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Urolithiasis is a common problem with a high recurrence rate. Medical therapy directed to relieve agonizing pain, expulsion of stone, dissolution of uric acid and cystine stone and prevention of recurrence. NSAIDs are superior to opioids for renoureteral colic because their use doesn't induce vomiting and there is lesser requirement of rescue analgesia. In randomized trials, anticholinergics were not found to be beneficial. Alpha blockers, particularly tamsulosin, reduce pain and facilitate expulsion of stone and fragments of stone following extracorporeal shock wave lithotripsy (SWL) and ureterorenoscopic lithotripsy. Potassium citrate helps in chemodissolution of uric acid and cystine stones and is useful in prevention of stone recurrence in general and in those who have undergone SWL or percutaneious nephrolithotomy. Other measures for prevention of stone recurrence include fluid and dietary therapy, counteracting underlying metabolic abnormalities using suitable medications, phytotheurapeutic agents and probiotics. Once the role of nanobacteria is established in genesis of urinary stones, anti-nanobacteria therapy holds the promise of opening new horizons for prevention of urinary stones., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Objective: To assess the sensitivity of computed tomography (CT) scout topograms and kidney-ureter-bladder abdominal radiography (KUB) in detecting urinary tract stones., Patients and Methods: We assessed films taken on presentation for 163 consecutive patients referred to our service for stone follow-up. Only those with both CT and KUB imaging on the same day were studied further. Two urology registrars examined the films independently. Location, size and length of stone were recorded. Where there was discordance, the films were examined by an independent radiologist., Results: In all, 108 of 163 patients had both CT and KUB imaging on the same day. Stones were identified in 63% (68/108) of patients with KUB, with a mean length of 4.93 mm. There were 40/108 radiolucent stones subsequently measured on CT, with a mean length of 4.90 mm. Stones were seen on 47% (51/108) of the CT scouts, with a mean length of 5.22 mm. Importantly, all stones visible on CT scout were also visible on KUB. There was no correlation between stone location and visibility on KUB or CT scout films., Conclusion: KUB could be used for follow-up in 63% of cases. All stones seen on CT scout were also visible on KUB. Scout detected 75% of stones visible on KUB. We suggest CT scout film should be reported before proceeding to KUB. If the stone is visible on CT scout film, then the decision to use KUB for follow-up can be made. This minimizes radiation exposure and other costs.

Objective: To study the urological manifestations of familial multiple endocrine neoplasia type 1 (MEN-1)., Patients and Methods: The study included 26 adults (median age 38.5 years, range 18-80) from two unrelated MEN-1 pedigrees. In 15 of the patients the diagnosis was confirmed by genetic analysis, while in the rest the diagnosis was based on clinical criteria combined with genealogy data., Results: Urolithiasis associated with primary hyperparathyroidism was present in 65% of MEN-1 patients and in 77% of those who were symptomatic. In 68% of patients complications of urolithiasis (renal/ureteric colic, urinary tract infection) were the presenting clinical manifestations of MEN-1, whereas in 50% they constituted the only clinical manifestation of the syndrome. The mean time from the onset of symptoms of urolithiasis to the diagnosis of the polyendocrinopathy was 17.2 years. Initial failure to recognize the presence of MEN-1 in patients with primary hyperparathyroidism led to conservative parathyroid surgery, with subsequent relapse of the hyperparathyroidism, requiring re-operation. Serious renal morbidity included one case of pyonephrosis necessitating nephrectomy. While urolithiasis was a cardinal clinical manifestation of MEN-1, there was otherwise considerable phenotypic polymorphism, even among patients bearing the same MEN1 gene mutation., Conclusion: In patients with familial MEN-1 the complications of urolithiasis are the commonest presenting clinical manifestations and the cause of significant morbidity. In the presence of a family history of renal stones, appropriate investigations may lead to the timely diagnosis of this important, albeit rare, disorder.

