Stone prevention? Water, Water, Water!

Posted on by John McHugh

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Some people will buy a 24 pack of bottled water and keep in a cool place in their car and drink a bottle every time they get in or out of their car. Ideas like this are helpful in making sure you are well hydrated. JM

Only Half of First-Time Stone Formers Achieve Stone Prevention Targets for Fluid Intake, UV

Urology – December 30, 2017 – Vol. 36 – No. 2

Approximately 50% of first-time stone formers achieve compliance targets for fluid intake and urine volume (UV). Factors decreasing compliance include initial UV <1 L, older age, female gender, and the presence of lower urinary tract symptoms.

Article Reviewed: Factors Associated With Compliance to Increased Fluid Intake and Urine Volume Following Dietary Counseling in First-Time Kidney Stone Patients. Khambati A, Matulewicz RS, et al: J Endourol; 2017;31 (June): 605-610.

Background: Fluid intake is critical for kidney stone prevention. Not all patients are compliant with this recommendation despite its effectiveness.

Objective: To evaluate compliance with fluid intake and urine volume (UV) recommendations in patients with nephrolithiasis and assess factors influencing compliance.

Design: Retrospective study.

Methods: Between 2010 and 2015, first-time kidney stone patients with UV <2.5 L/d on initial 24 hour urine were reviewed. Patients received instruction on strategies to increase fluid intake and target goals of >3 L/d fluid intake and >2.5 L/d UV. Repeat 24 hour urine collections were obtained at 6 and 18 months. Demographic and clinical data were analyzed to determine factors associated with compliance.

Results: 363 patients were included in the study. Mean baseline UV was 1.63 L/d, which increased to 2.5 L/d at 6 months. The compliance rate for UV >2.5 L/d at 6 months was only 50.1%, and decreased to 47.5% at 18 months. Overall, 30 patients (8.3%) had UV <1L/d, and only 20% of these patients reached the target 2.5 L/d at 6 months compared to 50.2% of patients with baseline UV of 1 to 2 L/d, and 61.8% of patients with baseline UV of 2 to 2.5 L/d (P =0.001). Factors associated with increased compliance included male gender (odds ratio [OR], 3.27), surgical procedures for stones (OR 2.3 to 3.5), and baseline UV >1L/d (OR, 3.0). Lower compliance was seen for patients aged >58 years and those with lower urinary tract symptoms (LUTS) (OR, 0.39 and 0.50).

Conclusions: Approximately 50% of first-time stone formers achieve compliance targets for fluid intake and urine volume. Factors decreasing compliance include initial UV <1 L/d, older age, female gender, and the presence of LUTS.

Reviewer’s Comments: When I ask my recurrent stone formers what advice they have been given for stone prevention, I often hear “my doctor only told me to increase fluids.” It occurs to me that patients do not understand the importance of increasing fluid intake and in turn urine volume. Of all the strategies we preach for stone prevention, fluid intake is one of the few that have randomized controlled trial data to support it. It is important to explain that UV is even more important than intake as insensible losses differ from patient to patient; therefore, UV will also differ between patients with the same fluid intake.

The current study assists in understanding which patients are likely to need additional instruction to achieve compliance.In the technology age, there are aides to help patients including apps for mobile devices and attachments for water bottles that flash to remind a patient to drink.

This study also illustrates how as urologists we need to assess and treat patients with LUTS, which can greatly influence compliance with fluid recommendations particularly given the significant impact LUTS have on quality of life.(Reviewer–Nicole L. Miller, MD).

 

Author: Khambati A, Matulewicz RS, et al
Author Email: aziz.khambati@medportal.ca

Got kidney stones? Take a ride on a roller coaster!

Posted on by John McHugh

images (1)

Roller Coaster Riding May Help Facilitate Kidney Stone Passage 

Urology – April 30, 2017 – Vol. 35 – No. 4

Individuals with small kidney stones may pass them during or after roller coaster rides.

