Miller -Management Kidney Stones

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468 BMJ| 3 March 2007 | VoluMe 334

Methodist Hospital Institute forKidney Stone Disease, IndianaUniversity School of Medicine,and International Kidney StoneInstitute, Indianapolis, IN 46202,USA

cspndn t: J e lingmn

[email protected]

BMJ 2007:334:468-72

doi: 10.1136/bmj.39113.480185.80

Mngmnt f kidny stnsNicole L Miller, James E Lingeman

For the full versions of these articles see bmj.com

Urolithiasis aects 5-15% o the populationworldwide.1w1 Recurrence rates are close to 50%,2w2and the cost o urolithiasis to individuals and societyis high. Acute renal colic is a common presentationin general practice, so a basic understanding o itsevaluation and treatment would be useul. Most o theliterature is retrospective, but we will try to providean evidence based review o the management o uro-lithiasis and will cite prospective randomised controlledtrials when available.

Sourcs d scto crtr

We perormed a literature search to identiy inorma-tion on the management o urolithiasis. We searcheddatabases including Medline and the Cochrane Libraryto assemble appropriate evidence based reerencematerial

wht s th cc prstto d t uto?

Initial evaluation o the patient with urolithiasis shouldinclude a complete medical history and physical exami-nation. Typical symptoms o acute renal colic are inter-mittent colicky ank pain that may radiate to the lowerabdomen or groin, oten associated with nausea andvomiting.3 Lower urinary tract symptoms such as dys-uria, urgency, and requency may occur once a stoneenters the ureter.

Comorbid diseases should be identifed, particularlyany systemic illnesses that might increase the risk okidney stone ormation or that might inuence the clini-cal course o the disease (box 1). Other important ea-tures are a personal or amily history o kidney stones

with previous treatments and stone analysis, and anyanatomical abnormalities or surgery o the urinary tract(box 1). A complete history o drugs use can help iden-tiy those that are known to increase the risk o kidneystones (box 1).w3

Assessment should include measurement o vitalsigns because ever may be an indication or acuteintervention (box 2). Physical examination oten revealscostovertebral angle or lower abdominal tenderness.Urinalysis should be perormed in all patients. Micro-scopic haematuria combined with the typical symptomso renal colic is highly predictive o urolithiasis, butstones may occur in the absence o haematuria.3 Posi-

tivity or nitrites or bacteria and leucocytes on urinedipstick analysis may indicate urinary tract inection,

in which case urine should be sent or culture. Finally,microscopic urinalysis may identiy crystals, such asthe classic hexagonal crystals seen in cystinuria. In theacute setting, laboratory evaluation includes completeblood count, serum electrolytes, and measuremento renal unction. A more detailed metabolic evalua-tion is best perormed ater the acute stone event hasresolved.4

Ho s th dgoss md?

Unenhanced helical computed tomography is thebest radiographical test or diagnosing urolithiasis inpatients with acute ank pain.5 Intravenous urography

was ormerly the gold standard, but recent prospectivetrials have shown that computed tomography is the bestmethod or diagnosing ureteral calculi.6 I the symptomsare not caused by urolithiasis, computed tomographycan oten identiy the real cause.5 Most kidney stones(box 3) are visible on computed tomography, except orstones induced by certain drugs, such as indinavir.

A plain abdominal radiograph can determinewhether stones are radio-opaque and can be used tomonitor disease activity. Alternatively, some clinicianspreer to use computed tomography in the ollow-upo kidney stones, particularly when the stone is radio-lucent. Ultrasound is rarely used because o its relatively

low sensitivity, although it is oten used as the initialimaging test in pregnant patients with ank pain.w4

SUMMaRY POinTS

Unenhanced helical computed tomography is the bestradiographic technique for diagnosing urolithiasis

Shock wave lithotripsy, ureteroscopy, and percutaneousnephrolithotomy have replaced open surgery for treating

urolithiasisMost simple renal calculi (80-85%) can be treated withshock wave lithotripsy

Percutaneous nephrolithotomy is the treatment of choicefor complex renal calculi

Staghorn calculi should be treated, and percutaneousnephrolithotomy is the preferred treatment in mostpatients

Ureteroscopy is the preferred treatment in pregnant,morbidly obese, or patients with coagulopathy

Most ureteral calculi


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wht r th dctos for urgt trto?

