UNJ April 2007-113.ps 4/9/07 4:43 PM Page 113

SERIES

Dietary and Holistic Treatment of Recurrent Calcium Oxalate Kidney Stones: Review of Literature to Guide Patient Education

Laura R. Flagg

elivering care to pa- Urolithiasis is a condition that can cause significant morbidity among tients with recurrent patients. Dietary manipulations traditionally advised include fluid, kidney stones presents protein, oxalate, calcium, citrate, and sodium changes in the diet. unique challenges for Evidence-based practice guidelines suggest that there is not ample Dnurses and health care providers. evidence to confidently recommend dietary changes, since inade- Patients who develop sympto- quate studies have been done to quantify the risks of diet in stone matic urolithiasis may present formation. While fluid intake patterns have the weightiest evidence in with characteristic flank or groin the literature, not even fluid intake meets the guidelines for evidence- pain, nausea and vomiting, based practice. Health care providers should recognize that current dysuria, and hematuria, regard- patient education is largely based on intuition. It behooves us as clin- less of the presence of hydro- nephrosis or hydroureter. Those icians to look critically at all our practices, review the available litera- who have developed one stone ture, and question what we believe we know. A summary of available are at approximately 50% risk for literature is provided to guide the clinician in educating patients in developing another within 5 to 7 reducing their risk of recurrent calcium oxalate stone disease. years (Parmar, 2004). For patients who are unfortunate enough to have recurrent stones, quality of Evidence-Based Practice (RCT) as the gold standard by life may be affected significantly. Nurses and other health care which to judge information for Members of this population often providers are increasingly turn- validity, relevance, and applica- become distressed in their search ing to evidence-based practice bility. Unfortunately, scant infor- for relief of symptoms and will (EBP) to critically evaluate the mation collected regarding kid- look to health care providers for health information that may have ney stone formation and recur- assistance. This article is designed been previously accepted as true. rence meets the RCT gold stan- to guide health care providers in Our current practice may be dard. The Cochrane Database of educating patients to reduce their based in fact, simple tradition, or Systematic Reviews is one data- risk of recurrent calcium oxalate intuition. EBP allows for critical base that compiles information stones. evaluation of scientific studies. based on the best available data. Available studies are critically Only one study is currently pub- appraised for validity, relevance, lished in the Cochrane Database Laura R. Flagg, MSN, RN, CNP, is a and applicability. This guides for kidney stone risk reduction, Clinical Nurse, The University assimilation of the most accurate but it does not rise to the level of Hospital, and a Graduate Student, the information, based on the best best recommendation as defined University of Cincinnati, Cincinnati, available evidence, and gives the by the Cochrane Database. This OH. clinician concrete evidence to study, on fluid intake, is the only guide practice, rather than rely- recommendation listed in the Note: Objectives and CNE Evaluation Cochrane Database for the treat- Form appear on page 123. ing on mere custom, intuition, or tradition. ment of kidney stones. This fur- Note: The author reported no actual or Cochrane Database. Evidence- ther highlights the scarcity of potential conflict of interest in relation to based practice relies heavily upon available strong evidence upon this continuing nursing education article. the randomized controlled trial which we base our practices.

UROLOGIC NURSING / April 2007 / Volume 27 Number 2 113 UNJ April 2007-114.ps 4/9/07 4:43 PM Page 114

SERIES

The National Guideline stone risk. These patterns tice. Qiang and Ke (2004) con- Clearinghouse. In addition to the include fluid intake, ingestion of cluded, in their opinion for Cochrane Database, The National many minerals, such as calcium, Cochrane Database for Systematic Guideline Clearinghouse also com- oxalate, ascorbic acid, sodium, Reviews, that this one study alone piles recommendations for prac- and magnesium, as well as pro- did not provide enough evidence tice. Until earlier this year, the tein and specific types of fluids. to recommend increased fluid National Guideline Clearinghouse A discussion of the measurable intake to reduce the incidence of published guidelines recommend- evidence in individual studies primary or recurrent kidney ing increased fluid intake for follows. stones. These researchers strong- patients with stones. This guide- Fluid intake. Scientists have ly emphasized the need for more line, however, was rescinded since suggested for decades that RCTs to improve the information it had not been updated from 1997. increased fluid intake could upon which to base recommen- Until rescinded, increased fluids reduce the rate of stone forma- dations. for treatment of kidney stones was tion, though the recommenda- Calcium intake. Calcium is the only recommendation suggest- tion was based solely in intuition present in more stones than any ed by the National Guideline and tradition. Pak, Sakhaee, other element, with calcium Clearinghouse (2006). Crowther, and Brinkley (1980) oxalate the most common com- The dearth of information were perhaps the first to scientif- pound (Hall, 2002; Holmes, available for use in development ically measure the effect of fluid Goodman, & Assimos, 2001; of recommendations for kidney intake on the risk of stone forma- Moyad, 2003). Tradition once stone management has not gone tion. Their results indicate that if held that a reduced calcium diet unnoticed (Gambaro, Reis- urine volume could be increased would benefit those with a histo- Santos, & Rao, 2004; Straub & to 2.5 liters per day, the risk of ry of urolithiasis by reducing the Hautmann, 2005). Gambaro et al. stone formation was reduced. rate of calcium absorption and (2004) note a stagnancy of Curhan, Willett, Rimm, and filtration into the urine. A large research on the risks of stone for- Stampfer (1993) also found that prospective study of the risk of mation, in part due to the popu- among 45,000 men studied, symptomatic stone formation in larity of extracorporeal shock increased fluid intake was more than 45,000 men ages 40 to wave lithotripsy (ESWL), which inversely proportional to the risk 75 years of age was conducted by has grabbed the attention of of symptomatic stone formation. Curhan et al. (1993). They researchers since its introduction Men with the highest fluid administered dietary pattern in the 1980s. ESWL is a highly intake, over 2,530 ml per day, questionnaires and then tracked popular treatment for urolithia- had a 0.71 relative risk of symp- the incidence of symptomatic sis. Pak (1999) has been critical tomatic stone formation com- stones over the following 4 years. of the change in emphasis away pared with men who drank the Contrary to expectations, there from metabolic factors causing lowest volume of fluids, less than was a relative risk of only 0.66 for stones, now that ESWL has 1,275 ml per day. Similar results stone formation among men with become a relatively easy treat- were found for women. Among the highest dietary calcium ment recommendation. more than 91,000 women aged intake (1,050 mg per day or While having EBP recom- 34 to 59 years who were studied more), compared with men with mendations for dietary kidney over 12 years, the relative risk for the lowest dietary calcium intake stone management is still opti- women who drank more than (605 mg or less per day). Curhan mal, clinicians must continue to 2,592 ml per day was 0.61 com- and associates (1997) followed provide care with the best knowl- pared with women who drank less up this large study of men’s edge at hand. In the meantime, than 1,412 ml per day (Curhan, dietary patterns with a similar there are individual studies to Willett, Speizer, Spiegelman, & study of women. In the Nurses’ guide us in tentative recommen- Stampfer, 1997). Health Study I of over 90,000 dations to patients. Most studies Qiang and Ke (2004) reviewed female nurses, ages 34 to 59 are not as rigorously controlled, available studies in a meta-analy- years, calcium intake was and therefore difficult to inter- sis regarding fluid intake as one assessed via questionnaires, and pret for validity. Patients should method to reduce stone formation. cases of symptomatic stones be advised of the knowledge we While many individual studies were tracked for 12 years. The have, but cautioned that our proposed that a reduced risk of relative risk for women with the understanding is incomplete at stone formation occurred with highest dietary calcium intake best. increased fluids, only one study (more than 1,098 mg per day) of 199 patients by Borghi et al. was 0.65, compared with women Dietary Patterns (1996) met the standard RCT cri- with the lowest dietary calcium Dietary patterns have been teria for inclusion as strong evi- intake of less than 488 mg per identified as possibly increasing dence upon which to base prac- day (Curhan et al., 1997).