Objective: To present the results of the first clinical study of a synchronous twin-pulse technique for extracorporeal shock-wave lithotripsy (ESWL), which is effective for in vitro stone fragmentation and safe when assessed in vivo on animal tissue., Patients and Methods: Fifty patients with urinary stones (35 men and 15 women) were enrolled and treated with the TWINHEADS lithotripter. The entry criteria were: age > or = 18 years, with a radio-opaque single stone in the kidney or upper ureter, a normal laboratory profile (serum creatinine, liver function, blood, bleeding and clotting times, and prothrombin concentration). The exclusion criteria included lower ureteric stones, patients with urinary tract infection, obstructed urinary tract distal to the stones, or congenital abnormalities. All patients received one session and were evaluated by ultrasonography (US), urinary tract plain X-ray, and complete laboratory investigations before and immediately after treatment, and after 2, 14 and 30 days. Patients requiring re-treatment at the 14-day visit received a second session and were re-evaluated after 7 and 14 days., Results: The mean (sd, range) stone size (longest diameter) was 12.3 (2.6, 9-18) mm. Intravenous sedation was used in 30 patients. There was mild haematuria in 25 patients on the day of treatment. During the follow-up there was no evidence of haematoma, gross renal injury, upper urinary tract obstruction or significant changes in the laboratory investigations. After 14 days, 17 patients (34%) were free of stones, with residual stones of < or = 5 mm in 20 (40%); they were free of stones at the 1-month follow-up. Thirteen patients (26%) had residual stones of 6-9 mm, but the stones were half or less of the original size. Patients with residual stones of > 5 mm had another ESWL session and were free of stones within 14 days. Thus all patients were rendered stone-free within 1 month., Conclusions: Synchronous twin-pulse ESWL is promising, seems safe and effective for treating patients with renal and upper ureteric lithiasis.

Objective: To evaluate the impact of admission for acute urinary retention (AUR) on patients' health-related quality of life (HRQoL) compared with that on admission for elective surgery for benign prostatic hyperplasia (BPH) and emergency admission for renal colic (RC)., Patients and Methods: Over a 2-year period, three groups of men were recruited from one institution: group 1, men aged >50 years presenting to the accident and emergency (A&E) department with AUR; group 2, for comparison, men aged >50 years admitted for elective surgery for BPH; and group 3, men aged >40 years presenting to A&E with RC. A self-completed HRQoL questionnaire was administered at five visits (72 h from admission, and 1, 2, 3 and 6 months afterward) over a 6-month follow-up., Results: Group 1 reported mean pain scores on admission of 7.7, compared with 5.6 for group 2 and 8.3 for group 3. Patients in group 1 had the most investigations and recurrent attendance to A&E throughout the study, compared with almost none for the other two groups. There was a substantial economic burden for group 1; 15% had extra help at home at a mean cost of 403 UK pounds for the duration of the study. For the other domains assessed (e.g. emotions, mental state, general health) groups 1 and 2 were similar., Conclusions: An episode of AUR has a measurable impact on patients' HRQoL, which often occurs in the community and therefore may not be appreciated by the urology team providing their care. Further work is therefore required to improve the "patient journey" for those with AUR, and to prevent patients developing AUR in the future.

