Urol. int. 30 : 228-236 (1975)
An Observation on the Composition and Recurrence of Urinary Calculi1 E. T akasaki2 Department of Urology (Director: Prof. H. T akayasu), Faculty of Medicine, University of Tokyo, Tokyo
Abstract. Seven hundred patients with 735 urinary calcu- Key Words li were studied for the compositions of calculi by infrared Calculus analysis and for stone recurrence. Of these 700 cases, 422 Stone recurrence cases were possible to follow up, and 250 cases have had no Stone composition further stone; 138 cases experienced recurring stones, and 34 cases had multiple stones. The length of follow-up period was 1-19 years averaging 8 years, 8 months. 41.2°/» of patients with calcium oxalate-calcium phosphate calculi had stones recurrently, and although there was some variation of recurrence rates for patients with various proportions of oxalate to phosphate in the calculi, it was impossible to predict the tendency of recurrence by these proportions. The stone re currence was noted in 38.6°/o of patients with magnesium ammonium phosphate cal culi, in 38.9°/o with mixed magnesium ammonium phosphate-calcium oxalate calculi, in 55.6°/o with uric acid calculi, and in 50°/o with cystine calculi.
1 This investigation was supported by a Metropolitan Hospital Clinic Grant from the Public Health Bureau of Tokyo Metropolitan Government, Japan. 2 The author wishes to thank Professor H. T akayasu for his help in preparing this study.
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Recurring stone formation in the urinary system after operative or nonoperative treatment of urolithiasis is clinically an important problem. While patients with some metabolic disorders - such as cystine, uric acid, etc. - have a tendency to form stones frequently in the urinary tract, the recurrence rates of nonmetabolic stones, i.e., oxalate or phosphate stones, are also high. To date, a number of surveys on recurrence of urolithiasis after medical intervention have been reported [1, 3, 9, 10, 17]. However, not so many systematic studies on the recurrence rate of urinary calculi combined with stone analysis have appeared. Thus far the author has ex perienced 700 cases with urolithiases in which stones were obtained by
229
T akasaki 150
□ Total c a s e s 023 C a s e s possible to follow up ■ 1 C a s e s with r e c u r r e n t or multiple calculi
-
-9 10-19 A ge , y e a r s
2 0 -2 9
3 0 -3 9
4 0 -4 9
5 0-59
6 0 -6 9
70-77
Fig. 1. Age distribution of patients with upper urinary tract calculi. M = Male; F = female.
operations or spontaneous passages and analyzed by infrared spectrosco py. This paper is purposed to show the results of analytical studies on re lationships between recurrence rates and chemical composition of urinary calculi.
The subjects in this study were 700 patients with urolithiases whose stones had been removed by surgical or endoscopic manipulations or expelled spontaneously. These patients were admitted to the University of Tokyo Hospital, the University of Tokyo Branch Hospital, Tokyo Metropolitan Komagome General Hospital, or Musashino Red Cross Hospital during an 18-year period (1953-1970). Central nuclei of 735 urinary calculi obtained from these 700 patients were analyzed by infrared spectroscopy by KBr pellet method, which has been described in detail previously elsewhere [14, 16). There were 597 cases with upper urinary tract calculi, 83 cases with lower uri nary tract calculi, 4 cases with both upper and lower urinary tract calculi, and 16 cases with prostatic calculi; there were 507 males and 193 females in this study. The
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Materials and Methods
T akasaki
230
Age, y e a r s
Fig. 2. Age distribution of patients with lower urinary tract calculi and prostatic calculi. M = Male; F = female; P = prostatic.
age of the patients ranged from 2 to 81 years; the maximal incidence was noted in males aged 30-39 years and in females aged 20-29 years (fig. 1, 2). Furthermore, these 700 patients were studied for recurrence of calculi through personal interviews or by letters of inquiry. The recurrence was confirmed by either spontaneous passage or appearance on the radiographic film and/or operation of the new stone. In this manner it has been possible to survey 422 cases. The term ‘re currence’ in this paper means occurrence of urinary stone formations two or more times, and ‘multiple’ indicates occurrence of stones in bilateral sides of the upper urinary tract or in both sites of the upper and lower urinary tracts.
