Nephro-urolithiasis Flashcards
What are six different stone types?
- Calcium oxalate 45%
- Calcium oxalate + phosphate 25%
- ‘Triple phosphate’ (infective) 20%
- Calcium phosphate 3%
- Uric acid 5%
- Cystine 3%
What is urolithiasis?
The formation of stony concretions in the bladder or urinary tract
What are the symptoms and signs of urolithiasis?
- Renal pain (fixed in loin)
- Ureteric colic (radiating to groin)
- Dysuria / haematuria / testicular or vulval pain
- Urinary infection
- Loin tenderness
- Pyrexia
What is dysuria?
Pain on urination
What are the investigations for urolithiasis?
- Blood tests - FBC, U&E, Creatinine
- Calcium, Albumin, Urate (components of crystals)
- PTH (hyperparathyroidism -> kidney stones)
- Urine analysis and culture
- 24hr urine collections
What radiological investigations for urolithiasis?
- KUB (kidney, ureter, bladder)
- USS
- IVU
- CT KUB
- CT Urogram
What are the indications for surgical treatment for urolithiasis?
- Obstruction
- Recurrent gross haematuria
- Recurrent pain and infection
- Progressive loss of kidney function
- Patient occupation
What surgical treatments are available for urolithiasis?
- Open surgery (rare)
- Endoscopic surgery - Percutaneous nephrolithotomy (PCNL)
- ESWL
These treat: renal, ureteric and bladder stones
What is ESWL?
Extracorporeal Shock Wave Lithotripsy:
Treatment for kidney stones; shock waves from outside the body are targeted at a kidney stone causing the stone to fragment.
What are the advantages and disadvantages of open surgery?
Ad:
Single procedure with least recurrent rate
Dis:
Large scar, long hospital stay, genial wound complications, longer recovery
What are the indications for open surgical stone treatment over ESWL and PCNL?
Non functioning infected kidney with large stones necessitating nephrectomy.
Cases which for technical reasons cannot be managed by PCNL or ESWL.
What are different types of open surgeries?
- Simple pyelolithotomy: surgical incision of the renal pelvis of a kidney for removal of a kidney stone
- Simple radial nephrotomy
What is the indication for simple partial and total nephrectomy?
Non functioning kidney with large staghorn stones or elderly frail patients with complex stones and normal contralateral kidney.
Contralateral stone formation in up to 30% after total nephrectomy has been reported.
What are the indications for PCNL?
- Large stone burden (risk of Steinstrasse with ESWL (fragments block ureter))
- Associated PUJ stenosis
- Infundibular stricture
- Calyceal diverticulum (cystic cavity within the kidney that is lined by transitional epithelium)
- Morbid obesity or skeletal deformity
- ESWL resistant stones e.g. Cystine
- Lack of availability of ESWL
How is PCNL carried out?
- Guided by USS or X-Ray
- Pt lies on their abdomen
- Contrast injected to affected kidney to map it through catheter placed through ureter
- Small needle through skin under Xray guidance to access the stone then dilated with lithotripsy device inserted to fragment stone
What are contraindications for PCNL?
- Uncorrected coagulopathy
- Active Urinary Tract Infection
- Obesity or unusual body habitus unsuitable for X-ray tables
- Relative contraindications include small kidneys and severe perirenal fibrosis.
What are possible complications of PCNL?
- UT injury: pelvic or ureteral tear, stricture of PUJ
- Injury to adjacent organs: bowel injury, pneumothorax or liver and spleen (rare)
- Systemic: fever, sepsis or MI
How does ESWL work?
Simples stones too large to pass through renal pelvis into ureter
Shock waves crush stones
Smaller fragments pass out of body into urine
What is ESWL commonly used to treat?
Used for renal and ureteric calculi as first line treatment
When is ESWL not used for treatment?
- Not used as first line treatment for stones > 2cms and less effective for lower pole stones
- If not effective after two treatments then further treatments not justified
- Often ineffective for treating cystine stones
What are injections for open ureterolithotomy?
Open surgical removal of a stone from the ureter
Used after failed ESWL or ureteroscopy
What is an endoscopic surgery for ureteric stones?
Ureteroscopy
Name an open surgery to remove ureteric stones
Open ureterolithotomy
What are the indications for ureteroscopy?
Severe obstruction, uncontrollable pain, persistent haematuria, lack of progression, failed ESWL and patient occupation.
The rigid ureteroscope is the standard instrument for treating lower ureteric stones with a 90-100% success rate.
What a through instruments used for surgery for ureteric/renal stones?
Flexible ureteroscopes
Flexible lithoclast
Holmium laser
What are the complications of ureteroscopy?
Minor complications:
Haematuria, fever, small ureteric perforation, minor vesico-ureteric reflux.
Major complications:
Major ureteric perforation, ureteric avulsion, ureteral necrosis and stricture formation.
What are the symptoms and signs of bladder stones?
- Suprapubic / groin / penile pain
- Dysuria, frequency, haematuria
- Urinary infection (persistent)
- Sudden interruption of urinary stream
- Usually secondary to outflow obstruction
How are bladder stones treated?
Most treated endoscopically but larger stones can be treated by open excision