114 UROLOGIC NURSING / April 2007 / Volume 27 Number 2 UNJ April 2007-115.ps 4/9/07 4:43 PM Page 115

SERIES

Borghi et al. (2002) noted Oxalate intake. Many ences in dietary oxalate intake twice the rate of stone formation researchers have studied the role between the hyperoxaluric and among the 60 stone-forming men of dietary oxalate in the forma- normooxaluric subjects. The who followed a low-calcium diet tion of calcium oxalate stones. authors concluded that the high- compared with an equal number No consensus, however, has er rates of oxalate urinary excre- who followed a low-protein and emerged in dietary oxalate’s tion were associated with two low-sodium diet in this prospec- impact on stone formation. This phenomena: (a) hyperabsorption tive randomized study. These is likely because of the complex- of oxalate from endogenous studies have largely discredited ities of digestion and metabolism sources, rather than from dietary the previous practice of reducing of minerals associated with the sources of oxalate; and (b) lower calcium intake among stone for- formation of oxalate, and its rates of calcium intake. This mers. excretion from the body. would lead to lower rates of com- Calcium ingested in supple- Oxalate is present in urine in plexing of calcium and oxalate in ment form, however, may much smaller quantities than cal- the gut, which would promote increase stone risk. Curhan et al. cium. It is believed that for this more oxalate filtration into the (1997) found that women may reason, changes in oxalate levels urine. Similar findings were have a greater risk of stone for- in the urine have a much greater reported by Chai, Liebman, mation (relative risk of 1.20) impact on stone formation than Kynast-Gales, and Massey (2004). compared with those who do not changes in calcium concentra- Likewise, Curhan et al. (1993) use supplemental calcium. Of tion – 23 times the impact for noted no added risk in ingestion of note, this risk was not found in oxalate as for calcium (Morton, oxalate-rich foods on the forma- men in two other studies. Curhan Iliescu, & Wilson, 2002). tion of stones in their large epi- et al. (1993) studied men who Urinary excretion of oxalate in demiologic study. took 500 mg calcium supple- excess of 45 mg per day is regard- Contrary to these studies, ments daily and compared them ed as hyperoxaluria. Hyper- Holmes et al. (2001) noted that to those who did not take calci- oxaluria may result from in- little strong evidence was avail- um supplements. No added risk creased dietary intake, increased able to support the belief that was found among the 45,000 intestinal absorption of oxalate stones are formed primarily by men studied. In another study by from the gut, or by increased higher levels of absorption of Stitchantrakul, Sopassathit, Pra- endogenous production of oxalate oxalate rather than from dietary paipanich, and Domrongkitch- by metabolic breakdown of differences. In their study of 12 aiporn (2004), 32 young healthy ingested precursors (Siener, stone-forming persons, highly males with low dietary oxalate Ebert, Nicolay, & Hesse, 2003). controlled diets were manipulat- intake were studied. Researchers Increased intestinal absorption ed to provide variations in gave calcium supplements (amount can occur by mechanisms such oxalate intake. They found that not specified) to the men, then as Crohn’s disease, short bowel dietary oxalate contributed up to measured the impact of calcium syndrome, or by destruction of 50% of the variability in oxalate supplementation upon factors Oxalobacter formigenes, a natu- excretion. The highest urinary thought to increase stone risk. rally present bacterium which oxalate excretion was found They found that calcium supple- breaks down oxalate in the gut when the calcium intake was ments increased urinary citrate, (Martini & Wood, 2000; Parmar, most severely limited to 391 mg decreased urinary oxalate, and 2004). Martini and Wood (2000) daily. The rate of actual stone for- increased urinary calcium levels. concluded that hyperoxaluria, mation among these persons was Researchers believed that the due to excessive dietary intake of not investigated but rather the increased risk of hypercalciuria oxalate, may be unusual despite metabolic environment expected was offset by the protective oxalate’s presence in most foods. to facilitate stone formation. effects of relative hypooxaluria They contend that hyperoxaluria Heilberg (2000) reviewed and hypercitraturia provided by is a result of increased intestinal studies regarding calcium and the calcium supplementation. absorption in those who are oxalate intake in animals and Concerning the traditional prone to this abnormality, partic- humans. He found that oxalate recommendations for calcium ularly malabsorption in the small stone formation was highly restrictions, Heilberg (2000) and bowel. dependent on the balance of McCarron and Heaney (2004) Siener et al. (2003) studied oxalate and calcium in the diet also called for adequate dairy 186 stone formers, half with and blood. Exceedingly high intake, citing the improvements hyperoxaluria and half with nor- oxalate intake could be com- in stone formation risk, as well as mal urinary oxalate. The subjects pletely offset by a concomitant effects on blood pressure, bone provided 24-hour dietary diaries increase in calcium intake. This strength, and management of and underwent urine studies. researcher concluded, however, obesity. There were no significant differ- that not enough information was

UROLOGIC NURSING / April 2007 / Volume 27 Number 2 115 UNJ April 2007-116.ps 4/9/07 4:43 PM Page 116

