How is urolithiasis treated?

Treatment and prevention of urolithiasis in children and adults remains a difficult task. Treatment of patients with urolithiasis can be conservative and surgical. As a rule, complex treatment is carried out.

Due to the fact that many questions about the etiology and pathogenesis of urolithiasis have not been resolved, surgical removal of a kidney stone does not mean a cure for the patient.

Goals of treatment for urolithiasis

Conservative treatment is aimed at correcting biochemical changes in the blood and urine, eliminating pain and inflammation, preventing relapses and complications of the disease, and also promotes the passage of small stones up to 5 mm. Conservative treatment is indicated mainly in cases where the stone does not cause a violation of the outflow of urine, hydronephrotic 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 carried out in the presence of contraindications to surgical treatment of nephroureterolithiasis.

Conservative therapy consists of general strengthening measures, dietary nutrition, medication and spa treatment.

Indications for hospitalization

Indications for urgent hospitalization and emergency surgery for urolithiasis:

• stones in both ureters;
• ureteral stone of the only functioning kidney;
• renal pelvis stone complicated by acute pyelonephritis;
• macrohematuria 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 include an attack of renal colic, especially one that is not relieved by antispasmodic drugs, the presence of a coral stone, to decide on the treatment tactics, and frequently or continuously recurring pyelonephritis in a patient with urolithiasis. In addition, it is necessary to hospitalize children for the purpose of differential diagnosis and establishing the causes of stone formation, in particular, to exclude hereditary and endocrine diseases and further selection of therapy (conservative and/or surgical).

Non-drug treatment of urolithiasis

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

Drug treatment of urolithiasis

Vitamins A and E have a moderate hypocalcemic effect, inhibiting lipid peroxidation processes and reducing the concentration of free oxygen radicals, while vitamin E deficiency increases metastatic calcification of the aorta, heart and kidneys.

In recent years, various bisphosphonates have been used to suppress bone resorption and the development of hypercalcemia - synthetic analogues of natural inorganic pyrophosphates that participate in the exchange of calcium and phosphorus in the body. It has been shown that the use of the domestic bisphosphonate - xydiphone (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 occupied by measures to relieve renal colic and litholytic drugs.

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

• Preparations for dissolving (litholysis) urinary stones and alkalizing urine. Urate and mixed stones are subjected to medicinal litholysis. Considering that urate stones occur against the background of a decrease in urine pH, to dissolve them it is necessary to create constantly elevated urine pH values (pH 6.2-6.8), which is achieved by taking citrate mixtures. Medicinal litholysis of stones of a different chemical structure is considered only an auxiliary method of treatment (for example, to achieve the best disintegration during lithotripsy, the passage of residual fragments). The complex effect of citrate on the physicochemical state of urine leads to the dissolution of urates, microcalcifications, primarily oxalate stones, mixed magnesium-ammonium-phosphate, helping to inhibit stone formation. Treatment with citrate preparations promotes the formation of highly soluble complexes with calcium, thereby increasing the inhibitory activity of urine.
• Citrate mixtures:
  • blemaren;
  • uralite U.
• Herbal litholytic preparations:
  • ginjaleling;
  • kejibiling;
  • cyston;
  • "Kanefron N";
  • phytolysin;
  • cystenal;
  • spasmocystenal;
  • urolesan;
  • madder extract;
  • avisan;
  • pinabin.
• Antispasmodics. Drugs of this group are used as a therapy aimed at eliminating an attack of renal colic. Spasmolytic analgesics improve the passage of small stones, reduce tissue edema with prolonged standing of the stone. Considering that inflammatory changes are usually accompanied by pain and fever, it is advisable in some cases to combine antispasmodics with NGTVP. Both neurotropic and myotropic antispasmodics are used to treat urolithiasis. The most frequently used drug in Russia is drotaverine.
• NSAIDs are the most commonly used pain relievers and anti-inflammatory drugs:
  • ketoprofen;
  • diclofenac;
  • ketorolac, etc.
• Thiazide diuretics (hypothiazide, indapamide) are used to treat idiopathic hypercalciuria; they inhibit the reabsorption of sodium and chloride ions in the proximal tubules of the kidneys.
• Potassium citrate reduces the saturation of urine with calcium salts by binding calcium and reducing the concentration of calcium ions. Due to this alkalizing effect, it also increases the dissociation of uric acid, reducing the amount of poorly soluble 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 stones from the urinary system (X-ray endourological operations, open operations, lithotripsy) is the main method of treatment. However, with the removal of the stone in the body, the process of stone formation does not stop, which without pharmacological correction often becomes the cause of secondary and recurrent nephrolithiasis.

Treatment of urolithiasis involves not only removing the stone (or allowing it to pass on its own), but also further anti-relapse treatment. This is due to the fact that, according to some authors, relapses of the disease, depending on the particular 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 complex task, which should be maximally individualized depending on the clinical form of the disease, the chemical composition of urinary stones, detected changes in laboratory parameters, etc.

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

Indications for consultation with other specialists

If there is a suspicion of a hereditary or endocrinological cause for stone formation, consultations with a geneticist and endocrinologist are recommended; when deciding on surgical treatment, a urologist or lithotripsy specialist is recommended.

Prognosis for urolithiasis

The prognosis depends on the underlying process that caused the stone formation. The prognosis is unfavorable for most hereditary and endocrinological diseases. In the case of small stones in the urinary system, it is usually possible to remove the stones conservatively, especially when using modern litholytic drugs. With subsequent metaphylaxis, the prognosis is favorable. In the case of large stones (10 mm or more) in the renal pelvis and / or calyces, especially coral-shaped, conservative therapy is most often ineffective and the prognosis is usually unfavorable. The kidney stone gradually increases in size, creating conditions for disruption of urine flow, the occurrence and progression of pyelonephritis. With timely surgical treatment, the prognosis is favorable, but a certain threat is always posed by a relapse of stone formation, since nephrolithiasis is a disease of not only the kidney, but the whole body, and stone removal does not mean the elimination of the disease. In children, relapse of stone formation is recorded in 3-10% of observations, in adults - in 11-28.5%. To prevent recurrent stone formation, it is recommended to carry out complex treatment (anti-inflammatory, litholytic, dietary, etc.).

In case of bladder stones, the prognosis depends mainly on the nature of the disease that disrupts the outflow of urine from the bladder and the underlying cause of stone formation (stricture of the urethra, prostate tumors, etc.). If this disease is eliminated, the prognosis is favorable; otherwise, relapse of bladder stone formation is most likely.

Provided that the stone is urgently removed from the urethra by one method or another, the prognosis is favorable.

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