76

N E P H R O L I T H I A S I S
A N D
O B S T R U C T I O N

GERHARD J. FUCHS
MARK S. LITWIN
JACOB RAJFER

rolithiasis accounts for approximately 30% of all urologic emergency room admissions and clinic visits in the
United States. Due to the disabling, acute onset of severe
abdominal colicky pain with nausea and vomiting, the
diagnosis of urolithiasis is often made in the emergency
room setting.
Nephrolithiasis usually occurs in the third to fifth
decade of life and is a common cause of time lost from
work. Prior to the advent of minimally invasive treatment
techniques in the early 1980s, including extracorporeal
shock wave lithotripsy (ESWL) and endoscopic stone
surgery, open surgery of kidney and ureteral stones or
blind (i.e., under fluoroscopic control, not observed
through an endoscope) basketing of ureteral stones were
the only treatment options. Since the mid-1980s, most patients are treated without resorting to open surgery,
thereby greatly reducing stone-related morbidity, time
lost from work, and overall stone-related costs to society.

CASE 1
URETERAL STONE WITH
HYDRONEPHROSIS
A 24-year-old white male was admitted to the emergency
room with acute onset of severe right-sided colicky flank
pain and nausea. He vomited once at home 1 hour after

dinner and took two over-the-counter painkillers that did

not bring any relief. He had no fever or chills. He had regular bowel movements until the afternoon of his admission
and reported no voiding symptoms. There was no history
of prior operations, his medical history was unremarkable,
and there was no familial history of stone disease. Physical
examination showed an otherwise healthy 24-year-old with
right flank tenderness, no rebound tenderness, and hypoactive bowel sounds. His vital signs were normal. His
urinalysis had 5 RBC/HPF and pH of 6.5. A plain abdominal x-ray showed a 7-mm calcification adjacent to the lateral process of L3 on the right side. A significant amount
of abdominal gas overlay the renal shadows. He was presumed to have a right ureteral stone. A right renal ultrasound showed a normal sized kidney with normal
parenchyma. Hydronephrosis grade III (out of IV) was
seen and no stones were identified in the kidney or proximal ureter. An IV catheter was started and he was then
given 75 mg of Demerol and 25 mg IM of Vistaril, which
relieved his pain within the next 30 minutes. In the painfree interval, an IVP confirmed the presence of a partially
553

5 5 4

U R O L O G I C

S U R G E R Y

obstructing right ureteral stone with gross hydronephrosis.

He remained asymptomatic after the IVP study and was
discharged taking oral pain medications and advised to report to the urology clinic the following morning.
The following day, after discussion of the treatment
options of conservative management versus interventional
therapy, the patient opted for a trial with conservative
management of fluid challenge and oral pain medication
as needed. He was instructed to return to the clinic in case
of unremitting pain and/or a fever of greater than 38.6C.
Otherwise, he was to return in 2 weeks time to review his
progress and the degree of ureteral obstruction. Over the
ensuing 2 weeks, he had three more severe pain attacks
that responded to the oral pain medication, and he was
seen once at an outside emergency room where he received intramuscular pain medication. At his 2-week follow-up, the KUB x-ray showed the stone in the same position at the level of L3 and ultrasound again showed
hydronephrosis grade III. Since there was no progress in
his status despite the repeated pain attacks, interventional
therapy was begun. The patient underwent cystoscopic
manipulation of the stone with repositioning of the stone
into the kidney pelvis followed by ESWL under the same
epidural anesthesia. Due to the amount of ureteral
edema, an indwelling ureteral stent was placed. At posttreatment follow-up 2 weeks after the procedure, the patient appeared to be stone-free by KUB and ultrasound,
and the hydronephrosis had resolved. The ureteral stent
was removed in the office under topical anesthesia. Analysis of the patients stone showed pure calcium oxalate
monohydrate. Since this was his first stone incident with
no obvious risk factors, no metabolic workup was performed. He was advised to modify his fluid intake (6
oz/hr) and avoid dehydration.