Article Reviewed: Validation of a Functional Pyelocalyceal Renal Model for the Evaluation of Renal Calculi Passage While Riding a Roller Coaster. Mitchell MA, Wartinger DD: J Am Osteopath Assoc; 2016;116 (October): 647-652.

Objective: To determine whether roller coaster riding facilitates kidney stone passage using a pyelocalyceal model.

Design: Prospective model study.

Methods: Renal calculi of 4.5, 13.5, and 64.6 mm3 were suspended in urine in the model and taken for 20 rides on the Big Thunder Mountain Railroad roller coaster at Walt Disney World’s Magic Kingdom theme park in Orlando, Florida. The effects of the rides were analyzed according to stone size, calyceal location, position on roller coaster, and renal calculi passage.

Results: 60 renal calculi rides were examined. Front seating in the roller coaster resulted in 4 of 24 stone passages (16.7%), whereas rear seating on the roller coaster resulted in 23 of 36 passages (63.9%). For rear-seated passengers, upper, middle, and lower calyceal locations had 100.0%, 55.6%, and 40.0% passage rates, respectively.

Conclusions: The pyelocalyceal renal model was used to demonstrate that roller coaster riding may be an activity to facilitate stone passage. Rear seating on the roller coaster led to the most renal calculi passages.

Reviewer’s Comments: This article received a lot of lay press when it was published. It showed that the rigors of riding a roller coaster may facilitate stone passage.

Even though it led to a lot of discussion, the study itself is essentially a joke.

The model used is a simple silicone model of a kidney with stone passage defined as a stone getting to the ureteropelvic junction area of the model. It does not simulate real-life kidney stones in that in vivo kidney stones may be attached to papilla, have peristaltic forces of the renal pelvis and ureter, and the kidney itself does not shift as much in the human body as a plastic model in a backpack. The authors go on to even suggest that individuals who may be at risk for developing kidney stones ride a roller coaster to pass small flakes, which would not be as painful. I don’t think telling our patients to ride roller coasters is sound medical advice. All this model shows us is that roller coasters cause things to move or bounce around if unsuspended – I do not think it takes a study to prove that to us.(Reviewer–David A. Duchene, MD).

Author: Mitchell MA, Wartinger DD
Author Email: david.wartinger@hc.msu.edu

Got stones? What to do with them in the kidney but they aren’t blocking- a very common question.

Posted on by John McHugh

Your Best Management for Asymptomatic Nonobstructing Kidney Stones

Urology – August 30, 2015 – Vol. 33 – No. 2

Lower-pole kidney stones are less likely to become symptomatic during observation.

Article Reviewed: The Natural History of Nonobstructing Asymptomatic Renal Stones Managed With Active Surveillance. Dropkin BM, Moses RA, et al: J Urol; 2015;193 (April): 1265-1269.

Objective: To determine the natural history of observed nonobstructing asymptomatic kidney stones and factors associated with eventual stone-related events.

Design: Retrospective chart review of the records of 160 kidney stones in 110 patients on active surveillance.

Methods: Stone characteristics, patient characteristics, and stone-related parameters were evaluated to determine factors for stone-related symptoms, spontaneous passage, requirement for surgical intervention, and stone growth.

Results: 160 stones with an average size of 7.0 mm ± 4.2 mm in 110 patients were followed up 41 ± 19 months. A total of 28% (45 of 160) of stones caused symptoms and 2% (3 of 160) caused silent obstruction on average of 37 ± 17 months. Upper-pole/mid-pole stones were more likely than lower-pole stones to become symptomatic (40%) or pass spontaneously (15%). No other factors demonstrated statistical significance in predicting symptoms.

Conclusions: Over a 3-year period, most asymptomatic nonobstructing renal calculi remained asymptomatic. Approximately 30% caused symptoms, 20% required surgical intervention, 20% grew >50% initial size, and 7% passed spontaneously. Lower-pole stones caused fewer issues than upper- or mid-pole stones. Silent obstruction may occur and necessitates regular imaging and follow-up of even asymptomatic stones.

