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Lecture 23 - Nephrourolithiasis Flashcards

1
Q

What is the prevalence of kidney stones in the general population?

A

2-3%

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2
Q

In which gender is kidney stones more common?

A

M (x3)

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3
Q

Chance of stone recurrence is __% within 10 years

A

50%

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4
Q

What is the commonest cause of urological emergency admission?

A

‘colic’

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5
Q

What are the different types of kidney stones? (from most common to least)

A 
Calcium oxalate (45%)
Calcium oxalate + phosphate
Triple phosphate (infective)
Calcium phosphate
Uric acid
Cysteine
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6
Q

What kind of stones will show up on X-ray?

A

Those high in calcium

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7
Q

What are signs and symptoms of urolithasis?

A

Loin pain: typically severe, intermittent colic
NV
Ureteric colic (radiates to groin)
Dysuria/haematuria/testicular/vulval pain
UTI
Loin tenderness
Pyrexia

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8
Q

What are the major risk factor for calcium oxalate stones?

A

Hypercalciuria
Hyperoxaliuria
Hypocitraturia (as citrate forms complexes with calcium making it more soluble)

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9
Q

Are calcium oxalate stones radio-opague?

A

Yes (less so than calcium phosphate stones however)

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10
Q

What causes cystine stones?

A

Inherited recessive disorder of transmembrane cysteine transport leading to decreased absorption of cystine from intestinal + renal tubule

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11
Q

Are cystine stones radio-opague?

A

Yes

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12
Q

Uric acid is a product of metabolism of what substrates?

A

Purines

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13
Q

What things can cause uric acid stones?

A

Diseases with extensive tissue breakdown, e.g. malignancy

More common in kids with inborn errors of metabolism

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14
Q

Are uric acid stones radio-opague?

A

No

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15
Q

When might you get calcium phosphate stones?

A

In renal tubular acidosis, high urinary pH increases supersaturation of urine with calcium and phosphate (only types 1 and 3 increase risk of stone formation)

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16
Q

Are calcium phosphate stones radio-opague?

A

Yes - they are of a similar composition to bone

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17
Q

What are struvite stones formed of?

A

Magnesium, ammonium, phosphate

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18
Q

What do struvite stones result form?

A

Urease producing bacteria (+thus are associated with chronic infections) –> alkaline condition under which crystals can precipitate

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19
Q

Are struvite stones radio-opague?

A

Slightly

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20
Q

Which type of renal stone leads to alkaline urine?

A

Struvate

Can also be alkaline in calcium phosphate stones

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21
Q

What kind of stones tend to cause acidic urine?

A

Uric acid

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22
Q

What stones tend not to shift the pH of urine?

A

Calcium phosphate
Calcium oxalate
Cystine

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23
Q

What are staghorn calculi?

A

Calculi involving the renal pelvis and extending into at least 2 of the calyces
They develop in alkaline urine and are composed of strutive

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24
Q

What kinds of infections tend to predispose to struvite stones?

