Renal Calculi


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Renal Calculi

  1. 1. Medical Management of Renal Calculi
  2. 2. Oscar
  3. 3. Introduction <ul><li>12% Men, 5% Women- 1 symptomatic stone by 70 y/o </li></ul><ul><li>>80%- Calcium Oxalate </li></ul><ul><li>Increasing prevalence of kidney stones in US (3rd NHANES) </li></ul><ul><ul><li>3.8-5.2% (1976-1980 vs 1988-1994) </li></ul></ul><ul><ul><li>3:1 (male:female) to 1.5:1 </li></ul></ul><ul><ul><li>?Increase incidence/ Increase detection </li></ul></ul>
  4. 4. The 1st Kidney Stone <ul><li>Likelihood of forming 2nd stone </li></ul><ul><ul><li>15% - 1 year </li></ul></ul><ul><ul><li>35-40% - 5 years </li></ul></ul><ul><ul><li>50% - 10 years </li></ul></ul><ul><ul><li>Men > Female </li></ul></ul><ul><li>5%/year for 1st 5 years </li></ul><ul><ul><li>Borghi L, J Urol. 1996 </li></ul></ul>
  5. 5. Asymptomatic Nephrolithiasis <ul><li>107 pt, 32 mths mean follow-up </li></ul><ul><li>Likelihood for symptoms </li></ul><ul><ul><li>32% at 2.5 years </li></ul></ul><ul><ul><li>49% at 5 years </li></ul></ul><ul><li>Of these patients, </li></ul><ul><ul><li>50%- Require intervention </li></ul></ul><ul><ul><li>50%- pass stone spontaneously </li></ul></ul><ul><ul><ul><ul><li>Glowaki LS. J Urol 1992. </li></ul></ul></ul></ul>
  6. 6. The 1st Kidney Stone <ul><li>May have same metabolic risk factors and severity of recurrent stone formers. </li></ul><ul><ul><ul><ul><li>Pak CY. J Urol 1982 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Strauss AL. Arch Intern Med 1982 </li></ul></ul></ul></ul><ul><li>May signify other stones. Careful imaging studies must be carried out. </li></ul><ul><li>Conservative Approach vs Approach based upon Risk Assessment </li></ul>
  8. 8. Risk factors for calcium stones <ul><li>Urinary </li></ul><ul><li>Lower volume </li></ul><ul><li>Higher calcium </li></ul><ul><li>Higher oxalate (CaOx stones) </li></ul><ul><li>Lower citrate </li></ul><ul><li>Higher pH (CaP stones) </li></ul><ul><li>Anatomic </li></ul><ul><li>Medullary sponge kidney </li></ul><ul><li>Horseshoe kidney </li></ul>
  9. 9. Risk factors for calcium stones <ul><li>Diet </li></ul><ul><li>Lower fluid intake </li></ul><ul><li>Lower dietary calcium </li></ul><ul><li>Higher oxalate </li></ul><ul><li>Lower potassium </li></ul><ul><li>Higher animal protein </li></ul><ul><li>Higher sodium </li></ul><ul><li>Higher sucrose </li></ul><ul><li>Lower phytate </li></ul><ul><li>Higher vitamin C </li></ul><ul><li>Other medical conditions </li></ul><ul><li>Primary hyperparathyroidism </li></ul><ul><li>Gout </li></ul><ul><li>Obesity </li></ul><ul><li>Diabetes mellitus </li></ul>
  10. 11. Frequency of biochemical abnormalities in the urine by gender and stone formation status <ul><li> Women Men </li></ul><ul><li>Cases(%) Controls(%) Cases(%) Control(%) </li></ul><ul><li>Hypercalciuria 33 27 25 14 </li></ul><ul><li>Hyperuricosuria 9 8 29 40 </li></ul><ul><li>Hyperoxaluria 13 14 47 43 </li></ul><ul><li>Hypocitraturia 11 9 8 4 </li></ul><ul><ul><ul><li>Curhan GC. Kidney Int 2001 </li></ul></ul></ul>
  11. 12. Goal of Diagnostic Evaluation <ul><li>Identify physiological defect in a patient </li></ul><ul><ul><li>Efficient </li></ul></ul><ul><ul><li>Economical </li></ul></ul><ul><li>Severity and type of stone disease </li></ul><ul><li>1st of recurrent stone </li></ul><ul><li>Presence of systemic disease (risk for recurrent stone formation) </li></ul>
  12. 13. Conservative Approach
