Nephro-urolithiasis

Question 1

What is the relative incidence of stones?

Answer 1

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)

Question 2

What is the commonest cause of urological emergency admission?

Answer 2

‘Colic’ is the commonest cause of urological emergency admission

Question 3

What is the relative incidence of stone types?

Answer 3

Calcium oxalate 45%

Calcium oxalate + phosphate 25%

‘Triple phosphate’ (infective) 20%

Calcium phosphate 3%

Uric acid 5%

Cystine 3%

Question 4

what are the symptoms and signs of stones?

Answer 4

Renal pain (fixed in loin)

Ureteric colic (radiating to groin)

Dysuria / haematuria / testicular or vulval pain

Urinary infection

Loin tenderness

Pyrexia

Question 5

what investigations can be done for stones?

Answer 5

Blood tests - FBC, U&E, Creatinine

Calcium, Albumin, Urate

Parathormone

Urine analysis and culture

24hr urine collections

radiology

Question 6

what radiology investigation is shown here?

Answer 6

KUB (KIDNEY/URETER/BLADDER)

Question 7

what radiology investigation is shown here?

Answer 7

Ultrasound

Question 8

what radiology investigation is shown here?

Answer 8

IVU

(intravenous urogram)

Question 9

what radiology investigation is shown here?

Answer 9

CT KUB

Question 10

what radiology investigation is shown here?

Answer 10

CT KUB/Urogram – 3D reconstruction

Question 11

Historical Background
of stone surgery

Answer 11

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

Question 12

What are indications for Surgical Treatment?

Answer 12

Obstruction

Recurrent gross haematuria

Recurrent pain and infection

Progressive loss of kidney function

Patient occupation

Question 13

what are techniques for surgical treatment?

Answer 13

Open Surgery (now very rare)

Endoscopic Surgery

ESWL

Question 14

What is ESWL?

Answer 14

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

Question 15

what type of stones may you get?

Answer 15

Renal stones

Ureteric stones

Bladder stones

Question 16

renal stone treatment - is open surgery more or less common now?

Answer 16

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)

Question 17

what is the advantage of open surgery?

Answer 17

Single procedure with the least recurrence rate

Question 18

what are the disadvantgaes of open surgery?

Answer 18

Large scar, long hospital stay, general wound complications, longer recovery

Question 19

what are the indications for open surgery?

Answer 19

Non functioning infected kidney with large stones necessitating nephrectomy

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

Question 20

what are indications for PCNL?

Answer 20

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

Question 21

Who would deal with Percutaneous Access?

Answer 21

In an ideal world it should be a joint venture between urologist and interventional radiologist

Both should understand the intrarenal anatomy and adjacent viscera

Question 22

Percutaneous Access - renal puncture, what is it guided by?

Answer 22

Guided by Ultrasound or X-Ray

Question 23

PCNL gets access to what?

Answer 23

the collecting system

Question 24

what are contraindications for PCNL?

Answer 24

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

Question 25

what are some ocmplications of PCNL?

Answer 25

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%

Question 26

What is ESWL?

Answer 26

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

Question 27

What is now commonly used for renal and ureteric calculi as first line treatment?

Answer 27

ESWL?

Question 28

Is ESWL painful?

Answer 28

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

Question 29

What is EWSL not effective in?

Answer 29

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 30

What are some indications for open ureterolithotomy?

Answer 30

Not suitable for laparoscopic approach Failed ESWL or ureteroscopy

Question 31

Endoscopic Surgery - Ureteric Stones What are some indications for ureteroscopy?

Answer 31

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%

Question 32

What are different surgeries for Ureteric/Renal Stones?

Answer 32

Flexible ureteroscopes Flexible lithoclast Holmium laser

Question 33

What are some Complications of Ureteroscopy?

Answer 33

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

Question 34

what does bladder stones cause?

Answer 34

Suprapubic / groin / penile pain Dysuria, frequency, haematuria Urinary infection (persistent) Sudden interruption of urinary stream

Question 35

what are bladder stones usually secondary to?

Answer 35

Usually secondary to outflow obstruction

Question 36

what is the treamtent of bladder stones?

Answer 36

Most treated endoscopically Larger stones can be treated by open excision

Question 37

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

Answer 37

Correct Answer: ?

Question 38

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

Answer 38

Correct Answer: ? CT KUB i believe