SERIES

available to recommend restric- P450 and its use is discouraged as one category (Curhan et al., tions in oxalate or calcium. He with many medications. However, 1998). recommended further studies to it is not known if grapefruit’s effect Cranberry juice. McHarg, determine if there was a benefit on stone formation may be due to Rodgers, and Charlton (2003) to altering the intake of oxalate- some unknown metabolic alter- studied the effects of cranberry rich foods, specifically rhubarb, ation of metabolic processes with juice on the urinary qualities spinach, chocolate, peanuts, food breakdown similar to those expected to impact the risk of pecans, almonds and instant tea. associated with drug metabo- stone formation. In a randomized Citrate intake. Citrates are lism. crossover study, 20 South compounds made from citric Orange juice. Orange juice African men were given two dif- acid, or vitamin C, and are ingestion is associated with no ferent diets with and without obtained exogenously through change in risk relative to water in cranberry juice, and urinary mea- dietary ingestion of such foods as the Nurses’ Health Study surements were analyzed. Use of strawberries, lemons, oranges, (Curhan et al., 1998). However, cranberry juice, which was high cranberries, and grapefruits. other studies have shown orange in both vitamin C and oxalate, Endogenous urinary citrate is juice to reduce stone risk. resulted in improvements in uri- derived via the breakdown of Wabner and Pak (1993) found nary properties expected to glucose through the Krebs cycle that orange juice was equally as reduce the risk of calcium and excreted by renal tubular effective in reducing the litho- oxalate stone formation, specifi- cells (Guyton & Hall, 2000; genic qualities of urine as was cally increased urinary citrate, Parmar, 2004). Urinary citrate potassium citrate supplementa- and reduced urinary oxalate and forms a soluble complex with tion among 11 men in a prospec- phosphate. Urinary calcium calcium, and is believed to inhib- tive crossover study. Coe, Parks, oxalate also decreased more with it the formation of calcium stones and Webb (1992) found a favor- cranberry juice than without. (Seltzer, Low, McDonald, Shami, able change in urinary citrate McHarg et al. (2003) reported & Stoller, 1996). The normal among six female participants that while high in oxalate, cran- range for citrate excretion is 300 who consumed calcium-fortified berries’ oxalate is not largely to 700 mg per day. Excretion is orange juice in an 11-week, bioavailable, and thus, not readi- reduced in periods of metabolic crossover study. No change was ly absorbed. This may explain acidosis, such as with inflamma- appreciated in the six male par- the reduction in urinary oxalate tory bowel disease or renal tubu- ticipants. It is not known what despite higher oxalate content. lar acidosis (Hall, 2002). part the calcium fortification Siener et al. (2003) studied Potassium citrate is often pre- may have played in the reduction dietary patterns in 186 stone- scribed to increase urinary citrate of risk in this small study. forming individuals with hyper- for stone prevention. Lemonade. As another source oxaluria vs. normooxaluria. The of citrate, lemonade is often rec- sample was equally divided with Dietary Vitamin C in ommended to patients with 93 subjects with hyperoxaluria Beverages stones. Seltzer et al. (1996) found and 93 subjects with normoox- Whether dietary alterations that the intake of lemonade in 12 aluria. Dietary contents were of citrate can affect the rate of calcium stone formers could aid measured scientifically and stone formation is unclear, as in reducing risk factors for stone recorded. Among those stone for- various studies contradict each formation. In this study, lemon- mers with hyperoxaluria, they other, and may vary by source of ade increased urinary citrate in noted higher dietary intake of vitamin C. While most vitamin C 11 of 12 subjects with hypocitra- ascorbic acid through fruits and is excreted as citrate, it can also turia (daily urinary citrate less vegetables. Larger ascorbic acid be metabolized and excreted as than 320 mg) by a mean value of intake was believed to result in oxalate (Mayne Pharma Ltd., 204 mg per day. Lemonade was conversion to oxalate and hyper- 2004). well tolerated and was believed absorption from the gut, when in Grapefruit juice. Curhan, to provide an inexpensive alter- the presence of reduced calcium Willett, Speizer, and Stampfer native to potassium citrate sup- intake. Researchers thought this (1998) found that grapefruit juice plementation. The study did not was at least partly responsible for was directly associated with kid- seek, though, to determine the the presence of hyperoxaluria in ney stone formation in women, actual rates of stone formation. this group of 93 stone formers. echoing similar findings in men The Nurses’ Health Study of Taylor, Stampfer, and Curhan (Curhan, Willett, Rimm, Spiegel- 81,000 women showed no signif- (2004) found a greater incidence man, & Stampfer, 1996). Grape- icant relationship between of stones among men with larger fruit juice is a well-known in- lemonade intake and stone risk, total vitamin C intake, regardless hibitor of the metabolism of although lemonade and fruit of origin. Among the 45,600 men numerous drugs via cytochrome punch use were studied together studied over 14 years, men with

