How is urolithiasis treated?

Treatment and prevention of urolithiasis in children and adults remains a difficult task. Treatment of patients with nephrolithiasis can be conservative and operative. As a rule, they carry out complex treatment.

In view of the fact that many questions of the etiology and pathogenesis of urolithiasis are not resolved, removing the stone from the kidney by operative means does not mean the cure of the patient.

Goals of treatment of urolithiasis

Conservative treatment is aimed at correction of biochemical changes in blood and urine, elimination of pain and inflammation, prevention of recurrences and complications of the disease, and also contributes to the removal of small stones up to 5 mm. Conservative treatment is shown mainly in those cases when the calculus does not cause a violation of urinary outflow, hydronephrosis transformation or shrinkage of the kidney as a result of the inflammatory process, for example, with small stones in the renal calyces. Conservative therapy is also performed in the presence of contraindications to the surgical treatment of nephroureterolithiasis.

Conservative therapy consists of general restorative measures, dietary nutrition, medicinal and sanatorium-and-spa treatment.

Indications for hospitalization

Indications for urgent hospitalization and emergency surgery for urolithiasis:

• stones in both ureters;
• stone of the ureter of the only functioning kidney;
• stone pelvis, complicated by acute pyelonephritis;
• hematuria, caused by a stone and not amenable to conservative therapy;
• anuria or acute urinary retention, the cause of which is stones in the urinary tract.

Indications for hospitalization may be an attack of renal colic, especially not removed by spasmolytic drugs, the presence of coral stone, to address the issue of management tactics and often or continuously recurring pyelonephritis in a patient with urolithiasis. In addition, it is necessary to hospitalize children in order to carry out a differential diagnosis and establish the causes of stone formation, in particular, to exclude hereditary and endocrine diseases and further selection of therapy (conservative and / or surgical).

Non-pharmacological treatment of urolithiasis

Dietotherapy helps restore normal metabolism and maintain homeostasis. It is prescribed depending on the type of violation of salt metabolism. An important role in therapy, and especially for the prevention of urolithiasis in children, is played by a diet that includes limiting oxalic (deciduous vegetables) and containing urate (poultry, sprats, offal) products and high-drinking drinking regime.

Drug treatment of urolithiasis

Moderate hypocalcemic action is exerted by vitamins A and E, which inhibit the processes of lipid peroxidation, reduce the concentration of free oxygen radicals, while vitamin E deficiency increases metastatic calcification of the aorta, heart and kidneys.

In recent years, various bisphosphonates, synthetic analogs of natural inorganic pyrophosphates, taking part in the exchange of calcium and phosphorus in the body, have been used to suppress bone resorption and promote hypercalcemia. It is shown that the use of domestic bisphosphonate - xidiphon (potassium and sodium etidronate) leads to the normalization of a number of pathological changes in calcium metabolism.

A special place in the treatment of nephroureterolithiasis is taken by measures to stop renal colic and litholytic drugs.

Below are the most commonly used drugs for the treatment of urolithiasis in children and adults.

