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Common Urological Problems

Urinary Stone Disease

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Urinary calculi are the third most common affliction of the urinary tract, exceeded only by urinary tract infections and pathologic conditions of the prostate. They are common in both animals and humans. The nomenclature associated with urinary stone disease arises from a variety of disciplines. Struvite stones, for example, composed of magnesium ammonium phosphate hexahydrate, are named in honor of H.C.G. von Struve (1772-1851), a Russian naturalist. image

Before the time of von Struve, the stones were referred to as guanite, because magnesium ammonium phosphate is prominent in bat droppings. Calcium oxalate dihydrate is frequently referred to as weddellite, because it was commonly found in floor samples collected from the Weddell Sea in Antarctica. The history of the nomenclature associated with urinary stone disease is as intriguing as that of the development of the interventional techniques used in their treatment.

Urinary stones have plagued humans since the earliest records of civilization. The etiology of stones remains speculative. If urinary constituents are similar in each kidney and if there is no evidence of obstruction, why do most stones present in a unilateral fashion? Why don't small stones pass uneventfully down the ureter early in their development? Why do some people form one large stone and others form multiple small calculi? There is much speculation concerning these and other questions. Advances in the surgical treatment of urinary stones have outpaced our understanding of their etiology. As clinicians we are concerned with an expedient diagnosis and efficient treatment.

Urinary Stone Disease

Urinary Stone Disease

Equally important is a thorough metabolic evaluation directing appropriate medical therapy and lifestyle changes to help reduce recurrent stone disease. Without such follow-up and medical intervention, stone recurrence rates can be as high as 50% within 5 years. Uric acid calculi can recur even more frequently. Physicians look forward to gaining a better understanding of this multifactorial disease process in hopes of developing more effective prophylaxis.

Marshall L. Stoller, MD

Ions In Urinary Stone Formation
Ackermann D et al: Influence of calcium content in mineral water on chemistry and crystallization conditions in urine of calcium stone formers. Eur Urol 1988;14:305.
Allie-Hamdulay S et al: Prophylactic and therapeutic properties of a sodium citrate preparation in the management of calcium oxalate urolithiasis: Randomized, placebo-controlled trial. Urol Res 2005;33:116.
Bilezikian JP et al: Primary hyperparathyroidism: New concepts in clinical, densitometric and biochemical features. J Intern Med 2005;257:6.
Fellstrom B et al: Dietary habits in renal stone patients compared with healthy subjects. Br J Urol 1989;63:575.
Gentle DL et al: Geriatric nephrolithiasis. J Urol 1997;158:2221.
Heller HJ et al: Effect of dietary calcium on stone forming propensity. J Urol 2003;169:470.
Langley SE, Fry CH: The influence of pH on urinary ionized [Ca2+]:
Differences between urinary tract stone formers and normal subjects. Br J Urol 1997;79:8.
Massey LK et al: Ascorbate increases human oxaluria and kidney stone risk. J Nutr 2005;135:1673.
Milosevic D et al: Determination of urine saturation with computer program EQUIL 2 as a method for estimation of the risk of urolithiasis. J Chem Inf Comput Sci 1998;38:646.
Moe OW, Bonny O: Genetic hypercalciuria. J Am Soc Nephrol 2005;16:729.
Parivar F, Low RK, Stoller ML: The influence of diet on urinary stone disease. J Urol 1996;155:432.
Preminger GM, Sakhaee K, Pak CY: Alkali action on the urinary crystallization of calcium salts: Contrasting responses to sodium citrate and potassium citrate. J Urol 1988;139:240.
Sheng X et al: Adhesion at calcium oxalate crystal surfaces and the effect of urinary constituents. Proc Natl Acad Sci U S A 2005;102:267.
Taylor EN, Stampfer MJ, Curhan GC: Dietary factors and the risk of incident kidney stones in men: new insights after 14 years of follow-up. J Am Soc Nephrol 2004;15:3225.

Asplin JR: Hyperoxaluric calcium nephrolithiasis. Endocrinol Metab Clin North Am 2002;31:927.
Holmes RP, Assimos DG: The impact of dietary oxalate on kidney stone formation. Urol Res 2004;32:311.
Kok DJ et al: The effects of dietary excesses in animal protein and in sodium on the composition and the crystallization kinetics of calcium oxalate monohydrate in urines of healthy men. J Clin Endocrinol Metab 1990;71:861.
Massey LK: Dietary influences on urinary oxalate and risk of kidney stones. Front Biosci 2003;8:s584.
Preputial calculi are rare and usually occur in adults. They develop secondary to a severe obstructive phimosis.
Ryall RL: The scientific basis of calcium oxalate urolithiasis: Predilection and precipitation, promotion and proscription. World J Urol 1993;11:59.
Ryall RL et al: Urinary risk factors in calcium oxalate stone disease: Comparison of men and women. Br J Urol 1987;60: 480.
Tiselius HG: Standardized estimate of the ion activity product of calcium oxalate in urine from renal stone formers. Eur Urol 1989;16:48.
Traxer O et al: Effect of ascorbic acid consumption on urinary stone risk factors. J Urol 2003;170:397.

