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Renal/Urology > Lecture 23 - Nephrourolithiasis > Flashcards

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
Q

Which kinds of renal stones are radio-opague?

A 
Calcium oxalate
Calcium phosphate
Triple phosphate stones (struvite)
Mixed calcium oxalate/phosphate stones
Cystine (semi opague)
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26
Q

Which renal stones are radio-lucent?

A

Urate stones

Xanthine stones

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27
Q

What investigations should you do in someone presenting with suspected kidney stones?

A

Bloods - FBC, UE, creatinine
Ca, albumin, urate
PTH (hyperparathyroidism may be an underlying aetiology)
Urine analysis + culture
24hr urine collections - excess Ca, uric acid?

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28
Q

What imaging can be done for suspected kidney stones?

A 
KUB USS
CT KUB (gold standard)
IVU (intravenous urogram)
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29
Q

What does KUB stand for?

A

Kidneys ureter bladder

doesn’t involve contrast

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30
Q

What are indications for surgical treatment of kidney stones?

A 
Obstruction of the urinary tract (painful, risk of infection, renal damage)
Recurrent gross haematuria
Recurrent pain + infection 
Progressive loss of kidney function 
Patient occupation
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31
Q

What are the different techniques that can be used for surgery for kidney stones?

A

Open (rare)
Endoscopic
ESWL
PCNL

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32
Q

What does ESWL stand for?

A

Extracorpeal shock wave lithotripsy

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33
Q

What are indications for open surgery for nephrourolithiasis?

A

Non-functioning infected kidney with a large stone necessitating nephrectomy
Cases which cannot be managed by PCNL or ESWL for technical reasons

34
Q

What are indications for simple partial and total nephrectomy for nephrourolithiasis?

A

Non-functioning kidney with large staghorn stones or elderly frail patients with complex stones + normal contralateral kidney

35
Q

What does PCNL stand for?

A

Percutaneous nephrolithotomy

36
Q

What are indications for PCNL?

A

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
Q

What does PCNL involve?

A

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
Q

What are contraindications for PCNL?

A

Uncorrected coagulopathy
Active UTI
Obesity/unusual body habitus unsuitable for X-ray tables

39
Q

What are relative CIs for PCNL?

A

Small kidneys

Severe perirenal fibrosis

40
Q

What are complications of PCNL?

A

Pseudoaneurysm or AV fistula
Pelvic tear, ureteral tear, stricture of PUJ
Injury to adjacent organs, e.g. bowel, pneumothorax, liver, spleen
Sepsis, MI

41
Q

What is ESWL used for?

A

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
Q

What kind of stones can ESWL not be used for?

A

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
Q

What tends to be the first line treatment for renal and ureteric stones?

A

ESWL

44
Q

Do you require to be admitted to get ESWL?

A

No - can be done on day case basis with simple analgesia

45
Q

What is the limit on the number of times you can have ESWL?

A

Can be repeated as often as req.

However, if not effective after 2 treatments, further treatment is not justified

46
Q

Where do kidney stones usually get stuck?

A

At constrictions, e.g. PUJ, pelvic brim, VUJ

47
Q

What are indications for open ureterolithotomy?

A

Not suitable for laparoscopic approach

Failed ESWL or ureteroscopy

48
Q

What is a ureterolithotomy?

A

Surgical removal of a stone from the ureter

49
Q

What are indications for ureteroscopy?

A

Severe unobstruction, uncontrollable pain, persistent haematuria, lack of progression, failed ESWL and patient occupation

50
Q

What is the standard instrument used for treating lower ureteric stones?

A

Rigid ureteroscope (this is less successful for proximal ureteric stones)

51
Q

What may be involved in surgery for ureteric or renal stones?

A

Flexible ureteroscopes
Flexible lithoclast
Holmium laser

52
Q

What are minor complications of ureteroscopy?

A

Haematuria, fever, small ureteric perforation, minor VUR

53
Q

What are major complications of ureteroscopy?