116 UROLOGIC NURSING / April 2007 / Volume 27 Number 2 UNJ April 2007-117.ps 4/9/07 4:43 PM Page 117

SERIES

the largest total vitamin C intake vides a mechanism for passive Virtamo (1999) studied 27,000 (over 1,000 mg daily) had a 41% reabsorption of calcium to the Finnish smoking men in a greater risk of stone relative to blood from the kidney’s filtrate. prospective epidemiologic study those with the smallest intake of Overingestion of sodium pro- of the risks of stones. This was total vitamin C (less than 90 mg vides for less calcium reabsorp- part of a larger study that looked daily). tion to the blood via passive reab- at smoking men’s risk of lung Supplemental vitamin C. sorption, leading to calcium cancer if they supplemented Supplemental sources of vitamin excretion in larger quantities via their diets with alpha-tocopherol C have been implicated in stone the urine. A low-sodium diet is and beta-carotene. After 5 years risk. Terris, Issa, and Tacker expected to conversely increase of followup, 329 men developed (2001) studied cranberry concen- the reabsorption of sodium and kidney stones. They found that trate supplement use in a very calcium from the proximal magnesium intake had a protec- small study of healthy adults. tubule into the blood so that less tive effect on stone formation. Five men and women provided remains in the urine, reducing Those men with the highest mag- urine studies before and after use stone risk. The recommendation nesium intake (563 mg or more) of cranberry supplements for 7 for reduced dietary sodium is had a relative risk of 0.52 for days. Urinary oxalate levels based on this understanding of stone formation, compared to increased in all subjects by an the balance of sodium and calci- those with the lowest magnesium average of 43% after concentrate um in the blood and urine. Kok, intake (382 mg or less). It is not use. Other factors such as Iestra, Doorenbos, and Papapoulos known whether these results increases in urinary magnesium (1990) found that a high sodium might be reproducible in other and potassium were noted which diet induced increases in urinary cultural groups, or what effect may reduce the risk of stone for- calcium and reductions in urinary smoking may have had, if any, on mation, mitigating the added risk citrate, which are commonly rec- these results. of increased urinary oxalate. ognized as risks for stone forma- Taylor et al. (2004) also Massey, Liebman, and Kynast- tion. This effect was more dra- found a reduced risk for stone Gales (2005) found that ascorbic matic when diets were high in formation among men aged 40 to acid in supplement form caused sodium and protein at the same 75 with increased dietary magne- increases in urinary oxalate time. sium intake. Men with the high- among stone formers and non- The role of sodium in actual est dietary magnesium intake stone formers alike, in their ran- stone formation, however, is less (over 450 mg/day) had a relative domized crossover controlled clear. Borghi et al. (2002) found risk of stone formation of 0.71, study of 48 adults. Forty percent reduced recurrence of stones in compared with men who con- of the subjects had increases in 120 men with a history of hyper- sumed the lowest amount of urinary oxalate when given 1,000 calciuric stone formation if they magnesium (less than 314 mg ascorbic acid twice daily, maintained a low-protein, low- mg/day). In a study of the physi- compared to those without the sodium diet, compared with a ology of magnesium intake’s supplementation. Oxalate stone- low-calcium diet. Curhan et al. effect on oxalate, Liebman and forming men and women had (1993), however, found no rela- Costa (2000) found that a diet higher rates of oxalate absorption tionship between sodium intake high in magnesium oxide and endogenous oxalate synthe- and stone formation in their reduced oxalate absorption and sis than did non-stone formers study of 45,000 men. It would oxalate excretion, compared to a when subjected to the same diet. appear that recommendations for diet with low magnesium oxide In addition, these stone formers low-sodium diets are based most- among 24 healthy men and increased their own urinary ly on the physiologic processes, women. This may at least partial- oxalate levels when given ascor- yet is not yet solidly borne out by ly explain the phenomenon of bic acid supplements, implying epidemiologic evidence. variable stone risk. that vitamin C supplementation Magnesium intake. Mag- Protein intake. High-protein may be risky among known stone nesium is thought to reduce intake has long been proposed as formers. stone risk by complexing with a stone-forming dietary pattern. Opposing evidence has been oxalate in the gut thereby reduc- Those eating a high-protein, low- presented. Taylor et al. (2004) ing oxalate excretion into the carbohydrate diet, so popular in noted no significant increased urine. Sources of dietary magne- recent years, may be at greater risk of stone formation with vita- sium include dairy products, risk of stone formation than those min C supplementation in their meat, seafood, apples, apricots, with a more balanced nutritional study of men with kidney stones. avocados, bananas, whole grain intake. Sodium intake. The reab- cereals, nuts, dark green vegeta- Kok et al. (1990) studied sorption of sodium and water in bles, and cocoa. Hirvonen, eight healthy Dutch men who the kidney’s proximal tubule pro- Pietinen, Virtanen, Albanes, and were given sodium and protein

UROLOGIC NURSING / April 2007 / Volume 27 Number 2 117 UNJ April 2007-118.ps 4/9/07 4:43 PM Page 118

SERIES

dietary modifications for 1 week former stone to determine if a risk per 240 ml ingested. For no followed by urine measurements low-protein diet might further yet discernible reason, liquor’s of select elements. Results reduce the risk of stone recur- effects showed no change in risk. showed a diet high in protein rence. Though not highly con- Similar results on the risk of (more than 2 g per kg body trolled over 4.5 years, their low- stones with beer intake were weight per day) produced protein intake intervention group reported by Hirvonen et al. increases in urinary calcium and showed a significant increase in (1999). The risk of stones was uric acid, and decreases in uri- rates of recurrent stone formation reduced by 40% for each bottle nary citrate, especially when the compared to those who were (quantity not given) of beer high-protein diet was accompa- instructed to only increase fluids ingested daily among smoking nied by a high-sodium intake. (7.1 stones in 100-person years Finnish men. Other “spirits” (not The urine showed a significant vs. 1.2 stones in 100-person specified as to type) had no sig- decrease in the ability to inhibit years, respectively). Martini and nificant effect on stone formation the formation of calcium oxalate Wood (2000) performed a meta- rates in this study. stones. The relative inability was analysis of studies related to cal- Tea. While Curhan et al. dependent proportional to the cium and protein restrictions. (1998) found reduced stone for- degree of decrease in urinary cit- They cautioned against stone- mation among tea drinkers, some rate. forming individuals undertaking practitioners continue to suggest Curhan et al. (1993) studied low-protein diets, citing risk of that teas, because of their high the rate of stone formation in elevation of parathyroid hor- oxalate contents, be removed or men relative to animal protein mone, inducing bone loss. limited in the diet of stone form- intake. They found that animal Martini and Wood (2000, p. 116) ers. In a separate study of various protein intake was directly asso- concluded that diets “restricting types of teas, black and herbal ciated with stone formation, with dietary protein to below RDA teas were studied to determine the highest protein intake (77 levels of 0.8 grams per kilogram oxalate levels with brewing. grams daily or more) showing a per day are dangerous and Many herbal teas were found to relative risk of 1.33 compared should be avoided.” As expected, have less oxalate than black tea, with the lowest protein intake these authors called for further and were recommended by the (50 grams daily or less). studies to further delineate the researchers as possibly helpful to Giannini et al. (1999) took connection, if any, between pro- patients with recurrent stone risks the protein intake question fur- tein intake and stone formation. (McKay, Seviour, Comerford, ther by studying the effect of pro- Vasdev, & Massey, 1995). tein restriction on a small group of Other Beverages Cola. Limited research has stone-forming adults. Researchers Coffee. Because of its oxalate been conducted concerning the studied 18 men and women, all content, coffee has been dis- risk of stones with cola intake. A with histories of calcium stones cussed as a potential stone-form- small study of four men, one and hypercalciuria. These 18 ing beverage. As a diuretic, cof- with a history of stones, under- subjects restricted their protein fee’s increased risk may be miti- went dietary manipulation to intake to 0.8 g per kg of body gated because of caffeine’s effect determine the risk of stone for- weight per day for 15 days, after in urine dilution. Indeed, Curhan mation with cola ingestion which serum levels and urinary et al. (1998) found coffee was asso- (Weiss, Sluss, & Linke, 1992). excretion of significant elements ciated with a reduced risk of stones Only three of the subjects were were measured. Researchers in women, whether caffeinated or able to ingest a full 3 quarts of noted a significant reduction in decaffeinated. Caffeinated coffee cola per day to complete the urinary uric acid, calcium, and had a 10% cumulative risk reduc- study. All subjects showed oxalate after protein restriction, tion for each 240 ml ingested, and decreases in urinary citrate and and increases in urinary citrate. decaffeinated coffee a 9% cumula- magnesium, and increased uri- Giannini et al. (1999, p. 270) tive reduction in risk for each cup nary oxalate, which are believed noted “a reduction of the entire ingested per day. Tea was credited to increase the risk of stone for- lithogenic potential of these with an 8% cumulative reduction mation patients” after the short 30 day in stone risk per 240 ml ingested. trial. No measurements were Wine and beer. The most dra- Holistic Treatments made of the residual effects of a matic reduction in risk, however, Holistic treatments embrace reduced-protein diet, nor of the was seen with wine consumption dietary and natural therapies to effects of the reduction if it were (Curhan et al., 1998). For each manage health. Phytotherapy, or undertaken for a longer period. 240 ml intake of wine per day, herbal therapy, is central to holis- Hiatt et al. (1996) conducted there was a 59% reduction in tic treatment. Phytotherapy is a randomized controlled trial of stone risk among women. Beer discussed below with regards to 99 persons with histories of one intake showed a 12% decrease in kidney stone disease manage-

