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Assessment of stone composition in the management of urinary stones

Nature Reviews Urology volume 8, pages 81–85 (2011)Cite this article

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Abstract

Several explanations have been suggested to account for the failure of extracorporeal shockwave lithotripsy (ESWL) treatment in patients with urinary stones, including large stone volume, unfavorable stone location or composition and the type of lithotriptor used. Unfavorable stone composition is considered a major cause of failure of ESWL treatment, and consequently knowledge of the stone composition before treatment is initiated is desirable. Plain abdominal radiographs cannot accurately determine either stone composition or fragility, and although the CT attenuation value in Hounsfield units (HU) (that is, normalized to the attenuation characteristics of water) is useful, this parameter has limited value as a predictor of stone composition or the response to ESWL treatment. By contrast, stone morphology as visualized by CT correlates well with both fragility and susceptibility to fragmentation by ESWL. For patients prone to recurrent calculi, analyses of stone composition are especially important, as they may reveal an underlying metabolic abnormality. The development of advanced imaging technologies that can predict stone fragility is essential, as they could provide extra information for physicians, enabling them to select the most appropriate treatment option for patients with urinary stones.

Key Points

  • The risk of urinary stone disease varies between 1% and 13% around the world and calcium oxalate lithiasis is the most common pathology worldwide

  • Knowledge of the stone composition can uncover underlying metabolic abnormalities and help urologists to provide optimal treatment and also prevent stone recurrence

  • Stone composition influences fragility, and thus knowledge of composition could enable urologists to predict the stone's susceptibility to fragmentation using extracorporeal shockwave lithotripsy (ESWL)

  • Plain abdominal radiography is incapable of determining stone composition, and the CT attenuation value in Hounsfield units (HU) has limited value for this purpose

  • Visualization of stone morphology on CT correlates well with susceptibility to ESWL, and could be used to select patients for this treatment

  • For patients prone to recurrent stones, chemical analysis of stones (either following spontaneous passage or after stone collection via ESWL or endoscopic procedures) is important

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Figure 1: CT scan from a patient with a 1.5 cm stone in the lower pole of the left kidney.

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References

  1. Amato, M., Lusini, M. L. & Nelli, F. Epidemiology of nephrolithiasis today. Urol. Int. 72 (Suppl. 1), 1–5 (2004).

    Article  PubMed  Google Scholar 

  2. Lingeman, J. E. et al. Extracorporeal shock wave lithotripsy: the Methodist Hospital of Indiana experience. J. Urol. 135, 1134–1137 (1986).

    Article  CAS  PubMed  Google Scholar 

  3. Dretler, S. P. Stone fragility—-a new therapeutic distinction. J. Urol. 139, 1124–1127 (1988).

    Article  CAS  PubMed  Google Scholar 

  4. Williams, J. C. Jr, Paterson, R. F., Kopecky, K. K., Lingeman, J. E. & McAteer, J. A. High resolution detection of internal structure of renal calculi by helical computerized tomography. J. Urol. 167, 322–326 (2002).

    Article  PubMed  Google Scholar 

  5. Turgut, M. et al. The concentration of Zn, Mg and Mn in calcium oxalate monohydrate stones appears to interfere with their fragility in ESWL therapy. Urol. Res. 36, 31–38 (2008).

    Article  CAS  PubMed  Google Scholar 

  6. Madaan, S. & Joyce, A. D. Limitations of extracorporeal shock wave lithotripsy. Curr. Opin. Urol. 17, 109–113 (2007).

    Article  PubMed  Google Scholar 

  7. Ansari, M. S. et al. Stone fragility: its therapeutic implications in shock wave lithotripsy of upper urinary tract stones. Int. Urol. Nephrol. 35, 387–392 (2003).

    Article  CAS  PubMed  Google Scholar 

  8. Grases, F., Costa-Bauza, A. & Garcia-Ferragut, L. Biopathological crystallization: a general view about the mechanisms of renal stone formation. Adv. Colloid Interface Sci. 74, 169–194 (1998).

    Article  CAS  PubMed  Google Scholar 

  9. Ansari, M. S. et al. Spectrum of stone composition: structural analysis of 1050 upper urinary tract calculi from northern India. Int. J. Urol. 12, 12–16 (2005).

    Article  PubMed  Google Scholar 

  10. Krishnamurthy, M. S., Ferucci, P. G., Sankey, N. & Chandhoke, P. S. Is stone radiodensity a useful parameter for predicting outcome of extracorporeal shockwave lithotripsy for stones < or = 2 cm? Int. Braz. J. Urol. 31, 3–9 (2005).

    Article  PubMed  Google Scholar 

  11. Oehlschlager, S., Hakenberg, O. W., Froehner, M., Manseck, A. & Wirth, M. P. Evaluation of chemical composition of urinary calculi by conventional radiography. J. Endourol. 17, 841–845 (2003).

