With available medical treatment programs a remission of stone disease could be achieved in more than 80 per cent of the patients and a decrease in individual stone formation rate obtained in greater than 90 per cent. The need for stone removal may be reduced dramatically by an effective prophylactic program. There is some evidence that certain stones (even calcareous types) may undergo dissolution in vivo with appropriate therapy. Moreover, properly applied medical treatments may be capable of overcoming nonrenal manifestations as well as preventing new stone formation. Thus, the potential development of bone disease in patients with renal tubular acidosis may be averted by potassium citrate therapy. Despite these advantages it is clear that the medical treatment approach cannot provide total control of the disease. Stone disease generally presents with a surgical problem related to an already formed stone before medical diagnosis and selective treatment may be applied. Some patients, albeit a minority, are recalcitrant to medical treatment no matter how heroic. A satisfactory response to medical treatment requires continued compliance by the patient to the recommended treatment program and a commitment by the physician to provide long-term followup care. There is no cure, only prophylaxis. The increasing ease and decreasing cost of new approaches to stone removal, particularly with the advent of second generation extracorporeal lithotripsy, will undoubtedly cast a continuing uncertainty on the need for medical diagnosis and treatment. Several factors might influence the choice between surgical and medical approaches. One factor is the severity of stone disease. Patients with repeated episodes of stone formation might be more likely to adopt preventive therapy, whereas those with infrequent stone episodes may elect simply to have them removed upon their occurrence without medical treatment between episodes. Also, the possibility that lithotripsy may cause long-term hazards (for example development of hypertension) must be clarified. Another factor is the occurrence of extrarenal manifestations. In patients suffering from systemic disorders in which nephrolithiasis is only 1 manifestation (for example distal renal tubular acidosis) a medical approach may be justified exclusive of effects on stone formation. Finally, one must consider the relative practicality and cost between stone removal and a medical approach. It is likely that improvements and reductions in costs will occur with both approaches. It is hoped that urologists and internists work jointly to find an appropriate balance between the 2 approaches. Only then will ultimate control of nephrolithiasis be achieved.
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