Results
The nuclei of 735 stones, including 632 calculi of the upper urinary tract (224 renal and 408 ureteral stones), 87 calculi of the lower urinary tract (81 bladder and 6 urethral stones) and 16 prostatic calculi, were an alyzed (table I). The 536 calculi (72.9%), including 508 upper urinary tract calculi, 23 lower urinary tract calculi, and 5 prostatic calculi, were composed of calcium oxalate and/or calcium phosphate. This composition is the most common in upper urinary tract calculi. Table I gives also the numbers of calculi in varying proportions of these components, because it is possible to measure the ratios of calcium oxalate to calcium phosphate in the calculi on charts of infrared spectra [14, 16]. It is noticed that the
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Stone Analysis
Composition and Recurrence of Calculi
231
Table I. The compositions of nuclei of 735 urinary calculi analysed by infrared spectro scopy
Calcium oxalate- calcium phosphate oxalate 100-91 % oxalate 90-81 % oxalate 80-71 % oxalate 70-61 % oxalate 60-51 % oxalate 50-41 % oxalate 40-31 % oxalate 30-21 % oxalate 20-11 % oxalate 10-0% Magnesium ammonium phosphate (mixed with calcium phosphate) Mixed magnesium ammonium phosphate-calcium oxalate Urid acid Mixed uric acid-calcium phosphate Sodium hydrogen urate Mixed sodium hydrogen urate-calcium phosphate Ammonium hydrogen urate Mixed ammonium hydrogen urate-calcium oxalate and/or calcium phosphate Cystine Mixed cystine-calcium phosphate Protein
Total
Number of lower urinary tract calculi
Number Number Total % of prost of total number atic calculi calculi
171 74 63 52 32 27 25 25 16 23
7 2 3 3 2 1 2 1
1
2
3
179 76 66 55 35 28 27 26 16 28
74
47
9
130
24
7
1
32
9
4
1 1
1
1
1
2
22.1
29
3.9
3
1 5
1
4 2
6
1 1
632
162
3
4 4
72.9
13
1 4
536
1 1
87
16
735
7 1
0.95 0.15
100.0 Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 12/26/2017 2:16:52 PM
Number of upper urinary tract calculi
T akasaki
232
greater the oxalate content in stone nuclei, the more frequent occurrence in the urinary tract. Magnesium ammonium phosphate is the common salt in lower urinary tract calculi and was found in 162 calculi (22.1°/o), including 98 stones of the upper urinary tract, 54 stones of the lower urinary tract, and 10 stones of the prostate. These calculi contained various amounts of cal cium phosphate, and some calculi may also contain calcium carbonate. Calcium oxalate was mixed in 32 of these samples. Magnesium hydrogen phosphate (MgHP04) was present in several calculi, and this substance was included in magnesium ammonium phosphate in table I, since mag nesium hydrogen phosphate is likely to be derived from magnesium am monium phosphate [16]. Calcium hydrogen phosphate (CaHP04) was found only in the cortices of a few stones. Uric acid and urate were identified in 29 calculi (3.9%), including 20 stones of the upper urinary tract, 8 stones of the lower urinary tract, and a prostatic stone, and they were partly mixed with calcium phosphate and/ or calcium oxalate. Urate was present as sodium hydrogen salt and am monium hydrogen salt. Cystine was found in seven calculi (0.95%), in cluding five stones of the upper urinary tract and two of the lower urinary tract; one of these calculi was mixed with calcium phosphate. A renal stone was composed of protein, and xanthine was not found in the present series.
