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Urolithiasis
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TABLE OF CONTENTS PAGE 1. BACKGROUND 6 1.1 References 7 2. CLASSIFICATION 8 2.1 Categories of stone formers 8 2.2 Specific risk factors for stone formation 8 2.3 References 9 3. DIAGNOSTIC PROCEDURES 9 3.1 Diagnostic imaging 9 3.1.1 Allergy to contrast medium 10 3.1.2 Metformin 10 3.1.3 Reduced renal function 10 Risk factors for the development of reduced renal function 11 Dosage of iodine 11 3.1.4 Untreated hyperthyroidism 11 3.1.5 References 11 3.2 Analysis of stone composition 13 3.2.1 References 14 3.3 Biochemical investigations 14 3.3.1 Analytical work-up in the acute phase 14 3.3.2 Analysis of urine in search for risk factors of stone formation 14 3.3.3 Comments on the analytical work-up 16 3.3.4 A simplified overview of the principles of analytical work-up 18 3.3.5 References 19 4. STONE BURDEN 21 4.1 References 22 5. TREATMENT OF PATIENTS WITH RENAL COLIC 22 5.1 Pain relief 22 5.1.1 Treatment with non-steroidal anti-inflammatory drugs (NSAIDs) 22 5.1.2 Prevention of recurrent episodes of renal colic 22 5.1.3 Effects of diclofenac on renal function 23 5.2 Spontaneous passage of stones 23 5.3 Medical expulsive treatment (MET) 23 5.4 References 23 6. INDICATIONS FOR ACTIVE STONE REMOVAL 24 6.1 References 24 7. ACTIVE REMOVAL OF STONES IN THE KIDNEY 25 7.1 Extracorporeal shock-wave lithotripsy (ESWL) for removal of stones in the kidney 25 7.1.2 Factors of importance for the outcome of ESWL 27 7.1.2.1 Location of the stone mass 27 7.1.2.2 Stone burden 28 7.1.2.3 Composition and hardness of the stone 28 7.1.2.4 References 28 7.2 Percutaneous removal of renal stones 35 7.2.1 Complications 36 7.2.2 References 36 7.3 Retrograde removal of ureteral and renal stones (retrograde intrarenal surgery [RIRS]) 37 7.3.1 Standard endoscopic technique 37 7.3.2 Anaesthesia 38 7.3.3 Assessment of different devices 38 7.3.3.1 Ureteroscopes 38 7.3.3.2 Disintegration devices 38 7.3.3.3 Baskets and forceps 38 2 UPDATE MARCH 2008 7.3.3.4 Dilatation, ureteral access sheaths and stenting 39 7.3.4 Clinical results 39 7.3.4.1 Renal calculi 39 7.3.5. Complications 39 7.3.6. Conclusion 40 7.3.7 References 40 7.4 Open and laparoscopic surgery for removal of renal stones 47 7.4.1 Indications for open and laparoscopic surgery 47 7.4.2 Operative procedures 48 7.4.3 References 48 7.5 Chemolytic possibilities by percutaneous irrigation 51 7.5.1 Infection stones 51 7.5.2 Brushite stones 51 7.5.3 Cystine stones 51 7.5.4 Uric acid stones 52 7.5.5 Calcium oxalate and ammonium urate stones 52 7.5.6 References 52 7.6 Recommendations for removal of renal stones 53 8. STAGHORN STONES 55 9. MANAGEMENT OF PATIENTS WITH STONES IN THE URETER. EAU/AUA 2007 GUIDELINE 56 FOR THE MANAGEMENT OF URETERAL CALCULI 9.1 Introduction 58 9.2 Methodology 58 9.3 Results of the Outcomes Analysis 60 9.3.1 Observation and Medical Therapies 61 Stone passage rates 61 9.3.1.1 Shock-wave Lithotripsy and Ureteroscopy 61 9.3.1.2 Efficacy Outcomes 61 Stone-free rates 61 9.3.1.3 Procedure Counts 64 9.3.1.4 Complications 66 9.3.1.5 Other Surgical Interventions 68 9.4 The Index Patient 68 9.5 Treatment Guidelines for the Index Patient 69 9.5.1 For All Index Patients 69 9.5.2 For Ureteral Stones <10 mm 69 9.5.3 For Ureteral Stones >10 mm 70 9.5.4 For Patients Requiring Stone Removal 70 9.6 Recommendations for