Caramia G et al: Uric acid, phosphate and oxalate stones: Treatment and prophylaxis. Urol Int 2004;72:24.

Uric Acid
Low RK, Stoller ML: Uric acid-related nephrolithiasis. Urol Clin North Am 1997;24:135.
Marangella M: Uric acid elimination in the urine. Pathophysiological implications. Contrib Nephrol 2005;147:132.
Sakhaee K, Adams-Huet B, Moe OW, Pak CY: Pathophysiologic basis for normouricosuric uric acid nephrolithiasis. Kidney Int 2002;62:971.
Shekarriz B, Stoller ML: Uric acid nephrolithiasis: Current concepts and controversies. J Urol 2002;168:1307.
Stoller ML: Gout and stones or stones and gout? J Urol 1995;154:1670.
Yu TF: Urolithiasis in hyperuricemia and gout. J Urol 1981;126:424.

Assimos DG et al: The impact of cystinuria on renal function. J Urol 2002;168:27.
Gupta M, Bolton DM, Stoller ML: Etiology and management of cystine lithiasis. Urology 1995;45:344.
Pietrow PK et al: Durability of the medical management of cystinuria. J Urol 2003;169:68.
Purohit RS, Stoller ML: Stone clustering of patients with cystine urinary stone formation. Urology 2004;63:630.
Sakhaee K, Poindexter JR, Pak CY: The spectrum of metabolic abnormalities in patients with cystine nephrolithiasis. J Urol 1989;141:819.
Shekarriz B, Stoller ML: Cystinuria and other noncalcareous calculi. Endocrinol Metab Clin North Am 2002;31:951.

Hediger MA et al: Molecular physiology of urate transport. Physiology (Bethesda) 2005;20:125.
Kario K, Matsuo T, Tankawa H: Xanthine urolithiasis: Ultrastructure analysis of renal and bladder calculi. Int Urol Nephrol 1991;23:317.

Daudon M, Jungers P: Drug-induced renal calculi: Epidemiology, prevention and management. Drugs 2004;64:245.

Lee MH et al: Silica stone-Development due to long time oral trisilicate intake. Scand J Urol Nephrol 1993;27:267.

Matrix Urinary Calculi
Bani-Hani AH et al: Urinary matrix calculi: Our experience at a single institution. J Urol 2005;173:120.
Iwata H et al: The organic matrix of urinary uric acid crystals. J Urol 1988;139:607.

Urinary Stone Inhibitors
Seltzer MA et al: Dietary manipulation with lemonade to treat hypocitraturic calcium nephrolithiasis. J Urol 1996;156:907.
Shah O et al: Genetic and dietary factors in urinary citrate excretion. J Endourol 2005;19:177.

Orthophosphates & Pyrophosphates
Gettman MT, Segura JW: Struvite stones: Diagnosis and current treatment concepts. J Endourol 1999;13:653.
Wolf JS, Stoller ML: Inhibition of calculi fragment growth by metal bisphosphonate complexes demonstrated with a new assay measuring the surface activity of urolithiasis inhibitors. J Urol 1994;152:1609.

Urinary Proteins
Khan SR: Interactions between stone-forming calcific crystals and macromolecules. Urol Int 1997;59:59.
Selvam R, Kalaiselvi P: Oxalate binding proteins in calcium oxalate nephrolithiasis. Urol Res 2003;31:242.

Trace Elements
Gentle DL et al: Protease inhibitor-induced urolithiasis. Urology 1997;50:508.
Puche RC et al: Increased fractional excretion of sulphate in stone formers. Br J Urol 1993;71:523.
Schwartz BF, Bruce J, Leslie S, Stoller ML: Rethinking the role of urinary magnesium in calcium urolithiasis. J Endourol 2001;15:233.

2, 8-Dihydroxyadenine Urolithiasis
Edvardsson V et al: Clinical features and genotype of adenine phosphoribosyltransferase deficiency in Iceland. Am J Kidney Dis 2001;38:473.
Hesse A et al: 2, 8-Dihydroxyadeninuria: Laboratory diagnosis and therapy control. Urol Int 1988;43:174.

