Management Of Urinary Stone Disease Research Articles

Atypical clinical presentation and management of urinary stone disease in non-verbal non-ambulatory children

Management of kidney stones primarily depends on various factors such as the presence of urinary tract obstruction, pain, stone size, location, impact on renal function, and the existence of infection. Renal colic is the classic presentation of an obstructive kidney stone. However, in this study, we present a cohort of non-verbal non-ambulatory (NVNA) patients who exhibit a distinct and uncommon presentation of kidney stones due to their medical conditions. Information about kidney stone disease in this gropup of complex pediatric patients is, scarce and their associated risk factors are not well understood. Therefore, we aim to summarize the clinical presentation, and management challenges in this unique group of NVNA patients to identify potential variables for prospective studies. A retrospective chart review was completed for all NVNA patients seen at the pediatric multidisciplinary kidney stone clinic between July 2020 to August 2022. Demographic variables, clinical presentation data, metabolic evaluation, radiological imaging, and surgical management was included for analysis. A total of 224 pediatric patients were referred to the multidisciplinary stone clinic. Of those, 27 were identified to be NVNA. The most common primary diagnosis was Cerebral Palsy followed by Lennox-Gastaut syndrome. Average age at first kidney stone presentation was 11.5 years±5.7 years. An obstructing stone was diagnosed in 18 (66%) patients, 4 (22.2%) of these presented with sepsis. Average stone burden was 9.2mm (±5.8mm). Of the obstructing stones, 13 (72%) were in the kidney. All patients with an obstructing stone underwent surgical management with retrograde endoscopic approach. Metabolic 24-h-urine analysis was completed in 24 (89%) patients. 17 (62%) had an elevated urine density, 15 (55%) demonstrated calcium oxalate supersaturation, 12 (44%) met criteria for acidosis, and 7 (26%) had significant hypocitraturia. NVNA patients represent a unique cohort whose clinical presentation is atypical. Limited ability to express symptoms makes early detection difficult to recognize. Twenty two percent of patients present with sepsis as their first manifestation of an acutely obstructing kidney stone. Pain is subjectively interpreted by caregivers and is an uncommon symptom. Our cohort demonstrates common risk factors for stones including propensity for chronic dehydration, slow urinary tract transit, ineffective bladder emptying, G-tube feeding, and lithogenic medications. NVNA pediatric patients have atypical kidney stone clinical presentation. Awareness of this unique group of patients should support future collaborative studies to focus on understanding these atypical presentations and reflect on improving management.

Litigation in the management of urinary stone disease.

ObjectiveTo present common technical and non‐technical issues leading to medicolegal litigation, illustrated by a series of 54 cases, with the aim of using these examples to prevent harm to patients and to prevent surgeons from having to experience the stress of litigation.MethodsA series of 78 medicolegal litigation cases reviewed by a single expert witness over 13 years from 2008 to 2021 was analysed by two reviewers. Twenty‐nine cases were identified as having a non‐technical learning point and 25 were identified as having a technical learning point. These are discussed using illustrative examples and the steps that could have avoided these issues are considered.ResultsAll major issues and themes are illustrated with cases demonstrating the errors that lead to litigation and the often‐simple steps that can be taken to avoid them. Out of 29 non‐technical issues, 13 involved consent issues (45%), eight involved delays in treatment (28%) and eight involved failure to provide adequate safeguarding advice (28%). Out of 25 technical issues, 13 cases involved intra‐operative problems (52%) including nine ureteric injuries, eight involved errors or omissions in the immediate preoperative period (32%) and four resulted from decisions around emergency decompression of the obstructed infected kidney. These emergency cases featured complications of amputation (two out of four) and death (one out of four). These decisions are complex and there are many subtleties to these cases, which are discussed in detail.ConclusionWe hope that this case series highlights the potentially catastrophic outcomes of even small errors of judgement, and allows careful stone surgeons to learn from the experiences of those unfortunate others without having to encounter these situations themselves.

A population-based, retrospective cohort study analyzing contemporary trends in the surgical management of urinary stone disease in adults.

