolithotomy: an update. http://www.gov/pubmed/16153221 Matlaga Br. renal intrapelvic pressure during percutaneous neprolithotomy and its correlation with the development of postoperative fever. Michel MS. nakada SY. The procedure is more likely to be difficult when anatomical conditions limit the space available for the initial puncture.nih.nlm.ncbi.nih.nih.ncbi. Patel S.gov/pubmed/9763096 desai M.ncbi. 6.173(6):2005-9.gov/pubmed/12796641 Lahme S.nih.gov/pubmed/12692448 knoll T. knoll T. Teichman J. nakada SY. Pearle MS.nih. Patel SH. ogan k. Percutaneous nephrolithotomy in infants and preschool age children: experience with a new technique.gov/pubmed/11805407 Jackman SV. grasso M. newman rc.2 1.ncbi.ncbi.ncbi. Tamaddon k.gov/pubmed/17227510 osman M. such as stones in diverticula.nih. docimo Sg. gutierrez-aceves J. kukreja ra.13(3):235-41.nih. Eur urol 2001. Wolf JS Jr. Lingeman JE. urology 1998.nih.ncbi.nlm. kahn rI. Michel MS. Zagoria rJ. Fabrizio M. 7.nlm. assimos d. 7.nlm. Monga M. and secondary intervention at a later date.gov/pubmed/15879805 albala dM. Wani ka. Bapat S.nih. http://www. venous bleeding stops when the nephrostomy tube is clamped for some hours. BJu Int 2005. Woods Jr.166(6):2072-80. Shah od. J urol 2005. 10. 12.nlm. or a large stone burden caused by complete or partial staghorn stones. 9. curr opin urol 2003. Percutaneous nephrolithotomy with ultrasonography-guided renal access: experience from over 300 cases. Hedican SP.gov/pubmed/10446796 Feng MI. Honey J. randomized trial comparing shock wave lithotripsy and ureteroscopy for lower pole caliceal calculi 1 cm or less. Minimally invasive PcnL in patients with renal pelvic and caliceal stones.gov/pubmed/12352390 2.gov/pubmed/11549477 Pearle MS. gotz T.ncbi. J urol 2003. Strohmaier WL. Leveillee r. however. Mikhail a. Persistent or late secondary bleeding is caused by an arterial injury and can be managed by angiographic super-selective embolisation. Lingeman JE. Prospective. computerized tomography guided access for percutaneous nephrolithotomy.nlm. Surgical atlas. http://www.nlm. J Endourol 1999. Bapat Sd. dyer rB. ridhorkar V. Watkins S. kaptein JS. only experienced surgeons should carry out the procedure.ncbi. Bichler kH. Mhaskar SS. J urol 2001. Munch Lc. clayman rV.168(4 Pt 1):1348-51.nlm. J urol 2002. http://www. a more invasive technique than ESWL.collecting system during manipulation. http://www. Pediatric percutaneous nephrolithotomy: assessing impact of technical innovations on safety and efficacy. http://www.ncbi. 11. dushinski J. In most cases. Preminger gM. Streem SB. kuo rL. stones completely filling the target calix.Munch Lc.99(1):213-31.52(4):697-701. BJu Int 2007. Bellman gc. http://www. percutaneous procedures have different degrees of difficulty. kumar u.3 Retrograde removal of ureteral and renal stones (retrograde intrarenal surgery [RIRS]) during the past 20 years. Macaluso Jn Jr.13(5):359-64.nih. ESWL and uPdaTE MarcH 2008 33 . http://www. assimos dg. 8. auge B. kuo r. Preminger gM.gov/pubmed/15247731 Troxel Sa.8).172(2):565-7.96(6):875-8. Mcdougall EM. assimos dg. and the treatment of choice for ureteral stones is therefore controversial. Turk T. http://www. urS is. denstedt Jd.ncbi. For renal calculi. placement of a nephrostomy tube. http://www. 4.2.170(1):45-7. a prospective randomized comparison of type of nephrostomy drainage following percutaneous nephrostolithotomy: large bore versus small bore versus tubeless. In these cases. albala dM. alken P. current scopes provide higher tip deflections and are more durable than the older generation (28-30). In the lower ureter. Holmium:yttrium aluminium garnet (Ho:Yag) laser lithotripsy is a reliable method for treating urinary calculi. 7.0-7. miniaturisation (and regular pre-stenting of the ureter) avoid the need to dilate the intramural ureter and associated complications (21-23). non-hydrophylic. cT or uS. Small stones and fragments are best retrieved with a basket or a forceps (6-9).3.3. Flexible ureteroscopes (5-7. floppy tip) under endoscopic and fluoroscopic control and secure it to drapes.1 Standard endoscopic technique LE = 4 gR = C Before URS.2 Disintegration devices disintegration devices are discussed in appendix 1. 7.2 Anaesthesia Improvement of ureteroscopes and stone retrieval instruments has enabled ureteroscopic procedures for ureteral calculi to be carried out using sedation analgesia with similar success rates (88-97%) to those using general anaesthesia (17-19). antibiotic prophylaxis should be administered to ensure sterile urine (4. Patients should be followed up by plain abdominal film (IVu). • Fluoroscopic equipment must be available in the operating room. 5). LE = level of evidence.5 F) are suitable for access to the upper part of the ureter and renal collecting system. Take care to avoid high-pressure irrigation as this is associated with an increased complication rate. 34-37). 7.5 F) allow easier and safer progression of rigid ureteroscopes up to the proximal ureter. without dilatation of the intramural ureter in most cases (3. • Retrograde access to upper urinary tract is usually obtained under video guidance. electrohydraulic lithotripsy (EHL). general anaesthesia may help minimise movements of the kidney. but depends on size of ureteroscope and width of ureter. LE = level of evidence. Lithotripsy devices are described in appendix 1. GR = grade of recommendation The basic endoscopic technique has been standardised (1-3).035-inch. with a rigid ureteroscope alongside safety wire.PnL are the recommended primary treatment options. Stent placement at the end of the procedure is optional and debatable (10-16). place patient in lithotomy position. The stone may be fragmented by ultrasonic lithotripsy. • Introduce a safety wire (usually an 0. GR = grade of recommendation 34 uPdaTE MarcH 2008 LE = 3 gR = B/C . • Pre-operative imaging of urinary tract confirms location of stone and identifies anatomical abnormalities • Under general anaesthesia. • Flexible ureteroscopes are most easily introduced via an additional guidewire or through an ureteral access sheath. spinal anaesthesia or intravenous sedation. Stone extraction with a basket without endoscopic visualisation of the stone (blind basketing) should not be performed (see chapter 9). The small tip diameters (5.3 Assessment of different devices 7. urS is particularly useful for removal of distal ureteral stones in women (20). In most cases. For treatment of renal calculi with flexible urS. regardless of hardness (31-34) and is the preferred method when carrying out flexible urS (3. • Intramural ureteral dilatation is not routine.3.3. laser lithotripsy or ballistic (= pneumatic) lithotripsy.1 Ureteroscopes rigid and flexible ureteroscopes are available.3. its value in removing renal calculi has to be determined. Following the wider availability and improvement of flexible urS. although there is no evidence regarding the optimal interval. 24-27). 7. Ho:YAg laser lithotripsy is the preferred method when carrying out flexible URS (3. GR = grade of recommendation LE = 4 gR = C Irrigation with a piston syringe is needed to ensure good direct vision. a flexible ureteroscope is less suitable because of its tendency to fall back into the bladder. • The safety guide wire prevents the risk of false passage if there is perforation. Most urologists leave the stent for about 1 week.3. 34-37). This latter procedure is termed retrograde intrarenal surgery (rIrS). • Endoscopic lithotripsy is based on the use of different devices to break the stone into dust or fragments small enough for extraction.3. LE = level of evidence. • Begin procedure using rigid or flexible cystoscopy. although last-generation scopes allow bare passage in experienced hands. nevertheless. operating time and post-operative ureteral stenting.4. the use of LE = 1a gR = A uPdaTE MarcH 2008 35 . GR = grade of recommendation LE = 2b/3 gR = B nitinol baskets are more vulnerable than a stainless steel basket.57-60). Nitinol baskets are most suitable for use in flexible URS.1 Renal calculi current guidelines suggest ESWL is the therapy of first choice for intrarenal calculi ≤ 20 mm. even if only temporary. First follow-up series indicate a low rate of ureteral strictures. Ballistic lithotripters (pneumatic or electropneumatic). ureteral stents increase the overall cost of urS.50).3. secondary cystoscopy is required for stent removal (13). 7. ureteral access sheaths and stenting attempts to modify the standard technique of dilatation and stenting have been carried out during recent years.or proximal ureter may limit the use of ballistic lithotripsy (47. operating time might be reduced for higher stone burdens where multiple ureter passages are necessary (51-53).3 Baskets and forceps ureteroscopic removal of small ureteral stones with a basket or forceps is a relatively quick procedure with a lower morbidity rate than that associated with lithotripsy (8. reduce quality of life (58-64).4 F probe in a semi-rigid ureteroscope. 7. laser lithotripsy is safe.3. 7. However. including: • ureteral injury • stricture • solitary kidney • renal insufficiency • a large residual stone burden. Moreover. respectively) (39). Indications for stenting after the completion of urS. Stenting following uncomplicated URS is optional (see also chapter 9). ureteral access sheaths are used widely to facilitate retrograde manipulation in the proximal ureter and the kidney.3. provide excellent fragmentation rates (90-96%). LE = level of evidence. as the results using ESWL for lower pole stones are poor.4 Dilatation. Nitinol baskets preserve tip deflection of flexible ureterorenoscopes and the tipless design reduces the risk of mucosa injury (38). Low cost with simple and safe handling are major advantages of this type of device (44-46).4 Clinical results 7.48). and laser or EHL might break the wires of the basket (49. comparable to sheathless urS (56). significant side-effects may be more common with EHL (39-43). using a 2. LE = level of evidence.The 200 μm fibre preserves tip deflection of flexible ureterorenoscopes and allows fragmentation of intracaliceal calculi (38).9). Several new endoscopic stone retrieval baskets are available. include: • stent migration • urinary tract infection • breakage • encrustation • obstruction.3. Today.70). If manipulated with care. For distal ureteral stones. The use of thin ureteroscopes has resulted in reduced dilatation (0-40%). however.3. unless a pull-string is attached to the distal end of the stent.a 365 μm laser fibre is the best choice for ureteral stones. complications associated with ureteral stenting. available access sheaths (9-16 F) have a hydrophilic surface and are introduced via a guide wire with the tip placed in the proximal ureter. another advantage is the maintenance of a low-pressure irrigation system by continuous outflow through the sheath (54-55). with PnL used to treat larger stones (69. Ho:Yag lithotripsy give better stone-free results at 3 months than EHL (97% versus 87%. ureteric stenting is associated with lower urinary tract symptoms and pain that can. stone migration towards the renal pelvis from the mid. GR = grade of recommendation Several randomised prospective trials have found that routine stenting after uncomplicated urS may not be necessary (10-16.3. In addition. LE = level of evidence. LE = 4 gR = C 36 uPdaTE MarcH 2008 .3. Flexible URS has been demonstrated to be an effective treatment for ESWL-refractory calculi (79-80).primary PnL might be justified for smaller calculi starting from ≥ 15 mm in this location (69-73). 93). autologous transplantation or uretero-ileoplasty are the methods of choice in these cases.87). In experienced hands. in selected cases. Morbidly obese patients can be treated with success rates and complication rates similar to those in the general population (88. and location are shown in Table 5.5 cm. Most perforations seen during the procedure are successfully treated with approximately 2 weeks of stenting (46. ureteral strictures were the only long-term complication (estimated rate 1%). The overall complication rates reported in the recent literature are 5–9%. Some authors have reported the combination of flexible urS with ESWL or PnL to improve stonefree rates (81-82). Flexible urS is an effective treatment for ESW-refractory renal calculi. ureteral access sheaths and nitional retrieval tools.66). However. LE = level of evidence. The major acute complication remains ureteral avulsion (44. flexible urS could become a reliable first-line treatment for lower pole stones ≤ 1. because using ESWL for lower pole stones has poor results. respectively (65. There is a pronounced relationship between the complication rate. although ESWL is less invasive and has the lowest complication rates. URS can also be applied when ESWL might be contraindicated or ill-advised.83. larger stones can also be treated successfully. and data from which to estimate their rates of occurrence were not available. 66).5 cm are 50-80% (51. stricture. ureteral perforation at the site of the stone is the primary risk factor for stricture. and there are no valid data to support such a recommendation. 7. ureteral injury and urinary tract infection (uTI). with a 1% rate of significant complications (7. ESWL or PnL are currently procedures of first choice. Complications a meta-analysis published by the Eau-aua guidelines panel has evaluated the most relevant complications of sepsis. However. urS for ureteral calculi had minimal side-effects (65-66). For ureteric calculi. GR = grade of recommendation urS can be carried out safely in patients for whom stopping anticoagulants is unsafe (42). Flexible urS may offer an alternative to ESWL or PnL. but to date. urS should be limited to carefully selected patients. The simultaneous use of flexible urS and PnL may offer an attractive approach to achieve complete stone-free states after one procedure and to avoid multiple percutaneous tracts. few comparative data are available on the use of flexible urS for renal calculi. and/or expertise of the urologist (83). chapter 9 Significant acute complication rates of 11% and 9% have been reported for the proximal and distal ureters. 7. 83-86). urS can be used safely to treat bilateral ureteral stones simultaneously (92. both ESWL and urS are acceptable alternatives. a stone-free state can be achieved faster using urS. Stone-free rates for calculi ≤1. size.74-78). Steinstrasse. Further studies are needed to determine whether flexible urS can be a first-line treatment of renal calculi where. unfortunately. 89) and has been used safely during pregnancy (90-91). enable the removal of most calculi. were rare.3. this procedure has not been mentioned by most guidelines. complication rates for the overall population by treatment. For larger calculi.5. 44. such an approach requires significant experience and equipment and is therefore not used routinely. Finally. Together with laser lithotripsy.85). including death and loss of kidney. The latest-generation ureterenoscopes allow access to almost all calices. depending on size and location. equipment used. the new generation of ureteroscopes can treat of proximal and distal ureteric stones. In addition. randomised and prospective studies to compare all forms of stone removal for renal and ureteric calculi are needed. Serious complications. the stonefree rates achieved using urS might be advantageous. 46. 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This allows removal of large staghorn stones by multiple small radial nephrotomies without loss of kidney function. stricture • morbid obesity • skeletal deformity.4% of cases (1-5). Wolf JS Jr.0-5.nih. nott L. contractures and fixed deformities of hips and legs • co-morbid medical disease • concomitant open surgery • non-functioning lower pole (partial nephrectomy).90. Beiko dT.17(10):881-5. ureteroscopy as a first-line intervention for ureteral calculi in pregnancy.1 Indications for open and laparoscopic surgery Indications for open stone surgery include: • complex stone burden • treatment failure of ESWL and/or PNL. However.nih.ncbi. skills and expertise in open renal and ureteral surgical techniques. http://www. and urologists must therefore maintain their proficiency. 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J Endourol 1996. a comparative study.ncbi. the chemolytic solution is allowed to flow in through one nephrostomy catheter and out through another. Evaluation of laparoscopic retroperitoneal surgery in urinary stone disease. guillonneau B. Lykourinas M. These solutions should be used only when there is good evidence that the renal tract has healed following surgery. however. rietbergen J.2).5-4) or Suby’s g solution.gov/pubmed/11890236 Brunet P. under antibiotic prophylaxis.9(4):315-7.2 Brushite stones Brushite is also soluble in the acid solutions hemiacidrin and Suby’s g solution. Mahe P. 39.88(7):679-82. The contact surface area between the stone or the stone remnants and the chemolytic agent is increased using ESWL.g. Meria P.ncbi.nlm.4 Uric acid stones a high concentration of urate and a low pH are the determinants of uric acid stone formation. http://www. goel a. 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Hemal ak.gov/pubmed/11805405 Skrepetis k.ncbi.nlm.nih. J Endourol 2001. oral chemolysis is.nlm. http://www. at least two nephrostomy catheters should be used to allow irrigation of the renal collecting system. kumar M. navarra S. Siafakas I. 7. Laparoscopic nephrectomy for benign disease: comparison of the transperitoneal and retroperitoneal approaches. clayman rV. 7.10(1):45-9.40(6):609-13.gov/pubmed/11697400 Feyaerts a. upper and mid-ureteric stones: a prospective unrandomized comparison of retroperitoneoscopic and open ureterolithotomy. 7. urS or open surgery to achieve more complete elimination of small residual stones or fragments.5 Chemolytic dissolution of stones using percutaneous irrigation chemolytic dissolution of stones or stone fragments is a useful adjunct to ESWL.nih. http://www. Eur urol 2001.40(1):32-6.5-9. http://www. e. discussion 37. uPdaTE MarcH 2008 45 . Percutaneous chemolysis can be achieved using THaM solutions. 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Endourological experience with cystine calculi and a treatment algorithm. 3. 4.gov/pubmed/3215233 rodman JS. Joseph dB.20(3):435-42. J urol 1984.18(2):127-30. Tank ES.nih.131(3):434-8. 7. Talwalkar YB.nlm.128(2):241-2. 12. [Perkutane chemolyse von Struvit-Steinen bei nierenbecken-und kelchhalsobstruktion] akt urol 1982.gov/pubmed/6708214 Fam B. http://www. eds.116(6):696-8.nlm. [auflösung von cystin-Steinen mit n-acetylcystein nach perkutaner nephrostomie.nlm. http://www.gov/pubmed/7154186 Weirich W. Further details of this regimen are given in Section 17. 10. http://www. Lingeman JE. [Lokale chemolitholyse von Harnsteinen] Zeitschrift fur klinische Medizin 1989. Schmiedt E. kersting H.5 Calcium oxalate and ammonium urate stones no physiologically useful chemolytic agents are available for dissolving calcium oxalate or ammonium urate stones (22).ncbi.ncbi. alken P.13(4):422-3.131(5):861-3.15(1):26-30. Schöpke W. chemolysis of calculi. For uric acid stones. and (at least in adults) avoids the need for regional or general anaesthesia. Peterson cM. the combination of stone disintegration and chemolysis can increase the rate of dissolution and may be considered for removal of large uric acid stones. GR = grade of recommendation Infection stones are also radiopaque and usually contain calcium in the form of carbonate apatite and hydroxyapatite. rIrS with a flexible ureteroscope.nih. 22. GR = grade of recommendation LE = 4 gR = C uPdaTE MarcH 2008 47 . this technique should be considered as an alternative before choosing open surgery. Huang Jk.nih. with or without percutaneous chemolysis. Videoendoscopic retroperitoneal or laparoscopic surgery is not a standard procedure for removing kidney stones.6 Recommendations for removal of renal stones The options for kidney stone removal are ESWL. Such a step might also be used as an auxiliary procedure for cystine stones. recent history of urinary tract infection or bacteriuria.131(6):1039-44.ncbi. 21. Verbeeck r. http://www.gov/pubmed/6726897 Lee YH. These stones should be treated in the same way as sterile calcium stones. ESWL has sometimes to be repeated and residual fragments are relatively common. video-endoscopic laparoscopic or open surgery.gov/pubmed/1317980 rodman JS. has a low rate of complications. However.nih.1 M THaM and 0.48(1):81-6.20(1):19-21. a follow-up programme is needed because patients with stone disease have an inherent tendency to new stone formation.51(3):147-51. cuvelier c.ncbi.19. unless a meticulous technique is used.ncbi. Local chemolysis of obstructive uric acid stones with 0. http://www. rationale for local toxicity of calcium chelators. and has advantages in some types of reconstructive surgery. urol Int 1992. http://www. antibiotic prophylaxis should be started before the stone-removing procedure and continued least 4 days afterwards. also including piezolithotripsy PnL rIrS Laparoscopic surgery open surgery LE 1b 1b 2a 2a 4 gR a a c c c LE = level of evidence. However. 20. Williams JJ. LE = level of evidence. chen MT.ncbi. Vergauwe d. residual fragments may remain. although PnL is faster at debulking stone than ESWL. mainly for patients in whom anatomical reconstruction is needed. which are associated with the most pronounced risk of recurrent stone formation.nlm. chang LS. urol res 1992. For any given stone situation.nlm. However.nlm. a method offering low invasiveness and morbidity should be selected. residual fragments of infection stones. oral chemolysis is the treatment of choice. urol Int 1993.02% chlorhexidine. provided there is no obstruction and that a symptomatic infection has been adequately treated. Indudhara r. debate continues about whether large renal stones are best treated with ESWL or with PnL. For small stones (maximum diameter ≤ 20 mm or a surface area of ~300 mm2).gov/pubmed/1736482 7.nlm. it must be emphasised that considerable expertise and experience is required to clear stones completely from the caliceal system. For all patients with infection stones. More than 20 years of experience with low-invasive methods have shown that open surgery is necessary only in exceptional cases. Table 17: Active removal of radiopaque (calcium) renal stones with a largest diameter < 20 mm (surface area ~ ≤ 300 mm2) preference (decreasing order) 1 2 3 4 5 procedure ESWL. ESWL is the standard procedure because it is non-invasive. http://www. There is a low risk that residual fragments can develop into new stones. chemodissolution of urinary uric acid stones by alkali therapy. can be eliminated with PnL. PnL.gov/pubmed/8249225 oosterlinck W. Sharma Sk. J urol 1984. dissolution of uric acid calculi. although large stones can be treated successfully with ESWL. an overview of treatment recommendations according to size and stone type is shown in Tables 17-22.nih. 5). Table 19: Active removal of cystine stones with a largest diameter ≤ 20 mm (surface area ~ ≤ 300 mm2) preference 1 1 2 3 4 procedure ESWL (including piezolithotripsy) PnL rIrS Laparoscopic surgery open surgery LE 2a 2a 4 4 4 gR B B c c c LE = level of evidence.Table 18: Active removal of uric acid renal stones with a largest diameter < 20 mm (surface area ~ ≤ 300 mm2) preference 1 2 procedure oral chemolysis ESWL (including piezolithotripsy) + oral chemolysis LE 2a 2a gR B B LE = level of evidence. stone disintegration with ESWL can advantageously be combined with percutaneous chemolysis (see Section 7. stone isintegration with ESWL combined with percutaneous chemolysis is a good alternative to quickly dissolve the stone material (see Section 7. ESWL = extracorporeal shock-wave lithotripsy Table 20: Active removal of radiopaque (calcium) renal stones with a largest diameter > 20 mm (surface area > 300 mm2) preference 1 2 3 4 4 procedure PnL ESWL (including piezolithotripsy) PnL + ESWL (including piezolithotripsy) Laparoscopic surgery open surgery LE 1b 1b 2b 4 4 gR a a B c c LE = level of evidence.5). ESWL = extracorporeal shock-wave lithotripsy For patients with uric acid stones and a percutaneous nephrostomy catheter in place. GR = grade of recommendation. ESWL = extracorporeal shock-wave lithotripsy For patients with uric acid stones and a percutaneous nephrostomy catheter in place. GR = grade of recommendation. GR = grade of recommendation. ESWL = extracorporeal shock-wave lithotripsy Table 21: Active removal of uric acid renal stones with a largest diameter > 20 mm (surface area ~ > 300 mm2) preference 1 2 3 procedure oral chemolysis ESWL (including piezolithotripsy) + oral chemolysis PnL LE 2a 2a 3 gR B B c 3 Percutaneous + chemolysis 3 c LE = level of evidence. GR = grade of recommendation. 48 uPdaTE MarcH 2008 . GR = grade of recommendation LE = 1b gR = A/B In patients with small staghorn stones and a non-dilated system. uric acid and calcium phosphate stones. with chemolysis may be useful. the combined use of ESWL or other stone-removing procedures. repeated ESWL sessions with a stent can be a reasonable treatment alternative. patients with staghorn stones can usually be treated according to the principles given for large stones (diameter > 20 mm / 300 mm2) (see chapter 7). LE = level of evidence.Table 22: Active removal of cystine stones with a largest diameter > 20 mm (surface area > 300 mm2) preference 1 1 1 2 3 3 procedure Percutaneous nephrolithotomy PnL+ ESWL (including piezolithotripsy) PnL+ chemolysis ESWL (including piezolithotripsy) + chemolysis Laparoscopic surgery open surgery LE 2a 2a 3 3 4 4 gR B B c c c c LE = level of evidence. uPdaTE MarcH 2008 49 . GR = grade of recommendation 8. ESWL = extracorporeal shock-wave lithotripsy patients for whom ESWL-treatment of stones (with a diameter exceeding 20 mm ~300 mm2) LE = 3 is scheduled should have an internal stent to avoid problems related to Steinstrasse. nephrectomy should be considered in the case of a non-functioning kidney. STAgHORN STONES a staghorn stone is defined as a stone with a central body and at least one caliceal branch. cystine. The principles of chemolytic treatment are discussed in chapter 7. GR = grade of recommendation. In selected cases with infection. gR = B LE = level of evidence. a complete staghorn stone fills all the calices and the renal pelvis. a partial staghorn stone fills only part of the collecting system. 