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PREVENTION OF RECURRENT UROLITHIASIS;

PROBABLE OR CERTAIN BENEFIT FROM DIFFERENT METHODS ?.

Dr. HIWA OMER AHMAD. CABS CONSULTANT SURUEON

SULAIMANI – IRAQ

SUMMARY

One hundred patients with urolithiasis were studied to evaluate the benefit of different diets

& medical programs in the prevention of the recurrence. The most common type of the urinary

stones was triphosphate (56%) followed by calcium oxalate (44%).

Female: male ratio was 34/66. The urolithiasis which may affect all age groups were more

common in forth decade of the life. Stones from all the patients were analyzed chemically and then

diet & medical programs applied accordingly. It seems to be possible to prevent high number of

recurrent urolithiasis by these easy, non -costly and tolerate methods.

INTRODUCTION

While the lithotomy is the first goal of the treatment of urinary tract stones, the prevention of

recurrence is the second & vital goal of the management.

Recurrent urolithiasis after surgery is considered as on of the global problems, which may be as

high as 50% within a year(1). In some articles, studies have shown that single stone formers have

same incidence & severity of metabolic derangement as patients with recurrent stone disease(1), so

every patient with urolithiasis may has a risk for recurrence.

The need for repeated stone removal may be dramatically reduced by prophylactic medical

program & dieting of the patients, to implement these preventive measures, we need identification

of the specific risk factors and composition of the stone an each case(2).

A study on recurrent urolithiasin was done in south Iraq(3), but none in our region, which have

different weather, style of life & composition of drinking water.

The present work done in Sulaimani Teaching Hospital (STH), which covers more than million

populations in Sulaimani & keruk governates.

The aim of the study was to evaluate the role of different medical programs & diets in the

prevention of the recurrence of urinary tract stones.

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Patients & Methods

This is prospective study of 100 patients having urolithiasis, conducted in STH over a period

of 3 years from 1st Jan. 1994 to 31st dec.1996.

Data were collected regarding age (Figure I), sex, type of the stones (Table I), history of

previous urolithiasis (Table II), familial history, type of work, presence of urinary tract infection

(UTI) & other predisposing factors (Table III), the water supply project, calcium content of drinking

water for each patient (Table IV), investigations including GUE, ultrasonography, KUB, serum

calcium, and IVU in selected cases.

All stones after surgical removal or when passed by medical treatment were sent for chemical

analysis, then accordingly each patient received a list of dieting & medical advice’s (Table V), Each

patient was asked to be reported regularly every 6 month for evaluation; clinically and by GUE,

ultrasonography each for 5 years (Table VI). All the recurrences (5%) were recorded and the patient

labeled as recurrence. Each patient investigated for the main factors of the recurrence (table VII).

Figure I: Showing different age groups of the patients with urolithiasis.

Type of stone %

Triphosphate 56

Calcium oxalate 44

Uric acid 00

Cystin 00

Table I: showing percentage of the different types of stones.

10 8

21

38

63

14

05

10152025303540

No. of Patients

1Age Years

Differemt Age Groups

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No. of patient Frequency of recurrence

2 04

2 17

4 05

6 02

6 10

Table II: showing history of recurrences before the present work in the patients.

ASSOCIATED CONDITIONS %

BPH 02

Stricture 04

Hypercalcaemia 08

UTI 16

Horseshoe kidneys 02

Table III: showing predisposing factors for urine stasis.

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Amount of calcium in water AREA PPM

Part per million mEq/L

No. of patients

Sulemani city

Water project of :

Aziz aga 76.0 38.0 06

Hagi bag 67.0 33.5 00

Girdi jow 50.0 25.0 14

New dokan 46.6 23.2 04

Serchenar 44.5 22.2 28

Sulemani governate

Kefri 187 93.9 08

Saidsadiq 100 50.0 08

Penjwen 89.0 44.5 02

Arbat 73.6 36.5 02

Old halabja 68.0 34.0 08

Mawat 66.0 33.0 08

Rania 65.6 32.5 07

Bazian 57.0 28.5 02

Dokan 36.0 18.0 03

Table IV: showing amount of calcium in different water project in the area.

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TYPE OF STONE Fluid

INTAKE FOOD RESTRICTIONS DRUGS

1. Calcium Oxalate ↑ Not to take diary products,

unless with oxalate

containing foods like:

spinach, tomato, lemon .etc,

& vice versa.