We aimed to review the trends and incidence of surgical intervention for adults with upper urinary tract stones in Ontario, Canada, and to hypothesize potential causes for the observed changes. We carried out a retrospective, population-based cohort study using administrative databases held at the Institute of Clinical Evaluative Sciences (ICES) to identify all adults (≥18 years) who underwent surgical treatment for urolithiasis, defined by records using a combination of both hospital and physician billing from 2002-2019. Descriptive statistics were used to summarize baseline patient demographics, and surgical trends were analyzed using the Cochrane-Armitage test for trend. From 2002-2019, 140 263 patients were treated surgically for urolithiasis. During this time period, the total number of surgically treated stone disease increased by 80.5%. By type of procedure, percutaneous nephrolithotomy (PCNL) increased by 187% and ureteroscopy (URS) increased by 158%, while the number of shockwave lithotripsy (SWL) declined by 31.4%. The adult population in Ontario in the years evaluated grew by 24.4%. The number of surgical procedures per 100 000 people over this time grew by 45.3%. For every 1% increase in the population, there was a 2.6% rise in stone-related surgical procedures. The number of stone-related surgical procedures performed rose significantly and cannot be accounted for by population growth alone. This rise was proportionally larger in the female population, further supporting a narrowing of the gender gap in urinary stone disease. The reasons for the increase are likely multifactorial and may imply an increasing incidence of surgically treated stone disease. The change in the proportion of URS and SWL performed may demonstrate a continued shift in surgical preference or may be reflective of resource limitations and availability. The increase in PCNL volumes may also suggest a greater complexity of cases. These findings should be considered for future resource planning and require further study.

Efficacy of Herbal Preparation(Cystone) in Management of Urinary Stone Disease

Objective:To evaluate the efficacy of herbal medicine cystone, in reduction of renal and ureteric stone size.Methodology: This observational follow up study was conducted in Urology Department, Madinah Teaching Hospital, associated with University Medical and Dental College, Faisalabad after obtaining the ethical approval from the mentioned institute during March 2018 to December 2018. One hundred and ninety two patients coming to urology outpatient clinic, fulfilling the inclusion criteria were recruited in the study. Out of which 27(14.06%) were lost in follow up and were excluded from study. Out of remaining 165 patients, 99 were male and 66 female patients. All patients with renal stones who were freshly prescribed with oral Tablet cystone twice a day for four weeks were enrolled in the study and were followed for stone size with ultrasonography followed for the duration of four weeks Patients were followed till the primary endpoint.Results: One hundred and seven (64.84%) patients cleared the stone, 10 (6.06%) patients had their stone size reduced,17(10.3%) patients had their stone size unchanged and 31 (18.78%) patients had their stone size increased. No significant adverse effects were noted during the study that required the patients to stop the treatment. There was significant decrease in stone size from initial mean stone size1.57 ±0.08 mm to end point stone size 0.69 ±0.09 mm after treatment with cystone (p- value 0.000).Conclusion: The mean stone size was reduced after using this herbal preparation for one month.

How does the COVID-19 pandemic affect the preoperative evaluation and anesthesia applied for urinary stones? EULIS eCORE-IAU multicenter collaborative cohort study.

Stone disease is a unique condition that requires appropriate management in a timely manner as it can result in both emergent conditions and long term effects on kidney functions. In this study it is aimed to identify the up-to-date practice patterns related to preoperative evaluation and anesthesia for stone disease interventions during COVID-19 pandemic. The data of 473 patients from 11 centers in 5 different countries underwent interventions for urinary stones during the Covid-19 pandemic was collected and analyzed retrospectively. Information on the type of the stone related conditions, management strategies, anesthesiologic evaluation, anesthesia methods, and any alterations related to COVID-19 pandemic was collected. During the preoperative anesthesia evaluation thorax CT was performed in 268 (56.7%) and PCR from nasopharyngeal swab was performed in 31 (6.6%) patients. General anesthesia was applied in 337 (71.2%) patients and alteration in the method of anesthesia was recorded in 45 (9.5%) patients. A cut-off value of 21 days was detected for the hospitals to adapt changes related to COVID-19. Rate of preoperative testing, emergency procedures, conservative approaches and topical/regional anesthesia increased after 21 days. The preoperative evaluation for management of urinary stone disease is significantly affected by COVID-19 pandemic. There is significant alteration in anesthesia methods and interventions. The optimal methods for preoperative evaluation are still unknown and there is discordance between different centers. It takes 21 days for hospitals and surgeons to adapt and develop new strategies for preoperative evaluation and management of stones.