Objective: To present the characteristic clinical and imaging findings of pelvi-ureteric junction (PUJ) obstruction caused by crossing renal vessels (CRV), as it presents particular features within the spectrum of congenital hydronephrosis., Patients and Methods: Between April 1982 and December 2000, 384 children underwent surgery for PUJ obstruction. In 71 (18.5%; mean age 8.5 years, range 2 months to 14 years; 49 aged> 5 years), the obstruction was caused by CRV. The data collected from the medical records of these patients were analysed for their clinical presentation and imaging findings, i.e. ultrasonography (US), intravenous urography (IVU) and diuretic renography., Results: The main presenting symptom was recurrent renal colic (pain, nausea, vomiting) in 59%, followed by urinary infection (UTI) in 20%, gross haematuria in 11% and an incidental diagnosis in 10%. By contrast, in the 313 children with intrinsic PUJ obstruction, renal colic was present in only 10.5%. Moreover, from 1991 to 2000, when the use of prenatal US became widespread, hydronephrosis was detected prenatally in 42 of 212 children (20%) with intrinsic PUJ obstruction, but in only two of 31 (6%) with obstruction by CRV. However, in 10 children with CRV operated on during this period, prenatal US had shown mild hydronephrosis (< 15 mm), which during the follow-up decreased until the children became symptomatic after 5-9 years (eight renal colic, two UTI). US during acute symptoms showed significant hydronephrosis (> 25 mm), and colour Doppler US of two patients directly showed the CRV. In all 71 children with CRV obstruction diuretic IVU and renography during the acute symptoms had an obstructive pattern, and in 24 renal colic was reproduced during the examination. The differential kidney function was < 40% in 11 children who presented with UTI; two required nephrectomy and in the remaining 69 an Anderson-Hynes pyeloplasty, after which none had an episode of renal colic or UTI during a mean (range) follow-up of 10.2 (2-20) years., Conclusions: PUJ obstruction by CRV should be suspected in older children presenting with recurrent renal colic and hydronephrosis. Good kidney function is expected in most of these children, despite their age, because the vascular obstruction is intermittent. Mild prenatal hydronephrosis that could decrease postnatally does not exclude the possibility of vascular obstruction, which may later become symptomatic. Imaging (US, diuretic IVU and renography) during an episode of pain is essential and colour Doppler US could help to establish the diagnosis in these cases. Knowing that a child has a CRV is important for choosing an open surgical approach rather than endoscopic pyelotomy, to avoid potential complications

Objective: To assess the spasmolytic effect of drotaverine hydrochloride in colicky pain caused by renal and ureteric stones., Patients and Methods: In a placebo-controlled, multicentre, multinational, randomized, double-blind study changes in the intensity of pain were recorded using a visual analogue scale (VAS), a four-grade (five points) pain intensity (PI) scale and a pain-relief scale. The primary endpoint was the evaluation of the antispasmodic effect of drotaverine during a 3-h study period, to confirm that drotaverine abolished or significantly decreased the intensity of pain in renal colic. The painkilling effect was defined as a decrease by at least half in the PI scale, and/or a >or= 40% decrease in the VAS 40 min after either the first or the second injection of 80 mg drotaverine or placebo (if necessary the dose could be repeated once). In all, 140 patients were enrolled but 38 withdrew, leaving 102 patients for analysis (48 drotaverine, 54 placebo; mean age 42.5 years, sd 11.25, and 41.7, sd 10.79)., Results: Drotaverine was effective in 79% of patients and placebo in only 46% (P < 0.001). There were no serious adverse effects. There were 20 minor side-effects in the drotaverine and four in the placebo group; none of the patients required treatment. The most frequent side-effects were a transitory decrease in blood pressure, vertigo, nausea or vomiting., Conclusion: Intravenous drotaverine provides effective pain relief in more than two-thirds of patients with renal colic, with no serious side-effects.

This study investigated the effect of prolonged administration of tramadol vs. placebo on behavioural indicators of ureteral pain and referred lumbar muscle hyperalgesia in a rat model of artificial ureteral calculosis. Four groups of 10 rats each (female, Sprague-Dawley) were treated twice a day, for 4 days, with i.p. injections of tramadol 1.25 mg/kg, 2.5 mg/kg, 5 mg/kg or saline, respectively. The first injection was delivered 45 min before laparotomy (under pentobarbital anaesthesia) for formation of the stone in the upper left ureter via injection of dental cement. All rats were video-taped 24 h non-stop from the immediate postoperative period until the 4th day for recording of behavioural ureteral crises indicative of colic pain. Lumbar muscle sensitivity was tested daily over the same period by verifying presence or absence of vocalization upon pinching of the parietal layers at L1 level, bilaterally, at a constant predefined pressure value with calibrated forceps. Tramadol significantly reduced number and global duration (ANOVA, P < 0.008 and P < 0.004) of ureteral crises with respect to saline and the effect was dose-dependent (linear regression analysis between doses and parameters of crises, P < 0.003 and P < 0.002). The drug also significantly reduced the incidence of referred muscle hyperalgesia (ANOVA, P < 0.0001). It is concluded that tramadol is highly effective in controlling pain phenomena from urinary stones and can represent a valid therapeutic approach in patients with urinary colics.