  13. 14. Conservative Approach <ul><li>Serum Calcium (Radioopaque stone) </li></ul><ul><li>Serum Uric Acid (Radiolucent stone) </li></ul><ul><li>Increase Fluid to 2L/d </li></ul><ul><li>Drinking at night </li></ul><ul><li>Focused history for stone risk factors </li></ul><ul><ul><li>Dietary habits </li></ul></ul><ul><ul><ul><li>High animal protein diet </li></ul></ul></ul><ul><ul><ul><li>Excessive Vit C/Vit D supplements </li></ul></ul></ul>
  14. 15. Conservative Approach <ul><ul><ul><li>Low fluid consumption </li></ul></ul></ul><ul><ul><ul><li>Excessive intake of stone provoking foods </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><li>Urinalysis </li></ul><ul><ul><li>pH </li></ul></ul><ul><ul><ul><li>> 7.5 - infection lithiasis </li></ul></ul></ul><ul><ul><ul><li>< 5.5 - uric acid lithiasis </li></ul></ul></ul><ul><ul><li>Crystalluria </li></ul></ul><ul><ul><ul><li>Urate, CaPO4, CaOx, Cystine </li></ul></ul></ul>
  15. 16. Crystals <ul><li>Urate: Acid Urine </li></ul><ul><li>CaPO4: Alkaline Urine </li></ul><ul><li>CaOx: Not dependant on urine pH </li></ul><ul><li>Cystine: Diagnostic of Cystinuria </li></ul><ul><li>MgNH4PO4: Occur when NH4 production(urine pH) is increased  decrease solubility of PO4 (urease producing bact- Proteus, Kleb) </li></ul>
  16. 17. Stone Analysis <ul><li>Uric acid: Uric acid nephrolithiasis </li></ul><ul><li>Cystine: Cystinuria </li></ul><ul><li>Ca Apatite/ MgNH4PO4: Infection (struvite) lithiasis </li></ul><ul><li>Hydroxyapatite: Type 1(distal) RTA or primary hyperparathyroidism </li></ul><ul><li>Ca Ox: Not very useful. Present in many conditions </li></ul>
  17. 19. Conservative Approach <ul><li>Subsequent monitoring:- </li></ul><ul><ul><li>KUB/USG yearly </li></ul></ul><ul><ul><li>If Negative  2-4 yearly KUB/USG </li></ul></ul><ul><li>Least costly </li></ul>
  18. 20. Approach Based Upon Risk Assessment
  19. 21. Risk Assessment <ul><li>Extent of evaluation is based on risk estimation </li></ul><ul><li>Evaluation may be justified in single stone formers as they have similar metabolic defects with pt with recurrent stones. </li></ul><ul><ul><ul><li>Sutherland JW. Min Elec Metab 1985 </li></ul></ul></ul><ul><ul><ul><li>Pak CY. J Urol 1982 </li></ul></ul></ul><ul><ul><ul><li>Strauss AL. Arch Int Med 1982 </li></ul></ul></ul>
  20. 22. Moderate-High Risk <ul><li>Middle aged, white, males with family hx </li></ul><ul><li>African Americans </li></ul><ul><li>Pt with chr diarrheal states ± malabsorption, pathological fractures, osteoporosis, UTI, gout </li></ul><ul><li>Cystine, Urate, Struvite stones </li></ul><ul><li>Obese or pt with DM (urate stones) </li></ul>
  21. 23. Abbreviated Protocol <ul><li>For all moderate/high risk groups </li></ul><ul><li>Low risk groups who want to be investigated </li></ul>
  22. 24. Laboratory Tests <ul><li>Serum electrolytes and Chemistry Panel </li></ul><ul><ul><li>Primary hyperPTH </li></ul></ul><ul><ul><li>Hyperuricemia </li></ul></ul><ul><ul><li>Distal RTA </li></ul></ul>
  23. 25. Imaging <ul><li>Acute stone colic - IVU </li></ul><ul><li>Unenhanced contrast CT </li></ul><ul><ul><li>Contrast free alternative </li></ul></ul><ul><ul><li>Specificity and sensitivity same with IVU </li></ul></ul><ul><ul><ul><ul><li>Smith RC. Radiol 1995 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Smith RC. Am J Roentgenol 1996 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Kobayashi T. J Urol 2003 </li></ul></ul></ul></ul><ul><ul><li>Advantage: </li></ul></ul><ul><ul><ul><li>Detects Uric acid/Xanthine stones </li></ul></ul></ul><ul><ul><ul><li>Detect alternative diagnoses </li></ul></ul></ul><ul><ul><ul><ul><li>Gray Sears CL. J Urol 2002 </li></ul></ul></ul></ul>
  24. 26. Imaging <ul><ul><li>Higher radiation </li></ul></ul><ul><li>Alternative: </li></ul><ul><ul><li>KUB + USG </li></ul></ul>