Urgent intervention is most oten needed in acuteobstruction. Once a stone passes into the ureter,obstruction may cause reduced glomerular fltrationrate and renal blood ow. Box 2 lists the indicationsor acute intervention.w5 A randomised controlled trialound that ureteral catheters, ureteral stents, and per-cutaneous nephrostomy tubes are equally eective ordecompressing the urinary tract.7 Bladder and renalpelvic urine should be sent or culture and antibioticsensitivity testing. Broad spectrum antibiotics are bestprescribed initially, and urther antimicrobial treatment

should be tailored to the results o urine culture.While parenteral narcotics have traditionally been

prescribed or acute renal colic,8 non-steroidal anti-inammatory drugs such as ketorolac and dicloenacare eective in relieving pain by inhibiting pros-taglandin mediated pain pathways and decreasingureteral contractility.9w6 However, non-steroidal anti-inammatory drugs should be avoided in patientswith compromised renal unction or a history ogastrointestinal bleeding.w7

wht r commo trtmts for phrothss?

Open surgery was the mainstay o treatment or

urolithiasis, but it has now been supplanted by lessinvasive treatments.

Shok wave lithotripsy

The introduction o shock wave lithotripsy in theearly 1980s revolutionised the treatment o nephro-lithiasis. A shock wave is generated by a sourceexternal to the patient that propagates through thebody beore being ocused on a kidney stone. Shock

waves cause stone ragmentation directly by produc-ing mechanical stresses or indirectly by the collapseo cavitation bubbles.10

Although shock wave lithotripsy is the most com-mon treatment or urolithiasis, it can have side eects.In human and animal models it can cause acuterenal injury.11w8 w9 Computed tomography and mag-netic resonance imaging have demonstrated renalinjury in 63-85% o patients treated with shock wavelithotripsy.12 w10-w12 A recent retrospective case-controlstudy with 19 year ollow-up noted an associationbetween shock wave lithotripsy and the developmento hypertension and diabetes mellitus.13w13 In the litho-tripsy group, diabetes developed in 16.8% o patientsversus 6.6% o controls.13 The chronic eects o shockwave lithotripsy are an area o ongoing research.

ureterosopy

Ureteroscopy involves retrograde visualisation o thecollecting system using a rigid, semi-rigid, or exibleendoscope. Improved fbreoptics and deectability andthe reduced size o ureteroscopes have expanded theuse o ureteroscopy or stones in the upper urinary tract.The ureteroscope has a working channel that allowsthe introduction o a variety o instruments or stoneragmentation and removal.

A retrospective study showed that ureteroscopy is use-

ul when lithotripsy ails; when complex or lower polerenal calculi are present14; or when patient actors suchas pregnancy, coagulopathy, or morbid obesity precludelithotripsy.w14 w15 One disadvantage o ureteroscopy isthat a ureteral stent, which causes considerable dis-comort in some patients, is oten necessary to preventobstruction rom ureteral oedema or stone ragments.

Pertaneos nephrolithotomy

Percutaneous nephrolithotomy involves creating anaccess tract into the renal collecting system throughwhich nephroscopy can be perormed. The nephro-scope has a working channel through which an intra-

corporeal lithotripsy device (lithotrite or laser) can beintroduced. Stone ragments are removed using suction,graspers, or basket extraction. The technique enablesstones to be retrieved or analysis, and all stone mate-rial can be removed so that the patient does not haveto pass any ragments, as is common with shock wavelithotripsy and ureteroscopy. Although percutaneousnephrolithotomy is thought to be more invasive thanother treatments, a large meta-analysis has demon-strated its saety and efcacy, particularly when stonesare large, multiple, or complex.15

wht r th guds for trtmt scto?