A

Ureaplasma urealyticum

Proteus infections

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25
Which kinds of renal stones are radio-opague?
``` Calcium oxalate Calcium phosphate Triple phosphate stones (struvite) Mixed calcium oxalate/phosphate stones Cystine (semi opague) ```
26
Which renal stones are radio-lucent?
Urate stones | Xanthine stones
27
What investigations should you do in someone presenting with suspected kidney stones?
Bloods - FBC, UE, creatinine Ca, albumin, urate PTH (hyperparathyroidism may be an underlying aetiology) Urine analysis + culture 24hr urine collections - excess Ca, uric acid?
28
What imaging can be done for suspected kidney stones?
``` KUB USS CT KUB (gold standard) IVU (intravenous urogram) ```
29
What does KUB stand for?
Kidneys ureter bladder | doesn't involve contrast
30
What are indications for surgical treatment of kidney stones?
``` Obstruction of the urinary tract (painful, risk of infection, renal damage) Recurrent gross haematuria Recurrent pain + infection Progressive loss of kidney function Patient occupation ```
31
What are the different techniques that can be used for surgery for kidney stones?
Open (rare) Endoscopic ESWL PCNL
32
What does ESWL stand for?
Extracorpeal shock wave lithotripsy
33
What are indications for open surgery for nephrourolithiasis?
Non-functioning infected kidney with a large stone necessitating nephrectomy Cases which cannot be managed by PCNL or ESWL for technical reasons
34
What are indications for simple partial and total nephrectomy for nephrourolithiasis?
Non-functioning kidney with large staghorn stones or elderly frail patients with complex stones + normal contralateral kidney
35
What does PCNL stand for?
Percutaneous nephrolithotomy
36
What are indications for PCNL?
Large stone burden Associated PUJ stenosis (obstruction to outflow of kidney) Infundibular strictures Calyceal diverticulum Morbid obesity/skeletal deformity ESWL resistant stones, e.g. cystine (v. hard)
37
What does PCNL involve?
Inserting a guidewire Using a retrograde catheter or balloon and injecting contrast Renal puncture guided by X-ray/USS to obtain access to collecting system Remove pieces of stone with small scope
38
What are contraindications for PCNL?
Uncorrected coagulopathy Active UTI Obesity/unusual body habitus unsuitable for X-ray tables
39
What are relative CIs for PCNL?
Small kidneys | Severe perirenal fibrosis
40
What are complications of PCNL?
Pseudoaneurysm or AV fistula Pelvic tear, ureteral tear, stricture of PUJ Injury to adjacent organs, e.g. bowel, pneumothorax, liver, spleen Sepsis, MI
41
What is ESWL used for?
For simple stones too large to pass through | Send shock waves to crush the stones and then the smaller fragments can pass in the urine
42
What kind of stones can ESWL not be used for?
Really big ones that may break off into fragments big enough to block the ureters - PCNL better for these Don't use for stones >2cm Often doesn't work for cystine stones
43
What tends to be the first line treatment for renal and ureteric stones?
ESWL
44
Do you require to be admitted to get ESWL?
No - can be done on day case basis with simple analgesia
45
What is the limit on the number of times you can have ESWL?
Can be repeated as often as req. | However, if not effective after 2 treatments, further treatment is not justified
46
Where do kidney stones usually get stuck?
At constrictions, e.g. PUJ, pelvic brim, VUJ
47
What are indications for open ureterolithotomy?
Not suitable for laparoscopic approach | Failed ESWL or ureteroscopy
48
What is a ureterolithotomy?
Surgical removal of a stone from the ureter
49
What are indications for ureteroscopy?
Severe unobstruction, uncontrollable pain, persistent haematuria, lack of progression, failed ESWL and patient occupation
50
What is the standard instrument used for treating lower ureteric stones?
Rigid ureteroscope (this is less successful for proximal ureteric stones)
51
What may be involved in surgery for ureteric or renal stones?
Flexible ureteroscopes Flexible lithoclast Holmium laser
52
What are minor complications of ureteroscopy?
Haematuria, fever, small ureteric perforation, minor VUR
53
What are major complications of ureteroscopy?
Major ureteric perforation, ureteric avulsion, ureteral necrosis + stricture formation
54
What are RFs for renal stones?
``` Dehydration Hypercalciuria, hyperparathyroidism, hypercalcaemia Cystinuria High dietary oxalate Renal tubular acisosi Medullary sponge kidney, PCKD Beryllium or cadmium exposure ```
55
What are RFs for urate stones?
Gout | Ileostomy
56
Why does ileostomy predipose to urate stones?
Loss of bicarbonate and fluid --> acidic uric --> precipitation of uric acid
57
What drugs can predipose to calcium renal stones?
Loop diuretics Steroids Acetazolamide Theophylline
58
What drugs are known to prevent calcium stones?
Thiazides (they increase distal tubular calcium repsorption)
59
What is the analgesic of choice for renal colic?
NSAID
60
For patients who require admission with renal colic what analgesic should be considered?
A parenteral analgesic, e.g. IM diclofenac for rapid relief of severe pain
61
What initial investigations should be done when someone presents with suspected renal colic?
``` Urine dipstick and culture Serum creatinine + electrolytes - to check for renal function FBC/CRP - infection? Calcium/urate - underlying cause? Clotting if PCNL planned ```
62
What investigation should be performed on all individuals presenting with renal colic?
Non-contrast CT KUB within 14h admission | If solitary kidney, diagnosis uncertain, fever --> immediate CT KUB
63
What size of stone will tend to pass spontaneously?
<5mm
64
How long does it tend to take stones <5mm to pass?
4 weeks from symptom onset
65
When might a <5mm stone require more intensive/urgent treatment?
If there is ureteric obstruction, renal development abnormality, e.g. horseshoe kidney or prev. renal transplant
66
How should ureteric obstruction + infection be managed?
Surgical emergency - decompress (options - nephrostomy tube placement, insert ureteric catheter and ureteric stent placement
67
What minimally invasive treatment options for renal stones are preferred to open surgery?
ESWL PCNL Ureteroscopy
68
How does ESWL work?
Shockwave generated external to patient | Internally cavitation bubbles + mechanical stress --> stone fragmentation
69
Is ESWL painful?
Can be comfortable so analgesia is recommended
70
What are complications of ESWL?
Ureteric obstruction | Shock waves may cause solid organ injury
71
When is ureteroscopy indicated?
In patients where ESWL is CI (e.g. pregnancy)
72
In most cases of ureteroscopy what is left in situ and how long is it left for post-op?
Stent for 4 weeks
73
How should a stone burden of less than 2cm in aggregate be managed?
Lithotripsy
74
How should a stone burden of less than 2cm in a pregnant female be managed?
Ureteroscopy
75
How should a complex renal calculi or a staghorn calculus be managed?
PCNL
76
How should a ureteric calculi less than 5mm be managed?
Expectantly
77
How can calcium stones due to hypercalciuria be avoided?
High fluid intake Low animal protein diet, low salt diet Thiazide diuretics
78
How can risk of getting oxalate stones be reduced?
Cholestryamine (reduces urinary oxalate secretion) | Pyridoxine (does the same)
79
How can risk of uric acid stones be reduced?
``` Allopurinol Urinary alkalinization (e.g. oral bicarbonate) ```
80
How might bladder stones present?
Suprapubic/groin/penile pain Dysuria, frequency, urgency Persistent UTI Sudden interruption of urinary stream
81
What usually is a bladder stone secondary to?
Outflow obstruction
82
How are bladder stones usually treated?
Mostly endoscopically | Larger stones can be treated with open excision

Renal/Urology (29 decks)

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