118 UROLOGIC NURSING / April 2007 / Volume 27 Number 2 UNJ April 2007-119.ps 4/9/07 4:43 PM Page 119

SERIES

ment along with available scien- evaluating the results of those benefits. For now, no such strong tific information to support it. with hypercalciuria only, those evidence exists. Phytotherapy. Phytotherapy is who took P. niruri had a significant included in many holistic recom- reduction in urinary calcium. Obesity and Weight Gain mendations for treatment of kid- Micali et al. (2006) studied Three large prospective epi- ney stones, as well as numerous the effect of P. niruri on 150 peo- demiologic studies looked at the other human conditions. The ple who had extracorporeal link between body weight and European Scientific Cooperative shock wave lithotripsy (ESWL). the risk of stones. The Health on Phytotherapy (ESCOP), estab- Seventy-eight patients received P. Professionals Follow-up Study of lished in 1989, defines phy- niruri for 3 months or more after 46,000 male physicians over 14 tomedicines as “medicinal prod- ESWL, while 72 received none. years, the Nurses’ Health Study I ucts containing as active ingredi- Those with lower pole stones of 93,000 older women, and ents only in plants, parts of who took P. niruri had fewer Nurses’ Health Study II of plants or plant materials, or com- stone recurrences over 6 months 101,000 younger women asked binations thereof, whether in the than those who did not use the about weight and incidence of crude or processed state…plant herb. Stones in mid or upper- symptomatic kidney stones that materials include juices, gums, pole positions did not show sig- followed over the course of years. fixed oils, essential oils, and any nificant recurrence rate changes Among the men in the Health other directly derived crude compared with the control Professionals Follow-up Study plant product. They do not group. (who were aged 40-75 years) include chemically defined isolat- In efforts to discover other weighing over 220 lbs, the rela- ed constituents, either alone or in examples of study of phytothera- tive risk of stones was 1.44, com- combination with plant materials” py, a subject search on the search pared to men who weighed less (European Society Cooperative on engine Alternative HealthWatch than 150 lbs. If the men gained Phytotherapy, n.d.). ESCOP sup- was performed in January 2006 more than 35 lbs since early ports clinical studies on the safety with the words “kidney stone.” adulthood, they had a relative and efficacy of phytotherapeutic Only peer-reviewed journals risk of stones of 1.35 compared to agents through financial support were used. The search retrieved men whose weight remained of the European Union. At this 55 articles, none of which was a unchanged. Among men, a BMI time, holistic and phytothera- scientific study of phytotherapy’s of 30 or more translated to a risk peutic management is based in use in managing urolithiasis. A of 1.33 vs. that of men with BMI the tradition of centuries, and search in January 2006 of the last of 21 to 22.9. Waist circumfer- seeks to validate its practices 6 years in the holistic journal ences also showed significance. with quantifiable research, but Phytotherapy Research with the Men with waist measurements of much work remains to be done. term “kidney stones” produced more than 43 inches had 1.48 One phytotherapeutic agent, no experimental studies of herbal times the risk of stones than men Phyllanthus niruri, has been supplement on humans. Likewise, with waist circumferences of less studied in humans to begin to a title search in the holistic journal than 34 inches (Taylor, Stampfer, evaluate its effectiveness in pre- Phytomedicine in December 2006 & Curhan, 2005). vention of stones. Phyllanthis found no human studies on kid- Among the older women of niruri is an herb used in Brazilian ney stone treatment with herbals the Nurses’ Health Study I, aged folk medicine, with reported ben- over the last 6 years. Nor were 30 to 55, those weighing 220 lbs efits to stone disease. Nishiura, any found in the journal or more had a relative risk of Campos, Boim, Heilberg, and Alternative Medicine Review for stones of 1.89 compared with Schor (2004) studied the effects of the last 7 years. Application of women weighing less than 150 this herb on the chemical promot- the principles of EBP indicates lbs. Older women who gained ers and inhibitors of stone forma- that there is currently no satisfac- more than 35 lbs since early tion in known stone-forming tory body of evidence to satisfy adulthood had a relative risk for patients. Sixty-nine previous EBP’s guidelines regarding phy- stone formation of 1.70 com- stone formers were randomized to totherapy for kidney stones. While pared to those who did not gain take either 1,350 mg of aqueous the above studies on P. niruri are weight. Among the older women, extract of P. niruri divided in exciting to see, they are quite pre- a BMI of 30 or more had a risk of three doses or placebo for 3 liminary at best. This author stones of 1.9 of that of women months. Researchers found that agrees with ESCOP that much with BMI of 21 to 22.9 (Taylor et among all subjects, there was no work needs to be done with phy- al., 2005). significant difference in urinary totherapeutic agents. Phyto- Similar trends were noted levels of measured metabolites therapy may prove beneficial if among the younger women of the calcium, uric acid, citrate, oxalate, studies such as those discussed Nurses’ Health Study II, who and magnesium. However, when here continue to show possible were aged 25 to 42. Younger

UROLOGIC NURSING / April 2007 / Volume 27 Number 2 119 UNJ April 2007-120.ps 4/9/07 4:44 PM Page 120