CASE 2
PYELONEPHRITIS SECONDARY TO
STAGHORN STONE
A 46-year-old female with a temperature of 39.7C, and
general malaise was seen by her internist. She had a history of 1 year of intermitent dull left-sided flank discomfort, and three episodes of bladder infections that were
treated with oral antibiotics. She related that she had dull
flank pain for the past 2 weeks and a low grade temperature of 38C. She had regular gynecologic examinations,
the last of which was 3 weeks previous and normal. Her
urinalysis revealed 80 WBC/HPF, 10 RBC/HPF, and pH
7.0; her Hct was 36%; WBC count, 16,000/mm3; creatinine level, 1.5 g/dl; BUN, 20 mg/dl. A KUB x-ray showed
a complete staghorn stone of the left kidney filling all
renal calyces. Urine and blood cultures were obtained and
the patient was admitted to the hospital with a diagnosis of
pyelonephritis secondary to left renal staghorn stone. An

intravenous line was started and antibiotics given. She defervesced and an IVP study showed equal excretion of
contrast bilaterally and no obstruction. The urine culture
grew Pseudomonas, sensitive to ciprofloxacin, and she was
discharged the following morning taking the antibiotic.
Three weeks later, she underwent percutaneous endoscopic stone removal of 80% of her stone burden, including all stone parts from the lower calyceal group, the renal
pelvis, and parts of the upper calyceal group. A nephrostomy tube was left in place. The patient was discharged
from the hospital on postoperative day 2 with oral antibiotics. She returned 1 week later as an outpatient and the
remainder of the stone was fragmented using ESWL
under intravenous sedation and analgesia. The patient was
discharged the same day. Ten days later, a nephrostogram
was obtained confirming patency of the ureter and unimpaired drainage of contrast into the bladder. The nephrostomy tube was clamped and removed 2 days later. Four
weeks later, a KUB x-ray and renal ultrasound did not
show any residual fragments and there was no evidence of
infection.

GENERAL CONSIDERATIONS

ost patients with stones present with unilateral

severe flank pain of sudden onset (Case 1). Macro- or microhematuria is present in the majority of cases (Cases 1
and 2). There is a 3:1 predominance of male patients, with
female patients being more prone to infection-induced
stones; females have a higher incidence of urinary tract
infections (UTIs) because of a shorter urethra. The etiology of stone formation in the urinary tract is not completely understood. The most common explanation for
stone formation is the concomitant presence of three
major parameters, namely, urine supersaturation with
stone forming crystals (e.g., calcium oxalate, uric acid, cystine), deficiency of urinary inhibitors such as citrate, and
formation of matrix, a mucoprotein that binds calcium.
Genetic factors such as certain enzyme defects (in cystinuria, renal tubular acidosis, uric acid) are rare causes of
stone formation. However, in these patients, onset of
stone disease is usually at a relatively young age and often
leads to renal insufficiency.
The most commonly found stones are of calcium oxalate composition (70%) caused by supersaturation of the
urine with calcium (Case 1). This is secondary to increased calcium absorption from the bowel (such as seen
with high doses of vitamin D, sarcoidosis, and hyperparathyroidism), increased calcium resorption from bone
(such as in immobilization and hyperparathyroidism), or
high urine calcium concentrations due to a renal leak
(such as in renal tubular acidosis and congenitally). Another common cause of the formation of calcium stones is
a high concentration of oxalate in the urine (hyperox-

N E P H R O L I T H I A S I S

aluria) from dietary sources (vegetarian diet) or hyperabsorption from the colon and terminal ileum in patients
whose status is postintestinal bypass for management of
obesity or patients suffering from Crohns disease. Uric
stones are found in 15% of patients and are caused by
high urine concentration of uric acid in the presence of
acidic urine and low urine volumes. Contributing factors
are a diet high in purine, myeloproliferative disorders, and
gout. Infection-induced struvite stones are found in approximately 15% of patients, mostly in females (Case 2).
These are found concomitant with UTIs caused by ureasplitting bacteria (proteus). Urea-splitting bacteria produce urease, which in turn splits urea into ammonia, thus
raising the urinary pH value. This causes lower solubility
of ammonium, magnesium, and phosphate in the urine,
thus precipitating ammonium-magnesium-phosphate to
form stones (struvite). Less frequent are cystine stones
(1%) and matrix stones (<1%).