the Pediatric Patient 71 9.7 Recommendations for the Nonindex Patient 71 9.8 Discussion 71 9.8.1 Medical Expulsive Therapy 71 9.8.2 Shock-wave Lithotripsy 72 9.8.3 Ureteroscopy 73 9.8.4 Percutaneous Antegrade Ureteroscopy 73 9.8.5 Laparoscopic and Open Stone Surgery 74 9.8.6 Special Considerations 74 9.8.6.1 Pregnancy 74 9.8.6.2 Pediatrics 74 9.8.6.3 Cystine Stones 75 9.8.6.4 Uric acid Stones 75 9.9 Research and Future Directions 75 9.10 Acknowledgements and Disclaimers 76 9.11 References 76 10. GENERAL RECOMMENDATIONS AND PRECAUTIONS FOR STONE REMOVAL 83 10.1 Infections 83 10.2 Aspects of anticoagulation and stone treatment 83 UPDATE MARCH 2008 3 10.3 Pacemaker 83 10.4 Hard stones 83 10.5 Radiolucent stones 83 10.6 Recommendations for special considerations 83 10.7 References 84 11. MANAGING SPECIAL PROBLEMS 85 11.1 References 85 12. MANAGEMENT OF STONE PROBLEMS DURING PREGNANCY 88 12.1 Symptoms 88 12.2 Diagnostic evaluation 88 12.3. Management of the stone problem 88 12.3.1 Surgical management 89 12.3.2 Temporary urinary diversion 89 12.3.2.1 Percutaneous nephrostomy catheter 89 12.3.2.2 Internal ureteral stent 89 12.3.2.3 Ureteroscopy 90 12.4 Conclusions 90 12.5 References 90 13. MANAGEMENT OF STONE PROBLEMS IN CHILDREN 92 13.1 Investigations 92 13.1.1 Imaging 93 13.1.1.1 Ultrasound 93 13.1.1.2 Plain films (KUB) 93 13.1.1.3 Intravenous urography (IVU) 93 13.1.1.4 Helical computed tomogram (CT) 93 13.1.1.5 Magnetic resonance urography (MRU) 93 13.1.1.6 Nuclear imaging 94 13.1.2 Metaphylactic investigations 94 13.2 Stone removal 94 13.2.1 Endourological procedures 94 13.2.2 ESWL 95 13.2.3 Conclusions 95 13.2.4 Open or laparoscopic surgery 96 13.3 References 96 14. RESIDUAL FRAGMENTS 99 14.1 References 100 15. STEINSTRASSE 102 15.1 References 103 16. INTERNAL STENTING – WHEN AND WHY 103 16.1 Introduction 103 16.2 The use of stents in the management of stones in the kidney 103 16.3 The use of stents in the ureter 104 16.3.1 Indications for stenting for urgent relief of obstruction 104 16.4 Stents in conjunction with ESWL therapy for ureteral stones 104 16.5 Stents in conjunction with ureteroscopy (URS) 104 16.6 References 105 17. RECURRENCE PREVENTIVE TREATMENT 106 17.1 Recurrence preventive treatment of patients with calcium stone disease 106 17.1.1 Drinking recommendations 107 17.1.2 Dietary recommendations 107 17.1.3 Pharmacological treatment 108 17.1.3.1 Thiazides and thiazide-like agents 108 17.1.3.2 Alkaline citrate 109 4 UPDATE MARCH 2008 17.1.3.3 Orthophosphate 110 17.1.3.4 Magnesium 110 17.1.3.5 Allopurinol 111 17.1.3.6 Pyridoxine 111 17.1.3.7 Management of patients with enteric hyperoxaluria 111 17.1.4 Recommendations 111 17.1.5 References 112 17.2 Medical treatment of patients with uric acid stone disease 120 17.2.1 Drinking an dietary recommendations 120 17.2.2 Pharmacological treatment 120 17.2.3 References 121 17.3 Medical treatment of cystine stone disease 121 17.3.1 Dietary recommendations 121 17.3.2 Drinking advice 122 17.3.3 Pharmacological treatment 122 17.3.4 References 122 17.4 Management of patients with infection stones 123 17.4.1 Pharmacological treatment of infection stone disease 123 17.4.2 References 124 18. ABBREVIATIONS USED IN THE TEXT 125 19. APPENDICES 126 A1: Devices for endoscopic disintegration of stones
A2: Approximate stone surface area with known diameters of the stone
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