Urolithiasis: Etiology Diagnosis. Hans-Joachim Schneider. M.Peacock W. G. Robertson H.-J. Schneider W. Vahlensieck

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2 Urolithiasis: Etiology Diagnosis Edited by Hans-Joachim Schneider Contributions by M.Peacock W. G. Robertson H.-J. Schneider W. Vahlensieck With 168 Figures Springer-Verlag Berlin Heidelberg New York Tokyo

3 Handbook of Urology Volume 17/1 Continuation of Handbuch der U rologie. Encyclopedia of Urology ISBN -13: e-isbn -13 : DOl: / Library of Congress Cataloging in Publication Data. Main entry under title: Urolithiasis: etiology, diagnosis. (Handbook of urology; vol Includes bibliographies and index. \. Calculi, Urinary. I. Peacock, M. II. Schneider, Hans-Joachim, III. Series. RC916.U ' ISBN-13: (U.S.) This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically those of translation, reprinting, re-use of illustrations, broadcasting, reproduction by photocopying machine or similar means, and storage in data banks. Under 54 of the German Copyright Law where Copies are made for other than private use, a fee is payable to "Verwertungsgesellschaft Wort", Munich. <!:l Springer-Verlag Berlin Heidelberg 1985 Sof tcover reprint of the hardcover I st edition 1985 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws lind regulations and therefore free for general use. Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2122/3\

4 List of Contributors SCHNEIDER, H.-J., Professor Dr. Ludwigsplatz 11, Giessen PEACOCK, M., Dr. MRC Mineral Metabolism Unit, The General Infirmary, Great George Street, Leeds LSI 3EX, Great Britain ROBERTSON, W. G., Professor Dr. MRC Mineral Metabolism Unit, The General Infirmary, Great George Street, Leeds LS 1 3EX, Great Britain VAHLENSIECK, W., Professor Dr. Oirektor der Urologischen UniversiHitsklinik Bonn, Sigmund-Freud-Str. 25, Bonn I

5 Preface The handbook on lithiasis edited by Kurt Boshamer and originally brought out in 1961 was for more than two decades the standard work in this field for researchers and clinicians alike. However, our knowledge of urolithiasis has been increased so enormously - by worldwide interdisciplinary research into the genesis of urinary calculi, by the new treatment possibilities opened up principally by advances in technology, and by the success achieved in prevention of recurrence - that it is almost impossible to take in all the relevant journal articles, books chapters, monographs, and proceedings. It was therefore our aim in this, the first of two independent volumes, to provide a concise but comprehensive summary of current knowledge concerning the morphology and composition of calculi, epidemiology, pathogenesis, and diagnostic techniques. The most recent developments are described, and nothing in the world literature is ignored. A second volume will cover medical therapy, operative, instrumental and noninvasive treatment, and prophylaxis. To have any chance of success, treatment and prophylaxis must be based on knowledge of calculus formation. Study of the composition of calculi has yielded important information regarding the conditions for formation, and this underlines once again the great value of analysis of urinary concretions. Evaluation of epidemiological data has important consequences for the individual patient. The authors of the central chapter on pathogenesis are probably the leading experts in this field, whose many research programs have made vital contributions to solving the problems encountered. The chapter on diagnosis of urolithiasis as a precondition for therapy comes from an experienced clinician whose symposia on urinary calculi have been invaluable in promoting cooperation between researchers and practicing urologists. My most heartfelt gratitude goes to these authors for the work they have put into this book. If the book spurs young colleagues to research into urinary calculi and is used as a work of reference, and if the dissemination of our knowledge concerning urolithiasis leads to reductions in the recurrence rate and in the numbers of new cases, we will have achieved our goal. I would like to take this opportunity to thank the many colleagues who offered constructive criticism and ideas, and to extend my gratitude to Mr. W. Bergstedt of Springer-Verlag for his creative and patient efforts in the preparation of the book. Giessen Hans-Joachim Schneider

6 Contents Morphology of Urinary Tract Concretions. H.-J. SCHNEIDER. With 102 Figures I. Definitions... II. External Appearance of Urinary Calculi in Relation to Site of Recurrence and Type of Stone 2 III. Physical Properties 18 l. Hardness Density X-Ray Absorption 19 IV. Chemical Composition ofuroliths 21 l. Compounds Ash and Mass Elements Trace Elements V. Structural Composition of Uroliths 31 l. Aggregate Structural Description 32 a) Central Region b) Peripheral Region Urolithogenesis as the Basis of Aggregate Configuration Urolith Phases a) Calcium Oxalate b) Uric Acid - Uric Acid Dihydrate 49 c) Apatite d) Struvite e) Ammonium Dihydrogenurate 57 f) Brushite. 59 g) Cystine h) Xanthine i) Organic Matrix 62 VI. Urolith Analysis Qualitative Chemical Analysis 67 a) Processing of Calculous Material 68 b) Analytic Procedure c) Discussion Quantitative Chemical Analysis 71 a) Sample Processing. 71 b) Analytic Procedure.o 71 c) Discussion