K E Y

P O I N T S

Urolithiasis accounts for 30% of all urologic emergency room

admissions and clinic visits
Because of acute onset of severe abdominal colicky pain with
nausea and vomiting, diagnosis made in emergency room
Common cause of time lost from work
Patients with stones present with unilateral severe flank pain
of sudden onset, and macro- or microhematuria present in majoriy of cases
Stones form from urine supersaturation with stone forming
crystals, deficiency of urinary inhibitors such as citrate, and formation of matrix (mucoprotein that binds calcium); most commonly found stones are of calcium oxalate composition (70%),
caused by supersaturation of urine with calcium, secondary to
increased calcium absorption from the bowel, increased calcium resorption from bone, or high urine calcium concentrations due to renal leak
Calcium stones also caused by high concentration of oxalate
in urine (hyperoxaluria) from dietary sources or hyperabsorption from colon and terminal ileum
Uric stones found in 15% of patients and caused by high
urine concentration of uric acid in presence of acidic urine and
low urine volumes
Infection-induced struvite stones found in 15% of patients,
mostly females, caused by urea-splitting bacteria (proteus)

DIAGNOSIS

he examination of the acutely symptomatic patient

includes a history and physical examination (vital signs,
temperature, abdominal examination), plain abdominal xray (kidney-ureter-bladder [KUB]) and ultrasound, blood
work (complete blood count, creatinine, blood urea nitrogen, uric acid, urinalysis, and urine culture and sensitivity.

A N D

O B S T R U C T I O N

5 5 5

These basic tests will allow the diagnosis or exclusion of urinary stones in the majority of cases. The KUB
x-ray will show radiopaque stones in approximately
8090% of cases (Cases 1 and 2). The renal ultrasound
will give important information on renal anatomy showing renal stones (including radiolucent stones) and/or
hydronephrosis as an indication of ureteral obstruction.
If a stone is identified with KUB and/or ultrasound, an
intravenous pyelogram (IVP) study is not required immediately. With the patient in acute ureteral colic, the
added diuretic fluid load of the IVP medium may cause
forniceal renal rupture and extravasation of urine. Secondly, the quality of an IVP study obtained during an
acute renal colic is usually poor because of abdominal
gas (paralytic ileus) overlying the shadows of the urinary
tract. It is prudent to postpone the IVP study until the
pain-free interval, and after appropriate bowel preparation. Also, before an IVP study, one should rule out
renal failure and ask whether the patient is allergic to
the contrast medium.
Urinalysis will reveal hematuria in almost all cases of
symptomatic stones. Pyuria and presence of bacteria suggest UTI, and urine should then be sent for culture and
sensitivity testing. The urine pH will give further clues as
to the chemical composition of the stone. An acid pH of 5
is found with uric acid stones and cystine stones. An alkali
pH of 7.5 and higher suggests an infection-induced struvite stone.
Flank pain, an elevated temperature (>38.6C), leukocytosis, and a urine specimen containing white blood cells
and bacteria hold the possibility of pyelonephritis. If
ureteral obstruction is present in this setting, this represents a urologic emergency since urosepsis or pyonephrosis
are immediate risks.
When the patient is oliguric/anuric or allergic to contrast media, a cystoscopy and retrograde pyelogram should
be performed to assess the course of the ureter, identify
the cause of obstruction, and establish ureteral drainage
by cystoscopic insertion of an indwelling ureteral stent. If
the patient is allergic to the IVP contrast medium, nonionic contrast can also be used. There is no established
role in the diagnosis of suspected urinary stone disease for
computed tomography (CT) scans or magnetic resonance
imaging (MRI) studies. These imaging modalities are
costly and do not add significantly to the information necessary to establish a diagnosis.

K E Y

P O I N T S

Examination includes history, physical examination, plain abdominal x-ray and ultrasound, blood work, urinalysis, and urine
culture and sensitivity; basic tests allow diagnosis or exclusion of
urinary stones in most cases
KUB x-ray shows radiopaque stones in 8090% of cases

5 5 6

U R O L O G I C

S U R G E R Y

Renal ultrasound shows renal stones (including radiolucent stones) and/or hydronephrosis as indication of ureteral
obstruction
Urinalysis reveals hematuria in cases of symptomatic stones;
pyuria and presence of bacteria suggest UTI, and urine should
be sent for culture and sensitivity testing
Flank pain, temperature above 38.6C, leukocytosis, urine
specimen with clumps of white blood cells indicate
pyelonephritis; if ureteral obstruction present, is urologic
emergency, since urosepsis or pyonephrosis are risks
In patient who is oliguric/anuric or allergic to contrast
media, cystoscopy and retrograde pyelogram should be performed to assess course of ureter, identify obstruction, and
establish drainage by cystoscopic insertion of indwelling
ureteral stent