The undamental principle guiding treatment selectionis to maximise stone clearance while minimising patient

Box 2 | Indications forurgent intervention

Presence of infectionwith urinary tractobstruction

Urosepsis

Intractable pain orvomiting, or both

Impending acute renalfailure

Obstruction in a solitaryor transplanted kidney

Bilateral obstructingstones

Box 1 | Important factors to identify in the patients history

Presence of systemic illness

Primary hyperparathyroidism

Renal tubular acidosis

Cystinuria

Gout

Diabetes mellitus

Inflammatory bowel disease

Renal insufficiency

Sarcoidosis

Medullary sponge kidney

Anatomical features

Presence of horseshoe kidney

Previous urinary diversion

Obstruction of the ureteropelvic junction

Solitary kidney

Previous renal or ureteral surgery

Previous kidney disease

History of urinary tract infection or pyelonephritis, or bothFamily history of urolithiasis

Detailed history of previous stone events

Treatment

Stone analysis

Drugs that affect stone disease

Carbonic anhydrase inhibitors (topirimate)

Ephedrine

Guaifenesin

Calcium with vitamin D

Triamterene

Indinavir or sulfadiazine


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morbidity. The decision making process can be simpli-fed by stratiying stones into clinical categories basedon location (renal or ureteral) and complexity (simpleor complex).

R ccu

The characteristics o the stones (size, number, location,and composition), renal anatomy, and clinical actorsare all considered when selecting a treatment approachor renal calculi.

Simple renal alli

Simple renal calculi are those with a stone burdeno 2 cm, suchas staghorn calculi; stones occurring in kidneys withabnormal anatomy; and stones resistant to ragmenta-

tion. Recently published guidelines o the AmericanUrologic Association recommend that staghorn calculishould not be treated with lithotripsy because o rela-tively poor stone-ree rates.15 Ureteroscopy has beenused to treat upper tract stones >2 cm, but stone clear-ance rates are signifcantly lower than with percuta-neous nephrolithotomy and stones recur rapidly (16%within six months).19 For this reason, percutaneousnephrolithotomy is the treatment o choice or mostcomplex renal stones (fg 2).15 Combined percutane-ous nephrolithotomy and shock wave lithotripsy (sand-wich therapy) or complex stones was commonplacein the 1990s, but improvements in percutaneous neph-

rolithotomy techniques have led to a decline in theneed or shock wave lithotripsy.15 20 Even the largest

staghorn calculi can be cleared percutaneously withthe aid o secondary look nephroscopy and multipleaccess tracts.

The management o lower pole calyceal calculiremains controversial. A prospective randomised multi-centre trial showed that percutaneous nephrolithotomy

was better than shock wave lithotripsy in the clearanceo lower pole calculi >1 cm (stone-ree rates o 91%v 21%).21 However, or lower pole calculi


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For the purposes o selecting treatment, ureteral cal-culi can be divided into categories on the basis o loca-tionproximal or distalwith the point o division beingthe narrow part o the ureter over the iliac vessels.

Proximal reteral alli

Several endourological options are available or thetreatment o proximal ureteral stones: shock wave

lithotripsy with or without stone manipulation, ureter-oscopy, and percutaneous nephrolithotomy. In 1997,the ureteral stones guidelines panel o the AmericanUrologic Association recommended shock wave litho-tripsy as the treatment o choice or stones 1 cm in theproximal ureter, with stone-ree rates up to 85%.23 A ret-rospective series noted that proximal ureteral stones >1cm have poor stone-ree rates with this treatment.2324However, exible ureteroscopy is increasingly popularas primary treatment or proximal ureteral stones as

a result o the availability o small diameter exibleureteroscopes, ureteral access sheaths, holmium laserlithotripsy, and stone baskets.19w20 Percutaneous neph-rolithotomy is reserved or large (2 cm) or impactedproximal ureteral stones.w21

Distal reteral alliAlthough the likelihood o spontaneous passage ostones is highest in the distal ureter, intervention withureteroscopy or shock wave lithotripsy is oten neces-sary. Both techniques are excellent options or sympto-matic ureteral calculi 1 cm.w22 Semirigidureteroscopy has a success rate o 90-99% or treatingdistal ureteral stones.w23 Ureteroscopy may also be thesimplest solution in institutions with limited access toa lithotripter.