SERIES

women weighing over 220 lbs evaluate, much less endorse. The supplemental calcium for those had a risk of stones of 1.82 times lack of specific information with a history of stones. the risk of women weighing less about some of these products There is some early evidence than 150 lbs. Those who gained makes it difficult to discuss with that high animal protein diets 35 lbs or more risked stones 1.82 patients who want input on their increase the risk of stones. times that of women whose track records of success. In addi- Patients have one more reason to weight did not change over the tion, many herbal remedies lack reconsider a decision to use a course of their adult lives. Those the standardization of content low-carbohydrate, high-protein with BMIs of 30 or more had 2.09 required of pharmaceutical agents diet for weight loss, because of times the risk of stones than regulated by the U.S. Food and the risk of kidney stones. women with BMIs of 21 to 22.9. Drug Administration. It is impos- Conflicting information exists on Finally, women with waist cir- sible to evaluate a therapy that the benefit or harm of a reduced cumferences of more than 40 does not give full disclosure of its protein diet. inches had 1.94 times the risk of contents. Clinicians must edu- There is insufficient evi- stones than women with waist cate patients about purchasing dence to recommend a limited measurements of less than 31 treatments, sometimes at great oxalate diet. Human oxalate lev- inches. Among the three groups, expense, that are uninvestigated els may vary widely based on the younger women had the as agents for treatment of kidney endogenous factors, and not greatest risk with greater degrees stones. While some may be effec- dietary intake of oxalate, making of obesity (Taylor et al., 2005). tive, they are clinically unproven. dietary alterations impractical for the typical person. Patients with The Internet as a Source of Implications for Practice Crohn’s disease or gastric bypass Information How do health care providers may benefit from reduction of In December 2006, a search assimilate results from these mul- dietary oxalate, but studies do of kidney stone treatments on the tiple studies and apply them to not yet show this as beneficial. World Wide Web via the Google our patients and practice? None There is some weak evidence search engine revealed a number of the information presented for that low-sodium diets may bene- of sites which offered to sell dietary changes meets the strict fit stone formers. The science products to dissolve calcium criteria of EBP. However, there are behind this recommendation, oxalate stones. Among them varying levels of evidence which however, is very incomplete and were the following two sites: might guide clinicians in their needs further study. http://webagt.com/a/kidney- recommendations to patients (see The information on vitamin stoneslink.htm; http://cgi.ebay. Table 1). There is good evidence C intake is contradictory. Sup- com/ws/eBayISAPI.dll?ViewIte to suggest that increasing fluids plemental vitamin C use should m&item=9519705774&refid=store. reduces the rate of stone forma- be undertaken cautiously among Other sites recommend herbal or tion. An easy guide is to suggest stone formers. Lemonade may be phytotherapeutic solutions such that urine should appear very a good fluid choice among as dandelion leaf as an alterna- light yellow to clear at all times. patients known to have low lev- tive diuretic to hydrochloro- This technique makes it easy to els of urinary citrate, rather than thiazide (All Natural Net, n.d.). quickly adjust oral intake, based grapefruit juice. Future studies Gravel Root, Jo Pye Weed, and on the appearance of urine, should attempt to evaluate the Queen of the Meadow are alter- assuming the patient is not using breakdown of ascorbate to nate names for an herb suggested drugs that change the color of oxalate vs. citrate, as the associa- for stones prevention as a pH urine, such as multivitamins tion each has to stone formation altering substance, and for treat- with carotene, or pyridium. This is significant. ing cystitis and dysuria (Purple recommendation is generally There is very little informa- Sage Botanicals, 2006). Such safe assuming the patient does tion upon which to base recom- treatments are attractive to not have kidney or heart failure mendations on the use of cola or patients because usage does not precluding higher fluid intake. other soft drinks. Given the require consultation from a There is also good, but not empty caloric value of sugared physician or nurse, giving overwhelming evidence, that cal- soft drinks, their use in large patients a sense of control over cium intake should not be limit- quantities should continue to be their own treatment decisions. ed for the sake of stone risk. discouraged. With their ubiqui- Just as dietary changes can be Dietary calcium may be safer tous presence in our culture, made without prescription, a than supplemental calcium. however, they certainly deserve prescription is not required to Those who use calcium supple- further study. obtain these herbal products. ments should consider adminis- Patients with calcium stones Many commercial treatments tration with meals only, until can continue to use teas and cof- offered online are difficult to more is learned about the risks of fees without particular concern,

120 UROLOGIC NURSING / April 2007 / Volume 27 Number 2 UNJ April 2007-121.ps 4/9/07 4:44 PM Page 121

SERIES

Table 1. Recommendations to Guide Clinicians in Patient Education

Nutrient Weight of Evidence Finding Water Good Maintain intake of 2.5 liters/day; maintain light yellow urine at all times. Dietary calcium Good Do not limit; maintain 1,000 mg/day by dietary sources. Supplemental calcium Fair Take with food if used for bone strength. Oxalate Fair but insufficient data May promote stones, but little evidence for limitation of dietary oxalate. Dietary vitamin C Fair Grapefruit juice possibly harmful. Lemonade possibly helpful. Orange juice possibly helpful. Cranberry juice possibly helpful.

Supplemental vitamin C Fair but contradictory Possibly stone forming. Sodium Fair but contradictory Possibly helpful to limit to 2.5 gms/day. Magnesium Good Likely beneficial. Protein Fair High-protein diet may risk stone formation; conflicting information about reduced protein diet risk vs. benefit. Coffee/Tea Fair Probably not stone forming; may be beneficial. Wine Fair Probably not stone forming; may be beneficial. Beer/Liquor Fair Possibly not stone forming. Cola Preliminary data May increase stone risk. Phyllanthus niruri Preliminary data May be beneficial to known stone formers. Other phytotherapy/herbal products No human studies to review Cannot recommend or discourage

Source: Developed by Flagg, 2006

though the evidence is not clear for the clinician to communicate, literature, and question what we that they are actually beneficial. through nonjudgmental language, believe we know. Equally unclear are the possible that there is insufficient evidence Kidney stones constitute a benefits of alcoholic beverages, to support the use of phytothera- problematic health condition for though wine and beer may carry peutic agents for kidney stones at many of our patients. Our profes- some weight as stone inhibitors. this time as the field remains sion requires us to update our Maintenance of proper body untested. knowledge as new information is weight may have benefits to revealed. Urologic nurses and reducing stone formation, though Future Implications associates can not only benefit information is very limited. There There is ongoing need for from understanding the litera- are certainly enough reasons to urologic nurses and health care ture, but also from taking part in maintain normal body weight, and providers to research and investi- studies that seek to evaluate the risking stones may be another rea- gate treatment modalities for kid- patient’s risk for kidney stones. son to avoid obesity. ney stones. As we embrace EBP In this way, we can develop pow- Patients may find the use of to guide recommendations, this erful experience in urologic herbal therapies appealing, par- review of available literature on research. Mainstream Western ticularly when traditional West- dietary management of calcium medicine and alternative treat- ern treatment fails. Clinicians oxalate kidney stones show little ments should be considered as need to inquire about herbal treat- is known with any degree of cer- subjects for future study as well ments used by patients in their tainty. It behooves us as clini- as seeking to incorporate the assessments, especially when cians to look critically at all our growing field of phytotherapy their stones recur. It is important practices, review the available into our knowledge base. •

UROLOGIC NURSING / April 2007 / Volume 27 Number 2 121 UNJ April 2007-122.ps 4/9/07 4:44 PM Page 122