DIFFERENTIAL DIAGNOSIS

ny other cause of acute severe abdominal pain, especially unilaterally severe pain with or without nausea and
vomiting, needs to be considered when evaluating the patient with presumed stone disease. It is imperative to rule
out potentially life-threatening acute abdominal disease
(viscus perforation, peritonitis, aortic aneursym) before labeling a patient as having only stone disease and administering pain medication. Using the above-described diagnostic workup, stone disease as the cause of abdominal
pain should be readily diagnosed or ruled out within the
first 2030 minutes of a patients presentation. If this basic
examination does not reveal any pathology of the urinary
tract, other causes for the patients pain need to be evaluated. This includes the gamut of differential diagnoses of
the acute abdomen. When the pain is predominantly in the
right upper quadrant, the more common differential diagnoses are biliary colic, acute cholecystitis, hepatic abscess,
pleurisy or pneumonia, peptic ulcer disease, subphrenic or
subhepatic abscess, obstructive and inflammatory disease
of the ascending and transverse colon, appendicitis of a
retrocecal appendix, pancreatitis, myocardial infarction,
pulmonary embolism, and dissecting thoracic aneurysm.
In the right lower quadrant, the main differential diagnoses are appendicitis, endometriosis, ectopic pregnancy
(ruptured), pelvic inflammatory disease, mittelschmerz,
salpingitis, torsion of an ovarian cyst, obstructive and inflammatory disease of the ascending colon, aortic aneurysm, and
hip pain (referred).
In the left upper quadrant, the main differential diagnoses include gastritis, pancreatitis, peptic ulcer disease, pericarditis and pleurisy, splenic rupture or infarct, and dissecting aneurysm of the thoracic aorta.
In the left lower quadrant, diverticulitis, obstructive
colon disease, aortic aneurysm, referred hip pain, and
female organ pathology need to be considered.

K E Y

P O I N T S

Imperative to rule out potentially life-threatening acute abdominal disease (viscus perforation, peritonitis) before labeling
patient with stone disease and administering pain medication
Stone disease should be diagnosed or ruled out within first
2030 minutes of patients presentation, using the above-mentioned workup

TREATMENT

herapy of stone disease depends on the presenting

symptoms as well as the stone characteristics. Stones associated with ureteral obstruction and infection are urologic
emergencies and need immediate treatment with removal
of the obstruction and broad spectrum antibiotic therapy.
All other stones can be treated according to specific stone
characteristics such as location, burden, composition,
anatomic and functional status of the urinary tract, and
concomitant disease.
Ureteral obstruction by a stone (or other cause, see
Ch. 21) associated with UTI is an indication for immediate
urologic intervention to prevent urosepsis (Case 2). Antibiotic treatment alone will not suffice in treating this condition, since the obstructed kidney may not excrete the antibiotic into the obstructed dead space urine. Even if the
antibiotic is excreted into the dead space, the patient is at
risk of succumbing to toxic shock syndrome secondary to
production of toxins. Therefore, it is imperative to remove
the obstruction from the kidney by means of bypassing the
obstacle (stone) with a ureteral catheter of sufficient caliber
or placement of a percutaneous renal drainage tube. An indwelling ureteral drainage stent may be placed via the cystoscope (under fluoroscopy control) with the patient under
intravenous sedation and local anesthesia. A percutaneous
renal drainage tube is usually placed by the uroradiologist
in the radiology suite under intravenous sedation and local
anesthesia. Once the patient has defervesced and the infection is appropriately treated, the underlying stone can be
addressed following the principles of elective stone treatment. The major determinants of the treatment choice for
elective stone treatment are location, burden, composition,
and anatomy and physiology of the upper urinary tract.
Stones located in the course of the ureter measuring 5
mm or less have a 90% chance of passing spontaneously.
Stones larger than 9 mm have a less than 10% chance of
passing spontaneously. Therefore, if the symptoms of pain
are intermittent and not disabling, stones smaller than 5
mm are treated conservatively with fluid challenge, pain
management, and observation. Stones between 5 mm and 9
mm in size are also managed with expectant waiting (Case
1) if consecutive pain episodes are productive (i.e., stone
migrating toward the bladder is documented on serial plain
abdominal x-rays). Stones causing disabling pain, progres-

