Advances in the Treatment of Genitourinary Lithiasis

Urinary lithiasis is characterized by the formation of stones that manifest themselves with intense pain. Nowadays, treatment is very varied thanks to technological innovation, with endoscopic surgery and urethral lithiasis being among the most frequently used techniques.

Lithiasis disease: what is it?

Ureteral lithiasis is a disease characterized by the formation of stones in the urinary tract (Figure 1). It appears in 5-10% of the general population and usually manifests as a picture of intense pain in the dorsal region radiating towards the genital area (nephritic colic). The pain is of such intensity that it often leads to accompanying nausea and vomiting. However, bleeding during urination or urinary tract infections occur with some frequency. On many occasions, the detection of a kidney stone occurs accidentally, when performing an ultrasound for other reasons.
Its incidence seems to increase in relation to the increase in socio-economic level. Thus, it is eight times more frequent among medical professionals, lawyers, etc. than in other activities. It can be stated that 6% of the population will have a stone during their lifetime.
The first episode usually appears between the 3rd and 4th decade of life. After that, the probability of recurrence is 50% in the following 5 years, a percentage that increases in cases with a family history of calculi.

Figure 1 below shows a “coralliform” renal calculus, so called because of its appearance.

Diagnosis of renal lithiasis

The diagnosis of renal lithiasis should include a complete morphological and functional evaluation of the urinary tract. The presence of urinary calculi and their repercussions at that moment must be confirmed. For this purpose we will basically use simple abdominal radiography (figure 2), abdominal ultrasound and the study with contrast of the urinary tract by means of Computerized Axial Tomography (CAT). The latter, without contrast, is currently the diagnostic technique of choice. The size of the calculus, its position and the possible obstruction it produces on the kidney will determine the best treatment options.
The following image (Figure 2) shows a large chorioriform lithiasis of the right kidney visible on an abdominal X-ray:

Once the stones have been removed, a metabolic study should be performed by the Urology expert to rule out any disorder that could lead to their reappearance. This study, often forgotten, is simple and convenient for the patient and, in some cases, will be the cornerstone of long-term treatment.

Treatment of renal lithiasis

The main objective of the medical treatment of lithiasis is to eliminate the existing stones, avoiding present or future complications derived from their growth, and to prevent their reappearance.
Many of the urinary stones will be expelled spontaneously. However, it is very often necessary to resort to active treatment. It is in this field where very important changes have taken place in recent years, due to the miniaturization of the instruments used and the incorporation of highly efficient energy sources such as lasers.
Traditionally, open surgery has been used for the treatment of large kidney stones. However, starting in the 70’s of the last century, the percutaneous approach (with metal tubes of 10 mm maximum diameter inserted into the kidney from the lumbar region) became generalized and external energy sources appeared (extracorporeal lithotripsy). Both techniques, widely used today, have allowed a minimally invasive and highly effective treatment; especially lithotripsy has changed the way urologists handle lithiasis like few other techniques.
The last 10 years have seen another new revolution in the management of urinary calculi, brought about by technological innovation. Laser sources can be applied to points with diameters of up to one third of a millimeter with energies as high as 30 watts or more. This has made it possible to miniaturize the working instruments and to reach the kidney itself from the urethra (thus using the natural orifices) with the intention of fragmenting and pulverizing stones up to 3 cm in diameter, a situation that was unthinkable only a few years ago. Similarly, it has facilitated access to renal lithiasis located in places that were previously only accessible from the outside (for example, caliceal diverticula).
Endoscopic surgery, which is what we generically call this type of technique, has gained notable efficacy, allowing successful treatments with minimal invasion, few complications and rapid recovery.
Ureteral lithiasis is currently well treated by ureterorenoscopy, a minimally invasive procedure through the natural pathways (urethra and ureter). The location and size of the stone will define the need for semi-rigid or flexible ureterorenoscopy.

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Necessary care after treatment of renal lithiasis

Once the existing stone or stones have been removed, the initial cause of the problem (gout, hyperparathyroidism, etc.) must be treated. If no biochemical disorders are discovered, nor extrarenal manifestations of another disease that could favor the formation of stones, we should indicate a conservative treatment, medical and dietary, if appropriate.
In general terms we should follow these guidelines:
1) Fluid intake:
Increasing fluid intake is a nutritional modification universally applicable to all types of stones. A urine volume greater than 2 liters per day should be achieved. For an average-aged individual with normal activity, this means an intake of 3 liters. Water will be the fundamental contribution, although only milk and tea are expressly discouraged.
2) Dietary restrictions:
Reducing salt in the diet or low protein intake with practically a constant are the recommendations given to people with genitourinary lithiasis. However, these measures used inappropriately will be ineffective at best. This type of treatment should not be initiated without a prior metabolic study to be performed in the urology office.
3) Medical treatment:
Medical treatment, aimed at preventing the formation of new calculi, should be tailored to each type of calculus and underlying metabolic disorder if present.