Nephro-urolithiasis Flashcards
What is the relative incidence of stones?
Prevalance in general population 2-3%
Lifetime risk in males 1:8
M:F ratio 3:1
Peak age in men is 30 years
Women bimodal peak – 35 and 55 years
Chance of stone recurrence is 50% within 10 years (with 10% within a year)
What is the commonest cause of urological emergency admission?
‘Colic’ is the commonest cause of urological emergency admission
What is the relative incidence of stone types?
Calcium oxalate 45%
Calcium oxalate + phosphate 25%
‘Triple phosphate’ (infective) 20%
Calcium phosphate 3%
Uric acid 5%
Cystine 3%
what are the symptoms and signs of stones?
Renal pain (fixed in loin)
Ureteric colic (radiating to groin)
Dysuria / haematuria / testicular or vulval pain
Urinary infection
Loin tenderness
Pyrexia
what investigations can be done for stones?
Blood tests - FBC, U&E, Creatinine
Calcium, Albumin, Urate
Parathormone
Urine analysis and culture
24hr urine collections
radiology
what radiology investigation is shown here?
KUB (KIDNEY/URETER/BLADDER)
what radiology investigation is shown here?
Ultrasound
what radiology investigation is shown here?
IVU
(intravenous urogram)
what radiology investigation is shown here?
CT KUB
what radiology investigation is shown here?
CT KUB/Urogram – 3D reconstruction
Historical Background
of stone surgery
Dates back to 4800 BC to Egyptian and Greek and Roman civilisations
Hippocrates (credited with the first renal operation) theorised the cause of stones to be ingestion of lime containing water
The operative removal of stones usually occurred secondary to the drainage of renal abscess
The intrarenal vascular anatomy was described by Hyrtl in 1872 and re-described by Brodel in 1901 (The Intrinsic Blood Vessels of the Kidney and Their Significance in Nephrotomy)
This allowed safe removal of renal stones with minimal damage to the kidney
What are indications for Surgical Treatment?
Obstruction
Recurrent gross haematuria
Recurrent pain and infection
Progressive loss of kidney function
Patient occupation
what are techniques for surgical treatment?
Open Surgery (now very rare)
Endoscopic Surgery
ESWL
What is ESWL?
Extracorporeal shock wave lithotripsy (ESWL) is a type of treatment for kidney stones. It uses high-energy shock waves to break down the kidney stones into small crystals. After the procedure, the kidney stones should be small enough to pass out of your body in your urine
what type of stones may you get?
Renal stones
Ureteric stones
Bladder stones
renal stone treatment - is open surgery more or less common now?
Open stone surgery has greatly reduced over the past four decades with the advent of PCNL and ESWL
(PCNL - Percutaneous nephrolithotomy is a minimally-invasive procedure to remove stones from the kidney by a small puncture wound through the skin)
what is the advantage of open surgery?
Single procedure with the least recurrence rate
what are the disadvantgaes of open surgery?
Large scar, long hospital stay, general wound complications, longer recovery
what are the indications for open surgery?
Non functioning infected kidney with large stones necessitating nephrectomy
Cases which for technical reasons cannot be managed by PCNL or ESWL
what are indications for PCNL?
Large stone burden (risk of Steinstrasse)
Associated PUJ stenosis
Infundibular stricture
Calyceal diverticulum
Morbid obesity or skeletal deformity
ESWL resistant stones e.g. Cystine
Lack of availability of ESWL
Who would deal with Percutaneous Access?
In an ideal world it should be a joint venture between urologist and interventional radiologist
Both should understand the intrarenal anatomy and adjacent viscera
Percutaneous Access - renal puncture, what is it guided by?
Guided by Ultrasound or X-Ray
PCNL gets access to what?
the collecting system
what are contraindications for PCNL?
Uncorrected coagulopathy (a condition in which the blood’s ability to coagulate (form clots) is impaired)
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 some ocmplications of PCNL?
Serious complications - in the 3-8% range
Local complications includes:
- Pseudoaneurysm or AV fistula 0.5-1%
- UT injury: Pelvic tear 8-15%, Ureteral tear 5%, Stricture of PUJ 0.1-0.8%
Injury to adjacent organs:
- Bowel injury 0.1%
- Pneumothorax 0.1-0.3%
- Liver, spleen Very rare
Systemic complications:
- Fever, sepsis 0.2-0.6%
- Myocardial infarction 0.1-0.4%
What is ESWL?
Extracorporeal Shock Wave Lithotripsy
a type of treatment for kidney stones. It uses high-energy shock waves to break down the kidney stones into small crystals. After the procedure, the kidney stones should be small enough to pass out of your body in your urine
What is now commonly used for renal and ureteric calculi as first line treatment?
ESWL?
Is ESWL painful?
Newer generation lithotriptors cause less pain
Treatments are usually done on a day-case basis with simple analgesia
Can be repeated as often as required
What is EWSL not effective in?
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 some indications for open ureterolithotomy?
Not suitable for laparoscopic approach
Failed ESWL or ureteroscopy
Endoscopic Surgery - Ureteric Stones
What are some 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
The success rate for proximal stones is lower at 60-70%
What are different surgeries for Ureteric/Renal Stones?
Flexible ureteroscopes
Flexible lithoclast
Holmium laser
What are some Complications of Ureteroscopy?
Minor complications: 0-30%
Haematuria, fever, small ureteric perforation, minor vesico-ureteric reflux
Major complications:
Major ureteric perforation, ureteric avulsion, ureteral necrosis and stricture formation
what does bladder stones cause?
Suprapubic / groin / penile pain
Dysuria, frequency, haematuria
Urinary infection (persistent)
Sudden interruption of urinary stream
what are bladder stones usually secondary to?
Usually secondary to outflow obstruction
what is the treamtent of bladder stones?
Most treated endoscopically
Larger stones can be treated by open excision
Theme: Urinary Tract Stones
An A&E doctor orders a plain KUB x-ray in someone with right loin/RUQ pain.
Urinary tract stone is suspected - What percentage of Renal tract Stones are likely to be visible on this plain x-ray ?
A. All renal tract stones
B. Approximately 90%
C. About half
D. Approximately 10%
E. None of them
Correct Answer: ?
Theme: Urinary Tract Stones.
An A&E doctor sees a man with right loin/ groin pain and suspects a Urinary tract stone.
What is the most sensitive imaging modality to detect a stone in the kidney or ureter?
A. Abdominal X-ray
B. Plain KUB X-ray
C. Ultrasound of the Renal Tract/Abdomen/Pelvis
D. CT KUB
E. MAG3 Renography
Correct Answer: ?
CT KUB i believe