  25. 27. Radiography <ul><li>Non contrasted helical CT (5mm cuts) </li></ul><ul><ul><li>Degree of opacity suggest type of stones </li></ul></ul><ul><ul><li>MgNH4PO4 stones- not as radiopaque as Calcium stones </li></ul></ul><ul><ul><li>Nephrocalcinosis- suggest RTA </li></ul></ul><ul><ul><li>Staghorn- suggest infection lithiasis </li></ul></ul><ul><li>IVU </li></ul><ul><ul><li>Outline radiolucent stones </li></ul></ul><ul><ul><li>Identify anatomic abnormalities </li></ul></ul>
  26. 28. Urine Stone Risk Profile <ul><li>Assessment of urine composition </li></ul><ul><ul><li>Two 24h urine collections </li></ul></ul><ul><ul><ul><li>Hess B. NDT 1997. </li></ul></ul></ul>
  27. 30. 24 hr Urine Collections <ul><li>Patient must be on usual diet. </li></ul><ul><li>Wait 2-3mths after acute stone episode before measurement. </li></ul><ul><li>Urine Volume, pH </li></ul><ul><li>Calcium, Sodium </li></ul><ul><li>Uric Acid </li></ul><ul><li>Citrate </li></ul><ul><li>Oxalate </li></ul><ul><li>Creatinine(assess completeness of collection) </li></ul>
  28. 31. Urine Analysis
  29. 32. Uric Acid Crystals <ul><li>Pleomorphic- most often as rhombic plates or rosettes. </li></ul><ul><li>They are yellow or reddish-brown and form only in an acid urine </li></ul>
  30. 33. Calcium Oxalate Cystals <ul><li>Dumbbell-shaped calcium oxalate monohydrate (long arrow). </li></ul><ul><li>Envelope-shaped calcium oxalate dihydrate (short arrows) crystals. </li></ul><ul><li>Formation of calcium oxalate crystals is independent of the urine pH. C </li></ul>
  31. 34. Calcium Oxalate Crystals <ul><li>Under polarized light  coarse, needle-shaped calcium oxalate monohydrate crystals </li></ul><ul><li>Similar appearance to hippurate crystals. </li></ul>
  32. 35. Cystine Crystals <ul><li>Hexagonal cystine crystals. </li></ul><ul><li>Pathognomonic of cystinuria. </li></ul>
  33. 36. Phosphate Crystals <ul><li>Multiple &quot;coffin lid&quot; magnesium ammonium phosphate crystals. </li></ul><ul><li>Forms only in an alkaline urine (pH usually above 7.0). </li></ul>
  34. 37. Indinavir Crystals <ul><li>Panel A: Rectangular plates of various sizes containing needle-shaped crystals. Irregular borders with occasional tapering, and internal layering (large arrows). Small, triangular pieces (small arrows) represent broken ends of needles. </li></ul><ul><li>Panel B: A sheaf of densely packed indinavir sulfate needles. </li></ul><ul><li>Panel C: Several indinavir crystal groupings are arranged in a rosette. </li></ul>
  35. 38. Preventive treatment in Calcium Stone Disease
  36. 39. General Recommendations <ul><li>Start with conservative measures </li></ul><ul><li>Pharmacological treatment when conservative approach fails </li></ul>
  37. 40. High Fluid Intake <ul><li>Irrespective of stone composition </li></ul><ul><li>24hour urine volume > 2L. </li></ul><ul><li>Supersaturation level monitored. </li></ul><ul><li>Fluid intake should be evenly distributed throughout the day. </li></ul><ul><ul><ul><li>Borghi L. Nephron 1999. </li></ul></ul></ul>
  38. 41. Protein load increases urine stone-forming tendency <ul><li>High protein diet (2 g/kg per day) in normal men </li></ul><ul><li>Effects the metabolic parameters </li></ul><ul><li>Risk of calcium stone formation </li></ul><ul><li>Increase in the urinary excretion of calcium and uric acid </li></ul><ul><li>Reduction in that of citrate. </li></ul><ul><ul><ul><li>Kok, DJ, J Clin Endocrinol Metab 1990 </li></ul></ul></ul>
