Nephro-urolithiasis

Question 1

What are six different stone types?

Answer 1

• Calcium oxalate 45%
• Calcium oxalate + phosphate 25%
• ‘Triple phosphate’ (infective) 20%
• Calcium phosphate 3%
• Uric acid 5%
• Cystine 3%

Question 2

What is urolithiasis?

Answer 2

The formation of stony concretions in the bladder or urinary tract

Question 3

What are the symptoms and signs of urolithiasis?

Answer 3

• Renal pain (fixed in loin)
• Ureteric colic (radiating to groin)
• Dysuria / haematuria / testicular or vulval pain
• Urinary infection
• Loin tenderness
• Pyrexia

Question 4

What is dysuria?

Answer 4

Pain on urination

Question 5

What are the investigations for urolithiasis?

Answer 5

• Blood tests - FBC, U&E, Creatinine
• Calcium, Albumin, Urate (components of crystals)
• PTH (hyperparathyroidism -> kidney stones)
• Urine analysis and culture
• 24hr urine collections

Question 6

What radiological investigations for urolithiasis?

Answer 6

• KUB (kidney, ureter, bladder)
• USS
• IVU
• CT KUB
• CT Urogram

Question 7

What are the indications for surgical treatment for urolithiasis?

Answer 7

• Obstruction
• Recurrent gross haematuria
• Recurrent pain and infection
• Progressive loss of kidney function
• Patient occupation

Question 8

What surgical treatments are available for urolithiasis?

Answer 8

• Open surgery (rare)
• Endoscopic surgery - Percutaneous nephrolithotomy (PCNL)
• ESWL

These treat: renal, ureteric and bladder stones

Question 9

What is ESWL?

Answer 9

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.

Question 10

What are the advantages and disadvantages of open surgery?

Answer 10

Ad:
Single procedure with least recurrent rate

Dis:
Large scar, long hospital stay, genial wound complications, longer recovery

Question 11

What are the indications for open surgical stone treatment over ESWL and PCNL?

Answer 11

Non functioning infected kidney with large stones necessitating nephrectomy.

Cases which for technical reasons cannot be managed by PCNL or ESWL.

Question 12

What are different types of open surgeries?

Answer 12

• Simple pyelolithotomy: surgical incision of the renal pelvis of a kidney for removal of a kidney stone
• Simple radial nephrotomy

Question 13

What is the indication for simple partial and total nephrectomy?

Answer 13

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.

Question 14

What are the indications for PCNL?

Answer 14

• 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

Question 15

How is PCNL carried out?

Answer 15

• 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

Question 16

What are contraindications for PCNL?

Answer 16

• 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.

Question 17

What are possible complications of PCNL?

Answer 17

• 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

Question 18

How does ESWL work?

Answer 18

Simples stones too large to pass through renal pelvis into ureter

Shock waves crush stones

Smaller fragments pass out of body into urine

Question 19

What is ESWL commonly used to treat?

Answer 19

Used for renal and ureteric calculi as first line treatment

Question 20

When is ESWL not used for treatment?

Answer 20

• 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

Question 21

What are injections for open ureterolithotomy?

Answer 21

Open surgical removal of a stone from the ureter

Used after failed ESWL or ureteroscopy

Question 22

What is an endoscopic surgery for ureteric stones?

Answer 22

Ureteroscopy

Question 23

Name an open surgery to remove ureteric stones

Answer 23

Open ureterolithotomy

Question 24

What are the indications for ureteroscopy?

Answer 24

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.

Question 25

What a through instruments used for surgery for ureteric/renal stones?

Answer 25

Flexible ureteroscopes
Flexible lithoclast
Holmium laser

Question 26

What are the complications of ureteroscopy?

Answer 26

Minor complications:
Haematuria, fever, small ureteric perforation, minor vesico-ureteric reflux.

Major complications:
Major ureteric perforation, ureteric avulsion, ureteral necrosis and stricture formation.

Question 27

What are the symptoms and signs of bladder stones?

Answer 27

• Suprapubic / groin / penile pain
• Dysuria, frequency, haematuria
• Urinary infection (persistent)
• Sudden interruption of urinary stream
• Usually secondary to outflow obstruction

Question 28

How are bladder stones treated?

Answer 28

Most treated endoscopically but larger stones can be treated by open excision