9.d. Margaret Sue Pearle. M. Vice chair Peter alken. M. Pharmd 50 uPdaTE MarcH 2008 .d. M. Ph.d.. M. co-chair dean g. Edith Budd karin Plass Michael Folmer katherine Moore Medical Writing Assistance: diann glickman. Patrick M. christian Türk. M. Stephen Y. Ph. Eau guidelines office chair Heddy Hubbard.d. co-chair Hans-göran Tiselius. colin Buck. Ph.d. Jr. James E.. Ph. Inc. Ph.d. kemal Sarica.d.d. 2007 gUIDELINE FOR THE MANAgEMENT OF URETERAL CALCULI European association of urology and american urological association Education and research... J. Lingeman. Ph. Ph.d.d. Ph.d. Ph.. M...d. assimos. M. Thomas knoll.d. Consultants: Hanan S. M. Ph... Ph. Michele gallucci. M.d.. nakada.d. M. M.. M. M. Stuart Wolf..d. Florer AUA and EAU Staff: gunnar aus. MANAgEMENT OF pATIENTS WITH STONES IN THE URETER. Preminger.d.d.d.d.. Bell. EAU/AUA Nephrolithiasis guideline panel Members: glenn M.d.d.d. M.d..d. 1 For all Index Patients 9.5 Laparoscopic and open Stone Surgery 9.4 Percutaneous antegrade ureteroscopy 9.5.6 9.1.11 uPdaTE MarcH 2008 51 .8.6.3.1.2 Pediatrics 9.5.8.5.6.4 9.3 For ureteral Stones >10 mm 9.6.THE MANAgEMENT OF URETERAL CALCULI: DIAgNOSIS AND TREATMENT RECOMMENDATIONS TABLE OF CONTENTS 9.3.4 uric acid Stones research and Future directions acknowledgements and disclaimers references pAgE 52 52 54 55 55 55 55 55 58 60 62 62 63 63 63 64 64 65 65 65 65 66 67 67 68 68 68 68 69 69 69 70 70 9.5.8 9.8.5 other Surgical Interventions The Index Patient Treatment guidelines for the Index Patient 9.8.3.3 ureteroscopy 9.1 Medical Expulsive Therapy 9.4 For Patients requiring Stone removal recommendations for the Pediatric Patient recommendations for the nonindex Patient discussion 9.1 Pregnancy 9.3.8.10 9.1.8.6.3.8.8.9 9.3.2 9.3 Introduction Methodology results of the outcomes analysis 9.8.7 9.1.1 Shock-wave Lithotripsy and ureteroscopy 9.1.3 Procedure counts 9.1 9.3 cystine Stones 9.2 Efficacy outcomes Stone-free rates 9.1 observation and Medical Therapies Stone passage rates 9.4 complications 9.2 For ureteral Stones <10 mm 9.5 9.6 Special considerations 9.2 Shock-wave Lithotripsy 9.8. articles were selected from a database of papers derived from MEdLInE searches dealing with all forms of urinary tract stones.1 Introduction The american urological association (aua) nephrolithiasis clinical guideline Panel was established in 1991. open surgery.. The abstract of each paper was independently reviewed by an american and a European Panel member. the most recent being a 2005 update of the original 1994 Report on the Management of Staghorn Calculi (1). In addition. and stone composition. outcomes were stratified by stone location (proximal. under the sage leadership of the late dr. This article will be published simultaneously in European Urology and The Journal of Urology. offering physician and patient guidance worldwide.e. which would be similar to that used in developing the previous aua guideline. 9. the Panel was able to provide some guidance regarding the management of pediatric patients with ureteral calculi. including treatment costs. 348 citations entered the extraction process. Joseph W. open stone surgery is still considered a secondary treatment option. additional articles were suggested by Panel members or found as references in review articles. observation and medical therapy 2. laparoscopic stone removal. including medical expulsive therapy (MET) to facilitate spontaneous stone passage. and laparoscopic expertise have burgeoned over the past five to ten years. In total. Treatments were divided into three broad groups: 1. Shock-wave lithotripsy and ureteroscopy 3. with updates in 2001 and 2006 (2). Based on their findings. intracorporeal lithotripsy techniques. patient data were stratified by age (adult versus child). integrity. and distal ureter) and by stone size (dichotomized as <10 mm and >10 mm for surgical interventions. Wa) 52 uPdaTE MarcH 2008 . other treatments were reviewed. Those situations may require physicians and patients to resort to treatment alternatives. redmond. stone-passage rate or probability of spontaneous passage. Later. or percutaneous antegrade ureteroscopy. Segura. all treatments commonly employed in the united States and/ or Europe were included in this report except for those that were explicitly excluded in the previous guideline or newer treatments for which insufficient literature existed. The Panel believes that future collaboration between the Eau and the aua will serve to establish other internationally approved guidelines. the Panel has developed three guidelines on the management of nephrolithiasis. In the analysis. SWL and ureteroscopy (urS) remain the two primary treatment modalities for the management of symptomatic ureteral calculi.2 Methodology The Panel initially discussed the scope of the guideline and the methodology. i.9. changes in shock-wave lithotripsy (SWL) technology. the position of the ureter that corresponds to the sacroiliac joint. number of procedures performed. yielding the publication of Guidelines on Urolithiasis. the proximal ureter is above and the distal ureter is below. the data were found to be insufficient to allow analysis by composition. The Panel recognizes that some of the treatment modalities or procedures recommended in this document require access to modern equipment or presupposes a level of training and expertise not available to practitioners in many clinical centers. This database was maintained by a Panel chair. We therefore dedicate this report to the memory of dr. percutaneous antegrade ureteroscopy. endoscope design. stone location. The team members reconciled the extractions. stone size. While both documents provide useful recommendations on the management of ureteral calculi. This joint Eau/aua nephrolithiasis guideline Panel (hereinafter the Panel) performed a systematic review of the English language literature published since 1997 and a comprehensively analyzed outcomes data from the identified studies. an american and a European Panel member each independently extracted data from each article onto a standardized form. however. for example as <10 mm and >10 mm). Joseph W. Segura whose vision. Blind basketing of ureteral calculi is not recommended. and perseverance led to the establishment of the first international guideline project. In concurrence with the previously published guidelines of both organizations. and laparoscopic and open surgical ureterolithotomy. The review of the evidence began with a literature search and data extraction. and the data were entered into a Microsoft access® (Microsoft. the aua Practice guidelines committee suggested to both the aua and the Eau that they join efforts in developing the first set of internationally endorsed guidelines focusing on the changes introduced in ureteral stone management over the last decade. the Panel concluded that when removal becomes necessary. Since that time. and articles were selected for data extraction if any panel member felt it might have useful data. The mid ureter is the part of the ureter that overlies the bony pelvis. and complications of treatment. and <5 mm and >5 mm for medical interventions and observation where possible. exceptions were made when data were reported. The outcomes deemed by the Panel to be of particular interest to the patient included the following: stone-free rate. mid. The European association of urology (Eau) began their nephrolithiasis guideline project in 2000. The Panel did not examine economic effects. corrected the extraction errors. The Fast*Pro computer software4 was used in the analysis. Many studies did not indicate how or when stone-free status was determined. The goal was to generate outcomes tables comparing estimates of outcomes across treatment modalities. The treatments used were not current or were not the focus of the analysis. differences in patient selection may have had more weight in analyses than differing treatment effects. The article did not provide usable data on the outcomes of interest. measures of variance were rarely reported in the studies reviewed. The Panel scrutinized the entries. The article was a review article of data reported elsewhere. Evidence from the studies meeting the inclusion criteria and reporting a given outcome was combined within each treatment modality. and the central 95% of the distribution serves as a confidence interval (cI). in the performance of the intervention. the results obtained reflect the best outcome estimates presently available. a random-effects. and after the total treatments. Because of the paucity of controlled trials found on literature review. one difficulty in estimating the total number of procedures per patient is that secondary and adjunctive procedures were not reported consistently. This program provides posterior distributions from meta-analyses from which the median can be used as a best estimate. uPdaTE MarcH 2008 53 . model was used to combine the studies. reconciled the inconsistencies in recording. estimates of the probabilities and/or magnitudes of the outcomes are required for each intervention. a total of 244 of the 348 articles initially selected had extractable data. a measure of variance (e. after examining the available evidence. For example. It is important to note that. Such a combination can be performed in a variety of ways depending on the nature and quality of the evidence. In addition. 3. given these differences. the outcome for each intervention was estimated by combining single arms from various clinical series. Initially. adjunctive procedures were defined as additional procedures that do not involve active stone removal. Studies that reported numbers of patients who were stone free after primary procedures were included in the stone-free analysis. nevertheless. and adjunctive procedures.database. 5. the number of procedures per patient is a discrete rate. For this report. these are derived from a synthesis or combination of the evidence. the Panel divided complications into three broad categories: acute. unfortunately. after all consecutive procedures using the primary treatment. standard error) is needed in addition to the mean. or hierarchical. secondary. and excluded some articles from further analysis for the following reasons: 1. The article was included in the previous guideline. In some cases discrete rates can be approximated with a continuous rate. and different methods of determining stone-free status. likely due to a combination of site-to-site variations in patient populations. long-term. only studies that specifically reported data on a type of procedure were included in estimates for that procedure type. Statistical significance at the p<0. but in order to meta-analyze continuous rates. the Panel elected to use the confidence Profile Method (3). 6. The article dealt only with salvage therapy. and adjunctive procedures separately. which provides methods for analyzing data from studies that are not randomized controlled trials (RCTs). Studies that reported only the combined number of patients who either were stone free or had “clinically insignificant fragments” were excluded.. To generate an outcomes table. Ideally. in the skill of those performing the intervention. the probabilities for certain outcomes can vary widely within one treatment modality. however. Procedures per patient were counted in three totals: primary procedures. the Panel determined that this breakdown was not useful.g. and medical. Primary procedures were all consecutive procedures of the same type aimed at removing the stone. results for patients with ureteral stones could not be separated from results for those with renal stones. however.05 level (two-tailed) was inferred when zero was not included in the cI. standard deviation. Secondary procedures were all other procedures used to remove the stone. While resulting cIs reflect available data. 4. for certain outcomes. 2. the fact that data from only a few rcTs could be evaluated may have somewhat biased results. Since the Panel had decided to analyze primary. The available data for procedures per patient would not permit a statistical analysis using these techniques. numbers of procedures per patient were evaluated by calculating the average across studies weighted by the number of patients in each study. This approach may have overestimated numbers of secondary and adjunctive procedures because some articles may not have reported that procedures were not performed. graphs showing the results for each modality were developed to demonstrate similarities and differences between treatments. These clinical series frequently had very different outcomes. unlike the binary outcome of stone-free status (the patient either is or is not stone free). as a result. The stone-free rate was considered at three time points: after the first procedure. secondary procedures. articles excluded from evidence combination remained candidates for discussion in the text of the guideline. more data were reported for one or another treatment modality. the Panel met to review the results and identify anomalies. 54 uPdaTE MarcH 2008 . Evidence obtained from well-designed nonexperimental studies. after the evidence was combined and outcome tables were produced. Recommendation: a guideline statement is a recommendation if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions. Evidence obtained from meta-analysis of randomized trials Ib. Where possible. agency for Health care Policy and research (5): Ia. the Panel revised the document based on the comments received. including studies that did not specifically mention that there were no occurrences of a specific complication may have led to overestimates of complication rates when metaanalyzed. data analyses were conducted for two age groups. department of Health and Human Services. from the original aua reports. and an “option” has the largest amount of flexibility. Evidence obtained from expert committee reports.Several factors caused inaccuracy in the estimates. but not unanimous majority agrees on which intervention is preferred.uroweb. The draft was sent to 81 peer reviewers of whom 26 provided comments. www. The guideline was submitted first for approval to the Practice guidelines committee of the aua and the guidelines office of the Eau and then forwarded to the aua Board of directors and the Eau Board for final approval. Standard: a guideline statement is a standard if: (1) the health outcomes of the alternative interventions are sufficiently well known to permit meaningful decisions. the current three levels are essentially the same. the result of the meta-analysis is best interpreted as the mean number of complications that a patient may experience rather than as the probability of having a complication. The panel’s attempt to differentiate results for pediatric patients from those for adults was not completely successful as most studies included both adults and children. and a second including only those studies or groups of patients that were comprised entirely of pediatric patients. the present statements are graded with respect to the degree of flexibility in application. The adult analysis included all other studies even if children were included. Evidence obtained from at least one randomized trial IIa. and options given were rated according to the levels of evidence published from the u. In this guideline the standard. or opinions. thereby reducing the magnitude of inaccuracy. the panel performed two analyses. the estimated rates given here are probably less accurate than the cIs would indicate. the Panel also potentially mitigated the overestimate by making it more likely that a complication in the class was reported. and (2) an appreciable. www. a “standard” is the most rigid treatment policy. recommendations. 3. Further details and tables corresponding to the figures in this section are found in chapter 3 and the appendixes. and (2) there is virtual unanimity about which intervention is preferred. By combining similar complications. Public Health Service. and on the European association of urology website. 9. such as comparative studies. From the evidence in the outcome tables and expert opinion. a “recommendation” has significantly less rigidity. and case reports IV. Evidence obtained from at least one other type of well-designed quasi-experimental study III. one analysis included studies of patients ages 18 or younger (or identified as pediatric patients in the article without specifying age ranges).org.S. one including all studies regardless of patient age. since reporting of complications is not consistent. 2. or (2) preferences are unknown or equivocal. Evidence obtained from at least one well-designed controlled study without randomization IIb. Moreover. These terms are defined as follows: 1. correlation studies. or clinical experience of respected authorities as in the previous aua guideline. although the terminology has changed slightly. but did so in opposite directions. chapter 1 will be published in The Journal of Urology and in European Urology. For example. Since the grouping of complications varies by study. Option: a guideline statement is an option if: (1) the health outcomes of the interventions are not sufficiently well known to permit meaningful decisions. There were insufficient data to permit meaningful meta-analyses of patient deaths.org. The probability that a patient will have a complication may still be overstated slightly because some patients experienced multiple complications.3 Results of the Outcomes Analysis The results of the analysis described in this chapter provide most of the evidentiary basis for the guideline statements. The guideline is posted on the american urological association website. the Panel drafted the treatment guidelines.auanet. 1. meta-analysis of four studies of nifedipine (160 patients) yielded an estimate of a 75% passage rate (95% cI: 63% to 84%). distal stones <10 mm 8. The Panel attempted to differentiate between bypass. Most differences were minimal and did not reach statistical significance. which was not statistically significant.3. which was statistically significant. analysis of three groups (104 patients) yielded an estimate that 47% would pass spontaneously (95% cI: 36% to 59%). details of the breakdowns by type of SWL and urS are given in chapter 3. the data presented in this chapter compare the meta-analysis of all forms of SWL to the meta-analysis of all forms of urS. Two medical therapies had sufficient analyzable data: the calcium channel blocker nifedipine and alpha-receptor antagonists. the stonepassage improvement increased to 16% (95% cI: 7% to 26%) which was statistically significant. The results of the meta-analysis of stone-free data are presented for the overall group in Table uPdaTE MarcH 2008 55 . using this approach. There is a lack of uniformity in the literature in reporting the time to stone-free status. For that reason. then that number was used. The Panel also attempted to determine whether alpha blockers provide superior stone passage when compared to nifedipine. The results for nifedipine showed an absolute increase of 9% in stone-passage rates (95% cI: -7% to 25%). data were analyzed for both efficacy and complications. The Panel also attempted to differentiate between flexible and rigid ureteroscopes. Mid-ureteral stones <10 mm 5. distal stones regardless of size analyses of pediatric groups were attempted for the same nine groups. Two randomized controlled trials were identified. although data were lacking for many groups. Proximal stones regardless of size 4. The second method was a standard Bayesian hierarchical meta-analysis of the available rcTs that compared either nifedipine or alpha blockers to control therapies. analyses were performed for the following patient groups where data were available. Mid-ureteral stones >10 mm 6. If not and the study reported the stone-free rate after the first procedure. details of the meta-analysis are presented in appendixes 8 and 9. the meta-analysis yielded a stone-passage rate of 81% (95% cI: 72% to 88%). When nonhierarchical methods were used. thereby limiting the ability to comment on the timing of this parameter. For stones <5 mm. The analysis yielded a 20% improvement in stone-passage rates with alpha blockers. pushback. Proximal stones <10 mm 2. complications were grouped into classes. Proximal stones >10 mm 3.1.1 Observation and Medical Therapies Stone-passage rates only limited data were found on the topic of spontaneous passage by stone size. The first combined all single arms evaluating the therapies.1 Shock-wave Lithotripsy and Ureteroscopy Stone-free rates were analyzed for a number of variant methods of performing SWL and urS. and in situ SWL as well as differences between lithotripters. that number was used. 9. The most important classes are reported herein. Mid-ureteral stones regardless of size 7. Metaanalysis of alpha blockers versus control showed an absolute increase of 29% in the stone-passage rate (95% cI: 20% to 37%). tamsulosin provided an absolute increase in stone-passage rate of 14% (95% cI: -4% to 32%) which was not statistically significant. analyses of stone-passage rates were done in three ways. 9. distal stones >10 mm 9. meta-analysis of five patient groups (224 patients) yielded an estimate that 68% would pass spontaneously (95% cI: 46% to 85%). The full complication results are in appendix 10. and the 95% cI of 1% to 37% just reached statistical significance.1. Two efficacy outcomes were analyzed: stone-free rate and procedure counts. For stones >5 mm and <10 mm.2 Efficacy Outcomes Stone-free rates The Panel decided to analyze a single stone-free rate. The intention of the Panel was to provide an estimate of the number of primary procedures and the stone-free rate after those procedures. the Panel used the results of the meta-analyses versus controls (second method above) to determine the difference between alpha blockers and calcium channel blockers. This method allows the use of more data but is risky since it depends on the control groups having comparable results. If the study reported the stone-free rate after all primary procedures.9.3. Finally. Six studies examined alpha blockers (280 patients).3. When hierarchical meta-analysis was performed on these two studies. URS Mid Ureter < 10 mm .1 and Figure 1.URS Mid Ureter .SWL Proximal Ureter < 10 mm .URS Proximal Ureter < 10 mm .SWL Mid Ureter > 10 mm .URS Mid Ureter > 10 mm .URS Proximal Ureter .SWL Mid Ureter . The results are presented as medians of the posterior distribution (best central estimate) with 95% Bayesian CIs (credible intervals [CIs]) Overall Population AUA / EAU Ureteral Stones Guideline Panel Stone Free Rate .SWL Proximal Ureter .SWL Mid Ureter < 10 mm .SWL Distal Ureter > 10 mm .SWL Distal Ureter .URS Distal Ureter < 10 mm .URS Distal Ureter > 10 mm .URS 0% 20% 40% 60% 80% 100% Figure 1.SWL Distal Ureter < 10 mm .SWL Proximal Ureter > 10 mm .Primary Treatments or First Treatment SWL URS G/P 59 5952 13 1622 8 412 30 1024 5 80 5 73 16 2242 9 243 8 230 Med / 95% Cl 94% (93-95)%* 97% (96-98)% 93% (88-96)% 86% (81-89)% 91% (81-96)% 78% (61-90)% 81% (77-85)% 80% (73-85)% 79% (71-87)% G/P 50 6981 17 1684 10 966 31 1607 5 44 2 15 41 6428 14 886 11 293 Med / 95% Cl 74% (73-75)%* 86% (80-91)% 74% (57-87)% 73% (66-79)% 84% (65-95)% 76% (36-97)% 82% (79-85)% 90% (85-93)% 68% (55-79)% Distal Ureter Distal ureter < 10 mm Distal ureter > 10 mm Mid Ureter Mid ureter < 10 mm Mid ureter > 10 mm Proximal Ureter Proximal ureter < 10 mm Proximal ureter > 10 mm G = Number of Groups/Treatment arms extracted. Stone-Free Rates for SWL and URS in the Overall population Stone Free Rates after Primary/First Treatment Distal Ureter . Stone-Free Rates for SWL and URS in the Overall population Estimated occurrence rate with 95% cI cI=confidence interval 56 uPdaTE MarcH 2008 . P = Number of Patients in those groups Table 1.URS Proximal Ureter > 10 mm . This analysis shows that overall, for stones in the proximal ureter (n=8,670), there was no difference in stone-free rates between SWL and urS. However, for proximal ureteral stones <10 mm (n=1,129), SWL had a higher stone-free rate than urS, and for stones >10 mm (n=523), urS had superior stone-free rates. This difference arises because the stone-free rate for proximal ureteral stones treated with urS did not vary significantly with size, whereas the stone-free rate following SWL negatively correlated with stone size. For all distal stones, urS yields better stone-free rates overall and in both size categories. For all mid-ureteral stones, urS appears superior, but the small number of patients may have prevented results from reaching statistical significance. unfortunately, rcTs comparing these treatments were generally lacking, making an accurate assessment impossible. However, the posterior distributions resulting from the meta-analysis can be subtracted, yielding a distribution for the difference between the treatments. If the cI of this result does not include zero, then the results may be considered to be statistically significantly different. This operation is mathematically justifiable but operationally risky: if the patients receiving different treatments are different or if outcome measures are different, results may be meaningless. nonetheless, the Panel performed the comparison and found that urS stone-free rates were significantly better than SWL rates for distal ureteral stones <10 mm and >10 mm and for proximal ureteral stones >10 mm. The stone-free rate for mid-ureteral stones was not statistically significantly different between urS and SWL. The results with urS using a flexible ureteroscope for proximal ureteral stones appear better than those achieved with a rigid device, but not at a statistically significant level. Stone-free results for pediatric patients are shown in Table 2 and Figure 2. The very small number of patients in most groups, particularly for urS, makes comparisons among treatments difficult. However, it does appear that SWL may be more effective in the pediatric subset than in the overall population, particularly in the mid and lower ureter. Table 2. Stone-Free Rates for SWL and URS, pediatric population PediatricPopulation AUA / EAU Ureteral Stones Guideline Panel Stone Free Rate - Primary Treatments or First Treatment SWL URS G/P 9 151 2 29 Med / 95% Cl 92% (86-96)%* 86% (72-98)% G/P 8 229 5 135 2 26 6 33 4 16 1 6 7 101 5 43 3 16 Med / 95% Cl 80% (68-90)% 86% (78-92)% 83% (58-97)% 82% (63-94)% 80% (41-98)% 96% (67-100)% 81% (69-90)% 89% (72-98)% 63% (21-94)% 1 5 5 18 78% (37-99)% 57% (25-85)% 3 11 80% (52-96)% Distal Ureter Distal ureter < 10 mm Distal ureter > 10 mm Mid Ureter Mid ureter < 10 mm Mid ureter > 10 mm Proximal Ureter Proximal ureter < 10 mm Proximal ureter > 10 mm G = Number of Groups/Treatment arms extracted; P = Number of Patients in those groups uPdaTE MarcH 2008 57 Figure 2. Stone-Free Rates for SWL and URS, pediatric population Stone Free Rates after Primary/First Treatment Pediatric Patients Distal Ureter - SWL Distal Ureter - URS Distal Ureter < 10 mm - SWL Distal Ureter < 10 mm - URS Distal Ureter > 10 mm - SWL Mid Ureter - SWL Mid Ureter - URS Mid Ureter < 10 mm - SWL Mid Ureter > 10 mm - SWL Mid Ureter > 10 mm - URS Proximal Ureter - SWL Proximal Ureter - URS Proximal Ureter < 10 mm - SWL Proximal Ureter > 10 mm - SWL 0% 20% 40% 60% 80% 100% Estimated occurrence rate with 95% cI cI=confidence interval 9.3.1.3 Procedure Counts Procedure counts were captured as three types: 1. Primary procedures – the number of times the intended procedure was performed. 