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Although a comprehensive metabolic evaluation maynot be cost eective in patients with their frst occur-rence o stones,4 26 patients with risk actors or stonerecurrence should be evaluated (box 4). Box 5 outlinesthe components o a standard metabolic evaluation.4First time stone ormers will beneft rom recommen-dations to prevent stone recurrence, such as increasinguid intake to maintain a urine output o at least twolitres a day, decreasing animal protein intake to lessthan 12 ounces a day, and restricting dietary sodiumand oxalate intake.1 27 28 Dietary restrictions o calcium

are not recommended as they may increase urinaryoxalate excretion and result in negative calcium bal-ance.28 Medical management o the recurrent or highrisk stone ormer can be individually tailored using theresults o the metabolic evaluation.

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This treatment comprises the use o drugs to helpthe spontaneous passage o ureteral calculi. Severaldrugs including calcium channel blockers (niedipine),

Box 4 | Indications for comprehensive metabolicevaluation

Family history of urolithiasis

Presence of bilateral stone disease

Presence of inflammatory bowel disease, chronicdiarrhoea, or malabsorption

History of bariatric surgery

Concurrent medical conditions associated withurolithiasis (primary hyperparathyroidism, gout, renaltubular acidosis)

Presence of nephrocalcinosis

Presence of osteoporosis or pathological skeletalfractures

Stones are formed from cystine, uric acid, or calciumphosphate

The patient is a child

Box 5 | Components of a comprehensive metabolicevaluation

Analysis of stone composition

Two 24 hour urine collections for:

Volume, pH, calcium, oxalate, citrate, uric acid,

phosphate, sodium, potassium, magnesium,

ammonium, chloride, sulfate, and creatinine

Cystine screen

Measurement of serum calcium, bicarbonate, creatinine,chloride, potassium, magnesium, phosphate, anduric acid

Measurement of blood urea nitrogen

In cystinuric patients, evaluation as above and 24 hourmeasurement of cystine

In hypercalcaemic patients, intact parathyroid hormoneand 1,25 dihydroxyvitamin D

Fg 2| Complex left renal calculus. The patient wassuccessfully treated with percutaneous nephrolithotomy


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steroids, and adrenergic blockers have recently beeninvestigated.w24 w25 The rationale or using blockers isbased on the presence o large numbers o1 adreno-ceptors in the distal ureter. These blockers inhibit basalureteral tone and peristaltic requency and decrease theintensity o ureteral contractions.

A recent prospective randomised study compared

three drugs as medical expulsive therapy or distal ure-teral calculi.29 Two hundred and ten patients with symp-tomatic distal ureteral stones >4 mm were randomlyassigned to three treatment groups: phloroglucinol andcorticosteroid, tamsulosin and corticosteroid, or nied-ipine and corticosteroid. Tamsulosin and corticoster-oid was the most efcacious combinationstones werepassed more quickly and the need or analgesics wasreduced. A randomised controlled prospective studyhas also shown tamsulosin to be a useul addition toshock wave lithotripsy.30w26 w27

cntibts: NLM performed the literature search and wrote the

manuscript. JEL reviewed, revised, and approved the final paper and will

serve as guarantor.cmpting intsts:JEL has been a consultant and adviser for Lumenis

and Olympus; meeting participant and lecturer for Karl Storz; and an

investigator and lecturer for Boston Scientific.

Pvnn nd p viw:Commissioned, externally peer reviewed.