The 700 patients with these calculi were surveyed by personal inter views or by letters of inquiry. The follow-up period of these 700 cases varied from 1-19 years averaging 8 years, 8 months. Of these 700 pa tients, 422 cases were possible to survey: 250 cases had no further stone, 138 cases experienced recurrences, and 34 cases had multiple stones. The duration of following up these 422 cases ranged from 1 year to 18 years, 11 months, averaging 7 years, 6 months. Among these 422 cases, there were 325 cases with calcium oxalatecalcium phosphate calculi, 134 of whom (41.2% of 325 cases) had recur rent or multiple stones (table II). The percentages of stone recurrences were not so different among cases with various ratios of calcium oxalate to calcium phosphate in these calculi, although they ranged from 28.6 to 100%, averaging 41.2%. Recurrences of stones in patients with magne sium ammonium phosphate calculi were noticeable in 22 of 57 cases (38.6%), and those in patients with mixed magnesium ammonium phos-
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Stone Recurrence
233
Composition and Recurrence of Calculi Table II. Relationship between stone composition and stone recurrence
Cases with recurrent or multiple stones number %
Number of patients
Cases able to trace
Calcium oxalate-calcium phosphate oxalate 100-91 % oxalate 90-81 % oxalate 80-71 % oxalate 70-61 % oxalate 60-51 % oxalate 50-41 % oxalate 40-31 % oxalate 30-21 % oxalate 20-11 % oxalate 10- 0%
173 73 66 52 32 27 26 25 16 24
119 50 42 33 20 19 15 5 7 15
49 16 20 13 7 8 5 5 2 9
41.2 32.0 47.7 39.4 35.0 42.1 33.3 100.0 28.6 60.0
Magnesium ammonium phosphate (mixed with calcium phosphate)
38.6
123
57
22
Mixed magnesium ammonium phosphatecalcium oxalate
29
18
7
38.9
Uric acid
11
9
5
55.6 -
Mixed uric acid-calcium phosphate
3
0
0
Sodium hydrogen urate
3
3
0
Mixed sodium hydrogen urate-calcium phosphate
1
0
0
_
Ammonium hydrogen urate
5
4
2
50.0
Mixed ammonium hydrogen urate-calcium oxalate and/or calcium phosphate
4
2
0
0.0
Cystine
5
4
2
50.0
Mixed cystine-calcium phosphate
1
0
-
Protein
1
0 0
0
-
700
422
172
40.8
phate-calcium oxalate calculi were in 7 of 18 cases (38.9%). Thus, it is evident that about 40% of patients with urinary oxalate and/or phosphate calculi experience recurrent or multiple stones. The patients with recurring uric acid stones were found in 5 of 9 cases (55.6%) and the patients with recurring ammonium hydrogen urate stones
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Total
0.0
234
T akasaki
were in 2 of 4 cases (50.0%), while there were no recurrences in patients with sodium hydrogen urate stones. Two of 4 patients with cystine calculi had recurrences (50%). The lower recurrence rates of uric acid stone and cystine stone may have resulted from modern therapy for these calculi. By analyzing the compositions of calculi in 31 patients with multiple or recurrent stones, it was found that multiple or recurrently formed cal culi in each individual are of quite similar types, and oxalate-phosphate calculi have similar calcium oxalatercalcium phosphate ratios in each case except for secondary calculi (magnesium ammonium phosphate) by infection following removal of the initial stone.
Up to now considerable data have concerned urinary stone analysis. P rien [11] reported on the crystallographic analysis of 24,000 urinary calculi and H erring [7] presented a statistic analysis of 10,000 calculi. Recently, infrared spectroscopy has been introduced to medical research, and it is also used to determine the composition of urinary stones in many laboratories. Since Beischer’s first application [2], several investigators have made infrared analyses of urinary stones. However, these reports are principally limited to qualitative techniques of stone analysis, and there is neither extensive statistical data nor quantitative application of infrared analysis of urinary calculi [16]. This paper presents results of analysis of 735 urinary stones by in frared spectroscopy (table I). The most commonly encountered compo nents of calculi were calcium oxalate and calcium phosphate, and the next was magnesium ammonium phosphate. A few calculi were composed of uric acid, sodium hydrogen urate, ammonium hydrogen urate, cystine, and protein. Magnesium hydrogen phosphate and calcium hydrogen phos phate were contained in some calculi. This statistical result of this study on urinary stone analysis by infrared spectroscopy agreed well with pre vious reports on analysis by other methods [6, 13]. It is well known that patients with urinary calculi suffer from recurr ences frequently following treatment of their initial stones. Williams [17] surveyed 538 patients with upper urinary tract stones on an average of 18.5 years; he demonstrated the incidence of recurrent stone formation in 80% for males and 60% for females, although these statistics did not con sider composition of calculi.