Thiazid VB6 Monthly

2.Triphosphate ↑ Treatment & control of UTI Antibiotics

Acidification of the urine

3.Cystin ↑ Eggs , meat , fish (9) D-penicillamin

Soluble alkaline; K+

citrate orally

4.Uric acid ↑ Red meat ,(offal , fish)(9) Alkalization of the urine

Allupurinol

Table V: Different diets in applied for prevention of recurrence of the stones (1,4,6)

Duration of follow up %

One year 30

Two years 14

Three years 38

Four years 10

More than 4 years 08

Table VI: period of follow-up in the study.

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Age (years)

sex

work

Residency

Type of the stone

Side of the stone

Drinking w

ater project

Tim

e of the R

ecurrence

Family history

Hypercalcacem

ia

UT

I

Dieting &

medical

program

36 +

Housew

ife Sulaimani,

Karezawishk

Calcium

oxalate

Left

New dokan

3rd visit 18 months - - + Omitted by

the patient

25 +

Housew

ife Sulaimani

Mamostayan

calciumo

xalate

left

New dokan

4th visit 24 months + + + Omitted by

the patient

26

Military

officer

Sulaimani Malkandi

calciumo

xalate

left

New dokan

3rd months - - - Omitted by

the patient

28

Farmer

Sulaimani Mama yara

calciumo

xalate

left

Aziz aga

2nd visit 12 months - - - Continued

6 +

child

Sulaimani Malkendi

triphosphat

left

Grdigow

1st visit 6 months + - + Omitted by

the patient

Table VII: showing the main common factors in the patients with the recurrence

RESULTS

Most of the patients were in the fourth decade of life (figure I). Most were male (M: F =

66/34). Majority of the stones were triphsphate, the rest was calcium oxalate (table I). With history

of recurrence in (20%) of the patients before entering the study (table II). There was family history

of urolithiasis in (32%) of the patients.

Thirty-two patients have associated predisposing factors of stone formation (table III) .The

patients were from different areas in the Sulaimani and Karkuk governates, were drinking water

from different water projects with various amounts of calcium contents (table IV).

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DISCUSSION Majorities of the stones were triphosphate types (56%) while in other studies it is ranging

between 10-20% (3). The cause may be due to the high incidence of UTI in our locality, predisposing

to formation of triphosphate stones.

The acceptable daily intake of calcium from the drinking water is 40 - 50 mEq /L. While our

patients were drinking water containing calcium from (18-93.9mEq/L)(5) . We found no any relation

between the level of the calcium in the drinking water and the incidence of calcium oxalate stones

or their recurrence, for example the highest level of calcium in the drinking water was in Kifri water

(187ppm=93.9mEq/L) followed by SaidSadiq (100 PPM = 50 mEq/L), but no patients from these

two places (16%) had recurrence. While all the recurrences were from Sulaimani City, with a level

of calcium in drinking water much lower (Table IV).

While the recurrent UTI appeared as an important factor in the predisposition for recurrence

of the stones, even in the recurrence of the calcium oxalate stones.

The incidence of recurrent urolithiasis without dieting & medical programs is 40 - 50 % in 5

years(6). But in the present work the incidence was (5%) .The main factors were omitting of the diet

& medical programs by the patients themselves, recurrent UTI & left sided stones (Table VII).

We found dieting & medical programs to be effective in reducing the incidence of

recurrence by 10 folds (from 40-50(6) to 5% in 5years). While in other studies they found a

remission rate of greater than 30% over all reduction in individual stone formation rate of greater

than 90% (1).

CONCLUSION The diet & medical programs is a non-costly, effective, acceptable method to decrease the

number of recurrent urolithiasis, but needs best doctor-patient cooperation.

ACKNOWLEDGMENT

Technical assistance received from staff in the 16th surgical unit, laboratory in STH and

administration of Sulaimani water projects thankfully acknowledged.

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REFERENCES

1. Shwartz, Shire, and Spenser, Principles of Surgery, 6th edition, and 1994: 1750-1754.

2. Francesco P. cappucio, BMJ, Kidney stone and hypertension, 1990 - 1234-6.

3. Lamia M al Naama, Saudia MJ, The incidence & composition of urinary stones in south

Iraq, Sept. 1987, Vol. 8 No 5 , 456-457 .

4. Kambal et al., British J of Urology, Urolithiasis in Sudan, 1981, 52, 7 - 12 .

5. From Sulemani water project Archive .

6. Edmund R Yendt, International Medicine, Renal calculi, Dec.1982,Vol. 94, No.24,

1110-1112 .

7. M.S abomelha, Saudia MJ, ESWL first experience in the mid east, Nov. 1986, Vol. 17

No.6, 89-90.

8. Jay Y Gillen water, year book of Urology, London,1994-29 .

9. RCU - Russell , Bailey & loves short practice of Surgery-London - 23rd

edition, 2000, 1188.