Nephro-Urolithiasis

Question 1

Urolithiasis?

Answer 1

Process of forming stones in the kidney, bladder, and/or urethra (urinary tract)

Question 2

What is the prevalence of nephro-urolithiasis?

Answer 2

2-3%

Question 3

What is the M:F of nephro-urolithiasis?

Answer 3

3:1

Question 4

What are the peak ages for nephro-urolithiasis?

Answer 4

• 30 in males
• 35 and 55 years in females

Question 5

What is the most common cause of urological emergency admission?

Answer 5

‘Colic’

Question 6

What are the different stone types?

Answer 6

• Calcium oxalate 45%
• Calcium oxalate and phosphate 25%
• Triple phosphate 20%
• Calcium phosphate 3%
• Uric acid 5%
• Cystine 3%

Question 7

What is the presentation of urolithiasis?

Answer 7

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

Question 8

Describe the renal pain due to urolithiasis?

Answer 8

• Renal pain (fixed in loin)

Question 9

What investigations are done for urolithiasis?

Answer 9

• Blood tests
  
  • FBC, U&E, creatinine
• Calcium, albumin, urate
• Parathoromone
• Urine analysis and culture
• 24 hour urine collections
• Radiology
  
  • KUB (kidney/ureter/bladder)
  • Ultrasound
  • IVU (intravenous urogram)
  • CT KUB
  • CT KUB/urogram – 3D reconstruction

Question 10

What are indications for surgical treatment of urolithiasis?

Answer 10

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

Question 11

What are techniques for surgical removal of urolithiasis?

Answer 11

• Open surgery (now very rare)
• Endoscopic surgery
• ESWL

Question 12

What are the different types of stones?

Answer 12

• Renal stones
• Ureteric stones
• Bladder stones

Question 13

What are advantages and disadvantages of open surgery for treatment of renal stones?

Answer 13

• Advantage of open surgery is single procedure with the least recurrence rate
• Disadvantage is large scar, long hospital stay, general wound complications, longer recovery

Question 14

What are indications for open surgery for treatment of renal stones?

Answer 14

• Non-functioning infected kidney with large stones necessitating nephrectomy
• Cases which for technical reasons cannot be managed by PCNL or ESWL

Question 15

What is simple pyelolithotomy?

Answer 15

Surgical incision of the renal pelvis of a kidney for removal of a kidney stone

Question 16

What is simple radial nephrotomy?

Answer 16

Surgical procedure wherein the kidney is incised, typically for removal of kidney stones

Question 17

What are 2 kinds of open surgery for kidney stones?

Answer 17

Simple pyelolithotomy

Simple radial nephrotomy

Question 18

What does PCNL stand for?

Answer 18

Percutaneous nephrolithotomy

Question 19

What are indications for percutaneous nephrolithotomy (PCNL)?

Answer 19

• Large stone burden (risk of Steinstrasse)
• Associated PUJ stenosis
• Infundibular stricture
• Calyceal diverticulum
• Morbid obesity or skeletal deformity
• ESWL resistant stones such as cystine
• Lack of availability of ESWL

Question 20

What is PCNL guided by?

Answer 20

Ultrasound of x-rayu

Question 21

What are contraindications for PCNL?

Answer 21

• Uncorrected coagulopathy
• Active urinary tract infection
• Obesity or unsuitable body habitus unsuitable for x-ray tablets
• Relative contraindications include small kidneys and severe perirenal fibrosis

Question 22

What are some complications of PCNL?

Answer 22

• Serious complications occur 3-8%
• Local complications include
  
  • Pseudoaneurysm or AV fistulas 0.5-
  • 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 23

What is ESWL?

Answer 23

Extracorporeal shock wave lithotripsy

Question 24

What are indications for ureteroscopy?

Answer 24

• Severe obstruction, uncontrollable pain, persistent haematuria, lack of progression, failed ESWL and patient occupation

Question 25

What is extracorporeal shock wave lithotripsy (ESWL) commonly used as first line treatment for?

Answer 25

Renal and ureteric calculi

Question 26

What is calculi?

Answer 26

A stone in the kidney

Question 27

When is ESWL not used as first line treatment?

Answer 27

Not used for first line treatment for stones >2cm and less effective for lower pole stones:

• If not effective after 2 treatments then further treatment not justified
• Often ineffective for treating cystine stones

Question 28

What are indications for open ureterolithotomy?

Answer 28

• Not suitable for laparoscopic approach
• Failed ESWL or ureteroscopy

Question 29

What is ureteroscopy?

Question 30

What is the standard treatment for treating lower ureteric stones?

Answer 30

Rigid ureteroscope is the standard instrument for treating lower ureteric stones with a 90-100% success rate:

• Success rate for proximal stones is lower at 60-70%

Question 31

What are the different kinds of ureteroscopy?

Answer 31

• Flexible ureteroscopes
• Flexible lithoclast
• Holmium laser

Question 32

What are complications of ureteroscopy?

Answer 32

• Minor complications 0-30%
  
  • Haematuria
  • Fever
  • Small ureteric perforation
  • Minor vesico-ureteric reflux
• Major complications
  
  • Major ureteric perforation
  • Ureteric avulsion
  • Ureteral necrosis
  • Stricture formation

Question 33

What is the presentation of bladder stones?

Answer 33

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

Question 34

Describe the pain due to bladder stones?

Answer 34

• Suprapubic/groin/penile pain

Question 35

What is the treatment of bladder stones?

Answer 35

• Most treated endoscopically
• Larger stones can be treated by open excision