Evidence-based management of upper tract urolithiasis in the spinal cord-injured patient

The objective is to review the published literature on the aetiology and evidence-based management of stone disease in the spinal cord-injured patient.

A PubMed and Medline search was performed using the terms 'spinal cord injury', 'paraplegia', 'stone', 'nephrolithiasis', 'urolithiasis', 'calculus', 'spinal cord injury' or 'paraplegia' with 'SWL', 'ureteroscopy', 'chemolysis' and 'PCNL.' The Cochrane database, the National Institute for Clinical Excellence guidelines and the Scottish Intercollegiate guidelines were searched using the terms 'spinal cord injury' and 'urolithiasis' and 'nephrolithiasis'.

A total of 32 papers were identified, mainly case series or case-cohort studies with few contemporary papers. The risk of developing a renal stone after spinal cord injury (SCI) is between 7 and 20% over a period of 8-10 years. Stone formation may be related to early demineralisation of bone or chronic infection. Biochemical abnormalities are not significantly different between stone-forming and non-stone forming patients, though these patients differ from healthy controls. Presentation may be atypical, but is most commonly recurrent urinary tract infection. Treatment may be complicated by lower limb contractures limiting retrograde access. Several case series report success with shock wave lithotripsy varying from 50 to 70%, though comparisons are limited by heterogeneous indications and reporting. Percutaneous nephrolithotomy remains the gold standard for stones measuring 2 cm and above. Stone-free rates of 90% have been reported, though surgery was often complex with higher complication rates.

Management of upper urinary tract stones in patients with SCI is complex regarding surgical technique, post-operative care and recurrence rates. Further contemporary case series must use standardised reporting tools to allow valid comparisons.