Objective: To review experience with open surgery for paediatric urolithiasis during a 10-year period., Patients and Methods: The hospital records of patients up to 13 years old and treated between 1990 and 2000 for stones were reviewed; there were 310 patients (98 girls and 212 boys, aged 9 months to 13 years, mean 6.8 years)., Results: The commonest symptoms were renal-ureteric colic (26.7%), gross haematuria (19%), urinary retention (16.7%), and abdominal and/or flank pain (13.2%). Because of poverty and the resultant inability to pay medical fees, 19 children presented very late with pyonephrosis (resembling peritonitis in nine) and obstructive renal atrophy in 23. In 18 other patients the delay was caused by the disappearance of pain. Delayed presentation was the most important factor in developing complications from the stone. The stones were in the calyces in 15 patients, the pelvis in 113, the ureter in 56, the bladder in 71, the urethra in 17 and in a combination of sites in 38. The mean (range, median) stone size was 27 (9-75, 22) mm; 80 (25.8%) were complete staghorn stones. Indications for open surgery were a complex stone burden (62%), ESWL failure (14.5%), need for nephrectomy (1.9%), anatomical abnormalities (2.2%), and unavailability of minimally invasive alternatives (19%). All of the nephrectomized patients underwent unilateral stone removal and contralateral nephrectomy. For parents, the cost and reliability of the result were more important than other considerations, e.g. having a large or small incision. The overall stone-free rate at discharge was 95.4% (100% for single stones). In five cases (1.6%) a repeat open procedure was needed. The mean (range, median) hospital stay was 4 (1-13, 3) days., Conclusions: Arguments against open surgery for urolithiasis in adults should not be extrapolated to children, in whom open surgery is safe and effective. In Iran and many 'developing' countries, open surgery is less expensive, more effective, more dependable, and more easily available than minimally invasive alternatives. At least in such countries it deserves to be among the first-line therapies for paediatric urolithiasis, and urologists in less-developed countries should not decline to offer open surgery because it is almost obsolete in developed countries. Delayed presentation (through poverty and/or unawareness) contributes significantly to the morbidity of urolithiasis.

Objective: To evaluate the efficacy and safety of ureteric stone treatment by ureteroscopy and laser lithotripsy during pregnancy., Patients and Methods: Four pregnant women (mean age 29.5 years, range 27-35) with five episodes of ureteric stones were treated by ureteroscopy and laser lithotripsy when the fetus was at 26-35 weeks of gestation. The stones (between 5 and 16 mm in diameter) were located in the proximal (one) or distal ureter (four)., Results: All five stones were removed successfully by ureteroscopy and laser lithotripsy. The operating time varied between 15 and 70 min. In two of the five cases, topical anaesthesia was adequate and in no case was fluoroscopy necessary. No complications occurred that could be related to the procedure., Conclusions: Ureteroscopy and laser lithotripsy seem, in experienced hands, to be a safe and reliable method in the treatment of ureteric calculi during pregnancy. Most cases can be treated without using fluoroscopy and in some cases the operation can be performed under local anaesthesia.

This study reviews 6 patients who were referred with severe loin pain radiating to the groin and in whom a presumptive diagnosis of ureteric colic was made. Of these, 3 patients were found to have carcinoma of the pancreas and the remaining 3 had retroperitoneal lymph node metastases. Retroperitoneal malignancies rarely present with loin pain, but this diagnosis should be considered in patients with long-standing loin pain in whom an obvious diagnosis is not apparent.

The association of renal tuberculosis and leukoplakia of the renal pelvis was quite common in the prechemotherapy era of tuberculosis but has apparently not been seen since effective drugs became available. Despite a prompt response of the tuberculosis to chemotherapy the leukoplakia formation with intermittent passage of keratinised material continued. Surgical removal of the accumulated material was of no lasting benefit.

A clinicopathologic correlation of 2 patients with crossed renal ectopia presenting with ureteric colic and 4 cases collected from the literature is presented. The correlation serves to reaffirm the theory of ureteral and not renal, migration as the primary aberration resulting in this defect.