Renal Tubular Acidosis
Buckalew VM Jr: Nephrolithiasis in renal tubular acidosis. J Urol 1989;141:731.
Caruana RJ, Buckalew VM Jr: The syndrome of distal (type 1) renal tubular acidosis: Clinical and laboratory findings in 58 cases. Medicine 1988;67:84.
Homayoon K: Spontaneous steinstrasse due to renal tubular acidosis. Br J Urol 1996;77:610.
Singh PP et al: A study of recurrent stone formers with special reference to renal tubular acidosis. Urol Res 1995;23:201.

Borghi L et al: Urine volume: Stone risk factor and preventive measure. Nephron 1999;81:31.
Meschi T et al: Body weight, diet and water intake in preventing stone disease. Urol Int 2004;72:29.
Robertson WG: Renal stones in the tropics. Semin Nephrol 2003;23:77.

Urinary Stone Disease in Uncommon Situations
Spinal Cord Dysfunction
Chen Y et al: Recurrent kidney stone: A 25-year follow-up study in persons with spinal cord injury. Urology 2002;60:228.
Wan J et al: Urinary tract status of patients with neurogenic dysfunction presenting with upper tract stone disease. J Urol 1992;148:1126.

McAleer SJ, Loughlin KR: Nephrolithiasis and pregnancy. Curr Opin Urol 2004;14:123.
Smith CL et al: An evaluation of the physicochemical risk for renal stone disease during pregnancy. Clin Nephrol 2001;55:205.
Strothers L, Lee LM: Renal colic in pregnancy. J Urol 1992;148: 1383.

Renal Transplantation
Benoit G et al: Occurrence and treatment of kidney graft lithiasis in a series of 1500 patients. Clin Transplant 1996;10:176.
Dumoulin G et al: Lack of increased urinary calcium-oxalate supersaturation in long-term kidney transplant recipients. Kidney Int 1997;51:804.
Klingler HC et al: Urolithiasis in allograft kidneys. Urology 2002;59:344.
Lu HF, Shekarriz B, Stoller ML: Donor-gifted allograft urolithiasis: Early percutaneous management. Urology 2002;59:25.

Ekeruo WO et al: Metabolic risk factors and the impact of medical therapy on the management of nephrolithiasis in obese patients. J Urol 2004;172:159.
Hofmann R, Stoller ML: Endoscopic and open stone surgery in morbidly obese patients. J Urol 1992;148:1108.
Koo BC, Burtt G, Burgess NA: Percutaneous stone surgery in the obese: Outcome stratified according to body mass index. BJU Int 2004;93:1296.
Taylor EN, Stampfer MJ, Curhan GC: Obesity, weight gain, and the risk of kidney stones. JAMA 2005;293:455.

Anatomic Renal Anomalies
Baskin LS, Floth A, Stoller ML: The horseshoe kidney: Therapeutic considerations with urolithiasis. J Endourol 1989;(3): 51.
Raj GV et al: Percutaneous management of calculi within horseshoe kidneys. J Urol 2003;170:48.
Sheir KZ et al: Extracorporeal shock wave lithotripsy in anomalous kidneys: 11-year experience with two second-generation lithotripters. Urology 2003;62:10.
Yohannes P, Smith AD: The endourological management of complications associated with horseshoe kidney. J Urol 2002;168:5.

Boormans JL et al: Percutaneous nephrolithotomy for treating renal calculi in children. BJU Int 2005;95:631.
Schuster TG et al: Ureteroscopy for the treatment of urolithiasis in children. J Urol 2002;167:1813.
Tan AH et al: Results of shockwave lithotripsy for pediatric urolithiasis. J Endourol 2004;18:527.

Caliceal Diverticulae
Miller SD et al: Laparoscopic management of caliceal diverticular calculi. J Urol 2002;167:1248.
Schwartz BF, Stoller ML: Percutaneous management of caliceal diverticula. Urol Clin North Am 2000;27:635.

Mhiri MN et al: Association between squamous cell carcinoma of the renal pelvis and calculi. Br J Urol 1989;64:201.
Raghavendran M et al: Stones associated renal pelvic malignancies. Indian J Cancer 2003;40:108.

Medical Therapy
Kato Y et al: Changes in urinary parameters after oral administration of potassium-sodium citrate and magnesium oxide to prevent urolithiasis. Urology 2004;63:7.
Pak CY, Peterson R, Poindexter JR: Adequacy of a single stone risk analysis in the medical evaluation of urolithiasis. J Urol 2001 Feb;165:378-81.
Pearle MS, Roehrborn CG, Pak CY: Meta-analysis of randomized trials for medical prevention of calcium oxalate nephrolithiasis. J Endourol 1999;13:679.
Preminger GM: The metabolic evaluation of patients with recurrent nephrolithiasis: A review of comprehensive and simplified approaches. J Urol 1989;141:760.