Reviewer’s Comments: This is a very nice article following the natural history of asymptomatic nonobstructing kidney stones, which are often picked up on imaging for other indications. It shows almost identical results to previous studies, which is that over a specified period (average of 3 years in this study), approximately 30% of stones will become symptomatic or need intervention. In this study, however, if you account for patients (instead of stones), nearly 40% became symptomatic over the study period. One must also consider that 20% of stones in this study grew >50% their original size. A small percentage developed silent obstruction, which is the most concerning aspect in regard to possible renal function loss. The authors conclude that most stones remain asymptomatic over time and hint that active surveillance may be the best option. The authors make a very valid point. However, the debate becomes whether you and your patient consider 30% to 40% as an acceptable number. Are we really saving 70% of individuals from needed intervention or having symptoms, or are we just delaying the inevitable? With the exception of uric acid stones, which may dissolve, stones do not disappear. I think with longer follow-up, more will eventually become symptomatic.

Whether you treat prophylactically or only treat when indications arise becomes a decision between you and your patient. It also is influenced by the patient’s age, health, anxiety, history of kidney stones, and lifestyle. Overall, this is a nice article to provide numbers to patients in regard to nonobstructing asymptomatic kidney stones.

(Reviewer–David A. Duchene, MD).

 

Author: Dropkin BM, Moses RA, et al
Author Email: Benjamin.m.dropkin.med@dartmouth.edu

A stone in your kidney but no pain…what to do?

Posted on by John McHugh

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In general “if it ain’t broke don’t fix it” however…read on…

Your Best Management for Asymptomatic Nonobstructing Kidney Stones

Urology – August 30, 2015 – Vol. 33 – No. 2

Lower-pole kidney stones are less likely to become symptomatic during observation.

Article Reviewed: The Natural History of Nonobstructing Asymptomatic Renal Stones Managed With Active Surveillance. Dropkin BM, Moses RA, et al: J Urol; 2015;193 (April): 1265-1269.

Objective: To determine the natural history of observed nonobstructing asymptomatic kidney stones and factors associated with eventual stone-related events.

Design: Retrospective chart review of the records of 160 kidney stones in 110 patients on active surveillance.

Methods: Stone characteristics, patient characteristics, and stone-related parameters were evaluated to determine factors for stone-related symptoms, spontaneous passage, requirement for surgical intervention, and stone growth.

Results: 160 stones with an average size of 7.0 mm ± 4.2 mm in 110 patients were followed up 41 ± 19 months. A total of 28% (45 of 160) of stones caused symptoms and 2% (3 of 160) caused silent obstruction on average of 37 ± 17 months. Upper-pole/mid-pole stones were more likely than lower-pole stones to become symptomatic (40%) or pass spontaneously (15%). No other factors demonstrated statistical significance in predicting symptoms.

Conclusions: Over a 3-year period, most asymptomatic nonobstructing renal calculi remained asymptomatic. Approximately 30% caused symptoms, 20% required surgical intervention, 20% grew >50% initial size, and 7% passed spontaneously. Lower-pole stones caused fewer issues than upper- or mid-pole stones. Silent obstruction may occur and necessitates regular imaging and follow-up of even asymptomatic stones.

Reviewer’s Comments: This is a very nice article following the natural history of asymptomatic nonobstructing kidney stones, which are often picked up on imaging for other indications. It shows almost identical results to previous studies, which is that over a specified period (average of 3 years in this study), approximately 30% of stones will become symptomatic or need intervention. In this study, however, if you account for patients (instead of stones), nearly 40% became symptomatic over the study period. One must also consider that 20% of stones in this study grew >50% their original size. A small percentage developed silent obstruction, which is the most concerning aspect in regard to possible renal function loss. The authors conclude that most stones remain asymptomatic over time and hint that active surveillance may be the best option. The authors make a very valid point. However, the debate becomes whether you and your patient consider 30% to 40% as an acceptable number. Are we really saving 70% of individuals from needed intervention or having symptoms, or are we just delaying the inevitable? With the exception of uric acid stones, which may dissolve, stones do not disappear. I think with longer follow-up, more will eventually become symptomatic. Whether you treat prophylactically or only treat history of kidney stones, and lifestyle. Overall, this is a nice article to provide numbers to patients in regard to nonobstructing asymptomatic kidney stones.(Reviewer–David A. Duchene, MD).