Artificial intelligence: the future of urinary stone management?

To investigate the application of artificial intelligence in the management of nephrolithiasis. Although rising, the number of publications on artificial intelligence for the management of urinary stone disease is still low. Most publications focus on diagnostic tools and prediction of outcomes after clinical interventions. Artificial intelligence can, however, play a major role in development of surgical skills and automated data extraction to support clinical research. The combination of artificial intelligence with new technological developments in the field of endourology will create new possibilities in the management of urinary stones. The implication of artificial intelligence can lead to better patient selection, higher success rates, and furthermore improve patient safety.

Prevalence of twenty-four hour urine testing in Veterans with urinary stone disease.

ObjectiveThe American Urological Association guidelines recommend 24-hour urine testing in patients with urinary stone disease to decrease the risk of stone recurrence; however, national practice patterns for 24-hour urine testing are not well characterized. Our objective is to determine the prevalence of 24-hour urine testing in patients with urinary stone disease in the Veterans Health Administration and examine patient-specific and facility-level factors associated with 24-hour urine testing. Identifying variations in clinical practice can inform future quality improvement efforts in the management of urinary stone disease in integrated healthcare systems.Materials and methodsWe accessed national Veterans Health Administration data through the Corporate Data Warehouse (CDW), hosted by the Veterans Affairs Informatics and Computing Infrastructure (VINCI), to identify patients with urinary stone disease. We defined stone formers as Veterans with one inpatient ICD-9 code for kidney or ureteral stones, two or more outpatient ICD-9 codes for kidney or ureteral stones, or one or more CPT codes for kidney or ureteral stone procedures from 2007 through 2013. We defined a 24-hour urine test as a 24-hour collection for calcium, oxalate, citrate or sulfate. We used multivariable regression to assess demographic, geographic, and selected clinical factors associated with 24-hour urine testing.ResultsWe identified 130,489 Veterans with urinary stone disease; 19,288 (14.8%) underwent 24-hour urine testing. Patients who completed 24-hour urine testing were younger, had fewer comorbidities, and were more likely to be White. Utilization of 24-hour urine testing varied widely by geography and facility, the latter ranging from 1 to 40%.ConclusionsFewer than one in six patients with urinary stone disease complete 24-hour urine testing in the Veterans Health Administration. In addition, utilization of 24-hour urine testing varies widely by facility identifying a target area for improvement in the care of patients with urinary stone disease. Future efforts to increase utilization of 24-hour urine testing and improve clinician awareness of targeted approaches to stone prevention may be warranted to reduce the morbidity and cost of urinary stone disease.

MP23-03 RAPID, EFFICIENT CROWDSOURCING ON SOCIAL MEDIA FOR THE SURGICAL MANAGEMENT OF STONE DISEASE

INTRODUCTION AND OBJECTIVES:The surgical management of urinary stone disease can be challenging due to complexity and multiple potential approaches. One advantage of urologists’ increasing social m...

Looking back on 50 years of stone treatment

Urolithiasis is an urologist's daily business. This article provides an overview of the developments in the management of urinary stone disease since the 1970s. While conventional KUB X-rays and intravenous pyelography were standard imaging procedures in the past, computed tomography is the first choice today. Conservative treatments such as medical expulsive therapy were established to facilitate ureteral stone passage, but have come into discussion in the past few years. Fifty years ago, open stone surgery was the standard procedure to access renal stones. This has been superseded by minimally-invasive procedures ranging from percutaneous nephrolithotomy (PCNL) to extracorporeal shock-wave lithotripsy (ESWL) and ureteroscopy (URS), which is today's standard for most upper urinary tract stones. It would have been desirable if such enormous efforts and progress had been made in the evaluation of stone pathogenesis and the improvement of preventative measures. Unfortunately, the knowledge on stone formation has hardly improved compared to 1970.

Payer Type, Race/Ethnicity, and the Timing of Surgical Management of Urinary Stone Disease.