SERIES

References patients with idiopathic hypercalci- BJU International, 92, 765-768. All Natural Net. (n.d.). Dandelion uria and calcium nephrolithiasis. McKay, D.W., Seviour, J.P., Comerford, A., Taraxacum officinale. Encyclopedia of American Journal of Clinical Vasdev, S., & Massey, L.K. (1995). herbs. Retrieved December 4, 2006, Nutrition, 69, 267-271. Herbal tea: An alternative to regular from http://www.allnatural.net/herb- Guyton, A.C., & Hall, J.E. (2000). Textbook tea for those who form calcium pages/dandelion.shtml of medical physiology (10th ed.). oxalate stones (abstract). Journal of Borghi, L., Meschi, T., Amato, F., Briganti, Philadelphia: Saunders. the American Dietetic Association, A., Novarini, A., & Giannini, A. Hall, P.M. (2002). Preventing kidney 95, 360-361. (1996). Urinary volume, water and stones: Calcium restriction not war- Micali, S., Sighinolfi, M.C., Celia, A., recurrences in idiopathic calcium ranted. Cleveland Clinic Journal of DeStefani, S., Grande, M., Cicero, nephrolithiasis: A 5-year random- Medicine, 69, 885-888. A.F. et al. (2006). Can Phyllanthus ized prospective study. Journal of Heilberg, I.P. (2000). Update on dietary rec- niruri affect the efficacy of extracor- Urology, 155, 839-843. ommendation and medical treatment poreal shock wave lithotripsy for Borghi, L., Schianchi, T., Meschi, T., of renal stone disease. Nephrology, renal stones? A randomized, Guerra, A., Allegri, F., Maggiore, U., Dialysis, Transplantation, 15, 117-123. prospective, long-term study. The et al. (2002). Comparison of two diets Hiatt, R.A., Ettinger, B., Caan, B., Journal of Urology, 176, 1020-1022. for the prevention of recurrent stones Quesenberry, C.P., Duncan, D., & Morton, A.R., Iliescu, E.A., & Wilson, in idiopathic hypercalciuria. New Citron, J.T. (1996). Randomized con- J.W.L. (2002). Nephrology 1: England Journal of Medicine, 346, trolled trial of a low animal protein, Investigation and treatment of recur- 77-83. high fiber diet in the prevention of rent kidney stones. Canadian Chai, W., Liebman, M., Kynast-Gales, S., & recurrent calcium oxalate kidney Medical Association Journal, 166, Massey, L. (2004). Oxalate absorp- stones. American Journal of 213-218. tion and endogenous oxalate synthe- Epidemiology, 144, 25-33. Moyad, M. (2003). Calcium oxalate kid- sis from ascorbate in calcium oxalate Hirvonen, T., Pietinen, P., Virtanen, M., ney stones: Another reason to stone formers and non-stone formers Albanes, D., & Virtamo, J. (1999). encourage moderate calcium intakes (abstract). American Journal of Nutrient intake and use of beverages and other dietary changes. Urologic Kidney Diseases: The official journal and the risk of kidney stones among Nursing, 23, 310-313. of the National Kidney Foundation, male smokers. American Journal of National Guideline Clearinghouse. (2006). 44, 1060-1069. Epidemiology, 150, 187-194. Nephrolithiasis. Retrieved on Coe, F.L., Parks, J.H., & Webb, D.R. (1992). Holmes, R.P., Goodman, H.O., & Assimos, December 4, 2006 from http:// Stone-forming potential of milk or D.G. (2001). Contribution of dietary www.guideline.gov/summary/sum- calcium-fortified orange juice in oxalate to urinary oxalate excretion. mary.aspx?doc_id=7463&nbr=004409 idiopathic hypercalciuric adults Kidney International, 59, 270-276. &string=kidney+AND+stones (abstract). Kidney International, 41, Kok, D.J., Iestra, J.A., Doorenbos, C.J., & Nishiura, J.L., Campos, A.H., Boim, M.A., 139-142. Papapoulos, S.E. (1990). The effects Heilberg, I.P., & Schor, N. (2004). Curhan, G.C., Willett, W.C., Rimm, E.B., & of dietary excesses in animal protein Phyllanthus niruri normalizes ele- Stampfer, M.J. (1993). A prospective and in sodium on the composition vated urinary calcium levels in calci- study of dietary calcium and other and the crystallization kinetics of um stone forming (CSF) patients. nutrients and the risk of sympto- calcium oxalate monohydrate in Urology Research, 32, 362-366. matic kidney stones. New England urines of healthy men (abstract). Pak, C.Y.C. (1999). Medical prevention of Journal of Medicine, 328, 833-838. Journal of Clinical Endocrinology renal stone disease. Nephron, Curhan, G.C., Willett, W.C., Rimm, E. B., and Metabolism, 71, 861-867. 81(Suppl. 1), 60-65. Spiegelman, D., & Stampfer, M.J. Liebman, M., & Costa, G. (2000). Effects of Pak, C.Y.C., Sakhaee, K., Crowther, C., & (1996). Prospective study of beverage calcium and magnesium on urinary Brinkley, L. (1980). Evidence justify- use and the risk of kidney stones. oxalate excretion after oxalate loads ing a high fluid intake in treatment of American Journal of Epidemiology, (abstract). Journal of Urology, 163, nephrolithiasis. Annals of Internal 143, 240-247. 1565-1569. Medicine, 93, 36-39. Curhan, G.C., Willett, W.C., Speizer, F.E., Martini, L.A., & Wood, R.J. (2000). Should Parmar, M.S. (2004). Kidney stones. British Spiegelman, D., & Stampfer, M.J. dietary calcium and protein be Medical Journal, 328, 1420-1424. (1997). Comparison of dietary calci- restricted in patients with Purple Sage Botanicals. (2006). Gravel um with supplemental calcium and nephrolithiasis? Nutrition Reviews, root. Retrieved December 4, 2006, other nutrients as factors affecting 58, 111-117. from http://www.purplesage.org.uk/ the risk for kidney stones in women. Massey, L.K., Liebman, M., & Kynast- profiles/gravelroot.htm Annals of Internal Medicine, 126, Gales, S.A. (2005). Ascorbate Qiang, W., & Ke, Z. (2004). Water for pre- 497-504. increases human oxaluria and kid- venting urinary calculi. The Curhan, G.C., Willett, W.C., Speizer, F.E., ney stone risk. The Journal of Cochrane Database of Systematic & Stampfer, M.J. (1998). Beverage use Nutrition, 135, 1673-1677. Reviews 3(CD004292.pub2). Re- and risk for kidney stones in women. Mayne Pharma Ltd. (2004). Information trieved November 23, 2005, from Annals of Internal Medicine, 128, for health professionals data sheet: http://www.cochrane.org/cochrane/r 534-540. Ascorbic acid injection. Retrieved evabstr/AB004292.htm European Society Cooperative on January 21, 2006, from Seltzer, M.A., Low, R.K., McDonald, M., Phytotherapy. (n.d.). What is ESCOP? http://www.medsafe.govt.nz/profs/D Shami, G.S., & Stoller, M.L. (1996). Retrieved December 22, 2006, from atasheet/a/Ascorbicacidinj.htm Dietary manipulation with lemonade http://www.escop.com McCarron, D.A., & Heaney, R.P. (2004) to treat hypocitraturic calcium Gambaro, G., Reis-Santos, J.M., & Rao, N. Estimated healthcare savings associ- nephrolithiasis. Journal of Urology, (2004). Nephrolithiasis: Why doesn’t ated with adequate dairy food intake. 156, 907-909. our “learning” progress? European American Journal of Hypertension, Siener, R., Ebert, D., Nicolay, C., & Hesse, Urology, 45, 547-556. 17, 88-97. A. (2003). Dietary risk factors for Giannini, S., Nobile, M., Sartori, L., McHarg, T., Rodgers, A., & Charlton, K. hyperoxaluria in calcium oxalate Carbonare, L.D., Ciuffreda, M., & (2003) Influence of cranberry juice stone formers. Kidney International, Corro, P., et al. (1999). Acute effects on the urinary risk factors for calci- 63, 1037-1043. of moderate protein restriction in um oxalate kidney stone formation. continued on page 143