N E P H R O L I T H I A S I S

sive obstruction, or those that show no migration despite recurrent pain episodes are treated with minimally invasive
therapy (i.e., either ureteroscopic fragmentation and removal or with ESWL [Case 1]). Ureteroscopy utilizes small
caliber endoscopes that can be advanced into the ureteric
orifice and up the ureter to the level of the stone under direct vision (the endoscope is usually connected to a video
camera). The stone can then be removed using a small
grasping device or, if the stone is lodged in the ureteral wall,
it is fragmented using electrohydraulic, ultrasonic, laser, or
pneumatic energy. In experienced hands, success rates with
ureteroscopy vary from 100% in the distal ureter below the
pelvic brim to 90% in the proximal ureter.
ESWL utilizes shockwave energy to noninvasively fragment stones in the kidney (or ureter). The device consists of
a shockwave source, focusing device, and x-ray and/or ultrasound localization. The shockwave is generated outside the
body in a semiellipsoid brass cylinder and focused onto the
stone inside the body using x-ray (fluoroscopy) or ultrasound
equipment. The stone is then broken by repeated shockwave exposures (5003,000) and the resulting stone fragments are excreted with the urine. Most patients with renal
stones can be treated with ESWL (Cases 1 and 2). The current range of indications include approximately 70% of nonselected urinary stone patients. An additional 25% of patients with more complex stones in the upper urinary tract
can receive treatment with the lithotriptor when combining
the method with endourologic procedures (Case 2).
Approximately 70% of nonselected stone patients are
eligible for ESWL monotherapy (Table 76.1). This group
includes patients with single and multiple stones (added
stone mass of <2.5 cm) in the kidney, selected ureteral
stones above the iliac crest (after successful repositioning
into the kidney); and staghorn stones that are filling a
nondilated collecting system (in the absence of internal
TABLE 76.1
SIZE

OF

Treatment of urinary calculi

STONE

MODALITY

OF

CHOICE

Nonstaghorn stone
<1.5 cm

ESWL

1.52.5 cm

ESWL ( double-J stent)

>2.5 cm

PCN

Staghorn stone

PCN ( ESWL)
Open surgery

Ureteral stone
Proximal ureter

In situ ESWL
Push back + ESWL
(bypass stenting + ESWL)
Ureteroscopy

Distal ureter

Ureteroscopy (ESWL)

Abbreviations: ESWL, extracorporeal shockwave lithotripsy; PCN, percutaneous nephrostomy.

A N D

O B S T R U C T I O N

5 5 7

stenosis or dilatation). The remainder of patients present

with more complex stone disease (larger stone burdens or
anatomic abnormalities that may preclude proper passage
of stone debris), or with stones that need auxiliary procedures to maximize the advantage of ESWL). The latter
group includes radiolucent and small semiopaque stones
that need to be made visible by use of contrast medium, as
they cannot be primarily identified on standard fluoroscopy (with the exception of ultrasound-based localization lithotripsy). Success rates with ESWL in the ureter
are between 60% and 90%. Therefore, the treatment of
choice at dedicated stone centers with experience in all
treatment modalities is ureteroscopic removal of ureteral
stones rather than ESWL treatment.
For staghorn stones, different treatment strategies are
used depending on user bias (monotherapy with ESWL versus the combined treatment of endourologic procedures and
subsequent ESWL). Success with ESWL of kidney stones is
dependent on (1) the overall stone burden in the kidney, (2)
the shape of the renal collecting system, (3) the architecture
of the dependent calyces, and (4) stone composition.
Based on these criteria, the following guidelines for the
treatment of staghorn stones have been established at our
institution. In partial and complete staghorn stones,
monotherapy with ESWL (in conjunction with the use of
indwelling ureteral catheters) is only preferable to percutaneous surgery in cases where the stone is filling a nondilated collecting system. A planned, staged ESWL procedure is a treatment option in staghorn stones that are filling
a slightly dilated collecting system. It must be pointed out,
however, that with increasing stone burden, the complication rates of second sessions and follow-up complications
are considerably higher than those encountered with
smaller stones. Also, the period of stone passage is significantly prolonged compared with percutaneous stone
surgery or combination therapy. Auxiliary procedures,
namely percutaneous nephrostomy tube placement and
ureteroscopic ureteral manipulations, are required in approximately 70% of patients after the ESWL treatment of
large branched stones (Case 2). Thus, in staghorn stones
with (1) a large stone mass filling a dilated renal collecting
system, and (2) with intrarenal anatomic alterations, a percutaneous procedure is performed first for debulking the
stone. In a second session, ESWL is employed for the disintegration of the remaining calyceal stone parts, and
under the same anesthesia, the patient undergoes a second
percutaneous procedure for removal of the stone gravel.
Although inherently more invasive than monotherapy with
ESWL, this approach is of great benefit for the patient
with regard to stone-free rates, hospitalizations, and time
lost from work.
Open surgery is rarely indicated (12%) in the stateof-the-art management of urinary stones. Severe anatomic
abnormalities that cannot be corrected endoscopically or
laparoscopically, such as multiple intrarenal or long ureteral