Surgery for upper tract urinary stone disease is often reserved for symptomatic patients and those whose stone does not spontaneously pass after a trial of passage. Our objective was to determine whether payer type or race/ethnicity is associated with the timeliness of kidney stone surgery. A population-based cohort study was conducted using the California Office of Statewide Health Planning and Development dataset from 2010 to 2012. We identified patients who were discharged from an emergency department (ED) with a stone diagnosis and who subsequently underwent a stone surgery. Primary outcome was time from ED discharge to urinary stone surgery in days. Secondary outcomes included potential harms resulting from delayed stone surgery. Over the study period, 15,193 patients met the inclusion criteria. Median time from ED discharge to stone surgery was 28 days. On multivariable analysis patients with Medicaid, Medicare, and self-pay coverage experienced adjusted mean increases of 46%, 42%, and 60% in time to surgery, respectively, when compared with those with private insurance. In addition, patients of Black and Hispanic race/ethnicity, respectively, experienced adjusted mean increases of 36% and 20% in time to surgery relative to their White counterparts. Before a stone surgery, underinsured patients were more likely to revisit an ED three or more times, undergo two or more CT imaging studies, and receive upper urinary tract decompression. Underinsured and minority patients are more likely to experience a longer time to stone surgery after presenting to an ED and experience potential harm from this delay.

Urinary stone profile at Tabanan Hospital within July 2014 to June 2016

Urinary tract stone disease is one of the most common cases in urology. These cases are increasing nearly 12% every year. Most cases occur in age group 40 to 60 years, and more common in male about three to four times than female. Patient with urinary tract stone at Tabanan General Hospital, always increase and recurrence rate still high. This is a descriptive-retrospective study. Samples are taken from all urology patients diagnosed with urinary stone disease at operating room of Tabanan Hospital between July 2014 to June 2016. We collected data from medical record regarding sex, age, living area, comorbidities, stone location, and management of urinary stone disease. Total 226 cases with urinary stone disease were managed at operating room of Tabanan General Hospital. Half of these patients aged between 46 to 60 years old, with sex ratio male two times higher than female. Hypertension is one of comorbidities for patient with urinary tract stone. Most of Kidney stone were treated by PCNL, ureter stone by URS and bladder stone by lithotripsy. In conclusion, urinary tract stone disease in Tabanan General Hospital commonly occurs in male, age more than 45 years old and mostly comes from urban area. The management of the patient tends to move from invasive approach to less invasive approach.

Management of Urinary Stone Disease: Prevention, Treatment and Follow-Up

Management of Urinary Stone Disease: Prevention, Treatment and Follow-Up

Retroperitoneal laparoscopic pyelolithotomy in renal pelvic stone versus open surgery - a comparative study.

BackgroundThe introduction of endourological procedures such as percutaneous nephrolithotomy and ureterorenoscopy have led to a revolution in the the management of urinary stone disease. The indications for open stone surgery have been narrowed significantly, making it a second- or third-line treatment option.Aims and ObjectivesTo study the safety and efficacy of retroperitoneal laparoscopic pyelolithotomy in retroperitoneal renal stone. We compared the results of laparoscopic and open surgery in terms of easy accessibility, operative period, renal injuries, and early recovery.MethodsThis prospective study was conducted on renal pelvic stone cases from January 2009 to February 2016 in Suchkhand Hospital, Agra, India. The study included a total of 1700 cases with the diagnosis of solitary renal pelvic stones. In group A - 850 cases - retroperitoneal laparoscopic pyelolithotomy was performed, while group B - 850 cases – underwent open pyelolithotomy.ResultsThe mean operative time was less in group B than group A (74.83 min vs. 94.43 min) which was significant (p<0.001). The blood loss was less in the laparoscopic group than in the open group (63 mL vs. 103mL). There were statistically significant differences in the post-operative pain scores, and postoperative complications compared to group B (p<0.001). The mean hospital stay was less in group A (p<0.03), which was significant.ConclusionLaparoscopic surgery reduces analgesic requirements, hospital stay, and blood loss. The disadvantages include the reduced working space, the cost of equipment and the availability of a trained surgeon.