• Preparations for dissolution (litholysis) of urinary calculi and urine alkalinization. Medicinal litholysis is subjected to urate and mixed stones. Given that urate stones occur against the background of a decrease in urine pH, to dissolve them, it is necessary to create constantly increased pH values of urine (pH 6.2-6.8), which is achieved by the intake of citrate mixtures. The medicinal litholysis of stones of other chemical structure is considered only an auxiliary method of treatment (for example, to achieve the best disintegration with lithotripsy, the separation of residual fragments). The complex effect of citrate on the physico-chemical state of urine leads to the dissolution of urates, microcalcinates, primarily oxalate stones, mixed magnesium-ammonium-phosphate, contributing to the inhibition of stone formation. Treatment with citrate preparations promotes the formation of highly soluble complexes with calcium, thereby increasing the inhibitory activity of urine.
• Citrate mixtures:
  • bleached;
  • uralit U.
• Plant Litholytic Preparations:
  • ginjaleling;
  • Kedibilling;
  • cystone;
  • kanefron N ";
  • phytolysin;
  • cystenal;
  • spasmocystenal;
  • urolesan;
  • extract madder dyeing;
  • avisan;
  • pinabine.
• Spasmolytic drugs. Drugs of this group are used as a therapy aimed at eliminating an attack of renal colic. Spasmoanalgesics improve the removal of small stones, reduce the edema of tissues with prolonged standing of the calculus. Given that inflammatory changes are usually accompanied by pain and fever, it is advisable in some cases to combine antispasmodics with NGTLD. To treat urolithiasis, both neurotropic and myotropic antispasmodics are used. Most often in Russia the drug drotaverin is used.
• NSAIDs are the most commonly used analgesic and anti-inflammatory drugs:
  • ketoprofen;
  • diclofenac;
  • ketorolac and others.
• Thiazide diuretics (hypothiazide, indapamide) are used to treat idiopathic hypercalciuria, they inhibit the reabsorption of sodium and chlorine ions in the proximal tubule of the kidneys.
• Potassium citrate reduces the saturation of urine with calcium salts, binding calcium and decreasing the concentration of calcium ions. Due to this alkalizing effect, it also increases the dissociation of uric acid, reducing the amount of sparingly undissociated acid, and reduces the tendency to form urate stones. Potassium citrate is preferable to sodium citrate in preventing urolithiasis.

Surgical treatment of urolithiasis

Surgical removal of calculi from the organs of the urinary system (X-ray endourological operations, open operations, lithotripsy) is the main method of treatment. However, with the elimination of the calculus in the body, the process of stone formation does not stop, which, without pharmacological correction, often causes secondary and recurrent nephrolithiasis.

Treatment for urolithiasis is not only the removal of the stone (or its separate separation), but also in the conduct of further anti-relapse treatment. This is due to the fact that, according to some authors, relapses of the disease depending on this or that form of urolithiasis occur in 10-40% of patients without anti-relapse treatment.

The variety of causes and clinical forms of urolithiasis makes anti-relapse treatment a difficult task, which should be maximally individualized depending on the clinical form of the disease, the chemical composition of urinary stones, the detected changes in laboratory indicators, etc.

Anti-relapse treatment is based on dietary recommendations, correction of biochemical changes, use of membrane stabilizing drugs, drug litholysis (according to indications), etc.

Indications for consultation of other specialists

If there is a suspicion of a hereditary and endocrinological cause of stone formation, the advice of a geneticist and an endocrinologist is shown when deciding on the question of surgical treatment - a urologist, a specialist in lithotripsy.

Prognosis for urolithiasis

The forecast depends on the main process that caused the stone formation. With the majority of hereditary and endocrine diseases, the outlook is unfavorable. With small stones in the urinary system, as a rule, it is possible to remove stones conservatively, especially when using modern litholytic drugs. In the subsequent metaphylactics, the outlook is favorable. In the case of large stones (10 mm and more) in the renal pelvis and / or calyces, especially coral ones, conservative therapy is most often ineffective and the prognosis is usually unfavorable. The kidney stone gradually grows in size, creates conditions for violation of the outflow of urine, the appearance and progression of pyelonephritis. With timely operative treatment, the prognosis is favorable, but a certain threat always represents a relapse of the stone formation, since nephrolithiasis is a disease not only of the kidney, but of the whole organism, and the removal of the stone does not mean the elimination of the disease. In children, recurrence of stone formation is recorded in 3-10% of cases, in adults - in 11-28.5%. To prevent recurrent stone formation, it is recommended to perform complex treatment (anti-inflammatory, litholytic, dietary, etc.).

With stones of the bladder, the prognosis depends mainly on the nature of the disease, which breaks the urine outflow from the bladder and is the basis of the stone formation (urethral stricture, prostate tumors, etc.). If this disease is eliminated, the prognosis is favorable, otherwise the relapse of stone formation in the bladder is most likely.

Subject to an emergency removal of the stone from the urethra in one way or another, the prognosis is favorable.

[1], [2], [3], [4], [5], [6], [7], [8]