7 x Contents 3. X-Ray Diffraction 71 a) Basic Principle 73 b) Sample Processing 74 c) Exposure Techniques. 74 d) Data Evaluation and Comparison of Techniques Infra-Red Spectroscopy 82 a) Basic Principle b) Sample Processing c) Measurement Technique and Data Evaluation 84 d) Discussion Thermoanalysis a) Basic Principle 88 b) Sample Processing 90 c) Data Evaluation. 90 d) Discussion Autoradiography Combination Techniques Microscopy a) Polarizing Microscopy 97 b) Transmitted Light Microscopy 105 c) Phase Contrast Microscopy d) Scanning Electron Microscopy. 107 e) Combined Microscopic Technique - Laser Microspectroanalysis - Polarizing Microscopy - Electron Microprobe f) Computer Tomography III 9. Centralising and Standardising Urolith Analysis III a) Centralisation III b) Standardisation c) Reporting, Documentation and Data Evaluation 113 References ,. 115 Epidemiology of Urolithiasis. H.-J. SCHNEIDER. With 17 Figures I. HistoricaIOverview II. The Frequency of Urolithiasis 141 III. Type Distribution of Calculi Geographic Distribution Age and Sex of Stone Patients According to Type of Calculus Distribution of Calculi in the Urinary Tract IV. Seasonal Variations in Incidence of Recurrent and de novo Stone Disease V. Race and Familial Predisposition 160 VI. Occupation and Lifestyle 161

8 Contents VII. Constitution, Psychological Factors and Concomitant Disease VIII. Urinary Calculi in Children 166 References XI Pathogenesis of Urolithiasis. W. G. ROBERTSON and M. PEACOCK. With 48 Figures I. Introduction II. Theories of Stone-Formation Localised Lesions in the Kidney 187 a) Randall's Plaques b) Anderson's Calcific Droplets 190 c) Carr's Pouch (Stewart's Nest) 190 d) Anderson-Carr-Randall Progression 191 e) Intranephronic Calculosis Hyperexcretion - Crystallisation Theory 193 a) General Principles. 193 b) Solubility Concept. 194 c) Saturation of Urine 195 d) Crystal Nucleation. 200 e) Crystal Growth f) Crystal Aggregation Matrix Theory a) General Principles. 207 b) Crystal Nucleation. 213 c) Crystal Aggregation 214 d) Crystal Adhesion to Cell Walls 216 e) Inhibition of Crystal Dissolution Inhibitor Theory a) General Principles b) Inhibitors of Nucleation c) Inhibitors of Crystal Growth 230 d) Inhibitors of Aggregation e) Modifiers of Inhibitory Activity 235 f) Naturally Occurring Inhibitors 235 g) Synthetic Inhibitors Unified Theories a) General Principles b) "Free Particle" Theories of Stone-Formation 236 c) "Fixed Particle" Theory of Stone-Formation 244 III. Types of Stone Disease Cystine Stone Disease a) Introduction b) Urinary Risk Factors 247 c) Stone Disease d) Stone-Formation

9 XII Contents 2. Uric Acid Stone Disease 251 a) Introduction. 251 b) Urinary Risk Factors 252 c) Stone Disease. 259 d) Stone-Formation Infected Stone Disease 263 a) Introduction. 263 b) Urinary Risk Factors 263 c) Stone Disease. 266 d) Stone Formation Calcium Stone Disease 269 a) Introduction. 269 b) Urinary Risk Factors 271 c) Stone Disease. 284 d) Stone-Formation Uncommon Stones 300 a) Introduction. 300 References 301 Diagnosis of Urinary Calculi. W. VAHLENSIECK. With 1 Figure I. History Pain. 335 a) Incidence. 335 b) Intensity and Radiation Changes in the Urine 338 a) Color. 338 b) Volume. 339 c) Disorders of Micturition Fever Predisposing Factors 341 a) First Attack or Recurrence 341 b) Anatomic Anomalies and Coexisting Disease 342 c) Drugs 345 d) Individual Dietary History 348 II. Examination. 352 I. Physical Examination Blood Pressure 354 III. Imaging Studies 354 I. Ultrasound Radiology. 355 a) Abdominal Plain Film 356 b) Intravenous Urography. 357 c) Retrograde Pyelography 358 d) Antegrade Pyelography. 359

10 Contents e) Computerized Tomography. f) Renal Angiography.. g) Micturating Cystogram. 3. Nuclear Medical Studies IV. Laboratory Investigations l. Basal Conditions.. 2. Sample Collection 3. Sample Preservation 4. Nature and Extent of Investigations a) The Basic Screen b) Advanced Test Panel. c) Maximum Test Panel References. Subject Index XIll