1 Moe OW. Kidney stones: pathophysiology and medical management.Lancet2006;367:333-44.

2 Sutherland JW, Parks JH, Coe FL. Recurrence after a single renal stone ina community practice. Miner Electrolyte Metab 1985;11:267-9.

3 Eskelinen M, Ikonen J, Lipponen P. Usefulness of history-taking,physical examination and diagnostic scoring in acute renal colic. EurUrol 1998;34:467-73.

4 Parks JH, Goldfisher E, Asplin JR, Coe FL. A single 24-hour urinecollection is inadequate for the medical evaluation of nephrolithiasis.

J Urol2002;167:1607-12.5 Vieweg J, Teh C, Freed K, Leder RA, Smith RH, Nelson RH, et al.

Unenhanced helical computerized tomography for the evaluation of

patients with acute flank pain.J Urol1998;160(3 Pt 1):679-84.6 Miller OF, Rineer SK, Reichard SR, Buckley RG, Donovan MS, Graham

ADDITIONAL EDUCATIONAL RESOURCES

Teichman JM. Clinical practice. Acute renal colic from ureteral calculus. N Engl J Med2004;350:684-93

Tiselius HG, Ackermann D, Alken P, Buck C, Conort P, Gallucci M, et al. Guidelines onurolithiasis. European Association of Urology, 2006. www.uroweb.nl/files/uploaded_files/guidelines/18%20Urolithiasis.pdf.

Information resources for patients International Kidney Stone Institute (www.iksi.org)Website of a charitable organisation

dedicated to supporting research into clinical and basic science and education to helpdetect, manage, and prevent kidney stone disease. It contains educational material forpatients as well as a description of the ongoing research projects in the area of kidneystone disease

National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) InformationClearinghouse (www.kidney.niddk.nih.gov/kudiseases/pubs/stonesadults/)Containsclear concise explanations of diseases affecting the kidneys, including kidney stones

American Urological Association-Urology Health (www.urologyhealth.org)Also containsuser friendly information on the diagnosis and treatment of kidney stones

Patient UK (www.patient.co.uk)This website contains comprehensive and free up to dateinformation on various medical conditions, including kidney stones

Royal Infirmary of Edinburgh Renal Unit (http://renux.dmed.ed.ac.uk/EdREN/

EdRenINFObits/KidStonesLong.html)A source of information about kidney diseases forpatients and non-specialist doctors

National Kidney Foundation (www.kidney.org/atoz/atozTopic.cfm?topic=13)An excellentsource of information for patients with various kidney problems such as chronic kidneydisease, kidney stones, and those who need dialysis

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7 Pearle MS, Pierce HL, Miller GL, Summa JA, Mutz JM, Petty BA, etal. Optimal method of urgent decompression of the collectingsystem for obstruction and infection due to ureteral calculi.J Urol1998;160:1260-4.

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300.9 Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs

(NSAIDS) versus opioids for acute renal colic. Cochrane DatabaseSyst Rev2004;(1):CD004137.

10 McAteer JA, Bailey MR, Williams JC Jr, Cleveland RO, Evan AP.Strategies for improved shock wave lithotripsy. Minerva Urol Nefrol2005;57:271-87.

11 Willis LR, Evan AP, Connors BA, Shao Y, Blomgren PM, Pratt JH, etal. Shockwave lithotripsy: dose-related effects on renal structure,hemodynamics, and tubular function.J Endourol 2005;19:90-101.

12 Rubin JI, Arger PH, Pollack HM, Banner MP, Coleman BG, Mintz MC,et al. Kidney changes after extracorporeal shock wave lithotripsy: CTevaluation. Radiology1987;162(1 Pt 1):21-4.

13 Krambeck AE, Gettman MT, Rohlinger AL, Lohse CM, Patterson DE,Segura JW. Diabetes mellitus and hypertension associated withshock wave lithotripsy of renal and proximal ureteral stones at 19years of follow up.J Urol2006;175:1742-7.