2. Secondary procedures – the number of times an alternative stone removal procedure(s) was performed. 3. adjunctive procedures – additional procedures performed at a time other than when the primary or secondary procedures were performed; these could include procedures related to the primary/ secondary procedures such as stent removals as well as procedures performed to deal with complications; most adjunctive procedures in the data presented represent stent removals. It is likely that many stent-related adjunctive procedures were underreported, and thus the adjunctive procedure count may be underestimated. as mentioned in chapter 2, it was not possible to perform a meta-analysis or to test for statistically significant differences between treatments due to the lack of variance data, and only weighted averages could be computed. The procedure count results for the overall population are shown in Table 3 and Figure 3. Figure 3 results are presented as stacked bars. 58 uPdaTE MarcH 2008 Table 3. procedure Counts for SWL and URS in the Overall population Overall Population Grps/Pts # Procs Grps/Pts # Procs Grps/Pts Procedure Counts # Procs Grps/Pts # Procs Grps/Pts # Procs Grps/Pts # Procs SWL Distal Ureter Distal ureter < 10 mm Distal ureter > 10 mm Mid Ureter Mid ureter < 10 mm Mid ureter > 10 mm Proximal Ureter Proximal ureter < 10 mm Proximal ureter > 10 mm Primary 48/7117 1.22 16/1618 11/951 10/291 2/31 3/53 37/5902 16/1243 10/409 1.34 1.44 1.11 1.29 1.76 1.31 1.26 1.49 20/2131 5/150 5/83 0.07 0.14 0.21 13/1329 3/114 4/45 0.24 0.77 0.56 Secondary 30/5069 0.12 5/170 3/1026 9316 0.12 0.10 0.18 4/241 0.23 Adjunctive 0.03 15/3875 Primary 1.04 56/5308 12/1117 5/231 25/686 4/32 2/18 42/1634 6/68 5/137 1.01 1.02 1.04 1.00 1.00 1.02 1.00 1.07 URS Secondary 0.03 25/5124 6/492 1/69 15/934 2/34 1/35 27/1831 4/62 1/130 0.05 0.14 0.07 0.34 0.31 0.26 0.39 0.13 Adjunctive 0.36 24/2848 4/305 1/110 8/357 1/7 1/5 14/1159 3/27 1/11 0.88 1.00 0.09 1.14 0.02 0.17 0.52 0.21 Figure 3. procedure Counts for SWL and URS in the Overall population Procedures per Patient Distal Ureter - SWL Distal Ureter - URS Distal Ureter < 10 mm - SWL Distal Ureter < 10 mm - URS Distal Ureter > 10 mm - SWL Distal Ureter > 10 mm - URS Mid Ureter - SWL Mid Ureter - URS Mid Ureter < 10 mm - SWL Mid Ureter < 10 mm - URS Mid Ureter > 10 mm - SWL Mid Ureter > 10 mm - URS Proximal Ureter - SWL Proximal Ureter - URS Proximal Ureter < 10 mm - SWL Proximal Ureter < 10 mm - URS Proximal Ureter > 10 mm - SWL Proximal Ureter > 10 mm - URS 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Weighted Mean Procedures per Patient Primary Procedures Secundary Procedures Adjunctive Procedures Procedure count results for pediatric patients are shown in Table 4 and Figure 4. again, the numbers of patients with available data were small and did not support meaningful comparisons among treatments. uPdaTE MarcH 2008 59 5 Weighted Mean Procedures per Patient Primary Procedures Secundary Procedures Adjunctive Procedures 9.42 1.SWL Mid Ureter .00 1/9 0.4 Complications The articles were extracted for various complications.5 1.38 5/135 4/26 4/32 3/16 1/6 5/83 5/43 4/16 1. other complications are listed in chapter 3.5 2.0 1.SWL Distal Ureter .08 1/14 0.07 2/43 Primary 1.SWL 0. ureteral injury 5.00 1.28 1.09 7/190 4/131 0.URS Proximal Ureter < 10 mm .SWL Proximal Ureter < 10 mm .71 0.00 1. were sufficiently rare that data were not available to estimate their rates of occurrence. size.00 1.0 0.11 4/18 1/7 1/5 6/27 1/9 1.URS Proximal Ureter > 10 mm .19 1.00 0. the Panel believes the following are the most relevant: 1.00 1.00 Figure 4.05 0.SWL Mid Ureter .20 1.00 0.Pediatric Patients Distal Ureter .50 1.75 0.URS Distal Ureter < 10 mm .14 0. 60 uPdaTE MarcH 2008 .17 0.42 1.1.Table 4. Stricture 4.36 Adjunctive 0.20 0.33 1.URS Mid Ureter > 10 mm .SWL Mid Ureter < 10 mm .00 URS Secondary 0.05 10/185 2/63 1.SWL Distal Ureter < 10 mm .3.URS Distal Ureter > 10 mm . urinary tract infection (uTI) Serious complications.44 1.33 Adjunctive 0. Steinstrasse 3.00 2/12 1/7 1/5 7/38 2/18 Secondary 4/98 0.SWL Proximal Ureter . and location are shown in Table 5. All Locations Procedures per Patient .URS Proximal Ureter .00 1/5 1/3 2/2 0. however.0 2. procedure Counts for SWL and URS in the pediatric population. including death and loss of kidney. procedure Counts for SWL and URS in the pediatric population.78 0. Sepsis 2.34 0.38 3/38 1/3 2/2 0.00 0.00 1.URS Mid Ureter < 10 mm .11 0.SWL Mid Ureter > 10 mm .72 5/96 1/5 2/12 1/7 1/5 1/9 1/9 0. The complication rates for the overall population by treatment. All Locations Pediatric Population Grps/Pts # Procs Grps/Pts # Procs Grps/Pts Procedure Counts # Procs Grps/Pts # Procs Grps/Pts # Procs Grps/Pts # Procs SWL Distal Ureter Distal ureter < 10 mm Distal ureter > 10 mm Mid Ureter Mid ureter < 10 mm Mid ureter > 10 mm Proximal Ureter Proximal ureter < 10 mm Proximal ureter > 10 mm Primary 7/212 1. 8)% 4% (2 .2)% 3% (3 .7)% groups/patients 7 1954 URS Med/95% CI 2% (1 .11)% Steinstrasse Stricture 7 326 10 514 4% (2 .7)% 6% (3 .5)% 4% (0 .4)% 5% (2 .8)% 2% (0 .6)% 0% (0 .20)% 1% (0 .4)% Steinstrasse Stricture ureteral Injury uTI Mid Ureter Sepsis 2 398 1 37 1 43 5% (0 .5)% 4% (1 .Table 5.4)% 4% (2 .17)% 0% (0 .5)% 6% (3 .7)% ureteral Injury uTI 1 37 6% (1 .8)% Steinstrasse Stricture ureteral Injury uTI uPdaTE MarcH 2008 61 .10)% 2% (0 . Complications Occurrence Rates with SWL and URS.7)% 8 360 1 109 8 987 10 1005 2 224 4% (2 . Overall population SWL groups/patients Distal Ureter Sepsis 6 2019 1 26 2 609 1 45 3 87 Med/95% CI 3% (2 .1)% 1% (0 .20)% 8% (2 .16)% 1 63 proximal Ureter Sepsis 5 704 3 235 2 124 2 124 5 360 3% (2 .8)% 2% (0 .12)% 16 1911 23 4529 3 458 1% (1 .9)% 4% (1 .2)% 2% (1 .6)% 4 199 4% (1 . P = number of patients in those groups. The following definition was created.PEDIATRIC SWL Groups/Patient Med / 95% Cl 5% (0-24)% 1% (0-6)% 18% (9-30)% 2% (0-7)% 4% (1-12)% 0% (0-1)% 1% (0-9)% 2% (1-6)% 2% (0-9)% 2 91 1 25 6 216 1 26 1 12 5 106 1 43 6% (2-13)% 5% (0-17)% 6% (3-10)% 1% (0-9)% 2% (0-19)% 5% (2-11)% 12% (5-24)% Groups/Patient 1 66 5 65 3 98 1 26 3 73 URS Med / 95% Cl 17% (9-27)% 5% (1-14)% 5% (1-13)% 4% (0-17)% 3% (0-9)% Bleeding Overall Significant complications Pain Retention Sepsis Skin Stricture Ureteral Obstruction UTI Infection Stent Migration Ureteral Injury Ureteral Obstruction UTI Stricture Other Long Term CX 2 206 1 38 3 106 1 63 2 101 1 168 1 25 4 283 2 63 g = number of groups/treatment arms extracted. 9. Because these procedures are usually reserved for special cases. The reported frequencies of pain may be inaccurate because of inconsistent reporting. a single pediatric report provided procedure counts for two patients who had one open procedure each. pediatric population Complications of Treatment. 9. the reported data should not be used to compare procedures with each other or with SWL or urS. Complication Occurrence Rates . and percutaneous antegrade ureteroscopy. 62 uPdaTE MarcH 2008 .1. it was not possible to stratify data by stone size or location. Two studies reported stone-free rates for children with open procedures (n=five patients). laparoscopic stone removal.Table 6 summarizes complications for all pediatric groups. these more invasive procedures yielded high stone-free rates when used. Table 6. the computed stone-free rate was 82% (95% cI: 43% to 99%). as expected. an “index patient” was defined to reflect the typical individual with a ureteral stone whom a urologist treats.4 The Index patient In constructing these guidelines.5 Other Surgical Interventions Small numbers of studies reported on open surgery.3. Since there are few groups and patients.Overall. The index patient is a nonpregnant adult with a unilateral noncystine/nonuric acid radiopaque ureteral stone without renal calculi requiring therapy whose contralateral kidney functions normally and whose medical condition, body habitus, and anatomy allow any one of the treatment options to be undertaken. 9.5 9.5.1 Treatment guidelines for the Index patient For All Index Patients Standard: patients with bacteriuria should be treated with appropriate antibiotics. [Based on Panel consensus/Level IV] untreated bacteriuria can lead to infectious complications and possible urosepsis if combined with urinary tract obstruction, endourologic manipulation, or SWL. urine culture prior to intervention is recommended; screening with dipsticks might be sufficient in uncomplicated cases (2). In case of suspected or proven infection, appropriate antibiotic therapy should be administered before intervention (6). Standard: Stone extraction with a basket without endoscopic visualization of the stone (blind basketing) should not be performed. [Based on Panel consensus/Level IV] Before the availability of modern ureteroscopes, extraction of distal ureteral stones with a basket with or without fluoroscopy was common. This procedure is, however, associated with an obvious risk of injury to the ureter. It is the expert opinion of the Panel that blind stone extraction with a basket should not be performed, and that intraureteral manipulations with a stone basket should always be performed under direct ureteroscopic vision. Fluoroscopic imaging of the stone alone is not sufficient. 9.5.2 For Ureteral Stones <10 mm Option: In a patient who has a newly diagnosed ureteral stone <10 mm and whose symptoms are controlled, observation with periodic evaluation is an option for initial treatment. Such patients may be offered an appropriate medical therapy to facilitate stone passage during the observation period. [Based on review of the data and panel opinion/Level 1a] The Panel performed a meta-analysis of studies in which spontaneous ureteral stone passage was assessed. The median probability of stone passage was 68% for stones <5 mm (n=224) and 47% for those >5 and <10 mm (n=104) in size (details previously discussed and provided in the appendixes). The Panel recognized that these studies had certain limitations including nonstandardization of the stone size measurement methods and lack of analysis of stone position, stone-passage history, and time to stone passage in some. a metaanalysis of MET was also performed which demonstrated that alpha blockers facilitate stone passage and that the positive impact of nifedipine is marginal. This analysis also indicates that alpha blockers are superior to nifedipine and, hence, may be the preferred agents for MET (details provided in the appendixes). a similar benefit of MET was demonstrated in a recently published meta-analytic study (7). The methods of analysis used in this study were somewhat different as the absolute improvement in stone passage was calculated in our study and the relative improvement in the latter. The vast majority of the trials analyzed in this and our analysis were limited to patients with distal ureteral stones. The majority of stones pass spontaneously within four to six weeks. This was demonstrated by Miller and kane (8), who reported that of stones <2 mm, 2 to 4 mm and 4 to 6 mm in size, 95% of those which passed did so by 31, 40, and 39 days, respectively. In a choice between active stone removal and conservative treatment with MET, it is important to take into account all individual circumstances that may affect treatment decisions. a prerequisite for MET is that the patient is reasonably comfortable with that therapeutic approach and that there is no obvious advantage of immediate active stone removal. Standard: patients should be counseled on the attendant risks of MET including associated drug side effects and should be informed that it is administered for an “off label” use. [Based on Panel consensus/Level IV] Standard: patients who elect for an attempt at spontaneous passage or MET should have wellcontrolled pain, no clinical evidence of sepsis, and adequate renal functional reserve. [Based on Panel consensus/Level IV] uPdaTE MarcH 2008 63 Standard: patients should be followed with periodic imaging studies to monitor stone position and to assess for hydronephrosis. [Based on Panel consensus/Level IV] Standard: Stone removal is indicated in the presence of persistent obstruction, failure of stone progression, or in the presence of increasing or unremitting colic. [Based on Panel consensus/Level IV] 9.5.3 For Ureteral Stones >10 mm although patients with ureteral stones >10 mm could be observed or treated with MET, in most cases such stones will require surgical treatment. no recommendation can be made for spontaneous passage (with or without medical therapy) for patients with large stones. 9.5.4 For Patients Requiring Stone Removal Standard: A patient must be informed about the existing active treatment modalities, including the relative benefits and risks associated with each modality. [Based on Panel consensus/Level IV] Specifically, both SWL and urS should be discussed as initial treatment options for the majority of cases. regardless of the availability of this equipment and physician experience, this discussion should include stone-free rates, anesthesia requirements, need for additional procedures, and associated complications. Patients should be informed that urS is associated with a better chance of becoming stone free with a single procedure, but has higher complication rates. Recommendation: For patients requiring stone removal, both SWL and URS are acceptable first-line treatments. [Based on review of the data and Panel consensus/Level 1a-IV (details provided in chapter 3)] The meta-analysis demonstrated that urS yields significantly greater stone-free rates for the majority of stone stratifications. Recommendation: Routine stenting is not recommended as part of SWL. [Based on Panel consensus/Level III] The 1997 aua guideline, Report on the Management of Ureteral Calculi, stated that “routine stenting is not recommended as part of SWL (9).” The 1997 guideline Panel noted that it had become common practice to place a ureteral stent for more efficient fragmentation of ureteral stones when using SWL. However, the data analyzed showed no improved fragmentation with stenting (9). The current analysis demonstrates similar findings. In addition, studies assessing the efficacy of SWL treatment with or without internal stent placement have consistently noted frequent symptoms related to stents (10-13). Option: Stenting following uncomplicated URS is optional. [Based on Panel consensus/Level 1a] Several randomized prospective studies published since the 1997 aua guideline document have demonstrated that routine stenting after uncomplicated urS may not be necessary (10,14-19). It is well documented that ureteral stenting is associated with bothersome lower urinary tract symptoms and pain that can, albeit temporarily, alter quality of life (15-17,20-26). In addition, there are complications associated with ureteral stenting, including stent migration, urinary tract infection, breakage, encrustation, and obstruction. Moreover, ureteral stents add some expense to the overall ureteroscopic procedure and unless a pull string is attached to the distal end of the stent, secondary cystoscopy is required for stent removal (27). There are clear indications for stenting after the completion of urS. These include ureteral injury, stricture, solitary kidney, renal insufficiency, or a large residual stone burden. Option: percutaneous antegrade ureteroscopy is an acceptable first-line treatment in select cases. [Based on Panel consensus/Level III] Instead of a retrograde endoscopic approach to the ureteral stone, percutaneous antegrade access can be substituted (28). This treatment option is indicated: 64 uPdaTE MarcH 2008 • • • • in select cases with large impacted stones in the upper ureter in combination with renal stone removal in cases of ureteral stones after urinary diversion (29) in select cases resulting from failure of retrograde ureteral access to large, impacted upper ureteral stones (30). Option: Laparoscopic or open surgical stone removal may be considered in rare cases where SWL, URS, and percutaneous URS fail or are unlikely to be successful. [Based on Panel consensus/Level III] The 1997 aua guideline stated that “open surgery should not be the first-line treatment (9).” The invasiveness and morbidity of open surgery can be avoided. In very difficult situations, however, such as with very large, impacted stones and/or multiple ureteral stones, or in cases of concurrent conditions requiring surgery, an alternative procedure might be desired as primary or salvage therapy. Laparoscopic ureterolithotomy is a less invasive alternative to open surgery in this setting. comparative series indicate that open surgical ureterolithotomy can be replaced by laparoscopic ureterolithotomy in most situations (31,32). From the 15 case series of laparoscopic ureterolithotomy included in the Panel’s literature review, the median stone-free rate was 88% for the primary treatment. It is notable that this success was achieved when virtually all of the procedures were for large and/or impacted calculi. 9.6 Recommendations for the Pediatric Patient Option: Both SWL and URS are effective in this population. Treatment choices should be based on the child’s size and urinary tract anatomy. The small size of the pediatric ureter and urethra favors the less invasive approach of SWL. [Based on review of data and Panel consensus/Level III] 9.7 Recommendations for the Nonindex Patient Standard: For septic patients with obstructing stones, urgent decompression of the collecting system with either percutaneous drainage or ureteral stenting is indicated. Definitive treatment of the stone should be delayed until sepsis is resolved. [Based on Panel consensus/Level III] The compromised delivery of antibiotics into the obstructed kidney mandates that the collecting system be drained to promote resolution of the infection. The choice of drainage modality, whether percutaneous nephrostomy or ureteral stent, is left to the discretion of the urologist, as both have been shown in a randomized trial to be equally effective in the setting of presumed obstructive pyelonephritis/pyonephrosis (33). definitive treatment of the stone should be delayed until sepsis has resolved and the infection is cleared following a complete course of appropriate antimicrobial therapy. 9.8 Discussion There are two significant changes in treatment approach that distinguish the present document from the guideline published by the aua in 1997. The most significant change is the use of retrograde urS as first-line treatment for middle and upper ureteral stones with a low probability of spontaneous passage. This change reflects both the vast technological improvements that have been made during the last decade and the experience and facility that surgeons now have with the procedure. The other change is the establishment of effective MET to facilitate spontaneous stone passage. These advances, the current status of other technologies and procedures, issues related to nonindex patients, and future directions and research germane to this condition will be subsequently discussed. 9.8.1 Medical Expulsive Therapy There is growing evidence that MET, the administration of drugs to facilitate stone passage, can be efficacious. Studies have demonstrated that this approach may facilitate and accelerate the spontaneous passage of ureteral stones as well as stone fragments generated with SWL (34-38). our meta-analysis demonstrated the effectiveness of MET. nine percent (cI: -7% to 25%) more patients receiving nifedipine passed their stones than did controls in our meta-analysis, a difference that was not statistically significant. In contrast, a statistically significant 29% (cI: 20% to 37%) more patients passed their stones with alpha blocker therapy than did control patients. These findings indicate that alpha blockers facilitate ureteral stone passage while nifedipine may provide a marginal benefit. Therefore, the Panel feels that alpha blockers are the preferred uPdaTE MarcH 2008 65 6. Similar findings have been reported by Hollingsworth and associates (7).607 patients). a combination of both fluoroscopy and uS can facilitate stone location and minimize radiation exposure. The current meta-analysis analyzed SWL stone-free results for three locations in the ureter (proximal. reported SWL stone-free results of 83% and 85%. mid. for the patient who desires treatment with minimal anesthesia. Tamsulosin has been the most common alpha blocker utilized in these studies. which divided the ureter into proximal and distal only. The results were very similar in the distal ureter. who recently performed a meta-analysis of studies involving alpha blockers or nifedipine in patients with ureteral stones. Today.742 patients). a large. placebo-controlled study has recently been funded in the united States for this purpose. as expected. The outcomes for SWL for ureteral calculi in pediatric patients were similar to those for adults. This observation is also confirmed by the present analysis.2 Shock-wave Lithotripsy Shock-wave lithotripsy was introduced to clinical practice as a treatment for ureteral stones in the early 1980s. randomized. regarding the use of SWL to treat distal ureteral calculi in women of childbearing age because of the theoretical possibility that unfertilized eggs and/or ovaries may be damaged. or SWL in situ). terazosin.85) and 1. although ureteroscopic stone removal is possible with intravenous sedation. distal). The cIs for the distal ureter do not overlap and indicate a statistically significant worsening of results in the distal ureter from the earlier results. in theory. Patients with ureteral stones in all segments of the ureter will be randomized to tamsulosin or placebo. However.52 for mid-ureteral stones.40) (7). respectively.422 patients) necessitating 1.agents for MET at this time.37). and doxazosin as equally effective in this setting (39). Shock-wave lithotripsy can be performed with the aid of either fluoroscopy or ultrasound (uS). Further prospective and randomized studies are warranted to determine the patients who best respond to MET. this imaging modality clearly limits SWL application in the ureter when compared to fluoroscopy.37 for distal ureteral stones). The cause of this difference is not clear.29 primary and secondary procedures per patient. there appears to be little. 66 uPdaTE MarcH 2008 . 73% in the mid ureter (31 studies. In fact. there may be circumstances such as when the stone is small or of low radiographic density where a stent or ureteral catheter (sometimes using a contrast agent) may help facilitate localization during SWL. one small study demonstrated tamsulosin. However. These studies also demonstrated that MET reduces the stone-passage time and limits pain. The newer generation lithotriptors with higher peak pressures and smaller focal zones should. Therefore. 0. and 0.62 procedures per patient for proximal ureteral stones. even with the refinement of endourologic methods for stone removal such as urS and PnL. The differences in methodology from our study have been previously mentioned. consequently. if any. additional procedures also were infrequently necessary (0. be ideal for the treatment of stones in the ureter but instead have not been associated with an improvement in stone-free rates or a reduction in the number of procedures needed when this treatment approach is chosen. The explanation for the lack of improvement in SWL outcomes is unknown. The Panel considered complications of SWL for ureteral stones to be infrequent. too.29 to 1. as documented in the 1997 aua report. The SWL stone-free results are 82% in the proximal ureter (41 studies.428 patients). no change is shown for the proximal ureter. SWL remains the primary treatment for most uncomplicated upper urinary tract calculi. 1. making this a useful option. The benefit of adding corticosteroids was reported to be small (7. 1. The meta-analysis published by the aua nephrolithiasis guideline Panel in 1997 documented that the stone-free rate for SWL for proximal ureteral stones overall was 83% (78 studies. 9.40 procedures were necessary per patient. particularly in patients where the size of the patient (and ureter/urethra) may make urS a less attractive option. The beneficial effects of these drugs are likely attributed to ureteral smooth muscle relaxation mediated through either inhibition of calcium channel pumps or alpha-1 receptor blockade. Patients given either one of these agents had a greater likelihood of stone passage than those not receiving such therapy. the SWL stone-free rates for stones in the distal ureter have declined significantly when compared with the 1997 aua analysis. the Panel suggested that the use of a ureteral stent to improve stonefree rates was not warranted. The pooled-risk ratios and 95% cIs for alpha blockers and calcium channel blockers were 1. SWL with stent or catheter bypass. with a stone-free rate of 85% (66 studies.981 patients). 6.8.51 to 2. stone-free rates were lower and the number of procedures necessary were higher for ureteral stones >10 mm in diameter managed with SWL.90 (1. multicenter. However. There was no significant difference between various SWL techniques (SWL with pushback. advantage to routine stenting when performing SWL for ureteral stones. SWL is an attractive approach.54 (1. and 74% in the distal ureter (50 studies. To achieve this result. concerns have been raised. 17. Serious complications were again infrequent. While some stones in the proximal and distal ureter can be imaged with uS. 9. The results in the 1997 guideline. one clear advantage of SWL over urS is that the procedure is more easily and routinely performed with intravenous sedation or other minimal anesthetic techniques. have been reduced to less than 5%. although the efficacy of urS for the treatment of ureteral calculi has been amply shown.9 With improved efficacy and reduced morbidity currently associated with ureteroscopic management of proximal ureteral stones. and long-term complications such as stricture formation occur with an incidence of 2% or less (47). the ureter may be left unstented without undue risk of obstruction or colic requiring emergent medical attention (10. this modality is now deemed appropriate for stones of any size in the proximal ureter. although success rates declined substantially when treating larger stones (>10 mm) compared with smaller stones (78% versus 91%. Several studies have shown that morbidly obese patients can be treated with success rates and complication rates comparable to the general population (51. complication rates.8. with little drop off in stone-free rates when treating larger stones. the aua nephrolithiasis clinical guideline Panel recommended SWL for <1 cm stones in the proximal ureter and either SWL or urS for >1 cm proximal ureteral stones.52). overall stone-free rates are remarkably high at 81% to 94% depending on stone location. In these cases with stone-free rates between 85% and 100%. SWL is associated with fewer postoperative symptoms and better patient acceptance than urS. Improved flexible ureteroscopes and greater technical skill. most notably ureteral perforation rates.8. The flexible ureteroscope is largely responsible for improved access to the proximal ureter. acceptable. its superiority to standard techniques has been evaluated in one prospective randomized (57) and in two prospective studies (28. the complication rate was low.To date. for example. a number of recent prospective. on the other hand. a stone-free rate of 86% was demonstrated in the current analysis.30). Indeed. 