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Management of urinary stones by experts in stone disease (ESD 2025)

Fecha de publicación:

Autores de IIS La Fe

Participantes ajenos a IIS La Fe

  • Papatsoris A.
  • Geavlete B.
  • Radavoi G.D.
  • Alameedee M.
  • Almusafer M.
  • Hammad Ather M.
  • Adrian Cumpanas A.
  • Can Kiremit M.
  • Dellis A.
  • Elhowairis M.
  • Antonio Galán-Llopis J.
  • Geavlete P.
  • Guimerà Garcia J.
  • Isern B.
  • Jinga V.
  • Manuel Lopez J.
  • Antonio Mainez J.
  • Mitsogiannis I.
  • Christian J.M.
  • Moussa M.
  • Multescu R.
  • Oguz Acar Y.
  • Petkova K.
  • Pinero A.
  • Popov E.
  • Rascu S.
  • Siener R.
  • Sountoulides P.
  • Stamatelou K.
  • Syed J.
  • Trinchieri A.

Grupos

Abstract

The formation of kidney stones is a complex biologic process involving interactions among genetic, anatomic, dietary, and environmental factors. Traditional lithogenic models were based on urine supersaturation in relation to the activity of crystallization promoters and inhibitors. However, modern research has added new principles such as the “renal epithelial cell response” and the role of inflammation and oxidative stress leading to the development of a “multi-hit hypothesis”. A strong correlation between urinary stones and kidney damage has been well demonstrated by both cohort and case-control studies. The main contributors to chronic kidney damage associated with urinary stones include crystal deposition within the renal parenchyma, associated comorbidities, repeated obstructive and infectious episodes, as well as the potential adverse effects of stone removal procedures. Most hereditary stones may cause high urinary saturation levels promoting obstruction of the Bellini ducts and consequent glomerulosclerosis and interstitial fibrosis in the cortex. These include hereditary hypercalciurias, primary hyperoxalurias, cystinuria, adenine phosphoribosyltransferase (APRT) deficiency (associated with 2,8-dihydroxyadenine lithiasis) and xanthinuria. Complete distal renal tubular acidosis occurs in childhood and presents deafness, rickets, and a short life expectancy. The incomplete form usually manifests in adulthood, primarily with recurrent urinary lithiasis, and less frequently with nephrocalcinosis. In all stone formers stone analysis and a basic metabolic evaluation, including blood biochemistry, urine sediment examination, urinary pH and culture are mandatory, in contrast high-risk stone formers require a more specific metabolic evaluation, including a 24-hour urine sample to measure calcium, phosphate, citrate, oxalate, uric acid, magnesium, sodium and proteinuria. The morpho compositional analysis of kidney stones offers essential insights beyond merely identifying their predominant chemical component. This approach reveals key aspets of the stone formation, such as nucleation sites, crystal growth patterns, and the presence of specific lithogenic processes. The ideal analytical protocol combines stereoscopic microscopy (StM), scanning electron microscopy with energy-dispersive X-ray spectroscopy (SEM-EDS), and, when necessary, Fourier-transform infrared spectroscopy (FTIR). Recurrence prevention and managing residual fragments require complementary strategies such as lifestyle modifications, dietary interventions, and pharmacological therapies. Among pharmacological options, alkaline citrate salts, particularly potassium citrate, are widely used due to their ability to modify urinary chemistry and inhibit stone formation. Recently, novel molecules have been introduced into the management of renal stone disease. Phytate a naturally occurring polyphosphorylated carbohydrate, exibits a potent inhibitory effect on calcium salt’s nucleation, growth, and aggregation. Theobromine, another natural compound, has been shown to effectively inhibit uric acid crystallization. The co-administration of urinary alkalinizing agents, such as potassium citrate, alongside theobromine has been proposed as a therapeutic strategy to optimize uric acid solubility and to reduce the risk of excessive alkalinization and subsequent sodium urate precipitation. Struvite stones are caused by urinary tract infection with urease- producing microorganisms. Their treatment requires specific measures including complete surgical stone removal, short or long-term antibiotic treatment, to maintain urinary acidification to a pH below 6.2, and a urine volume of at least 2 litres/24 hours. L-methionine has been shown to effectively lower urine pH and the relative supersaturation of struvite. An essential aspect of medical management of urinary stone disease is treatment adherence, which depends on perceived benefit, treatment duration, and side effect profile. The side effects of citrate treatment are mild gastrointestinal disorders whereas thiazide diuretics tend to cause hypokalemia-related symptoms and less frequent metabolic and dermatologic side effects. Urease inhibitors for struvite stones and drugs used to enhance cystine solubility are more frequently associated with side effects. The use of smartphone applications can support patients by promoting adequate hydration, adherence to dietary recommendations, and compliance with prophylactic medication. Endoscopic techniques currently play a prevalent role in the removal of renal stones, while extracorporeal shock wave lithotripsy is today marginally used for specific indications. Different technical modalities can be used for percutaneous nephrolithotomy (PCNL), each with its own advantages and disadvntages (standard vs. mini, prone vs. supine, fluoroscopic vs ultrasound-guided). Flexible ureteroscopy or retrograde intrarenal renal surgery (RIRS) has extended its indications due to technological advancements in endoscopes and their accessories. The availability of new laser technologies (thulium fiber laser and pulse-modulated Ho:YAG laser) has enhanced stone fragmentation and dusting capabilities. However, their use exposes the renal parenchyma to high temperatures and pressures which could potentially contribute to renal damage. Factors influencing heat release include laser type and settings, exposure time, stone location, fiber-to-stone distance, irrigation volume and fluid circulation. Reduction of heat release can be achieved by limiting the laser settings to reasonable values or by improving fluid circulation with use of ureteral access sheaths, especially those navigable and equipped with suction. High intrarenal pressure is also closely associated with renal damage. Sustained high pressure or even pressure spikes may increase this risk, highlighting the importance of real-time pressure monitoring through sensors integrated on guidewires, scopes, access she

Datos de la publicación

ISSN/ISSNe:
1124-3562, 2282-4197

Archivio Italiano di Urologia e Andrologia  PAGEPRESS PUBL

Tipo:
Review
Páginas:
-
PubMed:
40583613
Enlace a otro recurso:
www.scopus.com
Factor de Impacto:
0,326 SCImago ℠
Cuartil:
Q3 SCImago ℠

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Keywords

  • Humans; Kidney Calculi; Urinary Calculi; acetohydroxamic acid; alkaline citrate; citrate potassium; methionine; phytate; pyridoxine; theobromine; thiazide diuretic agent; unclassified drug; urease inhibitor; urinary tract agent; abdominal distension; alkalinization; alternative medicine; antibiotic therapy; anticoagulant therapy; arteriovenous fistula; blood clotting disorder; blood transfusion; calyceal diverticula; clinical decision making; clinical outcome; comparative study; cost benefit analysis; cost effectiveness analysis; diarrhea; diet therapy; distal renal tubular acidosis; diverticulosis; drug safety; end stage renal disease; endoscopic surgery; endoscopic therapy; endourology; energy dispersive X ray spectroscopy; extracorporeal shock wave lithotripsy; extracorporeal therapy; fever; fluoroscopy; Fourier transform infrared spectroscopy; gastrointestinal disease; headache; health care cost; health care management; hematoma; hematuria; high risk patient; horseshoe kidney; huma

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