14 Grasso M, Loisides P, Beaghler M, Bagley D. The case for primaryendoscopic management of upper urinary tract calculi. I. A critical

review of 121 extracorporeal shock-wave lithotripsy failures.Urology1995;45:363-71.

15 Preminger GM, Assimos DG, Lingeman JE, Nakada SY, Pearle MS, WolfJS Jr. Chapter 1: AUA guideline on management of staghorn calculi:diagnosis and treatment recommendations.J Urol2005;173:1991-2000.

16 Lingeman JE, Coury TA, Newman DM, Kahnoski RJ, Mertz JH,Mosbaugh PG, et al. Comparison of results and morbidi ty ofpercutaneous nephrostolithotomy and extracorporeal shock wavelithotripsy.J Urol1987;138:485-90.

17 Ramakumar S, Segura JW. Renal calculi. Percutaneous management.Urol Clin North Am 2000;27:617-22.

18 Grasso M, Beaghler M, Loisides P. The case for primary endoscopicmanagement of upper urinary tract calculi. II. Cost and outcomeassessment of 112 primary ureteral calculi. Urology1995;45:372-6.

19 Grasso M, Conlin M, Bagley D. Retrograde ureteropyeloscopictreatment of 2 cm or greater upper urinary tract and minor staghorncalculi.J Urol1998;160:346-51.

20 Lam HS, Lingeman JE, Mosbaugh PG, Steele RE, Knapp PM, Scott JW,et al. Evolution of the technique of combination therapy for staghorncalculi: a decreasing role for extracorporeal shock wave lithotripsy.JUrol 1992;148(3 Pt 2):1058-62.

21 Albala DM, Assimos DG, Clayman RV, Denstedt JD, Grasso M,Gutierrez-Aceves J, et al. Lower pole I: a prospective randomizedtrial of extracorporeal shock wave lithotripsy and percutaneousnephrostolithotomy for lower pole nephrolithiasisinitial results.JUrol 2001;166:2072-80.

22 Pearle MS, Lingeman JE, Leveillee R, Kuo R, Preminger GM, Nadler RB,et al. Prospective, randomized trial comparing shock wave lithotripsyand ureteroscopy for lower pole caliceal calculi 1 cm or less.J Urol2005;173:2005-9.

23 Segura JW, Preminger GM, Assimos DG, Dretler SP, Kahn RI, LingemanJE, et al. Ureteral stones clinical guidelines panel summary reporton the management of ureteral calculi. The American UrologicalAssociation.J Urol1997;158:1915-21.

24 Pace KT, Weir MJ, Tariq N, Honey RJ. Low success rate of repeat shockwave lithotripsy for ureteral stones after failed initial treatment.J Urol

2000;164:1905-7.25 Peschel R, Janetschek G, Bartsch G. Extracorporeal shock wave

lithotripsy versus ureteroscopy for distal ureteral calculi: aprospective randomized study.J Urol1999;162:1909-12.

26 Chandhoke PS. When is medical prophylaxis cost-effective forrecurrent calcium stones?J Urol2002;168:937-40.

27 Borghi L, Meschi T, Amato F, Briganti A, Novarini A, Giannini A.Urinary volume, water and recurrences in idiopathic calciumnephrolithiasis: a 5-year randomized prospective study.J Urol1996;155:839-43.

28 Borghi L, Schianchi T, Meschi T, Guerra A, Allegri F, Maggiore U, etal. Comparison of two diets for the p revention of recurrent stones inidiopathic hypercalciuria. N Engl J Med2002;346:77-84.

29 Dellabella M, Milanese G, Muzzonigro G. Randomized trial of theefficacy of tamsulosin, nifedipine and phloroglucinol in medicalexpulsive therapy for distal ureteral calculi.J Urol2005;174:167-72.

30 Gravina GL, Costa AM, Ronchi P, Galatioto GP, Angelucci A, CastellaniD, et al. Tamsulosin treatment increases clinical success rate of

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