Nephro-Urolithiasis Flashcards
Who is affected by stones?
- Prevalance in the general population 2-3%
- M:F ratio 3:1
- Peak age in men is 30 years
- Women biomodal peak 35 and 55 years
What is the chance of stone recurrence?
50% within 10 years (with 10% within a year)
What is the commonest cause of urological emergency admission?
Colic
What types of kidney stones are there?
- Calcium oxalate 45%
- Calcium oxalate + phosphate 255
- Triple phosphate (infective) 20%
- Calcium phosphate 3%
- Uric acid 5%
- Cystine 3%
What are the signs and symptoms of kidney stones?
- Renal pain (fixed in loin)
- Ureteric colic (radiating to groin)
- Dysuria / haematuria / testicular or vulval pain
- Urinary infection
- Loin tenderness
- Pyrexia
How are kidney stones investigated?
-Blood tests - FBP, U&E, Creatinine
-Calcium, Albumin, Urate
-Parathormone
-Urine analysis and culture
-24hr urine collections
-KUB x-ray
-Ultrasound
-IVU
-CT KUB
3D reconstruction
What are the indications for surgical treatment of the stones?
- Obstruction.
- Recurrent gross haematuria.
- Recurrent pain and infection.
- Progressive loss of kidney function.
- Patient occupation
What techniques are the for surgical treatment of stones?
- Opens surgery (now rare)
- Endoscopic surgery
- ESWL
Why has open surgery been reduced as a treatment?
Open stone surgery has been greatly reduced over the past two decades with the advent of PCNL and ESWL.
What is the advantage of open surgery?
Single procedure with the least recurrence rate
What are the disadvantages of open surgery?
- Large scar
- Long hospital stay
- General wound complications
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.
Who may a simple partial and total nephrectomy be performed in?
Non functioning kidney with large staghorn stones or elderly frail patients with complex stones and normal contralateral kidney
What is the percentage of contralateral stone formation after total nephrectomy?
Up to 30%
What are the specific indication 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.
Briefly describe how PCNL is carried out.
- Guide wire
- Retrograde catheter or balloon catheter
- Contrast injected
- Renal puncture guided by ultrasound or xray
What are the 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 local complications can occur with PCNL?
- Pseudoaneurysm or AV fistula 0.5-1%
- Pelvic tear 8-15%
- Ureteral tear 5%
- Stricture of PUJ 0.1-0.8%
What is the risk of serious complications in PCNL?
3-8%
What injury can occur to adjacent organs in PCNL?
- Bowel injury 0.1%
- Pneumothorax 0.1-0.3%
- Liver, spleen very rare
What systemic complications can occur with PCNL?
- Fever, sepsis 0.2-0.6%
- Myocardial infarction 0.1-0.4%
What does ESWL stand for?
Extracorporeal shock wave lithotripsy
Briefly describe how ESWL works?
- ‘Simple’ stones too large to pass through
- Shock waves crush stones
- Smaller pieces pass out of body urine
What is commonly used for renal and ureteric calculi as first line of treatment?
ESWL
How do new generation lithotripters compare to the old generation?
More powerful but less painful
How is ESWL usually carried out?
As a day case with some simple analgesia
When is ESWL not used as first line treatment?
Stones> 2cms
When is ESWL not effective?
- Less effective for lower pole stones
- Often ineffective for treating cysteine stones
- If not effective after 2 treatments then further treatments not justified
What are the indications for open ureterolithotomy?
- Not suitable for laparoscopic approach.
- Failed ESWL or ureteroscopy.
What are the indications for ureteroscopy?
- Severe obstruction
- Uncontollable pain
- Persistent haematuria
- Lack of progression
- Failed ESWL
- Patient occupation
What is the standard instrument for treating lower ureteric stones?
Rigid ureteroscope with a 90-100% success rate
What is the success rate of rigid ureteroscope in proximal stones?
60-70%
What surgery can be carried out for ureteric stones?
- Flexible ureteroscopes
- Flexible lithoclast
- Holmium laser
What is the risk of minor complications in ureteroscopy?
0-30%
What is the risk of major complications in ureteroscopy?
Up to 8%
What are the possible minor complications of urteroscopy?
- Haematuria
- Fever
- Small ureteric perforation
- Minor vesico-reflux
What are the possible major complications of ureteroscopy?
- Major ureteric perforation
- Ureteric avulsion
- Ureteral necrosis
- Stricture formation
How can bladder stones present?
- Suprapubic / groin / penile pain
- Dysuria, frequency, haematuria
- Urinary infection (persistent)
- Sudden interruption of urinary stream
How are most bladder stones treated?
Endoscopically
How can larger bladder stones be treated?
Open excision