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Discussion
Composition and Recurrence of Calculi
235
Patients with uric acid calculi and cystine calculi have stones recurred quite frequently because of the metabolic disorders. However, the modali ties of treatment for these calculi are established at present, and patients are well protected against recurrences of these calculi [5]. The recurrence rate of stones in patients with magnesium ammonium phosphate calculi and those with mixed magnesium ammonium phosphate-calcium oxalate calculi were 38.6 and 38.9%, respectively, in the present series (table II). The recurrence rate of magnesium ammonium phosphate calculi may be decreased by elimination of urinary infection and/or urinary stasis. L av engood and Marshall [8] have shown that there was known recurrence in 27% of patients with phosphate calculi over an average follow-up peri od of 4 years. The oxalate calculi always contain various amounts of calcium phos phate [4], The etiology of calcium oxalate-calcium phosphate calculus is problematic as well as obscure in many cases [12, 15], In the current study, the author surveyed patients with calcium oxalate calculi mixed with various amounts of calcium phosphate (table II). Although there is some variation of percentage, the recurrence rate of stones with various mixture of calcium oxalate and calcium phosphate was about 40%. This data suggests that the tendency of the oxalate calculi to recur cannot be predicted by the mixture rate of calcium phosphate in calcium oxalate.
References 1 Barzii ay, B. I. and K edar, S. S.: Surgical treatment of staghorn calculus by lower partial nephrectomy and pyelocalicolithotomy. J. Urol. 108: 689-694 (1972) . 2 Bf.ischer , D. E.: Analysis of renal calculi by infrared spectroscopy. J. Urol. 73: 653-659 (1955).
small urinary tract calculi. Invest. Urol. 9: 376-384 (1972). 5 D rach, G. W.; Sm ith , M. J. V., and Boyce, W. H.: Medical therapy of renal calculi. J. Urol. 104: 635-639 (1970). 6 E lliot , J. S.: Structure and composition of urinary calculi. J. Urol. 109: 82-83 (1973) . 7 H erring , L. C.: Observations on the analysis of ten thousand urinary calculi. J. Urol. 88: 545-562 (1962). 8 L avengood. R. W., jr., and M arshall, V. F.: The prevention of renal phosphat-
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3 Bennett , A. H. and H arrison, J. H.: Results o f surgery on branched renal cal culi. J. U rol. 107: 174-175 (1972). 4 C hambers, A.; H odgkinson , A., and H ornung , G.: Electron probe analysis of
236
10
11 12 13 14 15 16 17
ic calculi in the presence of infection by the Shorr regimen. J. Urol. 108. 368-371 (1972). M yrvold , H. and F ritjofsson , A.: Late results of partial nephrectomy for renal lithiasis. Scand. J. Urol. Nephrol. 5: 57-62 (1971). P edersen , J. F.: Partial nephrectomy for nephrolithiasis. Scand. J. Urol. Ne phrol. 5: 171-176 (1971). P rien, E. L.: Crystallographic analysis of urinary calculi: a 23-year survey study. J. Urol. 89: 917-924 (1963). P rien , E. L.: The riddle of urinary stone disease. J. amer. med. Ass. 216: 503-507 (1971). P rien , E. L. and P rien , E. L., jr.: Composition and structure of urinary stone. Amer. J. Med. 45: 654-672 (1968). T akasaki, E.: Urinary stone analysis by infrared spectrometry. II. Quantitative application. Jap. J. Urol. 51: 639-663 (1960). T akasaki, E. and Shimano, E.: The urinary excretion of oxalic acid and magne sium in oxalate urolithiasis. Invest. Urol. 5: 303-312 (1967). T akasaki, E.: An observation on the analysis of urinary calculi by infrared spec troscopy. Calcif. Tiss. Res. 7: 232-240 (1971). W illiams , R. E.: Long-term survey of 538 patients with upper urinary tract stone. Brit. J. Urol. 35: 416-437 (1963).
