Stone Disease

Abstract

Purpose: While the effect of jejunoileal bypass (JIB) reversal has been well studied regarding hepatic function, there is little information regarding the effect of reversal on renal function and even less data regarding the metabolic urinary stone environment. We evaluated the results of JIB reversal on renal function, the urinary stone milieu and the clinical development of recurrent calculi in affected patients.Materials and Methods: From 1995 to 2003, 4 female patients with a mean age of 48.2 years underwent JIB reversal primarily for refractory stone disease. The clinical and metabolic courses prior to and following bypass reversal were reviewed specifically to evaluate renal function, serum and urinary metabolic stone profiles, and clinical stone formation.Results: At initial presentation following JIB all 4 patients had significantly increased 24-hour urinary oxalate (range 80 to 160 mg, mean 112.5, normal less than 50) and significantly low 24-hour urinary citrate (range 5 to 62 mg, mean 21.5, normal greater than 320). Following reversal 24-hour urinary oxalate normalized to between 31 and 36 mg (mean 33.75). However, 24-hour urinary citrate continued to be low (range 215 to 248 mg, mean 226.5). After JIB reversal all 4 patients continued to have new stones until the commencement of urinary alkalization, following which only 1 had 1 calculus, which occurred 47 months after reversal. After JIB mean serum creatinine was 1.48 mg/dl (range 0.8 to 1.9) and mean urinary creatinine excretion was 0.91 mg per hour (range 0.69 to 1.15). After JIB reversal mean serum creatinine was 1.28 mg/dl (range 0.6 to 2.0) and mean urinary creatinine excretion was 1.0 mg per hour (range 0.85 to 1.10).Conclusions: JIB reversal normalizes 24-hour urinary oxalate. While urinary citrate improves, it continues to be low and such patients are at high risk for recurrent stone formation. However, in this setting appropriate replacement therapy has a significant and positive impact on that propensity. Editorial CommentBone loss, liver disease and renal calculi are only a few of the metabolic consequences of jejunoileal bypass. Stones form as a consequence of hyperoxalauria, low urine volume and pH and hypocitraturia that occur because of metabolic acidosis and malabsorption. Stone disease in some patients has been severe enough to prompt JI bypass reversal. Dhar and colleagues seized a unique opportunity to study 4 such patients before and after JI bypass reversal. They documented a significant reduction in stone formation rate, from 3.2 to 0.19 stones/ patient/year after bypass reversal. Of note, however, reversal of the JI bypass failed to completely reverse the marked hypocitraturia associated with bypass surgery that is due to severe metabolic acidosis. Initiation of alkalinization with potassium citrate, however, led to complete cessation of stone formation in all but 1 of the 4 patients, who produced a single stone. These findings are particularly relevant as laparoscopic intestinal bypass surgery has become increasingly popular....

Treatment of Lower Pole Renal Stones-Extracorporeal Shock Wave Lithotripsy vs Endourology. A literature review

“…Regarding the comparison of ESWL with flexible ureteroscopy, URS has a higher stone-free rate than ESWL, in the case of stones <10 mm [61,62] and 10-20 mm [59,60]. In one study, conducted by Kumar A et al, the efficacy of ESWL was similar to URS, but for the treatment of proximal ureteral lithiasis <10 mm [63].…”

“…Endourological maneuvers may cause more frequently cardiovascular complications (retroperitoneal hematoma) or iatrogenic ureteral perforations [70,71]. Following treatment of lower pole lithiasis by flexible ureteroscopy or percutaneous nephrolithotomy, convalescence is higher than ESWL [62]. Another disadvantage of flexible ureteroscopy is the need for fragile and expensive instruments, requiring frequent repair due to the rapidly degrading active deflection mechanism [71].…”

Treatment of Lower Pole Renal Stones-Extracorporeal Shock Wave Lithotripsy vs Endourology. A literature review

“…Regarding the comparison of ESWL with flexible ureteroscopy, URS has a higher stone-free rate than ESWL, in the case of stones <10 mm [61,62] and 10-20 mm [59,60]. In one study, conducted by Kumar A et al, the efficacy of ESWL was similar to URS, but for the treatment of proximal ureteral lithiasis <10 mm [63].…”

“…Endourological maneuvers may cause more frequently cardiovascular complications (retroperitoneal hematoma) or iatrogenic ureteral perforations [70,71]. Following treatment of lower pole lithiasis by flexible ureteroscopy or percutaneous nephrolithotomy, convalescence is higher than ESWL [62]. Another disadvantage of flexible ureteroscopy is the need for fragile and expensive instruments, requiring frequent repair due to the rapidly degrading active deflection mechanism [71].…”