Management of urinary stone disease in general practice: A French Delphi study

Background: Recommendations for the management of urolithiasis in primary care are lacking in France. The Delphi method was used to seek consensus from an expert panel regarding outpatient management of urolithiasis.Methods: We gathered 25 French experts from five clinical specialties: general practice, urology, nephrology, emergency medicine and radiology. The first survey was formulated after an exhaustive literature review. At each of the three rounds, the experts were given the results of the previous round and were asked again to complete the survey. The threshold of 70% of the vote was taken as defining consensus. A final round of validation involving five additional general practitioners was conducted.Results: Twenty experts participated in the study (five urologists, four nephrologists, four general practitioners, four emergency physicians, and three radiologists, participation rate = 80%). According to the survey results, most patients could be treated as outpatients (70.5% of the votes) but a biological (urine dipstick and culture, serum creatinine ± serum β-hcg) and imaging (renal ultrasound + Kidney-Ureters-Bladder X-ray or low-dose CT san) work-up is recommended within 24 hours. Non-steroidal anti-inflammatory drugs are the analgesics of choice. An aetiological work-up should be performed after the second episode of renal colic. A follow-up imaging should be carried out yearly in urolithiasis patients.Conclusion: With the use of the Delphi method, we propose a multidisciplinary recommendation for the management of urolithiasis patients in primary care.

Recent management of urinary stone disease in a pediatric population.

The incidence of stone disease has been increasing and the risk of recurrent stone formation is high in a pediatric population. It is crucial to use the most effective method with the primary goal of complete stone removal to prevent recurrence from residual fragments. While extracorporeal shock wave lithotripsy (ESWL) is still considered first line therapy in many clinics for urinary tract stones in children, endoscopic techniques are widely preferred due to miniaturization of instruments and evolution of surgical techniques. The standard procedures to treat urinary stone disease in children are the same as those used in an adult population. These include ESWL, ureterorenoscopy, percutaneous nephrolithotomy (standard PCNL or mini-perc), laparoscopic and open surgery. ESWL is currently the procedure of choice for treating most upper urinary tract calculi in a pediatric population. In recent years, endourological management of pediatric urinary stone disease is preferred in many centers with increasing experience in endourological techniques and decreasing sizes of surgical equipment. The management of pediatric stone disease has evolved with improvements in the technique and a decrease in the size of surgical instruments. Recently, endoscopic methods have been safely and effectively used in children with minor complications. In this review, we aim to summarize the recent management of urolithiasis in children.

The evolution of the treatment of urinary stone disease.

The surgical management of urinary stone disease has developed over recent years; treatment options include ESWL, percutaneous nephrolithotomy and ureterorenoscopy (rigid or flexible). The 2013 edition [1] of the European Association of Urology Guidelines on Urolithiasis indicates that laparoscopic kidney stone surgery should be considered in the following cases: complex stone burden, failed previous ESWL and/or endourological procedures, anatomical abnormalities, morbid obesity, and nephrectomy in case of non–functioning kidney. The ureteropelvic junction (UPJ) obstruction is an anatomical abnormality defined by a blockage of urine flow from the kidney to the proximal ureter. We consider that in the case of UPJ obstruction with concomitant kidney stone, the laparoscopic pyeloplasty should be the treatment of choice. This type of treatment offers the necessary guarantees for the treatment of the UPJ obstrucion and allows us to combine endoscopic instruments to treat the associated secondary lithiasis with a stone free rate of 100% and a success of UPJ obstruction resolution near 95% [2]. No comparative studies have been done in this field, but it seems that laparoscopic pyeloplasty procedures have better outcomes in UPJ obstruction with concomitant lithiasis. Anterograde endopyelotomy with concomitant percutaneous stone removal has been performed with a success rate of 64% to 85% in different series [3] and ureteroscopic endopyelotomy or endoureterotomy with a ureteral balloon device has also been used with a success rate of 78% [3]. The choice between retroperitoneoscopic or transperitoneal approach in laparoscopic pyeloplasty is a never–ending debate. Equivalent success rates have been quoted in the literature for both approaches [4] but as Dr. Marcin Slojewski said in his editorial comment [5] surgeon preferences and experience remains the main determinant of choice. In our department, we are starting to treat selected cases of kidney stone disease by retroperitoneoscopic approach; the results in the first cases are promising and we hope to have enough experience in a few years to show our findings.