  39. 42. Limit Oxalate <ul><li>Vit C up to 4g/d </li></ul><ul><ul><ul><li>Wandzilak TR. J Urol 1994 </li></ul></ul></ul><ul><ul><ul><li>Sutton RA, Miner Electrolyte Metab 1994 </li></ul></ul></ul><ul><ul><ul><li>Auer BL, Clin Chem Lab Med 1998 </li></ul></ul></ul>
  40. 43. Limit Urate (Not >500mg/d) <ul><li>Retrict in patient with hyperuricosuric calcium oxalate stone disease/ urate stones </li></ul>
  41. 44. Limit Sodium
  42. 45. Pharmacological Agents <ul><li>Fail conservative Mx </li></ul><ul><li>Halt formation of stones </li></ul><ul><li>Free of side effects </li></ul><ul><li>Easy to administer </li></ul>
  43. 46. Thiazide/ Thiazide like agents <ul><li>Hydrochlorothiazide </li></ul><ul><li>Indapamide </li></ul><ul><li>Trichlorothiazide </li></ul><ul><li>Reduces urinary calcium excretion </li></ul><ul><li>Mediated via increased reabsoprtion of calcium via proximal and distal nephron </li></ul><ul><li>Reduce intestinal absoprtion of calcium ==> decrease oxalate excretion </li></ul>
  44. 47. <ul><li>Significant better results with active Rx vs placebo (p<0.02) </li></ul><ul><li>Drawback: </li></ul><ul><ul><li>Dysglycaemia </li></ul></ul><ul><ul><li>Gout </li></ul></ul><ul><ul><li>Erectile dysfunction </li></ul></ul><ul><ul><li>Compliance rate 50-70% </li></ul></ul>
  45. 48. Alkaline Citrate <ul><li>Predominant use in hypocitraturia. </li></ul><ul><li>Citrate chelates calcium and reduces ion-activity poducts of both CaOx and CaPO4. </li></ul><ul><li>Citrate is also inhibitor of growth and aggregation of these crystals. </li></ul><ul><li>Alkaline salt also increases urine pH </li></ul>
  46. 49. Alkaline Citrate <ul><li>Na-K-Citrate </li></ul><ul><li>Na-Mg-Citrate </li></ul><ul><li>K-Citrate </li></ul><ul><li>K-Mg-Citrate </li></ul><ul><ul><li>K-Citrate more effective in reducing recurrence rate </li></ul></ul><ul><ul><ul><ul><li>Jendle-Bengten C, Scan J Urol 2000 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Berg C, J Urol 1992 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Sakhaee K, KI 1983 </li></ul></ul></ul></ul>
  47. 50. Allopurinol <ul><li>Counteract formation of CaOx stones. </li></ul><ul><li>May reduce Oxalate excretion </li></ul><ul><li>Use for pt with hyperuricosuric CaOx stone formation </li></ul>
  48. 51. Allopurinol prevents stones in hyperuricosuria <ul><li>When compared to placebo, allopurinol protects against new stone formation in hyperuricosuric calcium oxalate stone formers. Ettinger B, N Engl J Med 1986 </li></ul>
  49. 52. Other Agents <ul><li>Orthophophosphate </li></ul><ul><ul><li>reduce Ca excretion and increase excretion of pyrophosphate (inhibitor of CaOx, CaPO4 crystal growth) </li></ul></ul><ul><ul><li>Weak evidence </li></ul></ul><ul><li>Mg </li></ul><ul><ul><li>Reduce ion-activity product of CaOx and inhibit growth of CaPO4 crystals </li></ul></ul><ul><ul><li>Increase citrate excretion </li></ul></ul><ul><ul><li>High Mg in urine prevents Brushite formation </li></ul></ul><ul><ul><li>Weak evidence </li></ul></ul>
  50. 54. Surgical Management
  51. 55. Surgical Management Renal and Ureteral Stones <ul><li>10-20% of kidney stones would require surgical removal </li></ul><ul><li>Stone removal indication:- </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Obstruction </li></ul></ul><ul><ul><li>Infective struvite stone </li></ul></ul><ul><li><5mm stone usu  watch and see </li></ul>
  52. 57. Indications for Active Stone Removal <ul><li>Depends on size, shape and site of stone. </li></ul><ul><li>Stones ≤ 4mm ==> 80% spontaneous stone passage </li></ul><ul><li>Stones ≥ 7mm ==> very low stone passage </li></ul><ul><li>Ureteric stones </li></ul><ul><ul><li>Proximal ureteral- 25% </li></ul></ul><ul><ul><li>Mid ureteral- 45% </li></ul></ul><ul><ul><li>Distal ureteral- 70% </li></ul></ul>
