Internal Medicine

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

Renal Calculi 1283

Percutaneous Nephrostolithotomy (PCNL)

■endoscopic retrieval or fragmentation of stones via direct access to

kidney through small flank incision

■reserved for large renal or proximal ureteral calculi

➣Treatment of choice for staghorn calculi

■salvage therapy for SWL and ureteroscopy failures

Open or Laparoscopic Ureterolithotomy or Pyelolithotomy

■rare salvage therapy for SWL or endoscopic failures

follow-up

During Treatment

■Radiographic follow-up within approximately 1 month of surgical

treatment to ensure stone-free state and absence of obstruction

Routine

■KUB every 6–12 months

Medical Evaluation

■for recurrent stone formers and high-risk (family history of stones,

nephrocalcinosis, medical risk factors) first-time stone formers

■serum chemistries

➣creatinine, K, Ca, PO4, HCO3

➣uric acid

➣intact PTH

■urinalysis

■stone analysis

■24-hour urine collection for total volume, pH, calcium, oxalate,

sodium, citrate, uric acid, sulfate, phosphorus, magnesium

Medical Management – Conservative

■increased fluids

■sodium restriction

■limitation of animal protein

■mild calcium restriction if urinary calcium elevated

■limitation of oxalate-rich foods

■increased intake of citrus fruits and juices

Medical Management – Specific Drug Therapy

■hypercalciuria with normal serum calcium: thiazide diuretic and K

citrate

■hypercalciuria with elevated serum calcium and PTH: parathy-

roidectomy