9. urS can be used to safely simultaneously treat bilateral ureteral stones in select cases (53-55). particularly those >10 mm.46). an overall stone-free rate of 94% was achieved with either a rigid or semirigid ureteroscope. Finally. With the development of smaller caliber semirigid and flexible ureteroscopes and the introduction of improved instrumentation. The middle ureter poses challenges for all surgical stone treatments. clearly. In addition. superior stone-free rates are achieved using flexible urS (87%) compared with rigid or semirigid urS (77%). for the treatment of very large (>15 mm diameter) impacted stones in the proximal ureter between the ureteropelvic junction and the lower border of the fourth lumbar vertebra (30. ureteroscopy can be performed safely in select patients in whom cessation of anticoagulants is considered unsafe (50). despite the limitations. with surprisingly little difference in stone-free rates according to stone size (93% for stones <10 mm and 87% for stones >10 mm). likely due to difficulty maintaining access within the distal ureter with a flexible ureteroscope.3 Ureteroscopy ureteroscopy has traditionally constituted the favored approach for the surgical treatment of mid and distal ureteral stones while SWL has been preferred for the less accessible proximal ureteral stones.49) have improved the success of treating proximal ureteral stones. the need for a ureteral stent with its attendant morbidity has biased opinion towards SWL in some cases. with the vast majority of patients rendered stone free in a single procedure (Figure 1 and chapter 3). Historically. along with the introduction of devices to prevent stone migration (48. ureteroscopic treatment of distal ureteral stones is uniformly associated with high success rates and low complication rates. ureteroscopy can also be applied when SWL might be contraindicated or ill-advised.14-19). 9. including the holmium:Yag laser. in part because the proximal ureter is more difficult to access and stone fragments often become displaced into the kidney where they may be difficult to treat. flexible urS was less successful than rigid or semirigid urS for distal ureteral stones. In a total number of 204 patients.4 Percutaneous Antegrade Ureteroscopy Percutaneous antegrade removal of ureteral stones is a consideration in selected cases. the current analysis revealed a stone-free rate of 81% for ureteroscopic treatment of proximal ureteral stones. and not specifically different from any other percutaneous procedure. These stone-free rates are comparable to those achieved with SWL. and identification and targeting of mid-ureteral stones for SWL has proved problematic due to the underlying bone. randomized trials have shown that for uncomplicated urS. no objective evidence has been discovered to support such concerns. the location over the iliac vessels may hinder access with a semirigid ureteroscope. but many centers require that women age 40 or younger be fully informed of the possibility and give their consent before treatment with SWL (40-44). urS has been shown to be effective regardless of patient body habitus. However. ureteroscopic management is still highly successful. a number of adjunctive measures have contributed to the enhanced success of ureteroscopic management of ureteral calculi. In 1997.56). urS has evolved into a safer and more efficacious modality for treatment of stones in all locations in the ureter with increasing experience worldWide (45. stones in the proximal ureter have been associated with lower success rates than those in the mid and distal ureter. respectively). Percutaneous antegrade removal of ureteral stones is an alternative when SWL is not indicated or uPdaTE MarcH 2008 67 . these patients have traditionally been managed with temporizing therapies (ureteral stenting. In addition.has failed (58) and when the upper urinary tract is not amenable to retrograde urS. a number of groups have now reported successful outcomes with urS in pregnant patients harboring ureteral stones. Both retroperitoneal and transperitoneal laparoscopic access to all portions of the ureter have been reported. a 5.5 and 6. Less efficient SWL disintegration might be seen in children with stones composed of cystine. instrument-related complications have become uncommon (73-75). 9. 68 uPdaTE MarcH 2008 .0 Fr semirigid ureteroscopes. if at all. Selection of the most appropriate treatment has to be based on the individual stone problem. If the uS examination is unrevealing and the patient remains severely symptomatic.61). 9. one of the main problems with pediatric urS is the size of the ureteroscope relative to the narrow intramural ureter and the urethral diameter. However. For most cases with very large. Magnetic resonance imaging can define the level of obstruction. et al (63) who reported on the performance of urS in 24 pregnant women. once the diagnosis has been established. for example. The evaluation of pregnant patients suspected of having renal colic begins with ultrasonography. percutaneous nephrostomy). a limited intravenous pyelogram may be considered. although highly effective.8. the holmium laser has the advantage of minimal tissue penetration. and/ or multiple ureteral stones in which SWL and urS have either failed or are unlikely to succeed. In extreme situations or in cases of simultaneous open surgery for another purpose.1 Pregnancy renal colic is the most common nonobstetric cause of abdominal pain in pregnant patients requiring hospitalization. the temporizing approach typically requires multiple exchanges of stents or nephrostomy tubes during the remainder of the patient’s pregnancy due to the potential for rapid encrustation of these devices. these findings are nonspecific. an approach often associated with poor patient tolerance. When intracorporeal lithotripsy is necessary during ureteroscopic treatment of calculi in pregnant patients. and there were no adverse sequelae associated with ureteroscopic stone removal. open surgical ureterolithotomy might rarely be considered (60.8.6. and percutaneous antegrade urS can achieve success for the vast majority of stone cases. urS. noncontrast computed tomography is uncommonly performed in this setting because of the higher dose of radiation exposure. there is a paucity of experience with using this imaging modality during pregnancy (62). attendant longer recovery time. laparoscopic ureterolithotomy is not a first-line therapy in most cases because of its invasiveness.8. The first substantial report was by ulvik.8. the available equipment and the urologist’s expertise in treating children. and the greater risk of associated complications compared to SWL and urS.3 Fr flexible ureteroscope and a holmium:Yag laser energy source. 15 minutes and 60 minutes following contrast administration. Laparoscopic ureterolithotomy in the distal ureter is somewhat less successful than in the middle and proximal ureter. thereby theoretically limiting risk of fetal injury. laparoscopic ureterolithotomy is a better alternative than open surgery if expertise in laparoscopic techniques is available. mini or needle instruments as well as small flexible semirigid or rigid ureteroscopes and pediatric (6. With the availability of 4. Further. children appear to pass stone fragments after SWL more readily than adults (66-71). for example. and a stone may be seen as a filling defect. However. brushite and calcium oxalate monohydrate or when anatomic abnormalities result in difficulties in fluoroscopic or ultrasonographic visualization of the stone (72-74). the utilization of proper technique remains the most important factor for generating successful outcomes in this population.6. as ionizing radiation should be limited in this setting. Similar results have been reported by Lifshitz and Lingeman (64) and Watterson et al (65) who found that the ureteroscopic approach was both diagnostic and therapeutic in pregnant patients with very low morbidity and the need for only short-term ureteral stenting. 9. Such an approach might be considered for stone removal in children with a malformation of the lower urinary tract.9 Fr) cystoscopes. ureteroscopy may be used as a primary treatment or as a secondary treatment after SWL in case of poor stone disintegration. but the size of the stone does not appear to influence outcome. afterwards. impacted. in those with urinary diversion (29) or renal transplants (59). This problem has lately been circumvented by the use of smaller ureteroscopes.2 Pediatrics Both SWL and urS are effective treatment alternatives for stone removal in children.6 Special Considerations 9. Percutaneous stone removal is also possible in pediatric patients with comparable indications to those in adults.5 Laparoscopic and Open Stone Surgery Shock-wave lithotripsy. a typical regimen includes a preliminary plain radiograph (kuB) and two films. Most patients had stones or edema. can readily fragment cystine stones (81). ultrasonic and pneumatic devices. time point when stone-free rate is determined.9. are prone to recurrent stones. potentially compromising shock-wave focusing. particularly in a patient with a low urinary pH. certain imaging characteristics may predict SWL outcomes for this patient group. sodium citrate. and MET • providing measures of variability such as standard deviation. To improve the quality of research. The presence of a low attenuation or a radiolucent stone. and struvite calculi (87).0 to 7. these stones fragment readily with SWL. Medical expulsive therapy may be administered concomitantly. standard error. other types of stones with higher attenuation values have also been demonstrated to be resistant to shock-wave fragmentation (84). The Panel encountered a number of deficits in the literature. or sodium bicarbonate to a level ranging from 6. In addition. and can usually be distinguished from calcium.6. stone location.8. although the degree of resistance may be variable (77. this medical treatment may allow stone dissolution in patients whose symptoms are controllable. This venture should provide the foundation for future collaborative efforts in guideline development. kim and associates reported that the computed tomography attenuation coefficients of the latter were significantly higher than the rough-type stones (83). However. body mass index. stone size.4 Uric acid Stones uric acid calculi are typically radiolucent.6. 9. technology currently utilized for intracorporeal lithotripsy during urS. such as patient age. and has also been shown to enhance stone clearance with SWL (88). There are limited data regarding treatment outcomes in this group (76-83). In contrast to SWL. cystine. or variance with corresponding average patient numbers • reporting raw data to facilitate meta-analyses The Panel suggests focusing on the following issues in future investigations: • investigating the proposed current efficacy problems of second and third generation shock-wave machines and developing approaches to improve SWL uPdaTE MarcH 2008 69 . CI. When properly targeted.8. Prophylactic medical therapy and close follow-up can limit recurrence.3 Cystine Stones Individuals with cystinuria are considered nonindex patients by the Panel for a variety of reasons. These limitations hinder the development of evidence-based recommendations. should lead the clinician to suspect this diagnosis.78). and treatment modality • reporting all associated treatments including placement of ureteral stents or nephrostomies • using standardized methods to report acute and long-term outcomes • developing methods to predict outcomes for SWL. URS. gender. some of these stones may be barely opaque on standard imaging or fluoroscopy. the Panel strongly recommends the following: • conducting RCTs comparing interventional techniques like URS and SWL • conducting pharmacological studies of stone-expulsion therapies as double-blinded RCTs • reporting stone-free data without inclusion of residual fragments • using consistent nomenclature to report stone size. While the management of ureteral stones remains commonly needed. Moreover. In vitro studies also show that these stones are commonly resistant to SWL. The structural characteristics of these stones are thought to contribute to their decreased SWL fragility. Extensive cooperation between aua and Eau Panel members has produced this unique collaborative report. starting from the definition of stone sizes and ending with variable definitions of a stone-free state. stone composition. stone-free rates. or method of imaging to determine stone-free rate • reporting data stratified by patient/stone characteristics.9 Research and Future Directions Ten years have elapsed since the last publication of the aua guidelines. this approach may be possible with devices that use uS if the stone can indeed be localized. and are consequently subject to repetitive removal procedures. should prevent the development of future uric acid stones. patients with cystinuria are at risk for developing renal insufficiency over time (85.86). Manipulation of the urinary pH with oral potassium citrate. including the holmium laser. stone location. few rcTs were available for data extraction. Bhatta and colleagues reported that cystine stones having a rough-appearing external surface on plain film imaging were more apt to be fragmented with shock-wave energy than those with a smooth contour (82). thus limiting the ability to treat such patients using in situ SWL. In addition. 9. ureteroscopy is a very effective method of treating patients who are not candidates for observation (89). The data were inconsistent. uric acid stones have lower computed tomography attenuation values. Patients with this rare genetic disorder typically have their first stone event early in life. and one year since the Eau recommendations on ureteral stones.0 may obviate the need for surgical intervention. pp 115-27. addressing cost-effectiveness 9. doses and dosing regimens may deviate from that employed for the Food and drug adminstration-approved indications. assimos dg.nih.or consensus-based recommendations. 8. To date. kaufman Sr.6(1):31-55. Perioperative antibiotic prophylaxis in urology.nlm. The final report is intended to provide medical practitioners with a current understanding of the principles and strategies for the management of ureteral calculi. conort P. Thus.ncbi. nakada SY. and this difference should be considered in the risk-versus-benefit assessment.gov/pubmed/17011944 Miller oF.gov/pubmed/2361818 Eddy DM. department of Health and Human Services. Some of the medical therapies currently employed in the management of ureteral calculi have not been approved by the uS Food and drug administration for this specific indication. 1992. depending on the type of evidence available and Panel processes to support optimal clinical practices in the management of ureteral calculi.org/nc/professional-resources/guidelines/online/?no_cache=1&view=archive access date november 2008. Hasselbland V. Then it was forwarded to the aua Board of directors and the Eau Board for final approval. after revision of the document based upon the peer review comments.ncbi. 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Pozniak M. several days of drainage.nlm. viaa stent or a percutaneous nephrostomy.ncbi.gov/pubmed/16145473 Saw kc.nih. in others. In patients with an uncorrected bleeding diathesis.nlm.166(4):1255-60. The used of the holmium (Ho:Yag) laser.ncbi. http://www. Sundaram c. Hoenig dM.168(1):27-30. http://www.nlm.nlm. J urol 2001. reduced renal function and benefits of treatment of cystinuria vs other forms of nephrolithiasis. J urol 2002. is safe in these patients . Holmium:Yag lithropsy yields smaller fragments than lithoclast. Hatt Ek.gov/pubmed/9400428 Pearle MS. pulsed dye laser or electrohydraulic lithotripsy.55(6):816-9. 85. 2). J Endourol 2000.159(1):17-23. rodgers aL.gov/pubmed/16686727 nakada SY.nlm. http://www. Hess B. http://www. in combination with contemporary small-calibre ureteroscopes. Mcateer Ja.ncbi. J urol 1998. http://www.ncbi. Leslie SW.97(6):1285-90.ncbi.gov/pubmed/17396168 Teichman JM. For uncomplicated cases. dipsticks might be sufficient for screening. Fineberg nS. p. 84. Hart LJ. Lingeman JE. BJu Int 2006. 667. the following are generally contraindicated: • extracorporeal shock-wave lithotripsy (ESWL) • percutaneous nephrolithotomy with or without lithotripsy (PNL) • open surgery (1. dunn M. Hibbert BE. 90. nakada SY.gov/pubmed/12050485 Worcester EM.ncbi. 10. calcium tone fragility is predicted by helical cT attenuation values. Mcateer Ja.14(6):471-4. urine culture is necessary. J urol 2005.ncbi. rev urol 2007.174(4 Pt 1):1468-70. Prospective randomized trial comparing shock wave lithotripsy and ureteroscopy for management of distal ureteral calculi. chua gT. 89. cystine helical computerized tomography characterization of rough and smooth calculi in vitro. khan Sr.83. Parks JH. South africa: university of capetown 2000. ureteroscopic Ho:Yag laser lithotripsy. Bishoff JT.gov/pubmed/10954300 assimos dg.ncbi. urolithiasis 2000: Proceedings of the ninth International Symposium on urolithiasis. ureterorenoscopy migh offer an alternative approach.nlm. Furthermore. Shalhav aL. 87. The impact of cystinuria on renal function. Monga ag. coe FL. Bercowsky E.2 Anticoagulation and stone treatment Patients with bleeding diathesis or who are receiving anticoagulations should be referred to an internist for appropriate therapeutic measures before. kim Sc. Williams Jc Jr. chen c. Streem SB.gov/pubmed/10840083 ngo Tc. South africa: university of capetown 2000. Heisey d. http://www. should be tested for bacteriuria. Williams Jc Jr.nih. Where there is clinically significant infection and obstruction. Preminger gM. determination of stone composition by noncontrast spiral computed tomography in the clinical setting.nih. without the need for pre-operative correction of the haemostatic parameters.nih. Mcdougall EM. should precede active intervention for stone removal.nlm.1 Infections a test should be carried out in all patients in whom stone removal is planned. Lingeman JE. Figenshau rS. Mutz J.9(1):17-27. assimos dg. 91.nih. uric acid nephrolithiasis: recent progress and future directions. http://www. and during. http://www. which is associated with less morbidity. Vassar gJ. 88.nih. uPdaTE MarcH 2008 75 . 10. the stone-removing procedure. Hoff dg. clayman rV. Bellman gc. ng c.gov/pubmed/11547053 Hoskins dH et al: In: urolithiasis 2000: Proceedings of the ninth International Symposium on urolithiasis.nlm. limits the risk of thromboembolic complications and avoids the costs associated with an extended hospital stay. Blankenbaker d. Evan aP. gENERAL RECOMMENDATIONS AND pRECAUTIONS FOR STONE REMOVAL 10. nadler rB. nadler r. nih. Hofbauer J. 5. 10. Higashi Y. arch Esp urol 1992.7 1. LE = level of evidence. Safety and efficacy of holmium:Yag laser lithotripsy in patients with bleeding diatheses. chaussy c. girvan ar. dorfinger k. Markakis c. only uric acid stones.ncbi. Percutaneous removal of these stones might be appropriate. chemolytic treatment of brushite stone fragments is possible.gov/pubmed/3169076 ruiz Marcellán FJ.gov/pubmed/8646601 Watterson Jd. ESWL = extracorporeal shock-wave lithotripsy. denstedt Jd.To decrease bleeding complications. There are two types of cystine stone: those that respond well to ESWL and those that respond poorly (9). electrohydraulic lithotripsy must be avoided (6. kramer g. http://www.nlm.ncbi. however. Extracorporeal lithotripsy in patients with hemophilia. Harada M. cabré Fabré P.nlm. Beiko dT. 4.168(2):442-5. karayannis a. positive dip-stick test or suspicion of an infective 3 component.ncbi.5 Radiolucent stones uric acid concrements can be localized using uS. [Extracorporeal shockwave lithotripsy in patients with coagulation disorders]. argentino gancedo rodríguez V. 76 uPdaTE MarcH 2008 . auge Bk. 3. Thüroff S. 10.43(1):75-9. PNL = percutaneous nephrolithotomy. or intravenous or retrograde administration of contrast medium. http://www. which avoids subjecting the renal tissue to too much shock-wave energy. GR = grade of recommendation LE = 4 gR = C 10.ncbi. renner c.gov/pubmed/11223679 klingler Hc. http://www.nih. however. güell oliva Ja.nih.6 Recommendations for special considerations in the removal of stones Table 23 summarizes recommendations for special considerations. Mandalaki T. J urol 2002.14(4):343-5. Eur urol 2001.nih. http://www.3(1):58-60. it is recommended that the patient’s cardiologist is consulted before ESWL is undertaken. http://www. 6. not sodium urate or ammonium urate stones. as some devices need to be deactivated during ESWL. 7). nott L. particularly if they are large.nih.39(2):187-99.gov/pubmed/12507547 Becopoulos T. Eur urol 1988. Extracorporeal shock wave lithotripsy in von Willebrand’s disease.gov/pubmed/1567255 Ishikawa J. 10.nlm. Preminger gM. Lodde M.nlm. Stone treatment and coagulopathy. Patients with implanted cardioverter defibrillators must be managed with special care.nlm. Ibarz Servio L.4 Hard stones Stones composed of brushite or calcium oxalate monohydrate are particularly hard. is the best alternative for efficient removal of large ESWL-resistant stones. 10. LE = level of evidence.gov/pubmed/12131284 2. Int J urol 1996.nih. can be dissolved by oral chemolysis.nlm.3 pacemaker Patients who have a pacemaker can be treated with ESWL. karafoulidou a. ramón dalmau M.45(2):135-7.ncbi. Table 23: Recommendations for special considerations Special considerations LE gR B B c c In the presence of a positive urine culture. Treatment of renal stones by extracorporeal shockwave lithotripsy: an update. this is important as a this type of stone is associated with a high recurrence rate. this might not be necessary with the use of new-generation lithotripters (8). Marberger M.ncbi. REFERENCES rassweiler JJ. treatment with antibiotics should precede stone removal Salicylates should be stopped 10 days before planned stone removal 3 ESWL and PnL are contraindicated in pregnant women ESWL is possible in patients with a pacemaker 4 4 GR = grade of recommendation. Mauri cunill a. Eur urol 2003. http://www. PnL. okamoto M. cook aJ. aslan P. 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Endopyelotomy and endoureterotomy with the acucise ureteral cutting balloon device: preliminary experience. ohl da. 30.44(4):609-13.6:357-60.gov/pubmed/8461946 gerber gS. Bohlen d. 29. kogan Ba. but fortunately a considerable number of the symptomatic stones (70–80%) pass spontaneously.nlm. pregnant women do not have an elevated incidence of urolithiasis.nlm. Br J urol 1993. pregnant women present with symptoms of urolithiasis in the second or third trimesters. http://www. Endopyelotomy with the acucise cutting balloon device. Stones affect the two kidneys with equal frequency.nlm.nih. The incidence of urolithiasis has been reported to be 0. Ben rais n.ncbi.026 – 0.gov/pubmed/9187895 Faerber gJ. MANAgEMENT OF STONE pROBLEMS DURINg pREgNANCY urolithiasis during pregnancy. no major differences in stone composition have been found when comparing pregnant women to the general population (1–6).5:49-50. Marechal JM. chang M. 34.159(1):66. Endopyelotomy: patient selection. http://www. Farah n. the practical diagnosis and the risks associated with urolithiasis (8). http://www. clayman rV.ncbi. retrospective analysis of the effect of crossing vessels on successful retrograde endopyelotomy outcomes using spiral computerized tomography angiography. J urol 1998. Mcdougall EM.43(1):2-10. Lyon ES. Stone aM.a panacea for ureteropelvic junction obstruction?. kenogbon J. Hussey Jk.gov/pubmed/8996330 conlin MJ. 36.nlm. retrograde balloon dilatation for pelviureteric junction obstruction. although physiological hydronephrosis of pregnancy more commonly affects the right side (7).gov/pubmed/9400436 Van cangh PJ. 38.gov/pubmed/9474135 nakada SY.ncbi. Bogaert ga. Eur urol 1997.gov/pubmed/8481721 Mcclinton S. though rare. Quillen SP. http://www. 37.nlm. ricciuti gP. ackermann dk. Stoller ML. Stegwell MJ. richardson Td.nlm. Symptomatic stone disease presents in the second or third trimester in 80–90% of women. results and complications. 31. Pediatric ureteropelvic junction obstruction treated with retrograde endopyelotomy.nih. di Silverio F.nih. J urol 1998. chandhoke PS. Stones may be present in both kidneys with an equal frequency.159(1):56-61. danuser H. clayman rV.nih.gov/pubmed/9400437 12. When compared to non-pregnant age-matched controls.ncbi. presents diagnostic and therapeutic challenges. http://www. Endopyelotomy . Bagley dH. Brink Ja. combe M. Studer uE. nadler rB. Hilal n. ramackers JM. location and configuration). preference An internal stent or percutaneous nephrostomy catheter are suggested firstline treatment alternatives. although more invasive. has been accepted as a minimally invasive treatment alternative (9–13). gadolinium-enhanced breath-hold gradient-echo MR excretory urography (MREU). appropriate hydration and analgesia should be the first-line treatment for all pregnant women with non1 complicated urolithiasis. carcinogenesis. LE = level of evidence. provided maternal hypotension is avoided. and mutagenesis. The most important factor complicating the radiological evaluation of stone disease in pregnancy is of the potential damage that can be caused by exposing the fetus to radiation. it may be helpful for selected patients who fail more conservative expectant management and when operative intervention is not possible (e. epidural blocks have been commonly used to reduce maternal pain. and their safety for mother and foetus are well accepted. the diagnosis of urolithiasis is often difficult as. LE = 1a gR = A LE = 4 gR = C preference Conservative management with bed rest. stones will pass spontaneously. although this approach is used infrequently. GR = grade of recommendation LE = 1b gR = A Stone-related pain during pregnancy has been managed using acetaminophen and narcotic analgesics with no known teratogenic effects. 