Surgical Therapy
Albala DM et al: Lower pole I: A prospective randomized trial of extracorporeal shock wave lithotripsy and percutaneous nephrostolithotomy for lower pole nephrolithiasis-initial results. J Urol 2001 Dec;166:2072-80.
Al-Kohlany KM et al: Treatment of complete staghorn stones: A prospective randomized comparison of open surgery versus percutaneous nephrolithotomy. J Urol 2005;173:469.
Assismos DG et al: A comparison of anatrophic nephrolithotomy and percutaneous nephrolithotomy with and without extracorporeal shock wave lithotripsy for management of patients with staghorn calculi. J Urol 1991;145:710.

Extracorporeal Shock Wave Lithotripsy
Barcena M et al: EMLA cream for renal extracorporeal shock wave lithotripsy in ambulatory patients. Eur J Anaesthesiol 1996;13:373.
Baskin LS, Floth A, Stoller ML: Monitored anesthesia care with the standard Dornier HM3 lithotriptor. J Endourol 1990;4:49.
Chaussy CG et al: First clinical experience with extracorporeally induced destruction of kidney stones by shock waves. J Urol 1982;127:417.
Drach GW et al: Report of the United States cooperative study of extracorporeal shock wave lithotripsy. J Urol 1986;135: 1127.
Dretler SP: Stone fragility: A new therapeutic distinction. In: Lingeman JE, Newman DM (editors): Shock Wave Lithotripsy: State of the Art. Plenum Press, 1988.
Elbahnasy AM et al: Lower caliceal stone clearance after shock wave lithotripsy or ureteroscopy: The impact of lower pole radiographic anatomy. J Urol 1998;159:676.
Gleeson MJ, Shabsigh R, Griffith DP: Outcome of extracorporeal shock wave lithotripsy in patients with multiple renal calculi based on stone burden and location. J Endourol 1988;2: 145.
Heine G: Physical aspects of shock-wave treatment. In: Gravenstein JS, Peter K (editors): Extracorporeal Shock Wave Lithotripsy for Renal Stone Disease. Butterworths, 1986.
Jewett MA et al: A randomized controlled trial to assess the incidence of new onset hypertension in patients after shock wave lithotripsy for asymptomatic renal calculi. J Urol 1998;160: 1241.
Kamihira O et al: Long-term stone recurrence rate after extracorporeal shock wave lithotripsy. J Urol 1996;156:1267.
Kaude JV et al: Renal morphology and function immediately after extracorporeal shock wave lithotripsy. AJR 1985;145:305.
Lingeman JE, Woods JR, Toth PD: Blood pressure changes following extracorporeal shock wave lithotripsy and other forms of treatment for nephrolithiasis. JAMA 1990;263:1789.
Lingeman JE et al: Shock wave lithotripsy with the Dornier MFL 5000 lithotriptor using an external fixed rate signal. J Urol 1995;154:951.
Low RL et al: Outcome assessment of double-J stents during extracorporeal shock wave lithotripsy of small, solitary renal calculi. J Endourol 1996;10:341.
Politis G, Griffith DP: ESWL: Stone-free efficacy based on stone size and location. World J Urol 1987;5:255.
Sorensen CM, Chandhoke PS: Is lower pole caliceal anatomy predictive of extracorporeal shock wave lithotripsy success for primary lower pole kidney stones? J Urol 2002;168:2377.
Stoller ML, Litt L, Salazar RG: Severe hemorrhage after extracorporeal shockwave lithotripsy. Ann Intern Med 1989;111:612.

Percutaneous Nephrostolithotomy
Irby PB, Schwartz BF, Stoller ML: Percutaneous access techniques in renal surgery. Tech Urol 1999;5:29.
Lam HS et al: Staghorn calculi: Analysis of treatment results between initial percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy monotherapy with reference to surface area. J Urol 1992;147:1219.
Meretyk S et al: Complete staghorn calculi: Random prospective comparison between extracorporeal shock wave lithotripsy monotherapy and combined with percutaneous nephrostolithotomy. J Urol 1997;157:780.

Bagley DH: Removal of upper urinary tract calculi with flexible ureteropyeloscopy. Urology 1990;35:412.
Busby JE, Low RK: Ureteroscopic treatment of renal calculi. Urol Clin North Am 2004;31:89.
Stoller ML et al: Ureteroscopy without routine balloon dilatation: An outcome assessment. J Urol 1992;147:1238.

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