SU‐E‐I‐37: Coherent Scatter Computed Tomography (CSCT) in Kidney Stones Imaging‐Composition Analysis

Purpose: To compare the ability of coherent scatter computed tomography (CSCT) to determine the composition of kidney stones, including the core components which are thought to be most important for recurrence prevention, with conventional infra‐red spectroscopy (IRS) in the management of urinary stone disease. Methods: CSCT is a tomographic imaging method being developed in our laboratory that is based on x‐ray diffraction measurements of intact specimens. In this study, intact kidney stones and large fragments obtained from minimal invasive surgery in 118 patients were collected and scanned using CSCT to determine the distribution of minerals, and in particular minerals at the stone core, before undergoing the conventional (destructive) IRS analysis. Results: Overall, the CSCT‐IRS agreement rate for the primary (most abundant) component was 85%. CSCT produces “maps” of each component including the core. In 42%, CSCT found a core mineral not reported by IRS. Overall, CSCT has detected minerals missed by IRS in 46% of all cases. In particular, struvite, which indicates a urinary bacterial involvement, was found in the stone core significantly more often (22%) than previously believed based on IRS.: Conclusions: The high agreement rate with IRS gives overall confidence in both CSCT and IRS. The ability of CSCT to identify the composition of the core where stone formation first starts, suggests an improved method for kidney stone composition analysis. The elevated presence of struvite in the stone core may indicate a more prominent role of specific bacteria in urolithiasis than generally accepted at present.

Flexible Ureteroscopy for Upper Ureteral Calculi in Children

Ureteroscopy is one of the therapeutic options in the management of urinary stone disease in children. Previous literature has described ureteroscopy primarily in mid to distal ureteral calculi. We report our experience with flexible ureteroscopy in the management of upper ureteral calculi. All children with upper ureteral stones were included prospectively in the study. Stone burden was measured in millimeters. Presentation, operative access, intraoperative complications, stone-free rates, and postoperative complications were evaluated. A total of 80 children (69 boys and 11 girls) underwent 88 ureteroscopic procedures. In 72 (90%) children, complete stone clearance was achieved after a single ureteroscopic session. In 6 (7.5%) others, complete stone clearance was achieved after the second ureteroscopic session. Complete stone clearance after single ureteroscopy is possible if the calculi are single, small (<10 mm), and below the level of the pelviureteral junction.

