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Treatment and prevention of urolithiasis in patients with stones of various locations

Keywords:

A.A. Kamalov  Academician of RAS, Dr.Sc. (Med.), Professor, Director of Medical Scientific-Educational Center of Lomo-nosov Moscow State University; Head of the Department of Urology and Andrology, Faculty of Fundamental Medicine, Lomonosov Moscow State University
E-mail: armais.kamalov@rambler.ru
V.K. Karpov  Urologist, Oncourologist, Associate Professor, Department of Urology and Andrology, Faculty of Fundamental Medicine, Lomonosov Moscow State University, Honored Doctor of the Russian Federation
E-mail: vk_karpov@mail.ru
D.A. Ochobotov – Dr.Sc. (Med.), Urologist, Senior Research Scientist, Scientific Department of Urology and Andrology, Educational and Scientific Center, Lomonosov Moscow State University; Scientific Secretary,e Russian Society «Men's health» (Moscow)
E-mail 14032007m@gmail.com
I.N. Otvetchikov – Dr.Sc. (Med.), Chief of the Urology Department, City Clinical Hospital №17 (Moscow)
E-mail: otvetchikov@list.ru
A.A. Prituko – Dr.Sc. (Med.), Urologist, Urology City Clinical Hospital №17 (Moscow)
E-mail: prityko@yandex.ru
E.S. Tichonov  Urologist, Urology City Clinical Hospital №17 (Moscow)
E-mail: ev.timoxin@yandex.ru


The study involved 4014 patients with stones of different localization. All patients underwent a complex laboratory examination, urine culture, ultrasound of the upper and lower urinary tract, if necessary, transrectal ultrasound (TRUS), CT of the abdomen. Patients with benign prostatic hyperplasia (BPH) were investigated with IPSS, PSA, and uroflowmetry. Ureteropyeloscopic examination was performed 3175 times for stones of different localization. Separately, we studied the results of treatment of 427 patients with ureterolithiasis in combination with BPH, who underwent contact ureterolithotripsy (CULT). Percutaneous nephrolitholapaxia (PNL) was performed in 412 patients, most procedures were performed according to the classical technique. In the pilot study, we tried to answer the question of how to optimize the prophylaxis of the recurrent urolithiasis. In the experimental part of the study 152 patients with recurrent calcium oxalate urolithiasis were enrolled, including those from the clinical part of the study. Patients were also divided into two groups: the 1st group (74 patients) did not receive treatment during the follow-up period, the second group (78 patients) received treatment including thiazide diuretics, water load, citrate mixtures, oral calcium preparations. During the follow-up of 6 months all patients underwent a bi-monthly comprehensive urological examination, including a Litos test and a blood and urine analysis for potential markers of stone formation (bikunin, osteopontin, nephrocalcin). Main complications after PNL: acute non-obstructive pyelonephritis - 3 patients, migration of the fragments of the calculus - 3 patients, perforation of the pelvis and ureter - 2 patients, three patients had bleeding that required conversion into the open operation. There were no periureteritis and complications during CULT procedure. The operation was performed under epidural anesthesia. The upper urinary tract was drained for 2-3 days by the ureteral catheter, followed by the placement of an internal stent, which was removed on day 14-30 after the operation. The incidence of complications in the first group (urolithiasis without infravesical obstruction) was 3.2%: acute non-obstructive pyelonephritis - 3 patients, exacerbation of prostatitis - 2 pa-tients, stone migration - 2 patients. In the second group (urolithiasis in combination with infravesical obstruction), the complication rate was 10.3%: ureteral perforation - 7 patients, stone migration - 6 patients, bleeding - 5 patients, acute pyelonephritis - 2 patients, exacerbation of chronic prostatitis - 2 patients. The duration of the operation in the second group was longer by an average of 25 minutes compared to the same index in the first group.
After 6 months of follow-up, the bikunin concentration was significantly higher in the group of patients who did not receive treatment compared to patients who received preventive therapy (6.1 ± 0.81 mg / ml vs 3.28 ± 0.86 mg / ml, respectively) . The concentration of osteopontin in the group of patients who did not receive treatment was significantly lower (2.3 ± 0.39 mg / ml vs 3.4 ± 0.36 mg / ml).
The overall incidence of complications in patients with urolithiasis undergoing complex treatment was 2%, there were mostly inflammatory and easily cured by antibiotic therapy. Taking into account the statistically significant results, the preliminary stenting of the upper urinary tract before performing CULT in patients with ureterolithiasis in combination with BPH is justified, since it allows reduction of the number of postoperative complications and the operation time. The use of percutaneous nephrolithotripsy is the "gold standart" in the treatment of patients with kidneys stones, the upper third of the ureter, staghorn stones.
An increase in bikunin concentration in patients who did not receive treatment during the observation period is associated with an increase of the expression of this stone formation inhibitor due to an increase in the activity of urolithiasis. Reduc-ing the concentration of osteopontin in patients with high activity of urolithiasis is a consequence of the fact that osteo-pontin is a one of the component of calcium oxalate stones.
The surgical intervention should not be the final stage of treatment of the urolithiasis. We believe that this disease requires constant monitoring of patients, and the priority task of a urologist is to prevent recurrent stone formation. This is achieved through the appointment of adequate conservative therapy, which includes thiazide diuretics, citrate mixtures, calcium preparations, water intake in adequate amount, and if necessary, magnesium preparations. The final composition of the conservative treatment depends on the type of stone. The change in the concentration of crystallization inhibitors (bikunin and osteopontin) is a predictor of an early relapse of the urolithiasis and can be used in monitoring patients in the postoperative period.

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June 24, 2020
May 29, 2020

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