Internal Medicine

0521779407-18 CUNY1086/Karliner 0 521 77940 7 June 13, 2007 8:1

1282 Renal Calculi

specific therapy

■likelihood of spontaneous passage depends on stone size, stone loca-

tion, and anatomy of urinary tract

■most small (<5 mm) ureteral stones will pass spontaneously

➣tamsulosin with or without short course of corticosteroids to

facilitate spontaneous stone passage

Indications for Surgical Management

■high grade or complete obstruction for >1 week

■persistent or recurrent renal colic

■occupational requirements (i.e., airline pilot)

■failure of partially obstructing stone to pass within 4–6 weeks

Options for Surgical Management

■optimal treatment depends on stone size, location, composition

Shock Wave Lithotripsy (SWL)

■historically treatment of choice for most (>85%) renal and ureteral

calculi, not cystine stones

■usually limited to stones <20 mm in kidney and <10 mm in proximal

ureter

■complications: related to bleeding and obstruction from stone frag-

ments

➣steinstrasse (column of stone fragments in ureter)

➣bleeding

➣infection

➣damage to surrounding organs

■absolute contraindications

➣pregnancy

➣middle and distal ureteral stones in women of child-bearing age

Ureteroscopy

■primarily, but not exclusively, used for ureteral stones

➣increasing use for renal calculi

■treatment of choice for cystine stones and salvage therapy for SWL

failures

■controversy regarding optimal treatment for lower ureteral stones

(stones below the pelvic bone): ureteroscopy versus SWL

■absolute contraindications

➣active urinary tract infection