The forgotten ureteric stent

A 79-year-old woman presented to the emergency department with malaena, poor appetite and weight loss. On general examination she was cachectic and pale. Physical examination revealed a suprapubic mass, and on rectal examination a large well-defined hard non-tender mass was palpated anteriorly. Blood tests revealed significant anaemia with a haemoglobin level of 47 g/L. Contrast enhanced computer tomography revealed a right sided ureteric stent in situ and a large well-defined bladder calculus, with measurements of 8 × 5.5 cm. Asymmetric marked mural thickening of the bladder wall was also present. The proximal ureteric stent had migrated down the right renal collecting system to the dilated right upper ureter (Fig. 1). Plain abdominal radiography also showed the bladder calculus and calcified ureteric stent (Fig. 2). The residual oral contrast from the earlier CT scan is also seen in the bowel lumen in the plain abdominal radiograph. Contrast enhanced computer tomography revealing the proximal ureteric stent (arrowed) which has migrated down the right renal collecting system into the dilated right upper ureter and the large well defined bladder calculus. Plain abdominal radiography showing the bladder calculus and ureteric stent in situ. The bowel lumen contains residual oral contrast from the earlier CT scan. Her anaemia was investigated with a gastroscopy that revealed a small area of gastric ulceration. This was biopsied and was confirmed as a gastric adenocarcinoma. Staging investigations revealed no evidence of metastatic disease. The patient declined active management. She continued to be troubled with significant urinary symptoms. Her past medical history included a bladder carcinoid that presented as haematuria 2 years earlier. This rare tumour of the urinary bladder recurred following initial transurethral resection of the bladder tumour. Consequently, she underwent partial cystectomy and during this procedure, a right sided ureteric stent was inserted. The patient was subsequently lost to follow-up and the ureteric stent had remained in situ for 27 months. As a staged procedure, she underwent extracorporeal shock wave lithotripsy to the proximal ureteric stent followed by open cystolithotomy and right rigid ureteroscopy and basket stone removal of the stone fragments. The bladder calculus, ureteric stent and associated stone were successfully removed intraoperatively (Fig. 3). Inspection of the bladder mucosa confirmed no tumour recurrence. The patient was stent and stone free after the procedure. Bladder calculus and ureteric stent following operative removal. Ureteric stents have become an essential part of urological practice since their introduction in 1978. The ureteric stent has an important function in management of urinary stone disease, genitourinary trauma, renal transplantation, genitourinary oncology, reconstructive surgery and ureteric obstruction secondary to extrinsic compression.1 Although commonplace in modern urology, ureteric stents are not without complication. Patients frequently experience irritative urinary symptoms, flank pain, suprapubic discomfort and occasional haematuria.2 Other complications include urinary tract infections, migration, forgotten or retained stent, encrustation, blockage and bladder erosion.2 This case highlights the preventable complication of retained ureteric stent and its morbidity if the stent becomes calcified. Monga et al. reported a series of 22 patients with forgotten stents that were left in situ for greater than 6 months. Of those patients with retained ureteric stents, 68% had calcified stents, 45% fragmented stents and 14% had calcified and fragmented stents.1 The incidence of stent encrustation increases with the duration that the stent remains in situ. El-Faqih et al. evaluated 299 stents in patients with calculi and noted an encrustation rate of 9.2% before 6 weeks, 47.5% from 6–12 weeks and 76.3% after 12 weeks.3 Although encrusted retained ureteric stents can be removed in a single procedure, often the management requires multiple modalities and several procedures to render patients stone and stent free.4 Monga et al. found that multiple procedures were required in 19% of patients and more recently, Borboroglu and Kane found that 50% of patients required more than one session to achieve a stone and stent free state.5 Common management modalities have their limitations. Extracorporeal shock wave lithotripsy is often unable to fully fragment the extensive calculous burden associated with retained stents. Also percutaneous nephrolithotomy does not address the vesical end of ureteric stent calcification.6 In this case both ends of the stent were calcified. As a result, the patient received extracorporeal shock wave lithotripsy to the upper curls the day prior to undergoing open cystolithotomy. It successfully fragmented the proximal ureteric stent calcification enabling the ureteric stent to be easily removed following the distal ureteric stent and bladder calculus removal. This case clearly demonstrates problems associated with ureteric stents and draws attention to the need for systems such as a registry of stent placement so that such events can be prevented.

Use of traditional Chinese medicine in the management of urinary stone disease

To assess the evidence-based literature supporting the use of traditional Chinese medicine Kampo herbal and Acupuncture in stone disease management. Four of the most commonly used herbal components of Kampo medicine in the treatment of stone disease are described according to their in vitro and in vivo effects. We also reviewed the role of Acupuncture in urologic clinical setting as well as its proposed mechanisms of action and results. Medline database was assessed using isolated and conjugated key words (Chinese Medicine, Kampo, Chinese Herbal, Calculi, Stone Disease, Kidney, Acupuncture, Herbal Medicine). Articles were reviewed and summarized. Herbal medicine has been proven to be free from side-effects and therefore suitable for long term use therapy. Its antilithic beneficial effects include increased urinary volume, increased magnesium excretion (Takusya), inhibitory activity on calcium oxalate aggregation (Takusya, Wulingsan and Desmodyum styracyfolium), inhibition of calcium oxalate nucleation and hydroxyapatite internalization (Wulingsan). In contrast, acupuncture, has shown to be effective as a pre-treatment anxiolytic and analgesic during colic pain and extracorporeal shock wave lithotripsy treatment, reducing the need for complementary sedative drugs. Chinese traditional medicine is promising as regards its role in stone prevention. An effort must be made in order to standardize study protocols to better assess acupuncture results since each procedure differs in regards to selected acupoints, electrostimulation technique and adjunct anesthetics. Similarly, standardization of Kampo formulations and acceptable clinical endpoints (imaging vs. symptomatic events) is needed.