  53. 58. Indications for Active Stone Removal <ul><li>Remove stones if exceed 6-7mm. </li></ul><ul><ul><li>Asymp stones will give rise to clinical problem sooner or later </li></ul></ul><ul><li>Stones <6-7mm residing in calix causes pain and discomfort </li></ul><ul><ul><li>Remove with minimally invasive procedure </li></ul></ul><ul><li>Narrow caliceal neck may require dilatation </li></ul>
  54. 59. Surgical Management Renal and Ureteral Stones <ul><li>Minimally Invasive Techniques </li></ul><ul><ul><li>Percutaneous Nephrostolithotomy (PCNL) </li></ul></ul><ul><ul><li>Rigid and Flexible Ureterorenoscopy (URS) </li></ul></ul><ul><ul><li>Shock Wave Lithotripsy (ESWL) </li></ul></ul>
  55. 60. Choice of Intervention <ul><ul><li>Location </li></ul></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Ureteral Calculi  ESWL, URS </li></ul></ul><ul><ul><li>Renal Calculi  ESWL, PCNL (>2cm) </li></ul></ul>
  56. 61. Percutaneous Nephrostolithotomy <ul><li>PCNL = Open Surgery (efficacy) </li></ul><ul><li>60% reduction of hospitalization time </li></ul><ul><ul><li>(1 week vs 3 weeks) </li></ul></ul><ul><li>40% less expensive </li></ul><ul><ul><ul><ul><li>Preminger GM. JAMA 1985. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Jewett MA. Urology, 1995. </li></ul></ul></ul></ul>
  57. 62. Percutaneous Nephrostolithotomy <ul><li>Indications:- </li></ul><ul><ul><li>>2cm stone </li></ul></ul><ul><ul><li>Complex calculi </li></ul></ul><ul><ul><ul><li>Filling the majority of intrarenal collecting system eg staghorn calculi </li></ul></ul></ul><ul><ul><li>Cystine stone (resistant to ESWL) </li></ul></ul><ul><ul><li>Anatomical abn </li></ul></ul><ul><ul><ul><li>Horseshoe kidney </li></ul></ul></ul><ul><ul><ul><li>Ureteropelvic junction obstruction </li></ul></ul></ul><ul><ul><ul><li>Stone within caliceal diverticula </li></ul></ul></ul>
  58. 63. Percutaneous Nephrostolithotomy <ul><li>Success of PCNL depends on correct placement of nephrostomy tube </li></ul><ul><li>Nephrostomy tube must allow easy access to calculi </li></ul><ul><li>After 24-48h of PCNL  antegrade nephrostogram to ensure adequate ureteral drainage without extravasation </li></ul>
  59. 64. Ureterorenoscopy <ul><li>Treatment of choice for middle and distal ureteric stones </li></ul><ul><li>Can also be used in Mx of proximal ureteric or intrarenal calculi </li></ul><ul><li>Failed ESWL in ureteric calculi </li></ul><ul><li>Rigid/Flexible </li></ul><ul><li>Flexible- proximal and intrarenal collecting system with 360°access to entire intrarenal collecting system </li></ul>
  60. 65. ESWL <ul><li>Not ideal management for </li></ul><ul><ul><li>Complex calculi </li></ul></ul><ul><ul><li>Large calculi </li></ul></ul><ul><ul><li>Hard calculi </li></ul></ul><ul><ul><li>Calculi in caliceal diverticulum </li></ul></ul><ul><ul><li>Patients with complex renal anatomy </li></ul></ul><ul><li>High energy shock waves produced by electrical discharge </li></ul><ul><li>Shock waves transmitted through water and directly focused onto stone with aid of biplanar fluoroscopy </li></ul>
  61. 66. ESWL <ul><li>Change in density between soft renal tissue and hard stone causes energy release at the stone surface </li></ul>
  62. 67. ESWL- Complication <ul><li>Pain due to obstruction in the renal pelvis and ureter (>4mm stones). </li></ul><ul><li>Reversible decreases in renal plasma flow and glomerular flow may also occur. </li></ul><ul><ul><ul><li>  Sheir KZ. Urology 2003 . </li></ul></ul></ul><ul><li>Current incidence of obstruction when SWL is used to treat single smaller stones (2 cm in diameter) is approximately two to three percent. </li></ul><ul><ul><ul><li>Ehreth JT. J Urol, 1994. </li></ul></ul></ul>