    Article  PubMed  Google Scholar 

  12. Teichman, J. M. Clinical practice. Acute renal colic from ureteral calculus. N. Engl. J. Med. 350, 684–693 (2004).

    Article  CAS  PubMed  Google Scholar 

  13. Wen, C. C. & Nakada, S. Y. Treatment selection and outcomes: renal calculi. Urol. Clin. North Am. 34, 409–419 (2007).

    Article  PubMed  Google Scholar 

  14. Joseph, P. et al. Computerized tomography attenuation value of renal calculus: can it predict successful fragmentation of the calculus by extracorporeal shock wave lithotripsy? A preliminary study. J. Urol. 167, 1968–1971 (2002).

    Article  PubMed  Google Scholar 

  15. Gupta, N. P., Ansari, M. S., Kesarvani, P., Kapoor, A. & Mukhopadhyay, S. Role of computed tomography with no contrast medium enhancement in predicting the outcome of extracorporeal shock wave lithotripsy for urinary calculi. BJU Int. 95, 1285–1288 (2005).

    Article  PubMed  Google Scholar 

  16. Ng, C. F. et al. Development of a scoring system from noncontrast computerized tomography measurements to improve the selection of upper ureteral stone for extracorporeal shock wave lithotripsy. J. Urol. 181, 1151–1157 (2009).

    Article  PubMed  Google Scholar 

  17. Perks, A. E. et al. Stone attenuation and skin-to-stone distance on computed tomography predicts for stone fragmentation by shock wave lithotripsy. Urology 72, 765–769 (2008).

    Article  PubMed  Google Scholar 

  18. Ferrandino, M. N. et al. Dual-energy computed tomography with advanced postimage acquisition data processing: improved determination of urinary stone composition. J. Endourol. 24, 347–354 (2010).

    Article  PubMed  Google Scholar 

  19. Dretler, S. P. & Spencer, B. A. CT and stone fragility. J. Endourol. 15, 31–36 (2001).

    Article  CAS  PubMed  Google Scholar 

  20. Stolzmann, P. et al. Dual-energy computed tomography for the differentiation of uric acid stones: ex vivo performance evaluation. Urol. Res. 36, 133–138 (2008).

    Article  PubMed  Google Scholar 

  21. Sheir, K. Z., Mansour, O., Madbouly, K., Elsobky, E. & Abdel-Khalek, M. Determination of the chemical composition of urinary calculi by noncontrast spiral computerized tomography. Urol. Res. 33, 99–104 (2005).

    Article  PubMed  Google Scholar 

  22. Zarse, C. A. et al. CT visible internal stone structure, but not Hounsfield unit value, of calcium oxalate monohydrate (COM) calculi predicts lithotripsy fragility in vitro. Urol. Res. 35, 201–206 (2007).

    Article  PubMed  PubMed Central  Google Scholar 

  23. Evan, A. P., Willis, L. R., Lingeman, J. E. & McAteer, J. A. Renal trauma and the risk of long-term complications in shock wave lithotripsy. Nephron 78, 1–8 (1998).

    Article  CAS  PubMed  Google Scholar 

  24. Krambeck, A. E. et al. Diabetes mellitus and hypertension associated with shock wave lithotripsy of renal and proximal ureteral stones at 19 years of followup. J. Urol. 175, 1742–1747 (2006).

    Article  PubMed  Google Scholar 

  25. Baumann, J. M. Can the formation of calcium oxalate stones be explained by crystallization processes in urine? Urol. Res. 13, 267–270 (1985).

    CAS  PubMed  Google Scholar 

  26. Ljunghall, S. & Hedstrand, H. Epidemiology of renal stones in a middle-aged male population. Acta Med. Scand. 197, 439–445 (1975).

    Article  CAS  PubMed  Google Scholar 

  27. Sutherland, J. W. Recurrence following operative treatment of upper urinary tract stone. J. Urol. 127, 472–474 (1982).

    Article  CAS  PubMed  Google Scholar 

  28. Strohmaier, W. L. Socioeconomic aspects of urinary calculi and metaphylaxis of urinary calculi [German]. Urologe A 39, 166–170 (2000).

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements

We would like to thank Professor Amnuay Thithapandha for his help and advice concerning the preparation of this manuscript.

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Authors and Affiliations

  1. Division of Urology, Department of Surgery, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270 Rama VI Road, Ratchatewi, 10400, Bangkok, Thailand

    Kittinut Kijvikai

  2. Department of Urology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands

    J. J. M. de la Rosette

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K. Kijvikai researched data for the article. K. Kijvikai and J. J. M. de la Rosette were both involved in discussion regarding article content, writing of the article, and review and editing of the manuscript before submission.

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Correspondence to Kittinut Kijvikai.

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Kijvikai, K., de la Rosette, J. Assessment of stone composition in the management of urinary stones. Nat Rev Urol 8, 81–85 (2011). https://doi.org/10.1038/nrurol.2010.209

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