Request reprints from Dr. Etsuji T akasaki, Department of Urology, Faculty of Medicine, University of Tokyo, Tokyo (Japan)
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9
T akasaki
An Observation on the Composition and Recurrence of Urinary Calculi1 E. T akasaki2 Department of Urology (Director: Prof. H. T akayasu), Faculty of Medicine, University of Tokyo, Tokyo
Abstract. Seven hundred patients with 735 urinary calcu- Key Words li were studied for the compositions of calculi by infrared Calculus analysis and for stone recurrence. Of these 700 cases, 422 Stone recurrence cases were possible to follow up, and 250 cases have had no Stone composition further stone; 138 cases experienced recurring stones, and 34 cases had multiple stones. The length of follow-up period was 1-19 years averaging 8 years, 8 months. 41.2°/» of patients with calcium oxalate-calcium phosphate calculi had stones recurrently, and although there was some variation of recurrence rates for patients with various proportions of oxalate to phosphate in the calculi, it was impossible to predict the tendency of recurrence by these proportions. The stone re currence was noted in 38.6°/o of patients with magnesium ammonium phosphate cal culi, in 38.9°/o with mixed magnesium ammonium phosphate-calcium oxalate calculi, in 55.6°/o with uric acid calculi, and in 50°/o with cystine calculi.
1 This investigation was supported by a Metropolitan Hospital Clinic Grant from the Public Health Bureau of Tokyo Metropolitan Government, Japan. 2 The author wishes to thank Professor H. T akayasu for his help in preparing this study.
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Recurring stone formation in the urinary system after operative or nonoperative treatment of urolithiasis is clinically an important problem. While patients with some metabolic disorders - such as cystine, uric acid, etc. - have a tendency to form stones frequently in the urinary tract, the recurrence rates of nonmetabolic stones, i.e., oxalate or phosphate stones, are also high. To date, a number of surveys on recurrence of urolithiasis after medical intervention have been reported [1, 3, 9, 10, 17]. However, not so many systematic studies on the recurrence rate of urinary calculi combined with stone analysis have appeared. Thus far the author has ex perienced 700 cases with urolithiases in which stones were obtained by
229
T akasaki 150
□ Total c a s e s 023 C a s e s possible to follow up ■ 1 C a s e s with r e c u r r e n t or multiple calculi
-
-9 10-19 A ge , y e a r s
2 0 -2 9
3 0 -3 9
4 0 -4 9
5 0-59
6 0 -6 9
70-77
Fig. 1. Age distribution of patients with upper urinary tract calculi. M = Male; F = female.
operations or spontaneous passages and analyzed by infrared spectrosco py. This paper is purposed to show the results of analytical studies on re lationships between recurrence rates and chemical composition of urinary calculi.
The subjects in this study were 700 patients with urolithiases whose stones had been removed by surgical or endoscopic manipulations or expelled spontaneously. These patients were admitted to the University of Tokyo Hospital, the University of Tokyo Branch Hospital, Tokyo Metropolitan Komagome General Hospital, or Musashino Red Cross Hospital during an 18-year period (1953-1970). Central nuclei of 735 urinary calculi obtained from these 700 patients were analyzed by infrared spectroscopy by KBr pellet method, which has been described in detail previously elsewhere [14, 16). There were 597 cases with upper urinary tract calculi, 83 cases with lower uri nary tract calculi, 4 cases with both upper and lower urinary tract calculi, and 16 cases with prostatic calculi; there were 507 males and 193 females in this study. The
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Materials and Methods
T akasaki
230
Age, y e a r s
Fig. 2. Age distribution of patients with lower urinary tract calculi and prostatic calculi. M = Male; F = female; P = prostatic.
age of the patients ranged from 2 to 81 years; the maximal incidence was noted in males aged 30-39 years and in females aged 20-29 years (fig. 1, 2). Furthermore, these 700 patients were studied for recurrence of calculi through personal interviews or by letters of inquiry. The recurrence was confirmed by either spontaneous passage or appearance on the radiographic film and/or operation of the new stone. In this manner it has been possible to survey 422 cases. The term ‘re currence’ in this paper means occurrence of urinary stone formations two or more times, and ‘multiple’ indicates occurrence of stones in bilateral sides of the upper urinary tract or in both sites of the upper and lower urinary tracts.
