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

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?

Spero072215-400x250

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?

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

download (3)

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).

Refreshing Cucumber and Lemon Water-A tasteful way to prevent kidney stones.

Cucumber-Lemon-Water

When it comes to managing Kidney Stones, drinking more water can help. Not drinking enough water is the number 1 risk factor for developing kidney stones. Try this recipe for Refreshing Cucumber and Lemon Water to help you prevent stones: Read More

Northeast Georgia Urological Associates-Kidney Stones

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.

Less Calcium Intake=Less Chance of Kidney Stones? No!

Spero072215-400x250

The Benefits of Lemon Juice for Kidney Health. Lemon juice contains high levels of citric acid, not to be confused with ascorbic acid (vitamin C). While lemon juice contains both, citric acid seems to contribute to reducing the chances of developing calcium oxalate stones. And what about Calcium? Read More

lemonade

Kidney Stone Treatment with ESWL.

Spero072215-400x250

The urologists of Northeast Georgia Urological perform ESWL (Shockwave Lithotripsy of Kidney Stones) every day of the week and at three locations: Our own Ambulatory Surgery Center, Northeast Georgia Medical Center and The Gainesville Surgery Center. If you have a stone and are having symptoms, we have the experience and the resources to help you safely and quickly.

Kidney stones often mimic a bladder infection.

image

The stone seen above is half in the ureter and half in the bladder. Much like a baby crowning before being delivered. Just before the ureter enters the bladder it travels about an inch between the layers of the bladder muscle. When a stone, such as you see above, is in this area of the ureter the patient will experience symptoms very similar to a bladder infection. Because the stone irritates the bladder the urine will have the look of a bladder infection as well, which further confuses the diagnosis.

Urologists often see females in consultation because of what is felt to be a recurrent or difficult to manage bladder infection when in fact on CT scan there is a stone in the intramural portion of the ureter. With treatment of the stone the symptoms very quickly go away.

A simple way to prevent stones is to always be well hydrated, limit salt and add lemon to the water you drink.