2 LE = 4 gR = C preference URS. although no drug is absolutely free of risk during pregnancy. a limited excretory urogram or magnetic resonance imaging may be carried out in particularly complicated cases. absence of equipment or lack of endourological expertise) (16). these drugs appear to be associated with minimal risk when used judiciously under medical supervision.2 Diagnostic evaluation as a consequence of the normal physiological changes occurring during pregnancy. 12. Failure to diagnose and manage urinary stones promptly during pregnancy might have adverse consequences for mother and child (9). ability of uS to differentiate between physiological dilation of pregnancy and ureteral. established treatment options should be considered. GR = grade of recommendation LE = 1a gR = A The value of uS is limited value in cases of acute obstruction because of poor sound transmission through gas and bone and the. aspirin and nSaIds can be used. while being aware of their non-teratogenic adverse effects (14. 12. because of patient refusal. other diagnostic modalities used to diagnose the presence of the stone(s) and assess the degree of obstruction in pregnant women include: • transvaginal/endoluminal US (evaluation of possible stones at the vesicoureteral junction) • magnetic resonance urography (MRU). which should be reserved for complex cases when uS fails to provide a diagnosis • more recently. 15).3 Management of the stone problem Following a correct diagnosis: In 70–80% of patients. including teratogenesis. imaging is essential for diagnosis and appropriate treatment planning. This is important because the obstetric complications associated with urolithiasis potentially include preterm labour and premature rupture of membranes. avoiding ionizing radiation and administration of iodinated contrast medium. If spontaneous passage of the stones does not occur or if complications develop (commonly the induction of premature labour). The risk of damage depends on gestational age and the amount of radiation delivered.be considered. in addition to maternal renal functional status and stone-related factors (number. operator-dependent. size. In recent years. 3 LE = level of evidence. Ultrasonography (US) (using the change in resistive index and transvaginal US when necessary) has become the primary radiological diagnostic tool. 80 uPdaTE MarcH 2008 .g. and it is important to always be aware of the potential risk of ureteral perforation and sepsis.3. Internal stents may also be associated with increased analgesic requirements and decreased overall quality of life.2. or without imaging procedures. intractable pain. which may be attributed to hypercalciuria. • The percutaneous approach enables immediate confirmation and continuous supervision of drainage. but some may require fragmentation.3.3 Ureteroscopy (URS) The use of flexible and thin ureteroscopes for diagnostic and therapeutic purposes in a less invasive and traumatic manner has led several urologists to consider this method as first-line treatment for pregnant women who have failed conservative management.2 Internal ureteral stent drainage of the obstructed renal collecting system can be accomplished using an internal ureteral stent inserted under local or general anaesthesia with transabdominal uS guidance or limited fluoroscopy.3. 12. obstetrician and anaesthesiologist should make a develop an appropriate management plan based on the patient’s wishes and her comfort level. 12. providing immediate urine drainage and culture to determine organism-specific antibiotic therapy. which can be accomplished safely with a pulsed-dye laser. The anatomical distortion of the bladder and distal ureter. However. each has its own advantages and disadvantages. The efficacy of these procedures is established. Infection and migration are other complications of internal stents and it has therefore been advocated that ureteral stent placement is reserved for the later stages (> 22 weeks) of pregnancy. • Subsequent percutaneous chemolytic irrigation of the renal collecting system might be useful for dissolution of uric acid. The intervention should be carried out by an experienced urologist.2. a team including a urologist. However.2. The choice between these methods is based on the factors discussed above (21–23). nausea or vomiting. or struvite stones (17). surgical intervention might be needed in certain situations such as for instance when there is febrile urinary tract infection. which might be required post partum and at the same time manipulation of the obstructed ureter.1 Percutaneous nephrostomy catheter This widely accepted approach is routinely carried out with local anaesthesia under uS guidance. cystine. LE = level of evidence. ureteroscopic management during pregnancy should be planned and performed at an experienced urological centre under close obstetric and anaesthetic surveillance.3. 12. dietary calcium restriction and antibiotics as well as frequent stent replacement at intervals of 4–8 weeks. general anaesthesia might be needed for urS.3. can make semi-rigid urS more difficult. insertion of a percutaneous nephrostomy catheter might be complicated by significant bleeding as as result of tract creation and dilatation. obstruction of a solitary kidney. sepsis. Ho:Yag laser or pneumatic lithotripsy (24. Stent insertion is routinely carried out by most urologists and the equipment should be readily available at most centres (18). Stone manipulation at or near term should therefore be discouraged. GR = grade of recommendation LE = 3 gR = B 12. pyonephrosis. the risk for accidental dislodgement and bacterial colonization. uPdaTE MarcH 2008 81 . hyperuricosuria or infection that occur during pregnancy. The potential risks of perforation and infection are avoided. both nephrostomy tube placement and internal ureteral insertion are appropriate alternatives.1 Surgical management despite the commonly accepted success of conservative management. however. The disadvantages of external tubes are the inconvenience of dealing with a collection device. particularly during the third trimester. When conservative management fails and urinary diversion is needed. are well-known problems associated with this approach. • This approach may provide access PNL. only local anaesthesia is needed to place the tube under US guidance in acutely ill or septic patients. Some investigators therefore recommend hydration. Failure to drain is easily identified and appropriately managed. stent-related irritative lower urinary tract symptoms and rapid encrustation.12. 25).2 Temporary urinary diversion decompression of the renal collecting system using a percutaneous nephrostomy tube or an internal ureteral stent was first suggested by Meares in 1978. also. Most distal-ureteral stones can be retrieved with a stone basket. Increasing experience has shown that the percutaneous approach has certain advantages over retrograde stent placement: • In most cases. http://www.gov/pubmed/8379026 Biyani cS. If conservative treatment fails. davis M.gov/pubmed/9240217 drago Jr. Surg clin north am 1995. REFERENCES gorton E. an algorithm for diagnosis and therapy of management and complications of urolithiasis during pregnancy.gov/pubmed/15075842 Swanson Sk.nih.nlm. http://www. 9. http://www.172(1):49-54. However.nlm.nlm. 12. Lal a. temporary urinary diversion with percutaneous nephrostomy or an internal stent may be appropriate. gr = B). BJu Int 2002. fetal considerations.nlm. ESWL in pregnancy remains an absolute contraindication. J urol 1998. http://www.14(2):123-7. an evaluation of the physicochemical risk for renal stone disease during pregnancy.ncbi. Surg gynecol obstet 1991.42(3):263-7. clin nephrol 2001. rohner TJ. BJu 1997. 8. J urol 1992.gov/pubmed/11972502 Hendricks Sk. isotope renography or MrEu is useful for delineating the level and grade of obstruction in case of hydronephrosis.The most important contraindications to urS during pregnancy are: • inexperience • inadequate endoscopic instruments • stones with a diameter > 1 cm • multiple calculi • transplanted kidney • sepsis (because of the higher risk of complications). and diagnosis. hydration and analgesia will result in spontaneous passage of the stone in two-thirds of patients. Endoscopy is therefore a feasible and safe approach both for diagnostic and therapeutic purposes.ncbi. urinary tract stones in pregnancy.nlm. Loughlin k. renal colic during pregnancy: a case for conservative treatment.nih.89(8):811-8.nih.nlm. as there are established and obvious risks associated with exposing the foetus to radiation as well as shock waves. obstruction.55(3):205-11.5 1.159(2):365-8. Wollin Mr.gov/pubmed/7179620 Mcaleer S.quiz i-ii. krieger Jn. abraham Pa. GR = grade of recommendation LE = 4b gR = C 12.nlm. 4.ncbi.nih.gov/pubmed/7855714 Smith cL.gov/pubmed/11316240 Jarrard dJ. http://www.g. developments in diagnostic technology and endoscopic instrumentation during the last 5 years. Lee LM. http://www.gov/pubmed/1985341 Stothers L.gov/pubmed/1433534 Parulkar Bg. ESWL and percutaneous nephrolithotripsy (pNL) are contraindicated in pregnancy.4 Conclusions urolithiasis in pregnancy remains a diagnostic and therapeutic challenge.nlm. although uS is the method of choice for the practical and safe evaluation of a pregnant woman.nih. gerber gS.nih.nih.ncbi.ncbi. 10. renal colic in pregnancy. urolithiasis in pregnancy I: pathophysiology.ncbi.nih. Joyce ad. depending on the stage of the pregnancy. Heilman rL. Lyon ES. ross So.ncbi. kristensen c.nlm. ureteroscopy in experienced hands can be an effective treatment alternative to removal of ureteral stones during pregnancy (LE = 1b.80(1):4-9. Whitfield H. 82 uPdaTE MarcH 2008 . 6.ncbi.ncbi. Eversman Wg. urosepsis and renal functional deterioration). http://www. LE = level of evidence. urology 1993. renal calculi in pregnancy.ncbi. http://www. 5. chez ra.148(5):1383-7. curr opin urol 2004. 2.gov/pubmed/9649240 3. 7. http://www. Howard PJ Jr.20(6): 578-81. a limited intravenous urography. Management of urinary calculi in pregnancy. urology 1982. http://www. have made it possible to use high-quality imaging and small-calibre ureteroscopes. nephrolithiasis and pregnancy. caution must be exercised when performing urS during pregnancy with a solitary kidney. Hopkins TB. degree of pain and presence of certain complications (e.nlm. conservative management with bed rest.nih.75(1):123-42. Management of acute ureteral obstruction in pregnancy utilizing ultrasound-guided placement of ureteral stents.nih. but should be carried out only in centres with sufficient experience. Influence of epidural analgesia on fetal and neonatal well-being. review.ncbi. Braun PM. norwalk: appleton & Lange. nephrostomy tube or ‘JJ’ ureteric stent in ureteric obstruction: assessment of patient perspectives using quality-of-life survey and utility analysis.nih.gov/pubmed/11257644 Lifshitz da. Wu WJ. Eur urol 2001. kaohsiung J Med Sci 2007.nlm. Pregnancy and lactation: therapeutic considerations. More than 1% of all urinary stones have been registered in patients <18 years.gov/pubmed/11972503 Tiselius Hg.nih. knoepp L. 14. Management of symptomatic urolithiasis during pregnancy.ncbi. Marcum ng. 18.nlm. 25. Joyce ad. neerhut g.nih. J urol 1989.ncbi.gov/pubmed/12350466 13. ackermann d. Long cY.gov/pubmed/7556818 Biyani cS.g. Johnson MP. 15.ncbi.ncbi. rao Pn. Buck c. Testing. Jaekle rk. Huang cH. Turkey. Edition presented at the 16th Eau congress.gov/pubmed/2926891 Juan YS. Yaron Y. 13. ureteroscopy and holmium:Yag laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy. girvan ar.nlm. Posey LM. Shen JT. ISBn 90-8061793-9. Lewis dF. 2006.nlm. razvi H.nih. Evans MI.nlm. [access date november 2008] http://www. there has been a shift in the age group experiencing a first stone episode (1–3).60(3):383-7.ncbi. gallucci M. http://www. http://www.148(3 Pt 2): 1072–4. 1298-1312.gov/pubmed/11464060 Mokhmalji H.nlm. köhrmann ku.59(Suppl):S17-S29. http://www. Siegsmund M. 17. Switzerland 2001.gov/pubmed/1507335 Mccombs J. conort P. obstet gynecol Surv 2006.gov/pubmed/17525006 Joshi HB. management and pregnancy outcome. 142-143.uroweb. pp. Beiko dT. J Endourol 2002.39(6):695-701. 2003. alken P. Portillo JM. Stedman cM. urolithiasis in pregnancy II: management. 4th edn. J urol 2001. drugan a.141(4):921-2.11. urolithiasis in pregnancy. razvi H. urolithiasis in pregnancy.nih.61(11): 733-41. in other regions the rates are similar to those observed in developed countries (4–7). guidelines on urolithiasis. pp.89(8):819-23. Management of urinary calculi during pregnancy. as a result of malnutrition and racial factors. chuang SM. Percutaneous nephrostomy versus ureteral stents for diversion of hydronephrosis caused by stones: a prospective.gov/pubmed/17044950 denstedt Jd. Matzke gr.nih. http://www. http://www. and Management. Mailhes JB.48(1):28-32. Payton aL. 21. cramer Mk. Pharmacotherapy: A Pathophysiologic Approach.nlm. ureteroscopy as a first line intervention for ureteral calculi in pregnancy.ncbi.nih. Wells Bg. the Far East). diagnosis. MANAgEMENT OF STONE pROBLEMS IN CHILDREN In addition to the global increase in the rates of urolithiasis in developed countries. http://www. Talbert rL.nih.nlm.nih. geneva. Prenatal diagnosis: genetics. Briery c.ncbi. canzoneri BJ. Management of acute hydronephrosis of pregnancy by ureteral stenting: risk of stone formation.nlm. Wollin Ta. alken P. Yee gc.16(1):19-22.nlm.165(4):1088-92.nlm.nih. Lagrange ca. eds. 19. 24. 1999. eds. http://www. robichaux ag 3rd. Lederer E. Lewis dF. http://www. 20. urolithiasis in pregnancy: current diagnosis. J urol 1992. In: Eau guidelines. Wang cJ.23(5):241-6. reproductive risks. http://www.org/nc/professional-resources/guidelines/online/?no_cache=1&view=archive Pais VM Jr.34(1):43-52. treatment. J reprod Med. Eur J obstet gynecol reprod Biol 1995. http://www. Lingeman JE. 22.gov/pubmed/11890444 Watterson Jd.gov/pubmed/17145360 goldfarb r. new York: Mcgraw Hill. In: diPiro JT.gov/pubmed/12611091 cormier cM. and pregnancy complications. randomized clinical trial.ncbi.ncbi. nott L. Holzgreve W. adams S. paediatric urolithiasis remains an endemic disease in some areas (e. uPdaTE MarcH 2008 83 . urol clin north am 2007. http://www. http://www.ncbi. 23. obadeyi oo. urology 2002. denstedt Jd.nlm. 16. 12.nih.ncbi.nih. Scherer r. BJu Int 2002. physical investigation. 84 uPdaTE MarcH 2008 . However. More than one imaging study or combinations of various procedures will be required in most cases (9). recently developed cT protocols may further reduce the exposure to radiation (18) (LE = 4. its advantages are absence of irradiation and that there is no need for anaesthesia.1 Investigations Paediatric patients with urinary stones are considered to be a high-risk group for developing recurrent stones. or be sensitive to ionizing rays. and laboratory tests of blood and urine. the injection of contrast dye is needed for IVu. uS can be used to obtain information about the presence. and the grade of dilatation and obstruction. For the investigation of stones in infants and children.13. intravenous urography (IVu). Intravenous urography (IVU) IVu is an important diagnostic tool with which nearly all stones in the collecting system can be identified and which will provide anatomical and functional information. as well as metabolic abnormalities. as this group is at high risk for developing recurrent stones (8). 49. investigations for stone diagnosis.1 Ultrasound uS is the most popular imaging study. US evaluation should include the kidney. GR = grade of recommendation 13. require anaesthesia. the radiation dose and the extent of information about renal function must be considered when using non-enhanced helical cT.1.1 Imaging When selecting diagnostic procedures to identify urolithiasis in paediatric patients. 13. 13. urine culture is mandatory (8). including anatomic and functional information about the urinary tract (‘imaging’) • those related to metabolism. However. Infants and children may present with a wide range of uncharacteristic symptoms in the presence of urinary stones. colour-doppler uS showing differences in the ureteric jet (11) (LE = 4. In paediatric patients. LE = level of evidence. US fails to identify stones in more than 40% of paediatric patients (13. GR = grade of recommendation LE = 4 gR = B LE = 2 gR =A In addition. 13. all investigations start with an evaluation of the patient’s personal and family history.1. Post-interventional kuB canbe easily compared with previous IVPs in cases of radiopaque stones. gr = c).1. The radiation dose for IVu is comparable to that used for a voiding cystourethrogram (dose range. nevertheless. gR = B LE = level of evidence. the filled bladder. kuB may help to identify stones and their radiopacity and to facilitate followup.1. several optional procedures. size and location of a stone.1. remember that these patients may be uncooperative. magnetic resonance urography (Mru). helical cT. gr = c) and in the resistive index of the arciform arteries of both kidneys are indicative of the grade of obstruction (12) (LE = 4. LE = 2a are essential. or nuclear imaging may be used.1. ultrasound (uS) is therefore very useful because it is an easy and gentle procedure.3.06 to 83. It will also indicate signs of abnormalities that facilitate the formation of stones. LE = level of evidence. GR = grade of recommendation Investigations can be divided into the following categories: • those related to the diagnosis of stones. including plain films (kuB). and adjoining portions of the ureter (10). Besides uS. 14) (LE = 4) and provides no information about renal function.33 cgy/cm2).2 Plain films (KUB) In combination with uS or Mru.1. For paediatric patients. including nutritional habits and fluid intake. uS is part of the metaphylactic work-up. gr = c). GR = grade of recommendation If urinary stones are suspected. GR = grade of recommendation although the use of nifedipine or alpha-blockers is very common in adults.1. 16). GR = grade of recommendation LE = 4 gR =C 13. suitable investigations must be performed. or metabolic failures. It has the highest sensitivity and specificity of all diagnostic procedures. 13. the most common non-metabolic disorders are vesico-ureteral reflux. A wet chemistry analysis is insufficient (20). identify obstruction in the kidney after injection of furosemide.1. GR = grade of recommendation LE = 2 gR = A LE = 2b gR = B LE = 4 13. GR = grade of recommendation LE = 4 Sedation or anaesthesia is rarely needed when a modern high-speed CT apparatus is used (10) LE = 4 LE = level of evidence. GR = grade of recommendation 13. gr = c or B). the specific circumstances of treating children must be taken into account.1. infrared spectroscopy or X-ray diffraction are mandatory for adult patients. the same treatment modalities are used for adult and paediatric patients. Additional serum chemistry and 24-hour urine collections may be required (8).1. LE = 4 gR = C uPdaTE MarcH 2008 85 .Conventional imaging models are indispensable in some cases (15. including genetic disorders. However. In paediatric patients. but does not help in the primary diagnosis of urolithiasis. In paediatric patients.1. 17). 14. a diuretic renogram with injection of a radiotracer (Mag3 or dPTa) and furosemide can be used to demonstrate renal function. LE = level of evidence. and indicate the anatomical level of the obstruction (10) (LE = 4. LE = level of evidence. or other voiding difficulties (9). LE = level of evidence.5 Magnetic resonance urography (MRU) Mru cannot be used to detect a urinary stone. both ESWL and endourologic are effective procedures for stone removal. a neurogenic bladder. there is no evidence to demonstrate the safety and efficacy of these agents in paediatric patients. Metabolic investigations are based on an appropriate or thorough stone analysis. and the morphology of renal parenchyma (19) (LE = 4).4 Helical computed tomography (CT) non-enhanced helical cT is a well-established procedure for diagnosing urolithiasis in adults. only 5% of stones escape detection by non-enhanced helical CT (4. it might provide detailed information about the anatomy of the urinary collecting system. the location of an obstruction or stenosis in the ureter. 13. however.6 Nuclear imaging The dMSa scan (99mTc-dimercaptosuccinyl acid) provides information about cortical abnormalities such as scarring. LE = level of evidence.2 Stone removal In principle. GR = grade of recommendation Based on the composition of stones (see also chapter 16). LE = level of evidence. Spontaneous passage of a stone is more likely to occur in children than in adults (21).1. ureteropelvic junction obstruction.1. In paediatric patients.2 Metaphylactic investigations Paediatric patients who have urinary stones are a high-risk group for developing recurrent urinary stones and therefore require specific metaphylaxis for effective stone prevention. According to the current standard. The risk may arise from anatomical or functional disorders of the urinary collecting system. LE = level of evidence. however. with satisfactory stone-free rates. LE = level of evidence. except possibly for older children. emphasizing the efficiency and safety of ESWL in paediatric urolithiasis. 23) (LE = 4. For paediatric patients the indications for ESWL are similar to those in adults. During URS. GR = grade of recommendation LE = 1a gR = A Stone-free rates of 67–93% in short-term and 57– 92% in long-term follow-up studies have been reported. in order to • anticipated stone composition (cystine stones are more resistant to ESWL) • co-morbidity and any concomitant treatment • the need for general anaesthesia for ESWL. US or pneumatic lithotripsy are appropriate alternatives (26). together with swifter and uncomplicated discharge of larger fragments. that the higher incidence of metabolic and anatomical abnormalities in paediatric patients. For PnL. depending on the age of the child and type of lithotripter. compared with the adult population. LE = level of evidence. dilatation of the ureteral orifice is rarely needed (24). However. Smaller ‘needle ureteroscopes’ and flexible scopes are also available. 28. gr = c). and larger stones. a general anaesthetic is needed for 30–100% of children treated by ESWL. is a major concern in stone formation and can influence the management options and ultimate effectiveness of the selected treatment. despite the increasing application of PnL. despite its effectiveness and minimally invasive character. GR = grade of recommendation as in adults (see chapters 7 and 9). for whom sedation is usually needed to relieve the discomfort caused by ESWL (23. the development of smaller-diameter flexible ureteroscopes and ancillary instruments.9% to 53. 27. 86 uPdaTE MarcH 2008 . GR = grade of recommendation For pNL or URS with larger instruments. 29). residuals may predispose to recurrent urolithiasis (28. Children with renal pelvic stones or caliceal stones with a diameter up to 20 mm (~ 300 mm2) are ideal cases for this form of stone removal. the re-treatment rate ranges from 13. a minimally invasive procedure. nephroscopes that are 15F or less are available (22. has been found to render the patients stone-free over a short period. ESWL. this need and the method of anaesthesia used vary widely. The success rates tend to decrease as the stone burden increases. additionally. GR = grade of recommendation LE = 4 gR = C LE = 4 gR = C LE = 3 gR = C 13.2. has grown considerably since 1986. 13. Stones located in calices. children pass fragments more rapidly after ESWL • for endourological procedures. 32). the likelihood of urinary obstruction is higher in such cases. LE = level of evidence. The holmium:yttrium aluminium garnet (Ho:YAg) laser is the preferred device for intracorporeal lithotripsy (25).2. US can be used for localization during ESWL. More effective disintegration of even larger stones. 28). using a reasonable number of shockwaves and only limited auxiliary procedures. LE = level of evidence.1 Endourological procedures The improvement of intracorporeal lithotripsy devices and the development of smaller instruments facilitate both PnL and urS in children. remember. and children should be followed closely for the prolonged risk of urinary tract obstruction. general anaesthesia is generally used. as well as in abnormal kidneys. residual fragments after ESWL should be followed closely by regular examinations. the smaller organ size in children must be considered when selecting instruments for PnL or ureteroscopy (urS) • to eliminate radiation exposure.Several factors must be considered when selecting the procedure to be used in children: • compared to adults. can be achieved with ESWL in children than in adults (29-31).9% and the need for ancillary procedures and/or additional interventions ranged from 7% to 33% (27. are more difficult to disintegrate and clear. 29). depending on the stone-related factors.2 ESWL The literature regarding the use of SWL in the paediatric population. despite a successful disintegration. this will depend on the patient’s age and the lithotripter used. ESWL is still the least invasive procedure (23. 2. alternative procedures should be considered. Vinhl cV. Urolithiasis. 13.gov/pubmed/14644124 djelloul Z. Southeast asian J Trop Med Public Health 2004. ESWL is the treatment of choice for most stones located in the upper urinary tract in children. ESWL is unlikely to be successful for the treatment of stones with a diameter >10 mm or for impacted stones. cape Town: university of cape Town. Preminger gM. acceptable success rates have made ESWL a favourable first-line treatment for most proximal ureteral stones.theoretical concerns have been raised regarding the safety and bioeffects that ESWL might have in children on the immature.34(2):96-101. when the potential deterioration of renal function is taken into account (although it is transient). ESWL is a safe and highly effective treatment alternative for the management of stones in children. however. unwin rJ. urolithiasis. Hess B. or an additional target of therapy apart from stone removal (e. Hess B.nih. khan Sr.nih. ureteral pre-stenting appeared to have decreased the stone-free rate after the initial treatment and retreatments of 12–14% were recorded (23. 36).ncbi. robertson Wg. Where appropriate.gov/pubmed/16821346 Sarica k. Bladder stones in childhood: a descriptive study in a rural setting in Saravan Province. Strobeli M.g. Whitfield H. Particular attention should be paid to residual fragments. treatment of stones in a primary obstructive megaureter) (40) (LE = 4.ncbi. 2000. 