Results
The nuclei of 735 stones, including 632 calculi of the upper urinary tract (224 renal and 408 ureteral stones), 87 calculi of the lower urinary tract (81 bladder and 6 urethral stones) and 16 prostatic calculi, were an alyzed (table I). The 536 calculi (72.9%), including 508 upper urinary tract calculi, 23 lower urinary tract calculi, and 5 prostatic calculi, were composed of calcium oxalate and/or calcium phosphate. This composition is the most common in upper urinary tract calculi. Table I gives also the numbers of calculi in varying proportions of these components, because it is possible to measure the ratios of calcium oxalate to calcium phosphate in the calculi on charts of infrared spectra [14, 16]. It is noticed that the
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Stone Analysis
Composition and Recurrence of Calculi
231
Table I. The compositions of nuclei of 735 urinary calculi analysed by infrared spectro scopy
Calcium oxalate- calcium phosphate oxalate 100-91 % oxalate 90-81 % oxalate 80-71 % oxalate 70-61 % oxalate 60-51 % oxalate 50-41 % oxalate 40-31 % oxalate 30-21 % oxalate 20-11 % oxalate 10-0% Magnesium ammonium phosphate (mixed with calcium phosphate) Mixed magnesium ammonium phosphate-calcium oxalate Urid acid Mixed uric acid-calcium phosphate Sodium hydrogen urate Mixed sodium hydrogen urate-calcium phosphate Ammonium hydrogen urate Mixed ammonium hydrogen urate-calcium oxalate and/or calcium phosphate Cystine Mixed cystine-calcium phosphate Protein
Total
Number of lower urinary tract calculi
Number Number Total % of prost of total number atic calculi calculi
171 74 63 52 32 27 25 25 16 23
7 2 3 3 2 1 2 1
1
2
3
179 76 66 55 35 28 27 26 16 28
74
47
9
130
24
7
1
32
9
4
1 1
1
1
1
2
22.1
29
3.9
3
1 5
1
4 2
6
1 1
632
162
3
4 4
72.9
13
1 4
536
1 1
87
16
735
7 1
0.95 0.15
100.0 Downloaded by: Thomas Jefferson University Scott Library 147.140.20.32 - 12/26/2017 2:16:52 PM
Number of upper urinary tract calculi
T akasaki
232
greater the oxalate content in stone nuclei, the more frequent occurrence in the urinary tract. Magnesium ammonium phosphate is the common salt in lower urinary tract calculi and was found in 162 calculi (22.1°/o), including 98 stones of the upper urinary tract, 54 stones of the lower urinary tract, and 10 stones of the prostate. These calculi contained various amounts of cal cium phosphate, and some calculi may also contain calcium carbonate. Calcium oxalate was mixed in 32 of these samples. Magnesium hydrogen phosphate (MgHP04) was present in several calculi, and this substance was included in magnesium ammonium phosphate in table I, since mag nesium hydrogen phosphate is likely to be derived from magnesium am monium phosphate [16]. Calcium hydrogen phosphate (CaHP04) was found only in the cortices of a few stones. Uric acid and urate were identified in 29 calculi (3.9%), including 20 stones of the upper urinary tract, 8 stones of the lower urinary tract, and a prostatic stone, and they were partly mixed with calcium phosphate and/ or calcium oxalate. Urate was present as sodium hydrogen salt and am monium hydrogen salt. Cystine was found in seven calculi (0.95%), in cluding five stones of the upper urinary tract and two of the lower urinary tract; one of these calculi was mixed with calcium phosphate. A renal stone was composed of protein, and xanthine was not found in the present series.
