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Cystine stones: the impact of new treatment
1Service d'Urologie et Chirurgie de la Transplantation, Hôpital Edouard Herriot, Lyon, France.
Insights
Cystine stones are challenging due to their hardness and recurrence. Instrumental treatments for cystine stones have a low stone-free rate, suggesting they should be reserved for symptomatic or medically refractory cases.
Area of Science:
- Urology
- Nephrology
- Medical Chemistry
Background:
- Cystine stones pose significant clinical challenges due to their inherent hardness and high recurrence rates.
- Previous surgical interventions are common among patients with cystinuria.
- Accurate diagnosis relies on metabolic evaluation and stone analysis via infrared spectrometry.
Purpose of the Study:
- To evaluate the effectiveness of various treatment modalities for cystine urolithiasis.
- To assess the stone-free rates and recurrence patterns following treatment.
- To provide evidence-based recommendations for managing cystine stones.
Main Methods:
- A cohort of 15 cystinuric patients underwent a 30-month follow-up.
- Treatments included percutaneous nephrolithotomy (alone or with ESWL), extracorporeal shock wave lithotripsy (ESWL) alone, and medical management.
- Medical therapy involved high fluid intake, alkalinization, and tiopronin (Thiola).
Main Results:
- A total of 74 cystine stones were treated across 23 recurrence instances in 11 patients.
- The overall stone-free rate at 3 months post-treatment was 44.7%, significantly lower than for non-cystine stones.
- Recurrence was a frequent issue, observed in over 73% of patients during the follow-up period.
Conclusions:
- The efficacy of instrumental treatments for cystine stones is limited, with a notably high recurrence rate.
- Instrumental interventions should be judiciously applied, primarily for symptomatic stones or those unresponsive to conservative medical therapy.
- Intensive medical management remains a cornerstone in the long-term care of cystinuric patients to mitigate recurrence.
Abstract:
The hardness and frequent recurrence of cystine stones present a special challenge to the urologist. In this study, 15 cystinuric patients (11 males, 4 females; mean age 36 years, range 17-54) were treated and followed up over a period of 30 months (range 2-40). Most patients had previous history of open surgery. The diagnosis of cystinuria was confirmed by metabolic studies and infrared spectrometry of stones. Over the follow-up period recurrence was observed in 23 instances in 11 patients, leading to 38 "stone treatments" on 74 cystine stones. The percutaneous approach was used alone in 9 cases and in association with extracorporeal shock wave lithotripsy (ESWL) in 9 cases. ESWL was used alone in 18 cases. Medical treatment included high fluid intake, alkalinisation and Thiola (tiopronin, N-(2-mercaptopropionyl)glycine) in 6 patients. The overall stone-free rate assessed 3 months after treatment was 44.7%, which compares poorly with the rate for non-cystine stones. The recurrence rate is very high and instrumental treatment should not therefore be used excessively; it is indicated only for stones that are symptomatic or refractory to intensive medical therapy.