13. kohrmann ku. 2000. calcium oxalate monohydrate and cystine stones. compared to adults. Phomluangsyl S. ESWL is the method of choice for smaller stones (diameters < 20 mm. http://www. although internal stents are seldom needed following ESWL-treatment of upper tract stones.4 Open or laparoscopic surgery The rate of open procedures in stone patients has dropped significantly in all age groups.and long-term follow-up. If the stone burden is so large. kaid-omar Z.nlm. surface area ~ < 300 mm2). as well as for impacted. http://www.ncbi. or stones in children with unfavourable anatomy and in whom localization difficulties exist. Possible causes of the changing pattern of the age of onset of urinary stone disease in the uk.3 1. urol res 2006. Pediatric urolithiasis: etiology. age of first stone episode. no irreversible functional or morphological side effects of high-energy shockwave have been demonstrated.16(3):328-35. although endoscopic procedures can be used to definitively remove ureteral stones. daudon M. 44(6):709-13. REFERENCES reis-Santos JM. Hesse a. In: rodgers aL. Hibbert BE.nih. Indications for surgery include failure of primary therapy for stone removal (38). In: rodgers aL. neild gH. overall stone-free rates have ranged from 80% to 97% in different series.nlm. eds. respectively (23. Wilbert d.2. [urinary stones in Western algeria: study of the composition of 1. In addition. that a ureteral stent is required. 31. 37).] Prog urol 2006. especially in children with predisposing metabolic. Mansell Ma. and the success rates for proximal and distal ureteral stones range from 75% to 100%. pp. 34).nlm. alken P. stones. currently. children pass stone fragments easily and the need for a stent is rare. open surgery. Eur urol 2003. 375-378. Lao Pdr1. eds.35(2):50-2. Brandle E. 27. Preminger gM. djelloul a. attar a. uPdaTE MarcH 2008 87 . 35. restriction of the number of shockwaves and the energy used during each treatment session will help to protect the kidneys (33. as well as anatomical. Hibbert BE. during both short. khan Sr. ureteral stones with a diameter < 5 mm are likely to pass spontaneously in up to 98% of paediatric patients. Study on the prevalence and incidence of urolithiasis in germany comparing the years 1979 vs. pp. 5. Intervention will be required for large.gov/pubmed/16432692 Sayasone S. However. 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J urol 2005.gov/pubmed/15205653 Thomson JM. curhan gc. kidney Int 2003.ncbi.174(4 Pt 2):1711-4. akhan o. 8. aragona F.gov/pubmed/16086170 Pepe P.40(1):11-4. Semi-rigid ureterorenoscopy in children without ureteral dilatation. diagnosis of pediatric urolithiasis: role of ultrasound and computerized tomography. Sahin a.nlm. abdomen. 174(4 Pt 1):1413-6. comparison of spiral cT and uS in the evaluation of pediatric urolithiasis. koehrmann ku. Bircan Mk. urology 2003. http://www. Hussain Z. doddamani d. 38.ncbi. Hussain M. Mehdi H.ncbi. Int Braz J urol 2002.ncbi. küpeli S. razvi H.nlm. Tekgül S.gov/pubmed/11350428 Landau EH.ncbi. 29.nlm. Shapiro a. denstedt Jd.87(8): 732-40. gofrit on.nih. Joyner Bd.28(6).19(3):225-9. http://www. kunit g. ozkuvanci u.ncbi.nih. http://www. Watterson Jd. Sarica n.ncbi. http://www. Binbay M.nih.ncbi. a 3-year retrospective study.8(6): 431-5. Sultan S.ncbi. Jueneman kP.nih. J urol 2003. curr opin urol 2005. golijanin d.nlm.nih.nlm.gov/pubmed/12544331 Schultz-Lampel d. Mitchell ME. computed tomography cT or tomographic examinations demonstrate small fragments better than a standard plain abdominal film of the uPdaTE MarcH 2008 89 .nih.169(2):634-7. However. al-omar M. 39.nlm. katz g. and follow-up.gov/pubmed/15725934 dogan HS. Pode d. http://www. RESIDUAL FRAgMENTS residual fragments are commonly seen after ESWL. Tefekli a. gupta Pk. Laparoscopically assisted percutaneous transperitoneal nephrolithotomy in pelvic dystopic kidneys: experience in 15 successful cases J Laparoendosc adv Surg Tech a 1998.ncbi. 35.nih. and most frequently present in the lower calix. residual fragments may occur following ESWL for all sizes of stones. Lampel a.nih.gov/pubmed/17303023 Sarica k. Is the holmium:Yag laser the best intracorporeal lithotripter for the ureter?.ncbi. Endourologic management of pediatric urolithiasis: proposed clinical guidelines. kuo rL.gov/pubmed/17144854 rizvi S.gov/pubmed/17094748 casale P. 26.nih.ncbi. J.nlm. Long-term follow-up after extracorporeal shock wave lithotripsy in children. 30.170(6 Pt 1):2405-8. grady rW. Sarica k. Manohar T.nih.nlm.54(2):95-8.Yurtseven c. J Endourol 2007.nih. J Endourol 2006. Saribas S.gov/pubmed/12670547 14. Symptomatic and complicated adult and adolescent primary obstructive megaureter-indications for surgery: analysis.172(2):680-3. desai Mr.20(10):737-48. 27.gov/pubmed/9916597 Hemal ak.21(3):305-9.nlm. Transperitoneal laparoscopic pyelolithotomy after failed percutaneous access in the pediatric patient. 32.gov/pubmed/15333214 Frick J. different imaging techniques have variable degrees of sensitivity. The surgical management of stones in children. outcome. Zafar Mn.15(2):107-12. Eur urol 1991.gov/pubmed/15748404 Erdenetsesteg g. Endoscopic management of stones in children. gupta nP. 28. Long-term follow-up of renal morphology and function in children after lithotripsy.nih. following the disintegration of large stones.Yagci F. altunrende F. Hashmi a.8(2):163-73.165(6 Pt 2):2316-9. Toth c.61(4):703-7. results of shockwave lithotripsy for pediatric urolithiasis. http://www.gov/pubmed/11371970 Tan aH. http://www.gov/pubmed/15247760 Holman E.nlm. http://www. 34. Erturhan S. http://www.ncbi.nlm. 33. ansari MS.nlm.gov/pubmed/14634438 Braun MP.18(6):527-30. 37. gögüs o. BJu Int 2001. 539-44. urol Int 1995. J urol 2004.nih. nott L. 36.25.nih.ncbi. 31. Meretyk S.nlm. 40.nlm. Sarilar o. http://www. Zeltser IS. http://www. Effect of potassium citrate therapy on stone recurrence and regrowth after extracorporeal shockwave lithotripsy in children.nlm.nih. http://www.gov/pubmed/17444776 desai M. Extracorporeal shockwave lithotripsy as the first line treatment alternative for urinary tract stones in children: a large scale retrospective analysis. http://www. Endourol 2006:20(11):875-9.nlm. curr urol rep 2007. alken P.ncbi.nih.gov/pubmed/1855529 Sarica k. Shenfeld oZ. kohle r. kiliç S. urolithiasis in children. Management of pediatric urolithiasis in Pakistan: experience with 1. Singh H. J urol 2001.ncbi. Extracorporeal shockwave lithotripsy is highly effective for ureteral calculi in children.gov/pubmed/7747366 Muslumanoglu aY. http://www.ncbi. J urol 2003. http://www.nlm. Seif c. J Endourol 2004. nagvi S. http://www.440 children. Management of pediatric stone disease. LE = level of evidence. • In a Japanese report. Most studies on the long-term course of the disease in patients with residual fragments are restricted to 1–6 years. GR = grade of recommendation LE = 4 gR = C LE = 1b gR = A In symptomatic patients. reports on residual fragments therefore vary between institutions. It is assumed that the percentage of stone-free patients is overestimated.4% after 1 year.2 years (16). Moreover. further intervention was needed in 9. after 6. • Residuals with a diameter ≥5 mm should be called residual stones. The clinical problem of asymptomatic stone residuals in the kidney is related to the risk of developing new stones from such nidi. an increased stone size was noted in 48% of patients with residual fragments followed up for 3. 28. Twenty-five per cent of patients with infection stones had formed new stones after 2 years.5 years and 7% after 3. GR = grade of recommendation LE = 1a gR = A The risk of recurrence in patients with residual fragments after treatment of infection stones is well recognized. visible only on cT scan.8% after 1. none of the identified risk factors for stone growth was found to be individually predictive for continuing stone formation (37).3 years. data from 104 patients with residual fragments showed that. a cT scan can also demonstrate uric acid concrements. For stones in the upper and middle calyces.5 years.2% after 1.6 years (18). treat according to the relevant stone situation. The role of cIrF has been a matter of concern and debate (2–13).7% after 3. The potential for new stone formation should therefore be considered in patients who have been treated with ESWL. or to treat this problem if it is present. In a 2. 78% of patients with stone fragments 3 months after treatment experienced stone progression. a 20% risk of recurrent stone formation was recorded during the first 4 years after ESWL.7%. LE = level of evidence. For a kidney with stones or fragments in the lower caliceal system and with no functioning parenchyma in that part. a new stone-removing procedure was undertaken in 22% of patients (15). GR = grade of recommendation Identification of biochemical risk factors and appropriate stone prevention is particularly indicated in patients with residual fragments or stones (35). For well-disintegrated stone material residing in the lower calix.4 years).0% and 41.kidneys. the remaining 2% had stable desease (1). uric acid. • Reported stone recurrences were 8. stone growth was observed in 26% of patients and recurrent stone formation in 15%. (14). there are no data in the literature demonstrating the clinical value of being able to detect very small concretions.3 years. however. 3 and 5 years.3% of patients. the residual fragments had increased in size in 37% of patients. and to take the therapeutic steps necessary to eliminate symptoms. The Panel recommends that the selection of a stone-removing procedure should be based on the findings of a good-quality kuB and that cT examination is necessary only for uric acid stones. during a follow-up of 7– 96 months (average 3. LE = level of evidence. The stone-free rate was 20%. lower pole resection is an alternative to ESWL (21).2 year follow-up of 53 patients. carbonate apatite. 6. the recurrence rates were 6. ureters and bladder (kuB). consider inversion therapy during high diuresis and mechanical percussion (38). which are otherwise radiolucent. it is important to rule out obstruction. • In a neural network analysis. while in 5% stone growth was seen during a mean follow-up of 1. • Stone residuals with a diameter ≤4 mm should be called residual fragments. The term ‘clinically insignificant residual fragments’ (cIrF) was introduced for calcium stone residual fragments. cT examinations are not universally available. patients with residual fragments or stones should be followed up regularly to monitor the course of their disease.6 years . However. in 40%. the size of the residual fragments had decreased or remained stable. In asymptomatic patients where the stone is unlikely to pass. cystine 90 uPdaTE MarcH 2008 . there was obvious increase in size in 37% and a need for retreatment in 12% (17) . In a 4-year followup of patients with residual fragments < 4 mm. 9. Percutaneous chemolysis can be used for stone fragments composed of magnesium ammonium phosphate. respectively (19). by 2 years of follow-up. the longest followup period was reported by Yu et al. • For a group of Swedish patients with calcium stones. urS with contact disintegration is another option. depending on which imaging method has been used. The greatest risk was seen in patients with stones containing a high content of calcium phosphate (20). 20% after 3. J Endourol 1992. J urol 1994. kumstat P. Schuster c.ncbi. nespoli r.nih.gov/pubmed/8254832 Fine Jk. naik k. natural history of residual renal stone fragments after ESWL. 12.nlm.nih.gov/pubmed/9439396 Yu cc. chen kk. chen MT. http://www.nlm. The fate of residual fragments after extracorporeal shock wave lithotripsy monotherapy of infection stones.155(4):1186-90. abstract. chen MT. kladensky J. Merlo F.nlm. anselmo g. cicerello E.nih.nlm.37(1):18-22.ncbi.5(1):8-18.nih. Eur urol 2000.153(1):27-32. http://www. del nero a. J urol 1996. 6. 5. Table 24: Recommendations for the treatment of residual fragments Residual fragments. Br J urol 1993. Extracorporeal shock wave lithotripsy retreatment (‘stirup’) promotes discharge of persistent caliceal stone fragments after primary extracorporeal shock wave lithotripsy.nih. Turjanica M. Hanak T.gov/pubmed/10148257 Sabnis rB. Patel SH. Br J urol 1993. Baggio B. Extracorporeal shock wave lithotripsy for lower calyceal stones: can clearance be predicted? Br J urol 1997. Preminger gM. J urol 1997. chen kk. 11. Lunz c. Mulley ag Jr. gambaro g.gov/pubmed/8281395 carlson kJ. 7.gov/pubmed/1984100 Eisenberger F. uPdaTE MarcH 2008 91 .discussion 1041-2. Liedl B. Table 24 summarizes the recommendations for the treatment of residual fragments.nih. Jelinek P.nlm. Extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for urinary calculi: comparison of immediate and long-term effects. Yost a. riehle ra Jr.ncbi.ncbi. Jacqmin d.1 1. Tuerk c.158(2):352-5.145(1):6-9. http://www.nlm. gladstone k. Effectiveness of SWL for lowerpole caliceal nephrolithiasis: evaluation of 452 cases.gov/pubmed/8281395 candau c. internal ureteral stenting before ESWL is recommended to avoid problems with an accumulation of stones obstructing the ureter.ncbi.ncbi. Lang H. Schmidt a. Lee YH. Lee YH.148(3 Pt 2):1040-1.nih. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy. urol res 1988. Maccatrozzo L.6:217-8.nih. Long-term results in ESWL-treated urinary stone patients.and brushite. Trinchieri a.ncbi. Faure F.gov/pubmed/9224301 Pacik d. renal stone fragments following shock wave lithotripsy.ncbi.nlm. 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The definition of success. http://www. 14. Pak Yc. http://www. Bub P. roy c. Saussine c. 15. Long-term stone regrowth and recurrence rates after extracorporeal shock wave lithotripsy. chang LS. J urol 1991.151(1):5-9.nlm.nlm. J urol 1995. Steinkogler I. clinical implications of clinically insignificant stone fragments after extracorporeal shock wave lithotripsy.ncbi. 13. roth ra.72(5 Pt 2):688-91. stones (largest diameter) < 4–5 mm > 6–7 mm Symptomatic residuals Stone removal Stone removal Asymptomatic residuals reasonable follow-up consider appropriate method for stone removal 14. http://www. Fandella a.nlm.ncbi. known as a Steinstrasse (see chapter 15) (22–34). The risk of developing a Steinstrasse is particularly high for stones located in the renal pelvis (36).80(6):853-7. 3. Eur urol 1997.nih.nlm. 3 years of experience. Bachor r. Eur urol 1987.nlm. Eisenstein EL.nih. http://www. 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Shapiro a. 31. katoh n. curr opin urol 1994.gov/pubmed/9265342 kamihira o.15(3):481-91. alund g. Scheiber k. Wilbert dM. comprehensive metabolic evaluation of stone formers is cost effective. Streem SB.ncbi.ncbi.nlm. Mizutani k. Long-term stone recurrence rate after extracorporeal shock wave lithotripsy.ncbi. [The staghorn calculus: anatrophic nephrolithotomy versus percutaneous litholapxy and extracorporeal shockwave therapy versus extracorporeal shockwave lithotripsy monotherapy. http://www.nlm. clark PB. claus r. Indications.ncbi.13(3):151-5.3:31-6. Honeycutt EF.ncbi. 24.nlm. Buchholz nP. J Endourol 1993.gov/pubmed/9032530 ackermann d.36(3):226-30. Partial nephrectomy for stone disease.15(1-2): 5-8. 26. http://www. Bichler kH.nlm.nlm. B Hess.156(4):1267-71. J urol 2007. discussion 1788-9.nih. Marguet cg. http://www.49(7):605-10. http://www. urology 1990. Urolithiasis. Follows oJ. Effect of medical management on recurrent stone formation following percutaneous nephrolithotomy. 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Extracorporeal shock wave lithotripsy for lower pole calculi: long-term radiographic and clinical outcome. cape Town: university of cape Town. recurrent stone formation in patients treated with extracorporal shock wave lithotripsy.36(1):52-4. J urol 1996.nlm. Pode d. ohshima S. Stent use with extracorporeal shock wave lithotripsy. pp. Extracorporeal shock wave lithotripsy for large renal stones. 22.ncbi. Jaeger P. rose MB. J Endourol 1988. 35. Saltzman B.ncbi.gov/pubmed/3609094 Sulaiman Mn. Extracorporeal shock wave lithotripsy as monotherapy of staghorn renal calculi.gov/pubmed/2741262 chen aS.] urologe a 1989. 25. (Significance of ‘clinically insignificant residual fragments’ [cIrF] after ESWL) urologe 1997 May. 32. Sr khan. eds. a report of over 6 years’ experience.13(3):174-5. Br J urol 1977. Eur urol 1988. http://www. 349-355.gov/pubmed/8808851 Tiselius Hg. Hautmann r.gov/pubmed/8863540 Lahme S. Lennon gM. 30. http://www. Extracorporeal shock wave lithotripsy for stones in solitary kidney.ncbi.gov/pubmed/10360492 kang dE.15(3):493-7. 17.nih.142(6):1415-8. ono Y. recker F. Pfau a.nih. http://www.nih.156(5):1572-5. Hofbauer J. nih. http://www. World J urol 1993. antibiotics must be given and adequate drainage provided as soon as possible. In all patients with signs of infection. Stent 1. In: kandel LB. http://www. diuresis.nlm.36. Brown B.nih. urS 1. Harrison LH. urology 1998. INTERNAL STENTINg – WHEN AND WHY 16. oksay T. urS 15. Serel Ta. Pn 4 c 1. Pn 4 c 1. Treatment recommendations are summarized in Table 25. http://www. ESWL = extracorporeal shockwave lithotripsy. niederberger cS. ESWL LE = level of evidence.nih. 2.ncbi. GR = grade of recommendation. eds. as internal ureteral stents are now commonly inserted before ESWL for large renal stones.51(2):335-8. new York: Futura Publishing. randomized controlled study of mechanical percussion.ncbi. golden rM.nih. ESWL Mid-ureter 1. pp. ureteral calculi. Soyupek S. synthetic polymers and constructed and designed to be retained in situ. REFERENCES Tolley da.65(6):1070-4. and inversion therapy to assist passage of lower pole renal calculi after shock wave lithotripsy. urS 1. urol Int 2005.nlm.gov/pubmed/15897697 Michaels Ek. urology 2005.74(4):323-5. 1987. koflar a. ESWL Distal ureter 1.nlm.ncbi. Stent 1. use of a neural network to predict stone growth after shock wave lithotripsy. urS 1. PN = percutaneous nephrostomy catheter. ureteroscopy (urS) might be useful to remove the leading stone fragment by contact disintegration. Liang S. URS = ureteroscopy position proximal ureter Unobstructed 1. kay LM. consensus of lithotriptor terminology. arma an a. 16.gov/pubmed/9495724 chiong E. Table 25: Recommended treatment of Steinstrasse Obstructed and/or of stone symptomatic LE gR 1. ESWL 2. 38. 2). cho L. Pn 4 c 2.nlm. 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 the passage of urine (1). The internal ureteral stent is made of flexible. ESWL 1. Perk H.1 1.gov/pubmed/15922429 15.1 Introduction Stents were introduced into clinical urological practice in the 1970s (1.11(1):37-42. For distally located accumulations of fragments. ESWL 1. State of the Art Extracorporeal Shock Wave Lithotripsy. Mccullough dL. Mt kisco. urS 1. Insertion of a percutaneous nephrostomy catheter usually results in passage of the fragments (2).gov/pubmed/8490666 griffith dP. Stent 1. Esuvaranathan k. The stent has become an important device in the urologist’s armamentarium to assist and maintain drainage of the upper urinary tract in uPdaTE MarcH 2008 93 . urS 1. Hong Y. http://www. risk factors for the formation of a steinstrasse after shock wave lithotripsy. kamaraj r.ncbi. 281-310. Hoflcan MB. Hwee ST. the frequency of Steinstrasse has decreased. 37. Even though retrograde insertion of the stent is the usual method. while PnL is the treatment of choice for complex renal calculi (4. However. a percutaneous antegrade approach through the loin under X-ray or ultrasound (uS) control might.4 Stents in conjunction with ESWL therapy for ureteral stones The assumption that a stent in the ureter contributed to more efficient fragmentation of the stone with ESWL led to the routine pre-treatment placement of an internal stent. as the renal calculus is the most commonest cause of upper urinary tract obstruction. this becomes almost obligatory when treating stones in a solitary kidney. miniaturized ureteroscopes facilitates the treatment of simple renal calculi. trained urological surgeon. Technological advances of flexible. where PnL is followed by ESWL for residual fragments. With stones > 20 mm in diameter. The placement of a stent might be indicated in this situation.1 Indications for stenting for urgent relief of obstruction The indications for stenting for urgent relief of obstruction are: • infection with urinary tract obstruction • urosepsis • intractable pain and/or vomiting • obstruction in a solitary or transplanted kidney • bilateral obstructing stones • ureteral calculus obstruction in pregnancy. character and location of stones in the ureter determine management.and intra-corporeal stone removal/disintegration. with bimodal therapy for staghorn stones. and placement of a stent in the ureter following ureteroscopic procedures was considered to be mandatory. where the avoidance of risk of obstruction by even small fragments is particularly relevant. GR = grade of recommendation LE = 1b gR = A 16. a randomized controlled trial showed that ureteral catheters. unlikely to pass. a revised approach in some circumstances is now being considered on the basis of experience. selection. requires intervention to remove the stone and relieve obstruction. The criteria that apply to the spontaneous passage of a stone are well documented and form the basis of expectant treatment. It was reported that the peri-operative placement of double-J stents can significantly reduce post ESWL morbidity and does not impede passage of the disintegrated stone fragments (6). with stone-free rates similar to those obtained using SWL and without the morbidity that accompanies PnL. 16. the percutaneous antegrade method is often and most commonly performed by radiologists. Several studies. For decompression of the renal collecting system ureteral catheters. ureteral obstruction by a stone. 16. The relative advantages. no stent is ideal and the surgeon must be to be familiar with indications for usage. the placement of a stent before ESWL was recommended to obviate the possible obstruction by a Steinstrasse. although both techniques are within the expertize of a competent. internalized stenting prevents obstruction if stone fragments fall into the ureter before ESWL and prevents subsequent formation of an obstructing Steinstrasse.3. The two competing approaches to the interventional management of stones in the ureter are ESWL and/or ureteroscopic (urS) stone removal/disintegration. There is little or no reason to leave a stent in situ after PnL because all disintegrated stone material is captured and removed at operation and the kidney drained by a nephrostomy tube. chapter 9). 16. In any case. stents and percutaneous nephrostomy catheters are apparently equally effective LE = level of evidence. Indications for the insertion of a stent together with SWL or urS and the relief of obstruction need to be defined (8). including randomized 94 uPdaTE MarcH 2008 . ureteral stents and percutaneous nephrostomy tubes were equally effective for decompressing the urinary tract (9.the face of obstruction or anticipated obstruction (3).3 The use of stents in the ureter The size. in some circumstances. although stent insertion for the immediate relief of significant and serious obstruction caused by a calculus is unquestionable. the decision to stent is a matter of clinical judgement and individual circumstances. pending definitive therapy in the post-partum period.2 Stents in the management of kidney stones Extracorporeal shock-wave lithotripsy (ESWL) or percutaneous nephrolithotomy (PnL) is the treatment of choice for renal calculi (see chapter 7 for principles of active removal). be undertaken. the ureteric stent has become almost a sine qua non in the surgical management of upper tract renal and ureteral calculi in conjunction with extra. benefits and results of the two are discussed elsewhere (7). 5). Most simple renal calculi (80–85%) can be treated with SWL. modes of insertion and potential complications. Likewise. ncbi.119(6):731-4.nlm. while there were no differences in stone-free rates.nlm.167(2 Pt 2):11358. J urol 1978.gov/pubmed/9751331 El-assmy a. In fact. nakada SY. stenting was seen to be significantly associated with a decreased stone-free rate (11).gov/pubmed/77917 Saltzman B.nih. Is pre-shock wave lithotripsy stenting necessary for ureteral stones with moderate or severe hydronephrosis. http://www. nabi et al. causes undesirable side effects.nlm. Steele rE.ncbi. J urol 2002.gov/pubmed/17070256 2. and was undertake to prevent: • obstruction • renal pain caused by oedema as a result of balloon dilatation • trauma of instrumentation • stone manipulation and disintegration.ncbi.ncbi. 9. J urol 2006.ncbi. discussion 1139.nlm.nih. Indeed.nih. What can we learn from the literature in trems of results and treatment efforts?. Mertz JH. J urol 1987. http://www. kryger JV.gov/pubmed/3625845 Miller nL. J urol 1998. http://www. J urol 1998.gov/pubmed/9720520 Pearle MS. 8. Management of kidney stones.nlm. El-nahas ar.5 Stents in conjunction with URS routine placement of a stent has been considered to be an integral adjunct to urS.nih. 16. It makes a non-invasive procedure into an invasive one.176(5):2059-62. Miller gL. up to 80% of participants experienced urinary symptoms and pain associated with indwelling ureteral stents. http://www. http://www.ncbi. It is therefore recommended that ureteric stents are not necessary following uncomplicated urS for stones.15(3):481-91. griffith dP. is that stent insertion before SWL for obstructing ureteral stones ≤2 cm provides no advantage and is unnecessary. Petty Ba. Self-retained internal ureteral stents: a new approach.nih. REFERENCES Finney rP. newman dM. 4. J urol 1988. urinary tract infection rates.ncbi. (17) reported that the incidence of irritative lower urinary tract symptoms was significantly higher in the stented patients. Indications. Several prospective.nlm. 10. In a non-randomized study. Leder ra. The role of silicone ureteral stents in extracorporeal shock wave lithotripsy of large renal calculi. Mutz JM. in large numbers of patients have now shown that there was no difference in stone-free rates between stented and non-stented patients (10). nelson rH. variations.gov/pubmed/11905888 Hepperlen Jr.160(4):1260-4. urol clin north am 1988. Preminger gM. http://www.138(3):485-90. and complications. Woods Jr. BMJ 2007. http://www. uPdaTE MarcH 2008 95 . 6.ncbi. controlled trials comparing non-stented versus stented ureteroscopic lithotripsy have shown significantly more morbidity with regard to haematuria.160 (3 Pt 1):679-84.nlm. The recommendation.33:185-90 Vieweg J. stenting has several disadvantages. http://www. requirements for analgesia or long-term ureteric stricture formation. therefore. Experience with new double J ureteral catheter stent.gov/pubmed/3275796 Tiselius Hg. roehrborn cg. coury Ta. 1978. Meacham rB. Mosbaugh Pg.334(7591):468-72. Lingeman JE. http://www. Pierce HL. removal of ureteral stones with extracorporeal shock wave lithotripsy and ureteroscopic procedures. 