The 700 patients with these calculi were surveyed by personal inter views or by letters of inquiry. The follow-up period of these 700 cases varied from 1-19 years averaging 8 years, 8 months. Of these 700 pa tients, 422 cases were possible to survey: 250 cases had no further stone, 138 cases experienced recurrences, and 34 cases had multiple stones. The duration of following up these 422 cases ranged from 1 year to 18 years, 11 months, averaging 7 years, 6 months. Among these 422 cases, there were 325 cases with calcium oxalatecalcium phosphate calculi, 134 of whom (41.2% of 325 cases) had recur rent or multiple stones (table II). The percentages of stone recurrences were not so different among cases with various ratios of calcium oxalate to calcium phosphate in these calculi, although they ranged from 28.6 to 100%, averaging 41.2%. Recurrences of stones in patients with magne sium ammonium phosphate calculi were noticeable in 22 of 57 cases (38.6%), and those in patients with mixed magnesium ammonium phos-
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Stone Recurrence
233
Composition and Recurrence of Calculi Table II. Relationship between stone composition and stone recurrence
Cases with recurrent or multiple stones number %
Number of patients
Cases able to trace
Calcium oxalate-calcium phosphate oxalate 100-91 % oxalate 90-81 % oxalate 80-71 % oxalate 70-61 % oxalate 60-51 % oxalate 50-41 % oxalate 40-31 % oxalate 30-21 % oxalate 20-11 % oxalate 10- 0%
173 73 66 52 32 27 26 25 16 24
119 50 42 33 20 19 15 5 7 15
49 16 20 13 7 8 5 5 2 9
41.2 32.0 47.7 39.4 35.0 42.1 33.3 100.0 28.6 60.0
Magnesium ammonium phosphate (mixed with calcium phosphate)
38.6
123
57
22
Mixed magnesium ammonium phosphatecalcium oxalate
29
18
7
38.9
Uric acid
11
9
5
55.6 -
Mixed uric acid-calcium phosphate
3
0
0
Sodium hydrogen urate
3
3
0
Mixed sodium hydrogen urate-calcium phosphate
1
0
0
_
Ammonium hydrogen urate
5
4
2
50.0
Mixed ammonium hydrogen urate-calcium oxalate and/or calcium phosphate
4
2
0
0.0
Cystine
5
4
2
50.0
Mixed cystine-calcium phosphate
1
0
-
Protein
1
0 0
0
-
700
422
172
40.8
phate-calcium oxalate calculi were in 7 of 18 cases (38.9%). Thus, it is evident that about 40% of patients with urinary oxalate and/or phosphate calculi experience recurrent or multiple stones. The patients with recurring uric acid stones were found in 5 of 9 cases (55.6%) and the patients with recurring ammonium hydrogen urate stones
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Total
0.0
234
T akasaki
were in 2 of 4 cases (50.0%), while there were no recurrences in patients with sodium hydrogen urate stones. Two of 4 patients with cystine calculi had recurrences (50%). The lower recurrence rates of uric acid stone and cystine stone may have resulted from modern therapy for these calculi. By analyzing the compositions of calculi in 31 patients with multiple or recurrent stones, it was found that multiple or recurrently formed cal culi in each individual are of quite similar types, and oxalate-phosphate calculi have similar calcium oxalatercalcium phosphate ratios in each case except for secondary calculi (magnesium ammonium phosphate) by infection following removal of the initial stone.
Up to now considerable data have concerned urinary stone analysis. P rien [11] reported on the crystallographic analysis of 24,000 urinary calculi and H erring [7] presented a statistic analysis of 10,000 calculi. Recently, infrared spectroscopy has been introduced to medical research, and it is also used to determine the composition of urinary stones in many laboratories. Since Beischer’s first application [2], several investigators have made infrared analyses of urinary stones. However, these reports are principally limited to qualitative techniques of stone analysis, and there is neither extensive statistical data nor quantitative application of infrared analysis of urinary calculi [16]. This paper presents results of analysis of 735 urinary stones by in frared spectroscopy (table I). The most commonly encountered compo nents of calculi were calcium oxalate and calcium phosphate, and the next was magnesium ammonium phosphate. A few calculi were composed of uric acid, sodium hydrogen urate, ammonium hydrogen urate, cystine, and protein. Magnesium hydrogen phosphate and calcium hydrogen phos phate were contained in some calculi. This statistical result of this study on urinary stone analysis by infrared spectroscopy agreed well with pre vious reports on analysis by other methods [6, 13]. It is well known that patients with urinary calculi suffer from recurr ences frequently following treatment of their initial stones. Williams [17] surveyed 538 patients with upper urinary tract stones on an average of 18.5 years; he demonstrated the incidence of recurrent stone formation in 80% for males and 60% for females, although these statistics did not con sider composition of calculi.