A

Major ureteric perforation, ureteric avulsion, ureteral necrosis + stricture formation

54
Q

What are RFs for renal stones?

A 
Dehydration 
Hypercalciuria, hyperparathyroidism, hypercalcaemia
Cystinuria
High dietary oxalate
Renal tubular acisosi
Medullary sponge kidney, PCKD
Beryllium or cadmium exposure
55
Q

What are RFs for urate stones?

A

Gout

Ileostomy

56
Q

Why does ileostomy predipose to urate stones?

A

Loss of bicarbonate and fluid –> acidic uric –> precipitation of uric acid

57
Q

What drugs can predipose to calcium renal stones?

A

Loop diuretics
Steroids
Acetazolamide
Theophylline

58
Q

What drugs are known to prevent calcium stones?

A

Thiazides (they increase distal tubular calcium repsorption)

59
Q

What is the analgesic of choice for renal colic?

A

NSAID

60
Q

For patients who require admission with renal colic what analgesic should be considered?

A

A parenteral analgesic, e.g. IM diclofenac for rapid relief of severe pain

61
Q

What initial investigations should be done when someone presents with suspected renal colic?

A 
Urine dipstick and culture
Serum creatinine + electrolytes - to check for renal function 
FBC/CRP - infection?
Calcium/urate - underlying cause?
Clotting if PCNL planned
62
Q

What investigation should be performed on all individuals presenting with renal colic?

A

Non-contrast CT KUB within 14h admission

If solitary kidney, diagnosis uncertain, fever –> immediate CT KUB

63
Q

What size of stone will tend to pass spontaneously?

A

<5mm

64
Q

How long does it tend to take stones <5mm to pass?

A

4 weeks from symptom onset

65
Q

When might a <5mm stone require more intensive/urgent treatment?

A

If there is ureteric obstruction, renal development abnormality, e.g. horseshoe kidney or prev. renal transplant

66
Q

How should ureteric obstruction + infection be managed?

A

Surgical emergency - decompress (options - nephrostomy tube placement, insert ureteric catheter and ureteric stent placement

67
Q

What minimally invasive treatment options for renal stones are preferred to open surgery?

A

ESWL
PCNL
Ureteroscopy

68
Q

How does ESWL work?

A

Shockwave generated external to patient

Internally cavitation bubbles + mechanical stress –> stone fragmentation

69
Q

Is ESWL painful?

A

Can be comfortable so analgesia is recommended

70
Q

What are complications of ESWL?

A

Ureteric obstruction

Shock waves may cause solid organ injury

71
Q

When is ureteroscopy indicated?

A

In patients where ESWL is CI (e.g. pregnancy)

72
Q

In most cases of ureteroscopy what is left in situ and how long is it left for post-op?

A

Stent for 4 weeks

73
Q

How should a stone burden of less than 2cm in aggregate be managed?

A

Lithotripsy

74
Q

How should a stone burden of less than 2cm in a pregnant female be managed?

A

Ureteroscopy

75
Q

How should a complex renal calculi or a staghorn calculus be managed?

A

PCNL

76
Q

How should a ureteric calculi less than 5mm be managed?

A

Expectantly

77
Q

How can calcium stones due to hypercalciuria be avoided?

A

High fluid intake
Low animal protein diet, low salt diet
Thiazide diuretics

78
Q

How can risk of getting oxalate stones be reduced?

A

Cholestryamine (reduces urinary oxalate secretion)

Pyridoxine (does the same)

79
Q

How can risk of uric acid stones be reduced?

A 
Allopurinol
Urinary alkalinization (e.g. oral bicarbonate)
80
Q

How might bladder stones present?

A

Suprapubic/groin/penile pain
Dysuria, frequency, urgency
Persistent UTI
Sudden interruption of urinary stream

81
Q

What usually is a bladder stone secondary to?

A

Outflow obstruction

82
Q

How are bladder stones usually treated?

A

Mostly endoscopically

Larger stones can be treated with open excision

Renal/Urology (29 decks)

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