 

Sex helps pass kidney stones?

Posted on by John McHugh

Want to improve your sex life? Get a kidney stone!

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Urology – January 30, 2016 – Vol. 33 – No. 9

Sexual intercourse 3 to 4 times per week may increase the probability of spontaneous stone passage for distal ureteral stones <6 mm in size.

Article Reviewed: Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones? A Prospective, Randomized, Controlled Study. Doluoglu OG, Demirbas A, et al: Urology; 2015;86 (July): 19-24.

Objective: To investigate the role of sexual intercourse on passage of distal ureteral stones.

Design: Prospective, randomized controlled study.

Participants: 90 male patients with distal ureteral stones <6 mm in size undergoing a trial of spontaneous passage.

Methods: Group 1 was randomized to sexual intercourse 3 to 4 times a week, group 2 received tamsulosin 0.4 mg/day for medical expulsive therapy, and group 3 served as a control. Expulsion rate was compared at 2 and 4 weeks.

Results: Mean stone size was similar between all groups at just under 5 mm (group 1, 4.7 mm; group 2, 5.0 mm; group 3, 4.9 mm). At 2 weeks, 83.9% (26/31) patients in the sexual intercourse group had passed stones. In comparison, 47.6% (10/21) in the tamsulosin group and 34.8% (8/23) in the control group had passed stones (P =0.001). At 4 weeks, the differences lost significance, but still showed benefit for the sexual intercourse group with 93.5% passage compared to 81.0% passage in the tamsulosin group and 78.3% passage in the control. The mean expulsion time was 10.0 days in the sexual intercourse group, 16.6 days in the tamsulosin group, and 18.0 days in the control group.

Conclusions: Sexual intercourse 3 to 4 times per week may increase the probability of spontaneous stone passage for distal ureteral stones <6 mm in size.

Reviewer’s Comments: This study led to lots of conversation given the unique and unusual approach proposed to improve spontaneous ureteral stone passage. The authors hypothesized that sexual intercourse may improve spontaneous stone passage by nitric oxide release leading to relaxation of ureteral muscles. They found that the sexual intercourse group passed their stones much faster than either the tamsulosin or control group. While intriguing, several problems exist with the study, which makes me somewhat surprised that it was published. The study is extremely underpowered based on overestimations in initial statistical planning. No compliance measures with sexual activity and/or lack of sexual activity or with taking tamsulosin as prescribed were performed. Only 6% of patients were lost to follow-up in the sexual activity group compared to 23% in the tamsulosin and control arms. If those patients were lost to follow-up because they passed their stones, then the study would have no significance. Last, sexual activity would be a very brief exposure of nitric oxide to the ureter (if the theory is correct). Younger patients should still get nocturnal erections, which would also release nitric oxide for brief periods. It seems that a more consistent delivery of nitric oxide such as with PDE5 inhibitors may be more successful, and PDE5 inhibitors have shown some promise in early studies. Overall, the study makes a good headline and interesting discussion, but much better studies are needed to find a relevant method to facilitate stone passage.(Reviewer–David A. Duchene, MD).

Northeast Georgia Urological Associates-Kidney Stones

Posted on by John McHugh

lemonade

  • Drink lots of water
  • Limit Salt
  • Add Lemon to your water-this makes the crystals slippery and less likely to grow
  • There are other medical options for prevention but not drinking enough water is the number one contributor to urolithiasis.

Treating kidney, ureteral and bladder stones is one of the most common things we do at Northeast Georgia Urological Associates. Call us-we can help.