5. dysuria and hospital stay in the stented patients (12–14).controlled trials. optimal method of urgent decompression of the collecting system for obstruction and infection due to ureteral calculi.nlm. Mardis Hk. and increases the cost of treatment.gov/pubmed/3043868 Lingeman JE.nih. Freed k.nih. In a metaanalysis of nine randomized controlled trials of stenting versus non-stenting after urS in 831 patients.discussion 2062. kammandel H. Summa Ja.139(1):15-7.ncbi. 3.nih. unenhanced helical computerized tomography for the evaluation of patients with acute flank pain. Sheir kZ. Teh c. randomized. 16. urological reseach 2005.nlm. which interfered with daily activites and resulted in a reduced quality of life (15).gov/pubmed/17332586 Libby JM.nih. kahnoski rJ. comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. Smith rH. flank and abdominal pain. a recent study has also reported that an indwelling ureteral stent can impair the quality of sexual life in both male and female patients (16).6 1. 7. ureteral stents. Wollin Ta. http://www.nlm. a prospective randomized controlled trial comparing nonstented versus stented ureteroscopic lithotripsy. Bianchi g.334(7593):572.nih. multivariate analysis. grande a. Mcclinton S.nlm. 7 28 LE 1b 1b gR a a reduced intake of sodium 28 12. 15 16. 13. http://www. ghilan a. provided there is a simultaneous adequate intake of calcium avoid excessive intake of vitamin c reduced urinary oxalate Thiazide reduced excretion of calcium Potassium citrate Increased excretion of citrate Inreased urine pH Increased inhibition of crystal 96 18 52-63. Timoney ag. http://www. d’a Honey rJ. Mcdonagh rP.169(3):1060-4.ncbi. The description of biochemical effects enables the most appropriate treatment to be selected in patients with known abnormalities in urine composition.nih. Showkey S. 12. 14. http://www. Indwelling ureteral stents and sexual health: a presspective. J urol 2001. http://www.93(7):1032-4.ncbi.1 Recurrence preventive treatment of patients with calcium stone disease Table 24 summarizes various therapeutic tools. http://www.gov/pubmed/14594691 denstedt Jd. discussion 1034-5. 67 70. Mofferdin a.nlm.11. Whether post-ureteroscopy stenting is necessary or not? Saudi Med J 2006.ncbi. http://www. abdel-khalek M.gov/pubmed/12576846 Sighinolfi Mc. El-nono I.nlm. 71 2b 1a 1b B a a uPdaTE MarcH 2008 . newns n. Scand J urol nephrol 2003.gov/pubmed/17311851 17. Micali S. Ferrari n. alwan M. keeley. Sheir k. 13 36 1b 2b 3 a B B Increased intake of fibres Increased intake of vegetables.gov/pubmed/16758048 Joshi HB. Elsobky E. The levels of evidence (LE) and the grades of recommendation (gr) refer to the effects on stone formation reported in the literature. kenawy M. BJu Int 2004. Bingadhi a. Weir M. BMJ 2007.outcomes of stenting after uncomplicated ureteroscopy: systematic review and meta-analysis.nlm. ureteric stenting after ureteroscopy for ureteric stones: a prospective randomised study assessing symptoms and complications. rivalta M.nlm.37(5):413-8. ureteral stent symptom questionnaire: development and validation of a multidimensional quality of life measure. which aim to reduce the risk of recurrent calcium stone formation.ncbi. n’dow J. J urol 2007:178(1):229-31.ncbi.27(6):845-8. RECURRENCE pREVENTIVE TREATMENT 17. FX Jr.gov/pubmed/15142158 al-Ba’adani T. Stainthorpe a.gov/pubmed/17499774 nabi g.nih. J urol 2003. Prognostic factors for extracorporeal shock-wave lithotripsy of ureteric stones--a multivariate analysis study. kwak c.nih.nih.165(5):1419-22.nih. giacometti M.nlm.nih. Sofer M. Lee SE. cook J.ncbi. 17.gov/pubmed/11342889 Jeong H. deStefani S.ncbi. nott L. Table 24: Dietary and pharmacological treatment regimens for prevention of recurrent calcium stone formation Treatment Increased fluid intake reduced intake of oxalate reduced intake of animal protein Biochemical effects dilution of urine reduced excretion of oxalate reduced excretion of: • Calcium • Oxalate • Urate Increased excretion of: • Citrate • Increased pH reduced excretion of calcium Increased excretion of citrate References 6. The aim should be to obtain a 24-hour urine volume of at least 2 L (LE 1b. 17.10).1 Drinking recommendations an inverse relationship between high fluid intake and stone formation has been demonstrated (6. the net result is neutralization. and aggregated crystals (1).Potassium magnesium citrate allopurinol (in patients with hyperuricuric calcium oxalate stone formation) Pyridoxine growth and crystal agglomeration. gr c). orange juice is beneficial but not cranberry juice (9. 375-1450 mg oxalate/100 g • Nuts.e. The abnormal crystalluria can cause: • A small urine volume • Increased excretion of urine variables important for increasing the ion-activity products of calcium oxalate/calcium phosphate. These factors have been extensively reported in a large number of articles and the issue has been previously comprehensively summarized (3-5). Moreover. should be adapted to the severity of the disease to avoid overtreatment and obtain reasonable patient compliance. a mixed balanced diet with contributions from all food groups. For this reason. 625 mg oxalate/100 g • Tea leaves. compared to non-stone formers. although grapefruit juice has a high potassium content. The treatment recommendations.1. This includes fruit and vegetable rich in oxalate such as wheat bran. with potassium. which are based on assumed or demonstrated abnormalities. 17. although most beverages can be drunk to increase fluid intake and help prevent stone formation. i. Inreased urine pH Increased excretion of citrate Increased inhibition of crystal growth and crystal agglomeration reduced supersaturation with caox as a result of increased urinary magnesium Increased inhibition of caP crystal growth and aggregation reduces urinary urate decreased risk of calcium oxalate crystal formation In patients with primary hyperoxaluria: reduced excretion of oxalate 73 1b a 98 1b a 103 3 c abnormal crystalluria is a common finding in patients with recurrent calcium stone disease. The alkaline content of a vegetarian diet also gives rise to a desirable increase in urinary pH (12). The presence of citrate appears to be the important determinant of the effect of fruit juices. The general recommendation for calcium stone formers is to maintain a high urine flow by a generous intake of fluids. vegetables and fibres: Fruit and vegetable intake should be encouraged because of the beneficial effects of fibre (13). It is axiomatic that without sufficiently supersaturated urine there can be no crystal formation and accordingly no stone formation. 200-600 mg oxalate/100 g. its effect on calcium oxalate supersaturation is counteracted by a high supply of oxalate (11). 7). stone-forming patients have been shown to have more. but without excesses of any kind (12). 530 mg oxalate/100 g • Spinach. However. The following products have a high content of oxalate (14): • Rhubarb. crystalluria found in early morning urine samples seems to predict the risk of recurrent stone formation (2). pH and citrate are increased. larger. It therefore seems essential to make the relevant corrections of urine composition in order to counteract critical supersaturation and pathological crystallization. gr a). or.1.2 Dietary recommendations diet should be of a ‘common sense’ type. Oxalate: an excessive intake of oxalate-rich products should be limited or avoided to prevent an oxalate load. 570 mg oxalate/100 g • Cocoa. Fruits. In the presence of hydrogen ions. grapefruit juice has been shown to be associated with an increased risk of stone formation (8) (LE 3. uPdaTE MarcH 2008 97 . This is particularly important in patients in whom an high oxalate excretion has been demonstrated. • Reduced activity of inhibitors of crystal growth and crystal agglomeration. Urate: The intake of food particularly rich in urate should be restricted in patients with hyperuricosuric calcium oxalate stone disease (29-34). 11). that there is no absolute consensus on such a view (42. an excessive consumption of animal protein gives rise to several unfavourable effects on stone formation. The ensuing recommendations are to a large extent still highly relevant. trichlorothiazide and the non-thiazide indapamide have been used for recurrence prevention in patients with calcium stone disease.8-1 g/kg body weight. The risk of forming sodium urate crystals is increased and the effect of thiazide in reducing urinary calcium is counteracted by a high sodium intake. anchovies. In case pharmacological treatment is considered (following prior unsuccessful therapeutic approaches) adequate patient education regarding drinking and dietary recommendations is even more imminent since treatment outcome will largely depend on patient compliance. Moreover. bendroflumethiazide. However.1. It seems logical and theoretically most attractive to administer pharmacological agents in a selective way with the aim of correcting one or several biochemical abnormalities. The intake of urate should not exceed 500 mg/day. In this respect. These aspects are all of utmost importance in order to achieve a reasonably good compliance. Some studies have shown that a daily intake of up to 4 g might be allowed without risk (15-17). but its role as a risk factor in calcium oxalate stone formation remains controversial. when additional calcium should be ingested with meals to bind intestinal oxalate.1 Thiazides and thiazide-like agents Hydrochlorothiazide. and have subsequently been referred to in several publications (37-41). hyperoxaluria and hyperuricosuria.Vitamin C is a precursor of oxalate. 43. a recent study demonstrated a significantly increased risk in stone formation for men taking 1 g/ day or more of vitamin c compared to men taking less than 90 mg (18). The recommendations given in this guideline document are based on what has been published in this field. germany in 1996. It therefore seems justified to advise calcium oxalate stone formers to avoid excessive intake of vitamin c. The pharmacological agents most commonly used for patients with recurrent calcium stone formation are thiazides. an extensive review and interpretation of literature results were carried out by the European urolithiasis research group at a consensus conference in Mannheim. Examples of food rich in urate (21) include: • Calf thymus. it is essential to choose the most appropriate form of treatment. urinary citrate is reduced due to loss of bicarbonate. Calcium intake should not be restricted unless there are very strong reasons because of the inverse relationship between dietary calcium and calcium stone formation (27). sardines. The allowed amount is not obvious but a daily intake of more than 500 mg (11) to 1 g (18) should probably be avoided. however. 260-360 mg urate/100 g • Kidneys. The purpose of thiazide treatment is to reduce 98 uPdaTE MarcH 2008 . an increased resorption of bone increases urinary calcium (26). 260-500 mg urate/100 g. It needs to be emphasized. calcium excretion is increased by reduced tubular reabsorption. The daily sodium intake should not exceed 3 g. 300 mg urate/100 g • Herring with skin.1. be free of side effects and be easy to administer.3. low pH. The ideal pharmacological agent should halt the formation of calcium stones. orthophosphate. 900 mg urate/100 g • Liver. calcium supplements are not recommended except in cases of enteric hyperoxaluria. The positive effect of such a regimen has been referred to as the ‘stone clinic effect’. advice on fluid intake and diet may be sufficient to prevent stone recurrence. Sodium: a high consumption of sodium brings about several changes in urine composition. and it is recommended that animal protein intake is limited to to 0. potassium citrate. The combined restriction of sodium and animal protein in a randomized study resulted in a reduced rate of calcium stone formation (28). such as hypocitraturia. as well as in patients with uric acid stone disease. magnesium and allopurinol. Animal protein should not be ingested in excessive amounts (19-25). The minimum daily requirement for calcium is 800 mg and the general recommendation is 1. The scientific basis of these forms of treatment is briefly summarized below. 17. sprats. In patients with an expected low risk of recurrent stone formation (S or rm). 17.000 mg/day.3 Pharmacological treatment The general opinion is that any treatment aiming at correction of abnormalities in urine composition and elimination of risk factors of pathological crystallization should always start by giving patients advice regarding dietary and drinking habits. 210-255 mg urate/100 g • Poultry skin. a favourable effect was also reported with potassium magnesium citrate.3 and 4. It has. citrate is an inhibitor of growth and aggregation/agglomeration of these crystals (67). a thiazide-induced reduction in urinary oxalate is not a consistent finding in the clinical studies. The thiazideinduced loss of potassium should be substituted by giving either potassium citrate 3. although the general principle is to give citrate preparations. There is more than 35 years of clinical experience with thiazides as a method for stone prevention. a significant effect was reported in five. compliance is usually in the range of only 50-70%. It is our opinion. development of diabetes and gout. administration of an alkaline salt brings about an increased pH and an increased excretion of citrate. There are also reports of favourable clearance of residual fragments during treatment with alkaline citrate (see below). three studies selected hypercalciuric patients (55-57) and all three showed a significantly positive effect of thiazides. Potassium citrate was used in two studies (68. most of which support a reduced rate of recurrent stone formation. In some other studies. a significantly reduced recurrence rate was recorded. The convincing positive effect of thiazide treatment was further supported by a meta-analysis based on randomized trials. a significantly reduced recurrence rate was recorded in three 3-year follow-up studies (51-55). The unmasking of normocalcaemic hyperparathyroidism. It has been shown. potassium citrate.the excretion of calcium in hypercalciuric patients. that the major indication for choosing a thiazide or a thiazide-like agent should be hypercalciuria.02) (65). The alkalinizing agents used to prevent recurrent calcium stone formation are sodium potassium citrate. sodium potassium in one study (70) and sodium magnesium citrate in another study (71). a low citrate excretion is a well-recognized and common finding in patients with calcium stone disease. as well as erectile dysfunction. whereas no effect was noted with sodium potassium citrate uPdaTE MarcH 2008 99 . possibly by a reduced intestinal absorption of calcium (45-47). The major drawback of thiazide treatment is the occurrence of side effects. However. been suggested that thiazides might decrease the excretion of oxalate.50) failed to confirm a positive effect of thiazides. Moreover. 17.57). In the two studies of potassium citrate. as in all situations when pharmacological treatment is considered. a similar result was also obtained in three groups of patients treated with thiazides between 2. in comparison with conservatively treated patients (56.e. four of which included placebo-treated patients.64). alkaline citrate has been used in four randomized studies. in which no selection was made. a judgment must be made between the benefits and risks of the medication. however. The clinical effect of thiazide treatment has accordingly been evaluated in 10 randomized studies. with only a small fraction of the administered citrate being excreted in urine.2 Alkaline citrate Treatment with alkaline citrate is commonly used as a method to increase urinary citrate in patients with hypocitraturia. This analysis showed significantly better results with active treatment than with placebo or no treatment (p < 0. the results were less convincing (63.3 years. that potassium citrate was superior to potassium chloride in this regard (66). In the other seven randomized trials. although two short-term placebo-controlled studies (49. however. contribute to a limited tolerance and a high drop-out rate. Whether or not thiazide treatment should be reserved only for patients with hypercalciuria.1. In the absence of high calcium excretion.44).5-7 mmol/24 hours or more than 4. This chelation reduces the ion-activity products of both calcium oxalate and calcium phosphate. 69). cannot be definitely concluded from the various studies. a significantly reduced rate of stone formation was also noted when a thiazide was given intermittently to recurrent stoneformers (58).3. due to the frequent occurrence of hypercalciuria also in an unselected group of stone formers. a large number of reports have been published. Hypocitraturia associated with hypokalaemia is thought to explain therapeutic failures in thiazide-treated patients. but it has been stated that calcium reduction is also seen in patients with normocalciuria (20). The hypocalciuric action of thiazides is thought to be mediated by increased reabsorption of calcium in the proximal as well as in the distal parts of the nephron (20. Hydrochlorothiazide is usually administered at a dosage of 25-50 mg once or twice daily. or used also in patients without this abnormality. Suffice it to mention that of the randomized studies.5-5 mmol/16 hours). treatment with thiazide is usually reserved for patients with a high excretion of calcium (i. more than 6. other forms of treatment may be better first-choice alternatives. potassium bicarbonate and sodium bicarbonate. Following the initial report by Yendt in 1970 (48). it is the alkalinization of the tubular cells that is the most important factor that results in an increased citrate excretion. sodium citrate. but recent studies have shown that such an effect is unlikely to occur. moreover. according to these considerations.5-7 mmol twice daily or another potassium salt. a reduced rate of recurrence was also observed in several other studies which compared treated patients with those not given any pharmacological agent (58-62). there is no strong scientific basis for a recommendation in this regard. potassium magnesium citrate. The role of citrate is important because of its complex formation with calcium. abdominal cramps. 86). 72-77) has a greater potential for preventing recurrence than sodium potassium citrate (39. In reviews of the literature results. it was also not possible to confirm a reliable effect of phosphate treatment. The usefulness of alkaline citrate as a way of increasing stone clearance after SWL has been studied by several groups. placebo-controlled study on potassium acid phosphate given during a period of 3 years. other non-randomized studies with alkaline citrate have shown a variable outcome.compared with an untreated group. a possible effect on parathyroid hormone must be considered. It is possible that the pattern of side effects is favourably affected by slow-release potassium phosphate (90). a high urinary concentration of magnesium is thus thought to decrease the risk of brushite formation.1. nevertheless. 88). Moreover. stone formation increased in the orthophosphate-treated group (84). although it is likely that this form of treatment is most beneficial for patients with a low citrate excretion. 78. studies (85. There are only a few studies in the literature that deal with the effect of orthophosphate on stone formation. In some. The effect of phosphate administration on calcium phosphate stone formation has not been elucidated. There are two randomized studies on the clinical effects of magnesium.25 (oH)2-vitamin d with an associated decreased absorption of calcium and reduced bone resorption. 79). In a randomized. This observation is also supported by the different effects of potassium citrate and sodium citrate on urine composition (80). so far there is insufficient evidence to recommend its use. nausea and vomiting are common. Further studies are necessary to show whether this preparation is superior to potassium citrate. an attempt to compare literature data has suggested a trend towards selective treatment (81). The risk of forming calcium phosphate stones as a result of the increased pH is theoretical.3. In conclusion. 53). there is only very weak evidence that orthophosphate significantly reduces calcium oxalate stone formation. side effects such as diarrhoea. this effect has not been confirmed. The effect on urinary calcium is assumed to be mediated by formation of 1. Magnesium oxide. less well-controlled. The frequency of side effects is fairly high and compliance with alkaline citrate administration was shown to be no better than approximately 50%. 89). Magnesium is also considered important for the transformation between various calcium phosphate crystal phases. Because of the many effects on calcium oxalate and calcium phosphate crystallization and stone formation. noted by others (87. potassium magnesium citrate and magnesium aspartate have been used. it was not possible to adequately analyse the therapeutic outcome (65). However.3. there is a lack of scientific evidence that phosphate is effective in preventing calcium stone formation (65. administration of orthophosphate (neutral) has been reported to also increase urinary citrate. treatment with alkaline citrate. 69. In a meta-analysis of randomized trials. one in which treatment with magnesium hydroxide was compared with a placebo control group (92) and one with magnesium oxide and 100 uPdaTE MarcH 2008 . There are also observations of an increased excretion of citrate following administration of magnesium (91). The number of patients in each of these studies was small and there were no statistically significant differences between treated and untreated patients. the general impression is that potassium citrate (68. The rate of stone formation during 3 years of treatment with phosphate was also studied in two randomized studies (52. although patient compliance with treatment is reported as good. increased the clearance of stone fragments. 17. according to preliminary and unpublished data from a European multicentre investigation. however. The recommended agent is potassium citrate. so far there is no solid evidence in the literature to support this assumption and further studies are necessary.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. a reduced rate of stone formation was. as well as potassium citrate (77. can be recommended as a treatment for preventing recurrent stones. 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. but there are only occasional reports of such an outcome. although potassium magnesium citrate appears efficient in prevention of recurrent stone formation. this agent is not yet generally available. 70. although this form of treatment may be a possible option in patients with absorptive hypercalciuria. It was accordingly shown that sodium potassium citrate (82). 17. magnesium hydroxide. Pyrophosphate is an inhibitor of both calcium oxalate and calcium phosphate crystal growth.1.4 Magnesium an increased excretion of magnesium might reduce the ion-activity product of calcium oxalate and inhibit the growth of calcium phosphate crystals. 83). The effect of potassium magnesium citrate is discussed above regarding alkaline citrate. 6 Pyridoxine Theoretically. The diet should be restricted with regard to fat (106). due to the rarity.3. calcium should therefore be given at meal times.untreated controls (52). 89).3. following jejunoileal bypass for treatment of obesity. The results indicate that allopurinol might be useful for treating patients with hyperuricosuric calcium oxalate stone formation. with the aim of reducing oxalate excretion in patients with primary hyperoxaluria Type I. it is definitely worthwhile trying pyridoxine therapeutically. it is essential to reduce the hyperabsorption of oxalate and correct any other urine abnormalities. The positive effects of magnesium administration reported previously (93. respectively. Because of the lack of other effective forms of treatment.7 Management of patients with enteric hyperoxaluria Enteric hyperoxaluria is a particularly problematic condition encountered in patients with intestinal malabsorption of fat. that a fraction of patients with Type 1 hyperoxaluria responds favourably to large doses of pyridoxine. hyperuricosuria. crystalluria and stone formation. This effect was statistically significant. and/or • Reduced excretion of oxalate. In a placebo-controlled randomized study of allopurinol-treated. uPdaTE MarcH 2008 101 . hyperuricosuric. This abnormality. Several reports confirm. There are no controlled studies to support the use of pyridoxine in patients with idiopathic calcium oxalate stone disease. The intestinal loss of fatty acids is combined with a loss of calcium. as well as patients with idiopathic hyperoxaluria (102). administration of pyridoxine (vitamin B6) might favourably influence the endogenous production of oxalate. 17. these patients usually present with hypocitraturia because of loss of alkali. This may be explained by an increased transamination of glyoxylate due to the action of the co-enzyme pyridoxal phosphate. there are no randomized studies on the efficacy of pyridoxine. These results are in contrast to those obtained in patients treated for hyperuricosuria (99. 75% of patients given allopurinol were free of recurrent stone formation compared with 45% in the placebo group (96). however.100). none of them showed a statistically significant effect on stone formation despite followup periods of 4 and 3 years. but severe side effects have been reported with high doses. there is insufficient evidence to recommend magnesium as monotherapy in calcium stone prevention.5 Allopurinol Treatment with allopurinol to counteract the formation of calcium oxalate stones was introduced following demonstration of a relationship between hyperuricosuria and calcium oxalate stone formation (95). 17. of primary hyperoxaluria.1. and severity. urine pH is usually low and so are urinary calcium and the urine volume. such as the marine colloid. and without. oxabsorb (104). in crohn’s disease and in pancreas insufficiency. which is associated with a high risk of stone formation is for example seen after intestinal resection. 94) have not been confirmed by recent controlled studies (65. allopurinol tolerance is usually good. There is no information on compliance. Three other randomized studies compared treatment with allopurinol and placebo or no treatment (96-98) in patients not selected because of hyperuricosuria.1. administration of alkaline citrate is recommended to raise urinary pH and citrate (105). Pyridoxine has successfully been used together with orthophosphate in the treatment of patients with primary hyperoxaluria (101). allopurinol has been used clinically to treat patients both with. a similar result was recorded in another Swedish study (98).3. calcium oxalate stone formers treated with 300 mg of allopurinol daily. 