Clinical Pattern of Urinary Stone Disease in Our Setting

Methodology: Structured and standardized history and clinical investigations collected in all of urolith patients. The diagnosis of stone disease was based on history, physical examination followed by KUB x-ray, ultrasonography and IVU .All patients subjected to open stone surgery. The data were analyzed prospectively with outcome measures of gender, stone location, clinical presentation and operative procedures.


Introduction
Urolithiasis is an ancient disease with global distribution and has perplexed human beings and physicians for many centuries.Pakistan is situated in the middle of Afro-Asian stone belt, a high region of stone incidence. 1Stone disease is an increasing problem in the Sindh province. 25][6][7] The etiology of urinary calculus is still not well understood but clearer concepts are gradually emerging with recent research.Stones are merely not life threatening because today's medical practice is extremely adept at removing most of the risk of passing a stone.Urinary stones can cause two problems: when it moves or when it grows to disrupt renal func-tion and damage occurs.The clinical approach to the stone forming patient includes both medical and surgical issues.The medical evaluation must identify patients at risk for recurrent stone formation, environmental factors that promote stones and systemic disease that contributes to stone formation.Although new and effective therapeutic methods to treat urolithiasis have been introduced recently, urinary stones continue to occupy an important place in everyday urological practice. 8Due to lack of research facilities and remoteness prevailing medical problems are virtually unknown outside of the state of Nawabshah.The high percentage of hospital admissions, surgical procedures and serious complications due to urolithiasis stresses the need to research this major health problem in Nawabshah.The purpose of this paper is to study the basic pattern of urinary stone disease, so that problem areas can be identified in context to medical literature and future research planned.

Material and Methods
This is a prospective and descriptive analysis of 257 patients with different stone burden treated between August 2003and August 2007 at the department of surgery of Nawabshah Medical College/Hospital Nawabshah.The diagnosis of stone disease was based on history, physical examination followed by KUB x-ray, ultrasonography and IVU.Urinalysis, blood picture, blood urea/serum creatinine done in all cases and renal function tests (DTPA) in selected cases.After complete medical evaluation and fitness protocol all patients were subjected to open stone surgery.Case records of all patients reviewed with the outcome parameters of age and sex, stone location, clinical presentation and operative procedures.

Results
Out of 257 patients 181 (70.42%) were male and 76 (29.56%) female with male to female ratio of 2.3:1.The age ranged from 1 year to 80 with the mean of 25.8 years.The peak incidence was of upper urinary tract stones in 20-30 years while lower urinary tract stones in both sexes were under 10 years (Table 1).Anatomical distribution of stone

Discussion
Urinary stones in its different forms are the third most common affliction of the urinary tract. 9Calculus disease is the commonest urological ailment in Pakistan. 10It has been apparent for several years that the incidence rates of lithiasis vary dramatically, not only from continent to continent but also between adjacent regions of a country, even if one allows for differences in methodology and criteria selection among epidemiology studies 8 .The lifetime prevalence of urinary stones has increased through out the 20 th century and occurs in up to 15% of the population. 11It is generally accepted that stones occur more commonly in males than females.3][14][15][16] No age group is spared to urinary stone disease in Pakistan though a change in the age pattern of patients of urolithiasis has been reported in industrialized countries.6][17][18] Calculi occurred in various sites in the urinary tract were in the following order of frequency vesical < renal < uretral < urethral (42%), (45.16%), (21%) and (4.66%) respectively in our series.The prevalence of vesical stones was extremely high in pediatric age group.These were endemic bladder calculi and predominantly male belonging to low socioeconomic class and mai-nly from rural areas.0][21][22][23] The natural history of disease varies in different populations. 23Urolithiasis still results in serious morbidity, pain, haematuria, infection and renal failure 24 .
The clinical presentation of patients with urolithiasis in our series is pain in (67.31%), haematuria (26.02%),UTI (15.1%),BOO (7%), stone passage (8.9%) and asymptomatic (8.1%).Symptoms with almost same frequencies have been reported by other researchers. 23,25,26This probably reflects low incidence of pyonephrosis and our conservative policy in the operative treatment of complex stones.It is concluded that although new modalities have been added to the armoury of surgeons to treat urinary stones and patients now have more choice but in our part of the world it remains out of the reach of common man because of high cost and non-availability in public sector.Open stone surgery remains the only treatment available in this part of the world with high success rates, yet it has its limitations and can be applied only to standard patients.

Conclusion
Stone disease is an increasing and major public health problem with high frequency of bladder stone with male predominance in our region of Sindh province.The pattern of urinary stone disease as seen in our setting, though in more aspects being similar to that in the developing countries.Open stone surgery is a more favorable option and commonest procedure applied with high success rates and excellent stone clearance in our part of the world.Establishment of new modern stone clinics in our setup and public education for the early detection and the treatment of stone disease are the need of today's medical practice.

Table 1 :
Age and Sex Distribution.

Table 2 :
Anatomical Location of Urinary Calculi.