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Discussion
Composition and Recurrence of Calculi
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Patients with uric acid calculi and cystine calculi have stones recurred quite frequently because of the metabolic disorders. However, the modali ties of treatment for these calculi are established at present, and patients are well protected against recurrences of these calculi [5]. The recurrence rate of stones in patients with magnesium ammonium phosphate calculi and those with mixed magnesium ammonium phosphate-calcium oxalate calculi were 38.6 and 38.9%, respectively, in the present series (table II). The recurrence rate of magnesium ammonium phosphate calculi may be decreased by elimination of urinary infection and/or urinary stasis. L av engood and Marshall [8] have shown that there was known recurrence in 27% of patients with phosphate calculi over an average follow-up peri od of 4 years. The oxalate calculi always contain various amounts of calcium phos phate [4], The etiology of calcium oxalate-calcium phosphate calculus is problematic as well as obscure in many cases [12, 15], In the current study, the author surveyed patients with calcium oxalate calculi mixed with various amounts of calcium phosphate (table II). Although there is some variation of percentage, the recurrence rate of stones with various mixture of calcium oxalate and calcium phosphate was about 40%. This data suggests that the tendency of the oxalate calculi to recur cannot be predicted by the mixture rate of calcium phosphate in calcium oxalate.
References 1 Barzii ay, B. I. and K edar, S. S.: Surgical treatment of staghorn calculus by lower partial nephrectomy and pyelocalicolithotomy. J. Urol. 108: 689-694 (1972) . 2 Bf.ischer , D. E.: Analysis of renal calculi by infrared spectroscopy. J. Urol. 73: 653-659 (1955).
small urinary tract calculi. Invest. Urol. 9: 376-384 (1972). 5 D rach, G. W.; Sm ith , M. J. V., and Boyce, W. H.: Medical therapy of renal calculi. J. Urol. 104: 635-639 (1970). 6 E lliot , J. S.: Structure and composition of urinary calculi. J. Urol. 109: 82-83 (1973) . 7 H erring , L. C.: Observations on the analysis of ten thousand urinary calculi. J. Urol. 88: 545-562 (1962). 8 L avengood. R. W., jr., and M arshall, V. F.: The prevention of renal phosphat-
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3 Bennett , A. H. and H arrison, J. H.: Results o f surgery on branched renal cal culi. J. U rol. 107: 174-175 (1972). 4 C hambers, A.; H odgkinson , A., and H ornung , G.: Electron probe analysis of
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ic calculi in the presence of infection by the Shorr regimen. J. Urol. 108. 368-371 (1972). M yrvold , H. and F ritjofsson , A.: Late results of partial nephrectomy for renal lithiasis. Scand. J. Urol. Nephrol. 5: 57-62 (1971). P edersen , J. F.: Partial nephrectomy for nephrolithiasis. Scand. J. Urol. Ne phrol. 5: 171-176 (1971). P rien, E. L.: Crystallographic analysis of urinary calculi: a 23-year survey study. J. Urol. 89: 917-924 (1963). P rien , E. L.: The riddle of urinary stone disease. J. amer. med. Ass. 216: 503-507 (1971). P rien , E. L. and P rien , E. L., jr.: Composition and structure of urinary stone. Amer. J. Med. 45: 654-672 (1968). T akasaki, E.: Urinary stone analysis by infrared spectrometry. II. Quantitative application. Jap. J. Urol. 51: 639-663 (1960). T akasaki, E. and Shimano, E.: The urinary excretion of oxalic acid and magne sium in oxalate urolithiasis. Invest. Urol. 5: 303-312 (1967). T akasaki, E.: An observation on the analysis of urinary calculi by infrared spec troscopy. Calcif. Tiss. Res. 7: 232-240 (1971). W illiams , R. E.: Long-term survey of 538 patients with upper urinary tract stone. Brit. J. Urol. 35: 416-437 (1963).
Request reprints from Dr. Etsuji T akasaki, Department of Urology, Faculty of Medicine, University of Tokyo, Tokyo (Japan)
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