122 UROLOGIC NURSING / April 2007 / Volume 27 Number 2 UNJ April 2007-143.ps 4/9/07 4:45 PM Page 143

the inpatient unit approximately hours after his surgery. Eichel, L., Ahlering, T.E., & Clayman, R.V. 1 hour after his surgery, where Postoperative visit on day 8 (2004). Role of robotics in laparo- scopic urologic surgery. Urologic his surgical sites, Foley catheter, revealed that Mr. M. had an Clinics of North America, 31(4), 781- and JP drain were assessed. The uneventful recovery. The patient 92. nurse also checked range of reported that he had minimal Francis, P., & Winfield, H. (2006). Medical motion of his arms and legs to discomfort after he was home robotics: The impact on perioperative assess for nerve damage that may and only required two doses of nursing practice. Urologic Nursing, 26(2), 99-109. have occurred during position- Vicodin. The Foley catheter was The Joint Commission. (2007). 2007 hospi- ing. The sequential stockings removed and Kegel exercise tal/critical access hospital national remained in use overnight. That instruction reviewed. It was the patient safety goals. Retrieved March evening the patient was assisted surgeon’s expectation that conti- 19, 2007, from http://www.jointcom- mission.org/PatientSafety/NationalP with ambulation. Mr. M. was nence would be achieved within atientSafetyGoals/07_hap_cah_npsgs given clear liquids postoperative- 2 months. Mr. M. was placed on .htm ly and by the next day he was tadalafil (Cialis®) to help aug- advanced to a regular diet for ment flow to the penile vascula- Additional Reading lunch prior to his discharge. The ture. Mr. M. was cleared to return Eichel, L., Ahtering, T.E., & Clayman, R.V. (2005). Robotics in urologic surgery: following medications were to work in 2 weeks. Risks and benefits. AUA Update administered: Heparin 5,000 Series (Lesson 13), 24. units subcutaneous every 8 hours Conclusion (to prevent blood clots), cefotetan Mr. M. underwent a typical 1 gram IV every 12 hours for peri-operative course for laparo- three doses (to prevent infection), scopic robotic prostatectomy. metoclopramide (Reglan®) 10 mg Multiple advantages are experi- IV every 8 hours, and pantopra- enced by men undergoing this zole (Protonix®) 40 mg daily (to procedure. The robot allows the Dietary and Holistic promote gastric motility and surgeon to have enhanced dex- Treatment decrease risk of gastric reflux). Pain terity, precision, and control. continued from page 122 was controlled with IV ketorolac Patients have a decreased length (Toradol®) and hydrocodone in hospital stay, reduced blood Stitchantrakul, W., Sopassathit, W., (Vicodin®) by mouth for break- loss, diminished postoperative Prapaipanich, S., & Domrongkitchaiporn, S. (2004). Effects of calcium supple- through pain. pain, and faster recovery com- ments on the risk of renal stone for- pared to other techniques of mation in a population with low Clinical Implications removing the prostate gland. oxalate intake (abstract). The Discharge teaching began Patient satisfaction is also Southeast Asian Journal of Tropical during the patient’s pre-admis- increased by less scarring and Medicine and Public Health, 35, 1028-1033. sion visit and was reviewed as faster return to daily activities Straub, M., & Hautmann, R.E. (2005). soon as the patient was fully and work. Developments in stone prevention awake after surgery. The patient We have found that with the (abstract). Current Opinion in and his wife were given postop- increased use of the Internet, Urology, 15, 119-126. Taylor, E.N., Stampfer, M.J., & Curhan, erative information sheets specif- patients are more informed. They G.C. (2004). Dietary factors and the ic to laparoscopic robot prostate- seek out the latest techniques risk of incident kidney stones in ctomy. Mr. M. and his wife were and are willing to travel in order men: New insights after 14 years of given hands-on leg bag and Foley to receive care from those urolo- follow-up. Journal of the American catheter care teaching. JP gists who offer this newest tech- Society of Nephrology, 15, 3225- 3232. drainage declined steadily after nology. As evidenced by the Taylor, E.N., Stampfer, M.J., & Curhan, surgery and was removed prior to events described in this case sce- G.C. (2005). Obesity, weight gain, discharge. Mr. M. declined a nario, patient satisfaction with and the risk of kidney stones. JAMA, community health nurse referral. the robotic laparoscopic prostate- 293, 455-462. Terris, M.K., Issa, M.M., & Tacker, J.R. Discharge instructions were ctomy is related to decreased (2001). Dietary supplementation reviewed: no lifting over 15 pain, shorter hospital stay, and a with cranberry concentrate tablets pounds; restriction of driving speedy return to normal activi- may increase the risk of nephrolithi- while on narcotics; dressing ties with minimal restrictions. • asis. Urology, 57, 26-29. removal after 24 hours; and Wabner, C.L., & Pak, C.Y. (1993) Effect of orange juice consumption on uri- showering but no bathing while Reference nary stone risk factors (abstract). The Foley catheter was in place. American Cancer Society. (2007). Journal of Urology, 149, 1405-1408. Estimated new cancer cases and Weiss, G.H., Sluss, P.M., & Linke, C.A. Postoperative medications were deaths by sex for all sites, U.S., 2007. also discussed including the use (1992). Changes in urinary magne- Retrieved March 19, 2007, from sium, citrate, and oxalate levels due of oral analgesics, antibiotics, http://www.cancer.org/downloads/ to cola consumption. Urology, 32, and a stool softener. The patient STT/CFF2007ESTCsDths07.pdf 331-333. was discharged to home about 24

UROLOGIC NURSING / April 2007 / Volume 27 Number 2 143