  63. 68. ESWL- Complication <ul><li>Reversibly damage all parenchymal components- blood vessels and tubules. </li></ul><ul><ul><ul><li>Smith LH. Am J Med 1991. </li></ul></ul></ul><ul><ul><ul><li>Evan AP. Am J Kidney Dis 1991. </li></ul></ul></ul><ul><ul><ul><li>Stoller ML. Ann Intern Med 1989. </li></ul></ul></ul><ul><ul><ul><li>Strohmaier WL. J Urol 1993. </li></ul></ul></ul>
  64. 69. ESWL- Complications <ul><li>The degree of injury is related to:- </li></ul><ul><ul><li>Number of shocks </li></ul></ul><ul><ul><li>Level of energy delivered </li></ul></ul><ul><ul><li>Size of the kidney, with smaller kidneys being at greater risk </li></ul></ul><ul><ul><ul><ul><li>  Willis LR. J Am Soc Nephrol 1999. </li></ul></ul></ul></ul><ul><ul><li>Often asymptomatic, but subcapsular or perinephric hemorrhage can occur. </li></ul></ul><ul><ul><ul><ul><li>Dhar NB. J Urol 2004. </li></ul></ul></ul></ul><ul><ul><li>Rarely, a perinephric hematoma may lead to acute renal failure. </li></ul></ul><ul><ul><ul><ul><li>  Jang YB. Nephrol Dial Transplant 2006. </li></ul></ul></ul></ul>
  65. 70. ESWL- Complication <ul><li>Chronic impairment in renal function and a rise in blood pressure </li></ul><ul><ul><li>Scarring in the areas of bleeding.   </li></ul></ul><ul><ul><li>Williams CM. N Engl J Med 1989 . Prospective study of 16 patients, 5/16 had a persistent 20 percent reduction in renal blood flow at 4 years </li></ul></ul><ul><ul><li>  Ackaert KS. Urol Res 1989 . </li></ul></ul><ul><ul><ul><li>8%- new hypertension. </li></ul></ul></ul><ul><ul><ul><li>15%- rise in blood pressure that remains within the normal range. </li></ul></ul></ul><ul><ul><ul><li>Increased renin release, due to focal areas of renal ischemia. </li></ul></ul></ul>
  66. 71. ESWL- Complication <ul><li>Long-term effects on renal function:- </li></ul><ul><ul><li>750 patients evaluated at 18 months after SWL </li></ul></ul><ul><ul><li>Minimal increase in diastolic pressure </li></ul></ul><ul><ul><ul><ul><li>Lingeman JE. JAMA, 1990. </li></ul></ul></ul></ul><ul><ul><li>1157 procedures noted a 4 to 6 percent incidence of a new diastolic pressure persistently above 95 mmHg </li></ul></ul><ul><ul><ul><ul><li>Ehreth JT. J Urol 1994 </li></ul></ul></ul></ul>
  67. 72. ESWL- Complication <ul><li>S tudy of 83 patients underwent </li></ul><ul><ul><li>SWL (53) </li></ul></ul><ul><ul><li>Percutaneous nephrolithotomy (18) </li></ul></ul><ul><ul><li>Both (12) </li></ul></ul><ul><ul><li>Changes in the serum creatinine concentration, blood pressure, and glomerular filtration rate were reported at a mean follow-up of 53 months (range of 1 to 167 months) </li></ul></ul><ul><ul><li>No significant changes in any measured outcome among the three patient groups. </li></ul></ul><ul><ul><ul><ul><li>  Liou LS, J Urol 2001. </li></ul></ul></ul></ul>
  68. 73. Open Stone Surgery <ul><li>Management of complex renal and ureteral calculi. </li></ul><ul><li>Failed Endoscopic stone removal. </li></ul><ul><li>Complex renal/ureteral anatomy. </li></ul><ul><li>Morbid obesity </li></ul><ul><ul><li>Matlaga BR, Urology 2002. </li></ul></ul>
  69. 75. Summary <ul><li>95% of patients- treatable metabolic etiology </li></ul><ul><li>High Fluid Intake </li></ul><ul><li>Thiazide (Hypercalciuria) </li></ul><ul><li>Allopurinol/K citrate (Hyperuricosuria) </li></ul><ul><li>K Citrate (Hypocitraturia) </li></ul><ul><li>With medical Rx- 75% remission rate, 94% reduced rate of stone passage </li></ul>
  70. 76. I-toilet