17. but its efficacy is often low because of the intestinal loss of water and increased diarrhoea.1. no significant difference was found between treated and untreated patients in any of these studies. It should also be mentioned that allopurinol may influence crystallization by its antioxidative properties. Thus. The effect of allopurinol on calcium oxalate stone formation may be mediated through: • Reduced salting-out effect • Decreased risk of uric acid or urate crystals as promoters of calcium oxalate precipitation • Complex formation between colloidal urate and macromolecular inhibitors. calcium-oxalate stone formers. In addition to the ensuing hyperoxaluria. an increased fluid intake is of course desirable. all these abnormalities contribute to particularly high levels of supersaturation with calcium oxalate. To prevent recurrence. a restricted intake of oxalate-rich foods should be combined with calcium supplements to enable calcium oxalate complex formation in the intestine (103). other oxalate-binding agents might also be useful. no effect was found on stone formation (97). In a long-term follow-up of non-selected. it cannot be recommended for patients with other biochemical abnormalities. However. The normal complex formation between oxalate and calcium is therefore disturbed and oxalate absorption is dramatically increased. There is no absolute consensus that a selective treatment is better than a non-selective treatment for recurrence prevention in idiopathic calcium stone disease. with or without a pharmacological agent rmo no general advice rm-res Yes* Specific advice. GR = grade of recommendation Urinary risk factor Hypercalciuria Hyperoxaluria Hypocitraturia Enteric hyperoxaluria LE 1a 2b 1b 3-4 2 3 1b 1b 1b 2b 3 2b gR a a a c B B a a a B B B Table 28: When should calcium stone formers be offered recurrence preventive treatment and how? Category Analysis of urinary risk factors Recurrence prevention So no general advice Sres Yes* Specific advice. the treatment of choice appears to be potassium citrate. however. nevertheless. For patients in category rs it is logical to take appropriate steps to stop or efficiently counteract recurrent stone formation. has suggested a slight difference in favour of treatment directed towards individual biochemical abnormalities (43).4. It is essential to note. it was shown that a water load had a positive effect on supersaturation and crystallization (110). It is generally considered that dietary and drinking advice should always be considered first and that pharmacological alternatives should be added only if the the first step fails or if there are specific reasons for starting pharmacological treatment from the beginning. but recent observations have indicated that calcium and oxalate influence the supersaturation with approximately equal power (108). rmo). with or without a pharmacological agent * Optional procedure that is recommended if it is likely that the information obtained can be useful for designing the subsequent treatment. that pharmacological treatment always should be combined with appropriate changes in dietary and drinking habits. In the absence of any common biochemical risk factors. In patients with incomplete distal renal tubular acidosis. Recommendations although there is no place for monotherapy with magnesium salts.17. however. citrate excretion and stone formation (109). For patients with mild recurrent calcium stone disease and without residual stones or fragments (So. Table 27: Suggested treatment for patients with specific abnormalities in urine composition Suggested treatment Thiazide + potassium citrate oxalate restriction Potassium citrate Potassium citrate calcium supplement oxalate absorption High excretion of sodium restricted intake of salt Small urine volume Increased fluid intake urea level indicating a high avoid excessive intake of animal Intake of animal protein protein distal renal tubular acidosis Potassium citrate Primary hyperoxaluria Pyridoxine no abnormality identified High fluid intake LE = Level of evidence. recommendations for a selective therapeutic approach are given in Table 27. it might be worthwhile applying a more aggressive treatment based on urinary findings as this approach has resulted in effective counteraction of active stone formation and growth of residuals (106). a regimen that has a positive effect on the acidosis.1. with or without a pharmacological agent rs Yes Specific advice. It has been assumed that oxalate is more powerful than calcium in affecting supersaturation with calcium oxalate. 102 uPdaTE MarcH 2008 . rm-res). this alternative is mentioned because of its possible role in prevention of brushite stones. but there is so far insufficient scientific evidence for this approach (107). it seems sufficient to give the patient general advice regarding dietary and fluid intake. It is therefore essential to correct abnormalities of both variables. For patients with a similar history of stone formation but with residual stones or fragments in the kidneys (Sres. a combination with thiazides might prove useful. irrespective of whether or not the patient has residual stone-fragments (Table 28). an analysis of data from the literature. urinary Stones: diagnosis.nih. Tiselius Hg. auer d.nlm. commentary: renal calculi–twenty years later. Morimoto S. garside J. eds.gov/pubmed/15840041 Hess B.174(2):590-4. Enteric and mild hyperoxaluria. 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In: Tiselius Hg. Lancet 1989.nlm.gov/pubmed/6837228 kang dE.5 L (2-5). pp. ed.24(3):392-403. http://www. Briganti a. Low-oxalate.gov/pubmed/4118468 coe FL. Wikström B.nlm.nlm. The intake of animal protein should not exceed 0.gov/pubmed/6645213 Milliner dS. These two abnormalities provide the basis for precipitation of uric acid.gov/pubmed/15496176 Preminger gM.0 (3). Springhart WP. http://www. Prevention of recurrent calcium stone formation with potassium citrate therapy in patients with distal renal tubular acidosis. allegri F. Tiselius Hg. Linköping: university Hospital.331(23):1553-8.nih.nih. ayiomamitis a. 107.nlm. Pearle MS.55(3):1041-50. J urol 2007.1 and 7.ncbi. oreopoulos dg. Pak cY.nih. Treatment of enteric hyperoxaluria with calcium-containing organic marine hydrocolloid. Kidney Stones. Washington dc: The national academies Press.ncbi. Barolla d. 9). 24-hour urine volume exceeding 2-2. J clin Invest 1977. 973-989. http://www. References Tiselius Hg.ncbi.nlm. It is interesting to know that a combination of alkali.gov/pubmed/17678984 Food and nitrition Board. urol clin north am 1997. 7. Table 29: pharmacological treatment of uric acid stone disease Therapeutic measures Urine dilution a high fluid intake.nlm. Stoller ML. Winearls cg. aettiological factors in stone formation. 5. grunfeld J-P. http://www.nih.gov/pubmed/16200192 Welch BJ. graybeal d. Preminger gM. Pak cYc. Medical and Surgical Management.nih. uric acid nephrolithiasis.ncbi. 3rd edn. Objective Prevention Ref 2-5 8-11 12 LE 3 2b 3 gR B B B 13. oxford: oxford university Press. pp. J clin Invest 2005. urinary Stones: diagnosis.168(4 Pt 1):1307-14.edu/catalog/10490. Sakhaee k. but with this therapy the risk of calcium phosphate stones is more pronounced because of the simultaneous decrease in citrate excretion. Worcester E.48(4):555-63. Maalouf nM. Mechanism for calcium urolithiasis among patients with hyperuricosuria: supersaturation of urine with respect to monosodium urate.ncbi.nlm. J urol 2002.gov/pubmed/16997051 Pak cY.gov/pubmed/9048857 Shekarriz B. Low rk.2. Moe oW.nih. kerr dn. uric acid stones. The pharmacological treatment of patients with uric stone disease is outlined in Table 29. allopurinol and a high fluid intake can be used to dissolve uric acid stones.nlm.3 1. cameron JS.34(3):335-46. cameron Ma. Lopez ML. eds. kidney stone disease. eds. Jahnen a. Favus MJ.5L uric acid Alkalinization stones Potassium citrate 6-10 mmol x 2-3 always reduce urate excretion allopurinol 300 mg x 1 LE = level of evidence.gov/pubmed/14173 uPdaTE MarcH 2008 109 . Oxford Textbook of Clinical Nephrology. 3. http://www. 4. This is because the solubility of potassium urate is greater than that of sodium urate (10.nih. Biochemical and stone-risk profiles with topiramate treatment. uric acid nephrolithiasis: current concepts and controversies.html coe FL. 9. 10.nlm.ncbi.115(10):2598-608. In: davison aM. http://www. Evan a. although both sodium bicarbonate and sodium citrate can be used to obtain an alkaline pH (1 g of sodium bicarbonate corresponds to 12 mmol and the recommended dose is 1 g x 3) the preferred agent is potassium citrate.to be less common than expected. Basel: karger. ritz E. 6. http://books. 1201-1223. Fiber. Sakhaee k. Fatty acids.nih. cholesterol.nlm. urol clin north am 2007. rodman JS.5 L Alkalinization Potassium citrate 3-7 mmol x 2-3 In patients with a high serum or urine level of urate allopurinol 300 mg x 1 Medical Urine dilution dissolution of a high fluid intake.14 4 1b 4 c a c 2. am J kidney dis 2006. 1996. 2002 dietary reference Intakes for Energy. cox c. uric acid-related nephrolithiasis. Treatment and Prevention of recurrence. For further alkalinization. 589-786. pp. 8.nih. Philadelphia: Lippincott-raven. Parks JH. Sosa E.59(3):426-31. http://www. pp. it has been suggested that acetazolamide or topiratmate might be considered (8. Tiselius Hg. Stoller ML. diagnosis and treatment of uric acid calculi.gov/pubmed/12352383 Hesse a. http://www. 2002:73-91. 11) and potassium does not increase the excretion of calcium. GR = grade of recommendation 17. In: coe FL. Protein and amino acids. carbohydrate.ncbi. 24-hour urine volume exceeding 2-2. Waters o. arnold L.24(1):135-48. Holt k. a reduced excretion of urate is accomplished with allopurinol and this agent should be used when the 24-hour urate excretion exceeds 4 mmol (12).nap. 2005. Fat. 2002. nlm. kippen I. probably more effective in reducing urinary cystine. http://www. but a substantial increment in solubility does not occur unless the pH is above 7. the daily dose is 1-2 g. white blood cells and thromocytes. 12).3 Medical treatment of cystine stone disease 17. or at least below its formation product.ncbi. 11. a third alternative is captopril (an angiotensin-converting enzyme inhibitor). a more accurate recommendation of the size of urine volume needed can be obtained by knowing the ion-activity product of cystine. Hess B.gov/pubmed/3784284 Mattle d. 17. Thiol compounds. sodium citrate or sodium potassium citrate should not be given because of the undesirable effect of sodium on the excretion of cystine (1). complex formation by chelating agents is necessary (2. The rule of thumb is that the solubility of cystine is approximately 250 mg/L (1 mmol/L) at pH 7.3 Pharmacological treatment The solubility of cystine increases in alkaline urine. a considerable fluid intake evenly distributed during the day is necessary. http://www.gov/pubmed/15875173 Shekarriz B.ncbi.9) and α-mercaptopropionyl glycine (tiopronin) (8-10). Med Biol Eng 1972. J urol 2002. When the combined effects of a high diuresis and alkalinization are not enough to prevent stone formation.gov/pubmed/5074854 Pak cY.gov/pubmed/12352383 17. For pencillamine. To alkalinize the urine.168(4 Pt 1):1307-14. but the required dose has to be determined by the effect this regimen has on urinary pH. http://www. 500 mg (2 mmol/L) at pH 7.5.nih.nih.1 Dietary recommendations although a diet low in methionine theoretically might be of value for reducing urinary excretion of cystine.5 and 750 mg (3 mmol/L) at pH 8 (2). but the daily required dose might be in the range 250-2000 mg.10(4):522-31. urol res 2005. The recommended dose is 50 mg/day. Fuller c. Moreover. Sakhaee k.11. uric acid nephrolithiasis: current concepts and controversies. the goal is a 24-hour urine volume of at least 3 L (2. the intake should be at least 150 ml/h Alkalinization For patients with a cystine excretion below 3 mmol/24h: References 1-3 LE 3 gR B 1-3 3 B 110 uPdaTE MarcH 2008 .ncbi. administration of thiols always should be accompanied by pyridoxine to avoid vitamin B6-deficiency. such as d-penicillamine (8. potassium citrate is the best alternative. klinenberg Jr. Sodium bicarbonate. Patients who are treated with thiols should regularly be examined with analysis of blood haemoglobin. To achieve this goal. The administration of acetazolamide can be used to improve the alkalinization (5). 17.3. Solubility of uric acid and monosodium urate. 3). kidney Int 1986.nlm. The latter compound seems to be associated with fewer side effects than penicillamine.nlm.2 Drinking advice a high diuresis is of fundamental importance. The aim is to dilute the urine so that supersaturation with cystine is decreased below the solubility product of cystine. Stoller ML. khalaf a. however. The recommended daily dosage is 10-15 mg/kg (or 750 mg/day). a typical dose of potassium citrate is 20-25 mmol per day given three times a day.nih.ncbi. the urine should be checked for proteinuria. Table 30: pharmacological treatment of patients with cystine stone disease Therapeutic measures Urine dilution a high fluid intake should be recommended so that the 24-h urine volume exceeds 3000 mL. 14. Successful management of uric acid nephrolithiasis with potassium citrate.3. The recommendation given is to avoid a daily consumption of sodium above 2 g (1). Preventive treatment of nephrolithiasis with alkali citrate--a critical review. 12.3. To reach this goal. are most commonly used. which can be calculated from the cystine concentration and the pH (4). 7). http://www. Weinberger a. The treatment of patients with cystine stone disease is outlined in Table 30. 6.33(2):73-9. 13. a restricted intake of sodium is. such a step is unlikely to result in reasonable compliance by the patient and this regimen is not usually used or recommended.nih.nlm. Positive effects on urinary cystine and stone formation have been reported with a daily dose of 75-100 mg (1. Wilcox Wr. In general.30(3):422-8. http://www.nih.nih. 5. http://journals. http://www.ncbi.gov/pubmed/13276628 Tiselius Hg. 1996. Philadelphia: Lippincottraven.142(6):1522-4. Parks Hg.61(2):86-9.nlm. Watts rW.13(9):645-51. Scowen EF. rosenberg LE.nih. Preminger gM. GR = grade of recommendation 17. Méjean a.gov/pubmed/7342491 Barbey F. 2006:175-83.ncbi. urol clin north am 2007.160(2):341-4. BMJ 1963.1(5330):588-90. 1-7 3 B 3. assimos dg. Management of cystinuria.4.gov/pubmed/1113405 rogers a.ncbi.27(4):317-32. http://www. nozumi k. 8.gov/pubmed/10608516 Biyani cS.gov/pubmed/14023737 Halperin Ec.nlm. Pak cYc.nlm.ncbi.ncbi.gov/pubmed/9679873 crawhall Jc. urol Int 1998. eds. issue 5. Favus MJ. 10. The use of d-penicillamine in cystinuria: efficacy and untoward reactions.nlm.nih. http://www. contemporary management of cystinuria. 6.ncbi. cystinuria–diagnosis and Management. Yale J Biol Med 1981. kalakish S. pp.4 1. It is fundamental that the renal collecting system is cleared of stone material to prevent recurrence in patients with infection stone disease. Solution chemistry of supersaturation. Ito H.nih.gov/pubmed/2685368 akakura k. 9.gov/pubmed/10751848 Streem SB. J Endourol 1999. 33-64. Egoshi k.nlm. J urol 2000.Potassium citrate 3-10 mmol x 2-3 should be given to achieve a pH > 7.elsevierhealth. Effect of captopril on urinary cystine excretion in homozygous cystinuria. The long-term outcome of cystinuria in Japan. Br J urol 1955. http://www.4 Management of patients with infection stones 17. 4. J urol 1998.1 Pharmacological treatment of infection stone disease The pharmacological treatment of patients with infection stone disease is outlined in Table 31. 2. Freed SZ. http://www.ncbi. Effect of penicillamine on cystinuria. 11. Joly d. Masai M. References ng cS. Medical treatment of cystinuria: critical reappraisal of long-term results. LE = 3 gR = C uPdaTE MarcH 2008 111 . These stones are caused by urease-producing micro-organisms. desai ra.nlm. http://www. ueda T. The alternating use of an alkalizing salt and acetazolamide in the management of cystine and uric acid stones. http://www. daudon M. Streem SB. Hall P.113(1):96-9. 75-150 mg LE = level of evidence.nih.54(6):439-46. cartledge JJ. Their So. The definition of infection stones is stones composed of magnesium ammonium phosphate and carbonate apatite.nih. J urol 1989. kotake T. contemporary urological intervention for cystinuric patients: immediate and long-term impact and implications. Streem SB.ncbi. rieu P.nih. http://www. Studies on the treatment of cystinuria.3. Kidney Stones: Medical and Surgical Management.nih.nlm.34(3):347-62.nih. Jungers P.gov/pubmed/9873246 17. J urol 1975.gov/pubmed/17678985 chow gk.ncbi.nlm. It is fundamental that the renal collecting system is cleared from stone material. In: coe FL. http://www. 7.nlm. Senior B.com/periodicals/eeus/issues/contents dent cE. 12. 250-2000 mg/day or captopril.nlm.163(5):1419-23.5 Complex formation with cystine For patients with a cystine excretion above 3 mmol/24 or when other measures are insufficient Tiopronin (α-mercapto-propionyl glycine). Eau-EBu update Series 4.ncbi. Jarrar k. Longuet r. http://www.30(3):112-17. Preminger gM. randomized double-blind trial of Lithostat (acetohydroxamic acid) in the palliative treatment of infection induced urinary calculi. Earle n.45(6):336-41. 6 2.nih. Lee H. 6. Pak cYc. 1996. Favus MJ.141(3 Pt 2):770-4.nlm. http://www. griffith dP.nih. pp. Medical management and prevention of struvite stones. Peterson cM.nlm. Kidney Stones: Medical and Surgical Management.ncbi.20(3):243-7. clinical and laboratory approaches for evaluation of nephrolithiasis.Table 31: pharmacological treatment of infection stone disease 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 1-2 x 3 Urease inhibition In very selected cases with severe infections. gleeson MJ.ncbi. Eur urol 1991.ncbi. References 1 LE 4 gR c 2 3 3 3 3 1b B B B B a 4 3 5. Weidner W. 4.ncbi.nlm. http://www.gov/pubmed/6472365 112 uPdaTE MarcH 2008 .2 1. riedl cr. urol Int 1990.ncbi. deman E. rodman JS.nih.311(12):760-4. 941-50.nih. Tiselius Hg. GR = grade of recommendation 17. treatment with acetohydroxamic acid (Lithostat) might be a therapeutic option LE = level of evidence.4.nih.nlm. 5.gov/pubmed/8766146 Wall I. References Wilson dM. ann urol (Paris) 1996. Parks JH.n Engl J Med 1984. Struvite stones: long term follow up under metaphylaxis. 3. http://www. J urol 1989. Boedeker rH.nlm. Philadelphia: Lippincott-raven. In: coe FL.gov/pubmed/2288050 griffith dP. a randomized double blind study of acetohydroxamic acid in struvite nephrolithiasis. Long-term acidification of urine in patients treated for infected renal stones. eds.gov/pubmed/1726639 Williams JJ. http://www.gov/pubmed/2918617 Wong HY. ABBREVIATIONS USED IN THE TEXT This list is not comprehensive for the most common abbreviations aPcaox aPcaP aP(caox) index aP(caP) index aua ca caHPo42H2o caox caP cI cIs cIrF cit cT cY Eau EHL ESWL gFr gr Hcl Ho:Yag InF IVP IVu kuB LE l MET Mg MrEu Mru nd: nH4cl nSaId ox PnL rIrS rmo rm-res rs rTa Sa So Sres SWL THaM ur urS uS uTI V w ion-activity product of calcium oxalate ion-activity product of calcium phosphate approximate estimate of aPcaox approximate estimate of aPcaP american urological association calcium calcium hydrogen phosphate calcium oxalate calcium phosphate confidence interval credible intervals clinically insignificant residual fragments citrate computed tomography cystine stone European association of urology electrohydraulic lithotripsy extracorporeal shock-wave lithotripsy. ureters and bladder level of evidence length (of stone) medical expulsive therapy magnesium Mr excretory urography Magnetic resonance urography Yag frequency doubled laser ammonium chloride non-steroidal anti-inflammatory drug oxalate percutaneous nephrolithotomy with or without lithotripsy retrograde intrarenal surgery 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 shock-wave lithotripsy trihydroxymethyl aminomethan uric acid/sodium urate/ammonium urate stone ureteroscopy ultrasonography urinary tract infection urine volume width (of stone) uPdaTE MarcH 2008 113 . also including piezolithotripsy glomerular filtration rate grade of recommendation hydrochloric acid holmium:yttrium aluminium garnet infection stone intravenous pyelography Intravenous urography plain abdominal film of the kidneys.18. an uS transducer and a probe. The reported results indicate that the Ho:Yag efficacy is superior to the nd:Yag and does effectively fragment all types of urinary stones. which are available in sizes 10 F and 12 F. with a tissue penetration of 4 mm. rods are 2. are passed through the straight working channel of a rigid ureteroscope or nephroscope. with a tissue penetration of less than 0. recently. It has been quite successful in fragmenting ureteral and intrarenal stones. The nd:Yag is used frequency-doubled and produces light of 1064 nm. The Ho:Yag system produces light of 2100 nm. EHL will effectively fragment all kinds of urinary stones. a 1.19.000. The electrical discharge is transmitted to the probe where it generates a spark at the tip. ELECTROHYDRAULIC LITHOTRIPSY The electrohydraulic lithotripsy (EHL) unit has a probe.000 Hz).6 F EHL probe was developed. Fibres for ureteroscopy are available for both lasers at 200 and 365 μm in diameter. The intense heat produced in the immediate area surrounding the tip results in a cavitation bubble. the calculus can be disintegrated. which produces a shock wave that radiates spherically in all directions.4-6 F in diameter and can be used through a semi-rigid ureteroscope and all rigid endoscopes. ULTRASONIC LITHOTRIPSY These commercially available units consist of a power generator. The probes. uric acid and calcium oxalate monohydrate. a piezoceramic element in the handle of the sonotrode is stimulated to resonate. including cystine stones. neodymium:yttrium-aluminium-garnet (nd:Yag) or holmium:Yag (Ho:Yag) lasers are used as sources for laser lithotripsy units. The probe consists of a central metal core and two layers of insulation with another metal layer between them.5 mm and complete absorption in water. In combination with the actively deflectable. and this converts electrical energy into uS waves (at a frequency of 23. It has superior flexibility compared to the laser fibre. Suction tubing can be connected to the end of the sonotrode. Potential complications of the Ho:Yag laser when used to fragment ureteral stones include possible perforation of the ureteral wall and consecutive formation of strictures. 114 uPdaTE MarcH 2008 . LASER LITHOTRIPSY Today. a similar effect is obtained by alternating mechanical displacement. forming the sonotrode. flexible ureteroscope. Pulses drive a metallic bullet that bumps the end of the rod against the stone. When the vibrating tip is brought into contact with the surface of a stone. The uS waves are transmitted along the hollow metal probe to create a vibrating action at its tip. AppENDICES AppENDIX 1: Devices for endoscopic disintegration of stones BALLISTIC LITHOTRIPSY Ballistic lithotripsy involves a device in which alternating compression caused by air or electromechanical forces is transmitted to a metal rod. Probes are flexible and available in many sizes for use in rigid and flexible nephroscopes. wherever they are located and whatever their composition.27. a power generator and a foot pedal. including very hard stones composed of cystine. the Ho:Yag laser has proven to be ideally suited for fragmenting stones in the upper ureter. 6 35 47 59 94 106 118 130 141 153 165 177 188 200 212 224 236 247 259 271 283 294 16 12.8 1.5 52 69 86 104 121 138 155 173 190 207 225 242 259 276 294 311 328 345 363 380 397 414 432 an approximate estimate of the stone surface area (mm2) can be extracted from the length and width on the kuB.1 38 50 63 88 100 113 126 138 151 163 176 188 201 214 226 239 251 264 276 289 301 314 93 107 120 133 147 160 173 187 200 214 227 240 254 267 280 294 307 320 334 99 113 127 141 155 170 184 198 212 226 240 254 268 283 297 311 325 339 353 17 13.1 4.7 9. 23 18.7 6 8 uPdaTE MarcH 2008 3 14 19 24 28 33 38 42 47 52 57 61 66 71 75 80 85 82 77 88 71 82 66 75 85 60 69 78 86 55 63 71 79 86 49 57 64 71 78 85 92 44 50 57 63 69 75 82 88 38 44 49 55 60 66 71 77 82 88 93 33 38 42 47 52 57 61 66 71 75 80 85 89 94 27 31 35 39 43 47 51 55 59 63 67 71 75 79 82 86 90 22 25 28 31 35 38 41 44 47 50 53 57 60 63 66 69 72 75 94 16 19 21 24 26 28 31 33 35 38 40 42 45 47 49 52 54 57 2. The calculated surface area for any combination of stone diameters up to 25 mm is shown in Table a1.Length mm 5 9 11 13 14 16 17 19 20 22 24 25 27 28 30 31 33 35 36 38 39 5 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 Width mm 1 0.1 28.6 17.4 4.1 6.3 42 57 71 19 14.1 36.0 16 22 27 99 104 110 115 121 126 132 137 8 6.4 14 19 24 99 104 108 113 118 7 5.3 12.3 34.4 47 63 79 21 16.0 49 66 82 Table A1: Approximate stone surface area (mm2) calculated from the length and width of the stone 22 17.9 12 16 20 6 4.1 21 28 35 99 106 113 120 127 134 141 148 155 162 170 177 10 7.3 26 35 43 95 104 112 121 130 138 147 155 164 173 181 190 199 207 216 12 9.6 19 25 31 94 100 107 113 119 126 132 138 144 151 157 9 7.6 25.0 33 44 55 15 11.9 15.7 31.5 33.8 28 38 47 94 104 113 122 132 141 151 160 170 179 188 198 207 217 226 236 13 10.2 20.9 30 45 60 75 89 104 119 134 149 164 179 194 209 224 239 254 268 283 298 313 328 343 358 373 94 110 126 141 157 173 188 204 220 236 251 267 283 298 314 330 345 361 377 393 99 115 132 148 165 181 198 214 231 247 264 280 297 313 330 346 363 379 396 412 AppENDIX 2: Approximate stone surface area with known diameters of the stone 20 15.1 9 12 59 79 98 4 3.4 13 16 5 3.3 27 40 53 67 18 14.4 31 41 51 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 11.6 2.1 54 72 90 108 126 144 162 181 199 217 235 253 271 289 307 325 343 361 379 397 415 433 451 115 24 18.7 57 75 94 113 132 151 170 188 207 226 245 264 283 301 320 339 358 377 396 414 433 452 471 .1 14.8 23.8 37.4 3 4 2 1.7 7.7 24 31 39 94 102 110 118 126 133 141 149 157 165 173 181 188 196 11 8.6 3.4 18.0 22.9 7.3 9.5 11. no external sources of funding and support have been involved. This information is kept on file in the European association of urology central office database. This guidelines document was developed with the financial support of the European association of urology. 116 uPdaTE MarcH 2008 . The Eau is a non-profit organisation and funding is limited to administrative assistance and travel and meeting expenses. no honoraria or other reimbursements have been provided.Conflict of interest all members of the urolithiasis guidelines writing panel have provided disclosure statements on all relationships that they have and that might be perceived to be a potential source of conflict of interest.
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