5 5 8

U R O L O G I C

S U R G E R Y

strictures, are the only remaining indications for open

surgery at experienced centers.
Most procedures for treatment of urinary stones are
performed in an outpatient setting. Patients undergo
procedures under epidural anesthesia (60%), general
anesthesia (30%), or intravenous sedation and analgesia
(10%). Perioperative antibiotics (e.g., ampicillin and gentamicin) are administered on-call to the operating theater in all patients undergoing endoscopic instrumentation and in those patients undergoing an ESWL
procedure who have a history of previous UTI. After
surgery, patients recover in the surgical recovery room
and are discharged from the outpatient surgical unit
after they have voided spontaneously. Admission to the
hospital is routine in patients undergoing percutaneous
renal surgery (average hospital stay is less than 2 days) or
for the management of concomitant medical disease as
preoperatively determined. Unplanned admissions from
the recovery room or the outpatient surgical unit are rare
exceptions (<2%). Pain management is the usual reason
for unplanned hospital admission.

K E Y

P O I N T S

Stones associated with ureteral obstruction and infection

are urologic emergencies and require immmediate relief of
obstruction and broad spectrum antibiotic therapy
Other stones treated according to stone characteristics
such as location, burden, composition, anatomic and functional status of urinary tract, and concomitant disease
Antibiotic treatment not enough to treat ureteral obstruction,
because kidney may not excrete antibiotic into dead space
urine; imperative to remove obstruction by means of bypassing
stone with ureteral catheter or placement of percutaneous
renal drainage tube
Major determinants of elective stone treatment are location,
burden, composition, and anatomy and physiology of upper urinary tract
Stones smaller than 5 mm treated conservatively with fluid
challenge, pain management, and observation
Stones causing disabling pain, progressive obstruction, or
those that show no migration despite recurrent pain episodes
are treated with minimally invasive therapy
Current range of indications for ESWL include approximately 70% of nonselected urinary stone patients; additional
25% of patients with more complex stones in upper urinary
tract can receive treatment with lithotriptor, in combination
with endourologic procedures
Open surgery rarely indicated (12%) in state-of-the-art
management of urinary stones
Most procedures for urinary stones done in outpatient
setting
Unplanned admissions from recovery room or outpatient surgical unit rare exceptions (<2%), usually for pain management

FOLLOW-UP

atients undergoing endoscopic surgery are discharged

with oral antibiotics for 5 days (e.g. Bactrim DS by mouth
twice a day) and pain medications (e.g., Tylenol 3, 12
tablets by mouth, as needed for pain). Patients undergoing
ESWL treatment without ureteral manipulation and without a history of UTI do not require routine postoperative
antibiotic coverage. Patients are usually seen 1 week postoperatively after uncomplicated ureteroscopy for a KUB
and possible stent removal, or after 2 weeks following either
ESWL treatment or percutaneous surgery for the assessment of the status of residual stone debris and the possible
removal of ureteral/renal drainage stents. Patients with
residual stone debris are seen at individualized intervals
until either all stone debris has passed or only a small and
clinically insignificant amount is present (usually residing in
a lower pole renal calyx). Routine stone metaphylaxis in a
first-time stone former stresses the importance of avoiding
dehydration by increasing fluid intake to 6 oz per waking
hour. The rate of stone recurrence in a nonselected group
of patients having had a first stone incident is approximately
10%/yr for a maximum of 70% over a 10-year observation
period. A metabolic stone evaluation is performed for all
patients with recurrent stone disease.

K E Y

P O I N T S

Patients with residual stone debris are seen at individualized

intervals until either all stone debris has passed or only clinically
insignificant amount is present

SUGGESTED READINGS
Eisenberger F, Miller K, Rassweiler J (ed): Stone Therapy in
Urology. Thieme Medical Publishers, New York, 1991
Hanno P, Wein A (ed): A Clinical Manual of Urology. AppletonCentury-Crofts, E. Norwalk, CT, 1986

QUESTIONS
1.Nephrolithiasis?
A. Is most commonly due to calcium oxalate
supersaturation.
B. In females is usually due to infection.
C. Requires an IVP for diagnosis.
D. Is often due to uric acid stones when the urine
pH is more than 7.5.
2. Options for removing ureteral stones include?
A. Ureteroscopic retrieval.
B. ESWL
C. Combined endoscopic and lithotripsy management.
D. Open surgical treatment.
E. All of the above.
(See p. 604 for answers.)