Is the conservative management of ureteric calculi of > 4 mm safe?

Abstract

Objective To determine the safety of the conservative management of ureteric calculi of >4 mm in diameter, using mercapto-acetyltriglycine (MAG3) radioisotope renography to monitor renal parenchymal function. Patients and methods Patients with symptomatic unilateral ureteric calculi were recruited prospectively. After con®rming the position of the stone using contrast urography, a MAG3 radioisotope renogram was taken within 48 h of admission and again 1 month after the patients became stone-free. The indications for intervention were ipsilateral loss of function (o5% loss), infection, pain or any combination of these factors. The recovery of function was determined by follow-up renography. Results In all, 54 patients were recruited; 18 were initially allocated to conservative treatment although four later required intervention for pain. The remainder required early intervention for pain (eight), diminished function only (15) or diminished function with infection (13). Of the 54 patients, 28% had silent' loss of renal function at presentation. No calculi of >7 mm diameter passed without intervention. The mode of initial management was determined according to individual clinical need. The upper tracts of all patients were relieved of obstruction and all patients were rendered stone-free. Intervention for reduced function only (at ¡7 days) gave a signi®-cantly better (P=0.03) recovery of function than those undergoing later intervention. The combination of reduced function and infection were unrelated to outcome after intervention. Conclusions The conservative management of stones of 5±7 mm diameter is safe, providing that radioisotope renography is used to identify those renal units requiring intervention. This approach allows timely intervention to maximize the recovery of renal function.

Predicting intervention in renal colic patients after emergency department evaluation

“…Complications from an intervention for ureteral obstruction are much higher when symptoms exceed 4 weeks' duration. 15,16 Irreversible renal damage can occur with urinary obstruction that impairs renal function for over 2 weeks. 5,[29][30][31] In the US, the societal burden and indirect costs for lost wages from urolithiasis are estimated to be US$139 million annually.…”

“…The potential implications of a valid decision tool in this patient population are optimization and standardization of care, reduction of return ED visits and, ultimately, reduction in complications from delayed procedures. [13][14][15][16] Additionally, health care costs could be impacted by reduced complications, fewer ED visits and unnecessary referrals. Future studies to prospectively validate this model in another cohort of patients are important before we would advocate widespread clinical use of these predictors.…”

“…Patients with persistent or recurrent pain who are waiting for procedures are repeatedly seen in the ED; this contributes to an increased risk of complications for the patients, and increased health care costs and ED patient volumes. [13][14][15][16] If intervention is unlikely after the initial ED evaluation, patients could be referred for further assessment and follow-up to their family physician rather than to a urologist. A valid decision tool to identify on initial ED visit those renal colic patients who will likely eventually undergo a procedure would allow emergency physicians to prioritize and standardize referrals for urological treatment.…”

Silent Ureteral Stones: Impact on Kidney Function—Can Treatment of Silent Ureteral Stones Preserve Kidney Function?

“…Decreased renal function was found in 18% of patients, but only 2 patients who had had previous treatment for a calculus had persistent kidney impairment after stone removal. Finally, Irving et al 13 prospectively followed up 54 patients with ureteral calculi Ͼ4 mm and found that 28% of patients had silent loss of renal function, obligating treatment at diagnosis. For this particular group, they also studied the effect of treatment timing on the recovery of renal function, with better results when the intervention took place within the first week.…”

Influência do cálculo ureteral silencioso sobre a função renal antes e após o tratamento

“…[44] . [45] . No ser humano, o tempo que o nefron tolera uma obstrução sem prejuízo permanente à sua função é controverso [46] .…”