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[Medicine and Surgery, (1993): (December), 21] Role of CYSTONE in Management of Ureteric CalculiS.K.S. Marya, Professor of Surgery and Urologistand Sham Singla, Lecturer in Surgery, Medical College, Rohtak, India. INTRODUCTION Ureteric calculi have been a problem since time immemorial. A number of methods have been tried to detect them. Sushruta (2700 B.C.) used Varuna (Crataevo religioso) and Shatavari (Asparagus racemosus) for prevention and dissolution of urinary calculi. Hippocrates (460-370 B.C.) recommended diuretics and large quantities of water to wash away the stones. Efforts have been continuing to find a suitable agent for dissolution of stones, which would otherwise be harmless. Unfortunately so far none of these agents like solution ‘G’, sodium citrate or Renacidin etc. has stood the test of time, although when discovered they were considered to be wonder drugs, but eventually were found useful for washing the catheters and urinary containers only. Mechanical methods like Dormina basket, ureteric catheters, stone catchers, loop catheters or even open surgery are not free from complications. We have been using Cystone, manufactured by The Himalaya Drug Company, ever since it was marketed. Considering the merits of Cystone, we are placing our experiences with this drug on record. COMPOSITION Each Cystone tablet contains :
MATERIAL AND METHODS Two hundred fifty-five patients of ureteric calculi treated with Cystone during the last 10 years have been reviewed in this study. Only those patients having stones of less than 1 cm size on X-ray and I.V.P., showing minimal or no hydronephrosis have been included. Cystone was administered in doses of 2 tablets t.i.d. along with plenty of fluids. For children below 14 years of age the dose was reduced to 1 tablet t.i.d. This regime was continued upto 3 months or earlier till the expulsion of the stone. No diuretics, anti-inflammatory or anti-spasmodic drugs were prescribed as a routine, except antispasmodic injection in the event of severe colic. Patients were instructed to pass urine in a glass so that the stone could be recovered for analysis. OBSERVATIONS AND ANALYSIS (1) Age and Sex: The age of the patients varied from 11 years to 60 years. Majority of the patients belonged to the 3rd and 4th decades (81.5%). Males out-numbered females in the ratio of 5:1 (Table I).
(2) Symptomatology : 96% of the patients had experienced pain in the groin or iliac fossa or the lumbar region at one time or the other. 4% of the patients presented only with burning micturition. (3) Urine Analysis : Table II shows the findings of urine analysis in these patients.
(4) Radiological findings : The stones could be seen on plain X-ray abdomen in 216 cases while in 39 cases the stones, being small or radiological, were detected only on IVP. The right side was involved in 60% of the cases. In 108 patients the stone was located above the sacroiliac joint and in the remaining 147 cases it was found below it. The stones were less than 5 mm size (maximum diameter) in 171 cases while in 94 patients the size varied from 6 mm to 10 mm. (5) Expulsion of stones per urethra : 233 patients(91.3%) reported expulsion of stone per urethra. Post expulsion plain X-ray abdomen did not show the radioopaque shadow seen on pre-treatment X-rays. One hundred eightysix patients expelled the same shape of stones seen on X-ray in one piece, while 47 patients confirmed passage of sand-like material on one or more occasions. In 22 patients the stones remained stationary requiring subsequent mechanical removal. (6) Time taken for expulsion of stone : The time taken for expulsion of the stone after Cystone therapy varied from 1-3 months (Table III).
ANALYSIS OF STONES Of the 233 stones expelled only 92 were brought by the patients for analysis. Calcium oxalate was the most common constituent present in 58 cases. Stones were mixed in 73 cases, while they were of pure oxalate or uric acid in 12 and 7 cases respectively. DISCUSSION Of all the calculi in the urinary tract, ureteric calculi constitute about 20% (Winsbury White, 1954). Mechanical removal by various methods are attended with possible complications. Therefore the necessity of a drug that can save the patients from undergoing surgical intervention for a ureteric stone cannot be over-emphasized. Cystone, an indigenous drug prepared by The Himalaya Drug Co., has been tried in this series. The exact mode of action of Cystone in expulsion or disintegration of ureteric calculi has not yet been conclusively elucidated. However many experimental studies in animals have shown that it does help in the disintegration and expulsion of the stones. Chopra et al. (1968) have found that Didymocarpus pedicellata (Pathar phori), Saxifraga ligulata (Pathar chati), Rubia cordifolia (Manjushta), Onosma bracteatum (Gaozaban) and Vernonia cinerea (Sahadevi) act as potent diuretics. Phukon et al. (1977) also confirmed the diuretic activity of Cystone. It exhibits a good spasmolytic action on the smooth muscle of rabbits and guinea-pigs. Because of this property, any associated spasm at the site of the impacted stone is relieved, thus further helping the expulsion of the stone. Disintegration of stones by Cystone has been postulated by Misgar and Kariholu, 1981. In our series also 47 patients confirmed passage of sand-like material on one or more occasions which goes in favour of the foregoing postulate. Many quacks have made a fortune by prescribing some undisclosed preparations. Some of these cases treated with unknown drugs have come under our observation when the conservative treatment failed and patients agreed for surgical intervention. On exploration, one has observed these kidneys to be badly adherent to the surrounding fat, along with changes of pyelonephritis, congestion and friable renal parenchyma. Haemorrhage above the stone in some cases had resulted in clot retention within the kidney leading to severe infection and even pyonephrosis. Since it is difficult to satisfy the urge of the patients to get the stone expelled as soon as possible, it is desirable to prescribe some drug of know constitution which may relieve the symptoms and help disintegration, reduction in size and finally expulsion of the stones. Cystone serves all these purposes in an effective and safe manner. It has been found to have no toxicity in experimental animals by Phukan et al. (1977). In the present series also there have been no side effects. Although advocates of mechanical means may not agree with our policy of management of ureteric stones, we feel that undue hurry for removing ureteric stones, particularly from normal calibre ureters without any hydronephrosis, may be fraught with dangers and should be withheld as long as there are no back pressure problems. Patience and perseverance invariably bear fruit under these circumstances, even if it involves long periods of waiting. In our series Cystone has been effective in expelling stones in as many as 91.3% of patients over a period varying from a few days to three months. It has also afforded a psychological satisfaction to the patients, and prevented them from running from pillar to post seeking all sorts of remedies. Patients have often returned with the expelled stone as a mark of gratitude to the prescribing doctor. SUMMARY Two hundred fifty-five patients of ureteric calculi have been treated with Cystone. In 91.3% of the patients the stones were expelled in a period varying from a few days to 3 months. No side effects were observed inspite of prolonged use. We feel Cystone is an effective, safe and cheap drug in the conservative management of ureteric calculi. It may avoid undue surgical intervention with its associated complications and morbidity. However, case selection must be done after through investigations together with periodic monitoring under adequate medical supervision. REFERENCES
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